Persius/hicric huggingface dataset:
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity

Treatment: Wegovy (semaglutide Injection)

The insurer denied coverage for Wegovy (semaglutide Injection)

The denial is overturned

This patient is an adult male with a diagnosis of Obesity. Comorbid conditions include Hyperlipidemia, Prediabetes and Hypertension. The patient has a body mass index (BMI) of 40. He was recommended and is currently following a low-calorie intake and exercising regularly. Wegovy is being requested.

The patient is obese and has failed diet and exercise. The provider has discussed continuing diet and exercise and is requesting Wegovy. Use of Wegovy for chronic weight management in this obese patient as an adjunct to lifestyle changes is in accordance with Food and Drug Administration (FDA) labeling and medical literature. Therefore, the request for Wegovy is medically necessary.

Food and Drug Administration (FDA) 2022, "WEGOVY is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in: adult patients with an initial body mass index (BMI) of 30 greater (obesity), or 27 greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia) (1)."

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Wegovy (semaglutide Injection) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits.
The determination is overturned.

This is a female patient who presented with a skeletal Class III malocclusion with spacing in the maxilla and the mandible. She also has a 4 millimeter (mm) anterior open bite. She is treatment planned for 30-36 months of orthodontics to address the spacing, crossbite, and open bite. At issue is the medical necessity of braces and monthly visits.

Patients with an anterior open bite are among the most difficult patients to treat. (1) One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2)
Studies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with a normal occlusion. (3) It has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion. (3) Given the patients malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Ventral Hernia
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

This patient is a female who presented to the hospital to undergo the scheduled repair of a ventral hernia. The records indicate that the patient underwent ventral hernia repair with mesh. A surgical drain was placed. A post-surgical note states that the patient was without pain and the surgical site was clean and dry. The drain had 10 milliliters (ml) in the reservoir. A nursing note states that the patient requested a different pain medication other than Dilaudid. There is a note that states that the doctor has not rounded yet. A note states that the patient was doing well and was tolerating an oral intake. Pain was mild at the operative site.
The records do not include a presurgical history and physical that details the patient's comorbid health conditions nor is the operative dictation submitted for review.
The discharge summary states that the operative and postoperative course was uncomplicated and she was cleared for discharge. This note states that the patient was discharged home with plans for surgical follow up.

Based on the submitted medical record, inpatient level of care was not required or medically necessary for this patient. This patient had a recurrent abdominal wall ventral hernia. The patient presented to the hospital for the scheduled repair of a ventral hernia. She was hemodynamically stable prior to and during surgery. The operation was performed without complications. The submitted records document clinical stability in the perioperative period. The records do not include a presurgical history and physical that details the patient's comorbid health conditions nor is the operative dictation submitted for review.
There is no documentation to support that criteria existed to warrant an inpatient level of care. The operation was completed without complication and the patient responded promptly and favorably to the therapy provided.  The care during this time could have been rendered at an alternate level of care.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Mental Health
Inpatient Hospital 

Diagnosis: Suicide Attempt, COVID 19 positive
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient who initially presented to the emergency department with concerns for a suicide attempt via drowning. The patient developed multiple suicidal plans. The pertinent history included depression, anxiety, and post-traumatic stress disorder (PTSD). The initial examination documented the patient as alert, oriented, with stable hemodynamics, and without hypoxia. Psychiatry consulted and recommended constant 1:1 observation and acute inpatient psychiatric care. During the emergency department evaluation, a coronavirus 2019 (COVID-19) polymerase chain reaction (PCR) test returned positive. The patient was admitted to the hospital with an impression of a suicide attempt and a positive COVID-19 test without symptoms or cardiopulmonary impairment. No treatment was initiated for COVID-19. The treatment included continuous observation, suicide precautions, and psychiatry recommendations. The inpatient psychiatric isolation unit was closed, thus continued inpatient care was pursued until cleared. Psychiatry performed medication adjustments with positive effect. As progress was achieved, the psychiatrist cleared the patient for an intensive outpatient follow-up plan. The patient was discharged to home with this plan. At issue is the medical necessity of an inpatient stay.

Based on the clinical documentation provided, evidence-based literature and standards of care, an acute inpatient level of care was medically necessary for the entire admission.
The patient had a history of depression, anxiety and PTSD and initially presented to the emergency department following a suicide attempt. Initial evaluation found the patient to be alert, oriented, hemodynamically stable, without hypoxia, and without significant laboratory abnormalities. Psychiatry consulted and recommended continuous observation and acute inpatient psychiatric care. The patient tested positive for COVID-19 and isolation was required. The inpatient psychiatric isolation was not available. The patient was placed in isolation in the hospital and psychiatry performed medication adjustments with positive effect. With continued care, psychiatry cleared the patient for an outpatient intensive program and the patient was discharged.
In summary, the clinical indications for admission to inpatient care were met. A psychiatrist consulted and deemed the patient acutely suicidal and a danger to self. In addition, isolation was indicated for COVID-19 that could not be performed outside of the hospital setting due to acute suicidal ideation.[3][4]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Short stature
Treatment: Growth Hormone
The insurer denied Humatrope. The health plan's determination is overturned. 

This is a young male diagnosed with idiopathic short stature (ISS). This request is for Humatrope. His growth hormone (GH) stimulation test on with glucagon and L-dopa (levodopa) peaked at 16. His Insulin-like Growth Factor 1 (IGF1) was 92; Insulin-like growth factor binding protein 3 (IGFBP3) was 2502.

Humatrope is medically necessary.
The patient's growth hormone (GH) stimulation testing peaked at greater than 10.
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient had a pretreatment height less than or equal to -2.25 standard deviation (SD). The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. Humatrope is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis of the knee (knee pain)
Treatment: Second dose of Zilretta 32 mg (milligrams)
The insurer denied the second dose of Zilretta 32 mg.
The denial is upheld.

This patient is an adult female with bilateral knee pain. She had been diagnosed with osteoarthritis. She received bilateral Zilretta injections 8 months ago. She was evaluated by a nurse practitioner 5 months ago, who recommended additional injections. Additional injections were provided on that date. The patient's body mass index was 45.

The Second dose of Zilretta was not medically necessary.

The health plan notes that repeat injections have not been reported to be effective or indicated. The package insert and current literature support this claim. Therefore, the Second dose of Zilretta was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids
Treatment: Outpatient Procedure 0404T x (times) 1
The insurer denied coverage for Outpatient Procedure 0404T x 1.
The denial is upheld.
 
The patient has complaints of symptomatic uterine fibroids. Magnetic resonance imaging (MRI) documented the presence of a large 9.5 centimeter (cm) intramural fibroid with sub serosal extension. The patient is requesting coverage for transcervical uterine fibroids ablation with ultrasound guidance, radiofrequency, code 0404T.

The Sonata system is Food and Drug Administration (FDA) approved for the management of fibroids. There are multiple studies documenting the safety and efficacy of this procedure in controlling symptoms due to fibroids.

The use of the Sonata system in this patient's case is not indicated as the fibroid is greater than the 5 cm (centimeter) size that is reported in all the published studies about the efficacy and safety of Sonata. In other words, there are no data about the effectiveness of the Sonata system in patients with larger fibroids. There is suggestion that larger fibroids above 5 cm may require the application of multiple ablations (i.e., multiple procedures).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Outpatient Procedure 0404T x (times) 1 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Respiratory
Inpatient hospital

Diagnosis: Difficulty breathing
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with asthma who presented to the emergency department (ED) with 1d (day) of dyspnea, chest tightness, and wheezing not responsive to albuterol after receiving 5 days of oral steroids the week prior. In the ambulance, she was given dexamethasone, epinephrine, and nebulized bronchodilators.
In the ED, she was wheezing but felt better. 

Inpatient admission was not medically necessary.
The patient presented with dyspnea and was diagnosed with asthma and COVID 19 infection. She had taken a recent course of steroids but had been off steroids before presenting. She had severe dyspnea when Emergency Medical Services (EMS) arrived, but her symptoms had improved significantly by the time of ED arrival and seem to have nearly resolved over the course of ED stay (to the point where a discharge home plan was considered). On re-assessment by the medical team after admission, she'd improved markedly with minimal wheeze. On re-assessment by pulmonary on day of admission, she wanted to go home, felt well, had no wheeze.
She improved rapidly, within an observation care time frame (symptoms nearly resolved over ED course, almost completely resolved in 12-24 hours). As such, given lower severity of symptoms on ED presentation and rapid improvement, an inpatient admission was not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Generalized Anxiety Disorder. 
Treatment: Vilazodone. 

The insurer denied Vilazodone. 
The determination is overturned. 

The patient is a male with a history of generalized anxiety disorder. He has had trials of numerous medications to treat his anxiety including gabapentin, buspirone, clonazepam, alprazolam, escitalopram, paroxetine, and fluoxetine. He has been on vilazodone and has had stability and improvement in his symptoms. His provider notes trials to reduce vilazodone have resulted in symptom resurgence. 
At issue is whether the formulary drugs will be or have been ineffective or would not be as effective as the non-formulary drug. 

The health plan's determination is overturned in whole. 

The formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug and would have adverse effects. 
The patient has failed four agents of formulary alternatives including fluoxetine, escitalopram, sertraline, and paroxetine due to side effects and/or ineffective response. There is evidence that vilazodone is an effective and tolerable medication that can treat generalized anxiety disorder (Schwasinger-Schmidt, 2019 and Gommoll et al., 2015). The patient has had a positive response to the medication and has had significant issues with tolerability for the majority of the formulary alternatives.
Therefore, the formulary drugs would be or have been ineffective, and would not be as effective as the non-formulary drug, vilazodone.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pharyngeal erythema with mild tonsillar swelling consistent with tonsillitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with a past medical history of mitral valve prolapse who presented to the emergency department for evaluation of throat pain, difficulty swallowing, fatigue/myalgias, subjective fevers, headaches, and diarrhea. On arrival to the emergency department, the patient was afebrile, heart rate was in the 100s, and he was saturating well on room air. Initial labs were notable for a white blood cell (WBC) count of 11 and potassium of 3.4. Twelve-lead electrocardiogram showed sinus tachycardia. Chest x-ray did not demonstrate any acute cardiopulmonary disease. On exam, the patient was noted to have pharyngeal erythema with mild tonsillar swelling consistent with tonsillitis. The patient was admitted to the inpatient unit and was treated with antibiotics. He had improvement of symptoms and was discharged with outpatient follow-up.

The proposed treatment was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. There was no evidence of airway compromise. There was no evidence of bacteremia. Based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg fracture. 
treatment: Skilled nursing facility. 

The insurer denied continued skilled nursing facility stay. The health plan's determination is upheld. 

The patient is a female with a history of end stage renal disease on dialysis. She suffered a broken leg and was non weight bearing and was subsequently admitted to a skilled nursing facility. Under review is the medical necessity of Continued Skilled Nursing Facility (SNF) Admission.

The requested Continued Skilled Nursing Facility (SNF) Admission was not medically necessary for this patient. 
Patients with multiple chronic illnesses can have many challenges for discharge planning. Discharge planning uses an inter-professional approach to provide additional support when patients experience changes in their health status caused by a new medical condition or worsening of a chronic medical condition complicated by other co-morbid diseases.
The medical criteria for Skilled Nursing Facility (SNF) include: 
1) Intravenous (IV) or intramuscular (IM) injection of drugs given at least every 12 hours (and they cannot be provided at a lower level of care) 
2) Parental feeding (TPN) or enteral feeding, (eg, nasogastric, gastrostomy or jejunostomy) requiring intervention or management of a complication. 
3) Active management of a complex medication regimen (maybe oral) to include documented monitoring.
4) Active management of an exacerbation of chronic disease conditions
5) Complex wound care of stage 3 or 4 or multiple stage 2 decubitus ulcer(s) (see definition below) or other complicated wounds requiring aseptic, daily dressing changes. 
6) Ostomy complication requiring intervention which may include patient/care-giver training that cannot be provided in an alternative care setting (home, outpatient, etc.)
7) Device or drain management, including initial care of urinary or wound drain catheters (such as bladder irrigation, nephrostomy tube, suprapubic catheter or Jackson-Pratt (JP)/biliary drains). 
8) Ventilator and/or tracheostomy weaning. 
9) New respiratory treatment or new use of oxygen; or nasopharyngeal or deep tracheal suctioning (superficial, oropharyngeal suctioning is not a skilled service) to stabilize an acute medical/respiratory condition. 
This patient does not meet the above criteria for continued Skilled Nursing Facility (SNF).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment: Dupixent
The insurer denied: Dupixent
The denial is overturned.

The patient is an adult female with atopic dermatitis, 10 percent body surface area (BSA), treated with topical steroids, topical calcineurin inhibitors, anti-histamines, systemic steroids and 
antibiotics. The provider is requesting Dupixent. The patient uses Opzelura as spot treatment. The health plan denied coverage of Dupixent as the patient uses Opzelura as well.

The proposed treatment with Dupixent is medically necessary.

There is no evidence based literature supporting the avoidance of Opzelura with Dupixent. Dupixent is not immunosuppressive. This patient has severe atopic dermatitis and Dupixent is an appropriate therapy. Use of Opzelura as spot treatment is within standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
treatment: Intraosseous Basivertebral Nerve Ablation
The insurer denied Intraosseous Basivertebral Nerve Ablation. The health plan's determination is upheld. 

The patient is a female with low back pain. Pain began 18 months ago. Prior treatment has included home exercise program, injections, medications, and physical therapy. She has trialed multiple medications. The pain impacts her activities. Pain can be as high as 10 out of 10. Magnetic resonance imaging (MRI) lumbar spine 1/30/23 reported Modic type I changes at L (lumbar) 5-S (sacral) 1 disc space.

The proposed Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has complaints of low back pain.
Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. An Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
treatment: Intraosseous Basivertebral Nerve Ablation
The insurer denied Intraosseous Basivertebral Nerve Ablation. The health plan's determination is upheld. 

This is a female diagnosed with Low Back Pain; Vertebrogenic Pain, and Myofascial Pain. The records provided note that the patient was recommended to undergo the Intracept procedure (interosseous basivertebral nerve ablation), which is the subject of this review.

There is no evidence that the Intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). There is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required."

This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure.