Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Depression. 
Treatment: Cymbalta 60 mg (milligrams) Capsule. 
The insurer denied Cymbalta 60 mg Capsule. 
The health plan's determination is overturned. 

The patient is an adult female who is in treatment with a psychiatric clinician for management of major depressive disorder (MDD). The patient has been effectively managed for several years with brand formulation of Cymbalta. The patient has been treated in the past with multiple other antidepressant medications including generic duloxetine with either lack of efficacy or adverse effect. The prescribing clinician requests coverage for continued treatment with brand Cymbalta. 

A formulary exception is indicated for this patient. 
In this case scenario, the formulary drug duloxetine has been ineffective, and the remaining formulary drugs would not be as likely to be effective as the non-formulary drug, or would pose risk for adverse effects. 
Continued treatment with a specific medication and dosage that is currently working is reasonable, in the patient's best interest, and consistent with prevailing medical standards and clinical guidelines pertaining to patients with major depressive disorder, as well as consistent with evidence-based studies of treatments known to benefit patients with depressive disorders, referenced below. 
Additionally, pharmaco-genetic studies and the scientific literature support the scientific basis of differential response to antidepressant medications by genotype and other clinical and demographic characteristics. Thus, a switch to another medication would have the probability of a 50 percent chance (at most) of producing a remission, whereas the patient has already demonstrated a robust response to brand Cymbalta at the currently effective dose with treatment for several years with a positive therapeutic response. As the appeal asserts, the continued use of brand Cymbalta is clinically appropriate and necessary, and to switch from Cymbalta would pose risk for a relapse.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic brain injury.
Treatment: Continued Stay in Skilled Nursing Facility.

The insurer denied: Continued Stay in Skilled Nursing Facility.  The denial is upheld.

The patient is an adult male with history of falling off a bus 5 months ago and sustaining traumatic brain hemorrhage with right subdural hematoma with loss of consciousness status post burr hole evacuation and developed epilepsy, associated with hemiparesis. The patient has a percutaneous endoscopic gastrostomy (PEG)-tube for supplemental feeding. The patient also developed lower gastrointestinal (GI) bleeding due to rectal ulcer. The patient has a relevant history of anemia, seizures, hypokalemia, sacral wound, hypertension, long QT syndrome, alcohol dependence, sarcoidosis, fracture of head of left femur, history of rheumatic fever with severe mitral valve regurgitation, etc. Prior to admission, the patient was independent with activities of daily living (ADLs) and works while living with his wife in an apartment building with an elevator. The patient started rehabilitation 3 months ago with total dependence or requiring maximum assistance for most activities of daily living, and as of 2 months ago, he required maximum assistance for most activities of daily living including repositioning, requiring moderate-maximal assist for bed-mobility and functional transfer, and has limitations. He also required percutaneous endoscopic gastrostomy and intravenous feedings with the patient waxing and waning with hypertonicity and cognitive deficits while alert, awake and oriented times one.

The proposed continued stay in subacute nursing facility (SNF) was not medically necessary.

The patient has traumatic brain injury with subdural hematoma and associated general debility along with ambulatory difficulty. He started rehabilitation 3 months ago with total dependence or requiring maximum assistance for most activities of daily living, and as of 2 months ago, he required maximum assistance for most activities of daily living including repositioning, requiring moderate-maximal assist for bed-mobility and functional transfer, and has limitations. He also required percutaneous endoscopic gastrostomy and intravenous feeding with the patient waxing and waning with hypertonicity and cognitive deficits while alert, awake and oriented times one. He has not shown tangible improvement in subacute nursing facility, as stated above.
Therefore, continued stay in subacute nursing facility was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Home Health Services

Diagnosis: Retrograde amnesia
Treatment: Personal Service to 12 hours a day, 7 days week , total 84 hours hours per week.
The insurer denied Personal Service to 12 hours a day, 7 days week , total 84 hours hours per week.
The determination is overturned.

This is a female patient with a past medical history significant for retrograde amnesia, hypertension (HTN) and nonrheumatic mitral valve insufficiency requesting increased personal care services after a recent traumatic fall complicated with rib fractures. Her daughter reported worsening memory deficits. Her current plan provides approximately 7 hours a day, seven days a week, for a total of 49 hours a week from. Her primary care provider is requesting 12 hours a day, 7 days a week, for a total of 84 hours a week and this is under review for medical necessity.

The requested services are medically necessary. The Uniform Assessment System New York- Comprehensive Community Health Assessment report identified multiple factors such as the patient's comorbidities, cognitive deficits, recent clinical deterioration due to traumatic fall, and most importantly, this recent decline limits the patient's ability to participate and benefit from the current plan such as physical therapy (PT) and occupational therapy (OT).
The patient requires increased personal care services. She has cognitive issues due to retrograde amnesia, memory deficits and visual hallucination. She consistently made unsafe decision due to cognitive deficits. Constant supervision is necessary to avoid recurrent falls. She has had recent clinical deterioration due to a traumatic fall complicated with rib fractures secondary to the above issues. She requires maximal assistance to perform all necessary Instrumental activities of daily living (IADLs) and activities of daily living (ADLs). The Uniform Assessment System-New York comprehensive community health assessment report determined that she cannot be left alone safely. The patient is at risk for further falls which may increase her mortality or morbidity in the setting of her significant comorbidities.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite. 
Treatment: Braces, Monthly Visit and Retainer. 

The insurer denied: Braces, Monthly Visit and Retainer. 
The denial is overturned. 

The patient is a teenage female. The request is for orthodontic treatment with monthly visits and a retainer. 

The proposed treatment is medically necessary. 

The patient has an anterior crossbite (tooth #24) with clinical attachment loss and recession of the gingival margin. This is an automatic qualifier according to the Handicapping Labiolingual Deviation (HLD) Index scale. The case has medical necessity, and the monthly visits are needed to make sure treatment is progressing. The retainer is needed also, to prevent relapse after the treatment is finished.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Ablation (64628, 64629)
The insurer denied intraosseous basivertebral ablation (64628, 64629).
The denial is upheld.

This patient is an adult male. An appeal has been filed for the denied procedure to treat his low back pain, code 64628 and 64629. It was denied as investigational.

The magnetic resonance imaging (MRI) of the lumbar spine noted central L (lumbar) 3-L4 disc herniation indenting the anterior aspect of the thecal sac, right-sided L4-L5 disc herniation indenting the anterior aspect of the thecal sac, right-sided L5-S (sacral) 1 disc herniation indenting the anterior aspect of the thecal sac, and intrahepatic sac and extending into the right of facet foramen, moderate bilateral L5-S1, moderate bilateral L4-5, and mild bilateral L3-4 foraminal stenosis.

The patient was noted to have a history of lower back pain. He had tried epidural steroid injections. The Intracept procedure can be considered as an alternative therapy.

The provider stated the patient's primary problem is chronic low back pain due to Modic changes on his imaging.

The request was upheld as experimental/investigational. The denial letter states, "The request tells us your doctor ordered a procedure (intraosseous basivertebral nerve ablation) to treat your low back pain. This treatment is not approvable under the plan clinical criteria because there is no proof or not enough proof it improves health. For this reason, the request is denied as investigational. It may help your doctor to know we reviewed this request using the plan medical policy, Percutaneous Vertebral Disc and Vertebral Endplate Procedures (SURG.00052)."

The health plan should not cover the proposed treatment.

As noted in the medical literature, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results. The requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease. Therefore, the health plan should not cover the proposed treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Ablation (64628, 64629)
The insurer denied intraosseous basivertebral ablation (64628, 64629).
The denial is upheld.

The patient is an adult male with low back pain that began over seven years ago. Past treatments include massage therapy, physical therapy, radiofrequency ablation, transforaminal epidural steroid injection, medical marijuana, and hydromorphone. Magnetic resonance imaging (MRI) of the lumbar spine shows central L (lumbar) 3-4 disc herniation, L4-5 disc herniation, L5-S (sacral) 1 disc herniation, moderate L4-S1 foraminal stenosis, and facet arthropathy. The request for Intracept was denied as investigational.

The health plan should not cover the proposed treatment.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit without a disproportionately greater risk of harm or complications than other possible treatments and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure. As such the health plan should not cover the proposed treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Ablation (64628, 64629)
The insurer denied intraosseous basivertebral ablation (64628, 64629).
The denial is upheld.

The patient is an adult male who has chronic low back pain. An Intracept procedure has been requested. The procedure was denied as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, medial branch blocks (MBBs), radiofrequency ablation (RFA), epidural steroid injections, and home exercises. The patient has failed multiple medications including muscle relaxants and pain medication. Magnetic resonance imaging (MRI) shows Modic changes according to the letter of medical necessity.

The health plan should not cover the proposed treatment.

The requested Intracept procedure is not medically appropriate. The patient is an adult male who has chronic low back pain. An Intracept procedure has been requested. The procedure was denied as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, MBBs, RFA, epidural steroid injections, and home exercises. The patient has failed multiple medications including muscle relaxants and pain medication. MRI shows Modic changes according to the letter of medical necessity.

The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new United States Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, this patient has not failed or attempted sacroiliac joint injections, which are common causes of axial low back pain. The Intracept procedure should be employed after all conventional and evidence-proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives like sacroiliac injections do show favorable outcomes in the literature and have lower risk and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertension
Treatment: inpatient hospital
The insurer denied the inpatient hospital.
The health plan's determination is upheld. 

The patient is a male with a past medical history (PMH) of hypertension (HTN), diabetes mellitus type 2 (DM2), and schizoaffective disorder who was admitted with complaints of hearing voices. Vital signs were notable for blood pressure (BP) 187/126. Physical exam was unremarkable. Lab work was unremarkable. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) without acute ischemia. The patient was diagnosed with hypertensive urgency and treated with multiple anti-hypertensives while awaiting psychiatric transfer. 

The inpatient hospital admission was not medically necessary. This patient presented to the emergency department (ED) with complaints of hearing voices and was found to have significant asymptomatic blood pressure (BP) elevation. He did not have any evidence of end-organ damage as there was no alteration of consciousness, neurologic deficits, encephalopathy, cerebrovascular accident (CVA), intracerebral hemorrhage (ICH), retinal hemorrhage/papilledema, acute coronary syndrome (ACS), aortic dissection, acute heart failure, or acute kidney injury. The patient was treated in the ED with oral and intravenous (IV) anti-hypertensives, and responded appropriately to the medications with a reduction in BP. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Cardiac
Inpatient hospital

Diagnosis: chest pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a female who presented to the emergency department (ED) complaining of one week of chest pain and lightheadedness with occasional palpitations. A recent Holter monitor showed episodes of sinus tachycardia. Her medical history was remarkable for anemia, post-traumatic stress disorder, panic disorder and obesity. In the ED, her blood pressure was 116/79 with a heart rate of 81 beats/minute. Her room air oxygen saturation was 98%. An electrocardiogram showed sinus arrhythmia without acute changes. Her serum troponin level was 11.9 and rose to 102.2 when re-measured. Chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. Urine toxicology screen was negative. The patient was treated with aspirin and was admitted to the hospital. 

The inpatient hospital admission was medically necessary.
This woman presented with chest pain and a mildly elevated troponin level that then increased nearly 9-fold. There was no obvious non-cardiac cause for her chest pain and troponin elevation. Thus, despite her young age there was significant concern for a non-ST segment elevation myocardial infarction (NSTEMI). Patients with NSTEMI are at significant risk for major adverse cardiac events including shock, malignant arrhythmias and death. They require careful and continuous monitoring with the ability to intervene emergently, if needed. This justifies an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with right upper quadrant pain with associated nausea who presented to the emergency room (ER). She had a history of hypertension, gastroesophageal reflux disease (GERD), sleeve gastrectomy. The patient was noted to be on the schedule for a gastric bypass and cholecystectomy. Her vital signs were unremarkable except for some mild hypertension. The patient was noted to be tender to the right upper quadrant. The white blood cell (WBC) count was 7.2. An ultrasound demonstrated cholelithiasis and cholecystitis. The patient was hospitalized with intravenous (IV) antibiotics and kept nothing by mouth (NPO). The patient's pain resolved. The patient's nausea and vomiting resolved. The patient's diet was advanced to clear liquid diet.  At issue is the medical necessity of an inpatient stay.

The patient's admission was not medically necessary at the inpatient level of care for the entire admission. The patient did not demonstrate signs of systemic infection in association with the cholecystitis. The patient also did not demonstrate significant concern for cholangitis. The patient did not demonstrate hemodynamic instability. The patient did not demonstrate severe or persistent pain that would require high dose administration and monitoring. The patient did not demonstrate significant vomiting. The patient did not have signs of sepsis or bacteremia. The documentation does not suggest that the patient's care could not have been performed at a lower level care. There is no evidence that additional complex testing or therapy was performed. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Withdrawal Symptoms (drug use)
Treatment: Inpatient admission
The insurer denied: Inpatient admission.
The denial is upheld.

He patient is an adult male. His medical history includes polysubstance abuse. He was discharged from the hospital after admission for asthma exacerbation. The patient then presented on the same day complaining of persistent wheezing and dyspnea. He used oxygen, Xanax, and cocaine prior to presenting to the emergency department. The patient's vital signs were stable. His heart rate was 124. His respiratory rate was 20. His oxygenation was 96%. His exam was remarkable for end expiratory wheezes. Labs were unremarkable. Chest X-ray showed no acute conditions. Echocardiogram showed normal ejection fraction. Electrocardiogram (EKG) showed normal sinus rhythm at 98 beats per minute and borderline QT prolongation. He was admitted. The patient's plan of care included clinical opiate withdrawal scale (COWS) protocol and continuation of home medications for asthma. On day #2, the patient's vital signs were stable. His heart rate was 80. His respiratory rate was 18. Clinical opiate withdrawal scale (COWS) score was 11. Addiction medication consultation noted restlessness, agitation, dilated pupils, and flushing. The patient was to start buprenorphine and clonidine for opioid withdrawal. On day #3, the patient stated he felt like his withdrawal was worse. Clinical opiate withdrawal scale (COWS) score was 4. Belbuca was started. On day #4, the patient's clinical opiate withdrawal scale (COWS) score was 1. On day #5, the patient's clinical opiate withdrawal scale (COWS) score was 3. He was cleared for discharge.

The proposed treatment is not medically necessary.

This patient with a history of polysubstance use was admitted for opiate withdrawal. The patient was hemodynamically stable and afebrile. He had tachycardia but did not have arrhythmia. He did not have nausea, vomiting, tremor, or diarrhea. He did not have physical findings of severe withdrawal. His labs were unremarkable. His comorbid conditions were stable. He did not have a history of delirium or repetitive seizures. The patient was admitted with plan for clinical opiate withdrawal scale (COWS) protocol and management with buprenorphine. He remained stable during hospital stay without signs of severe withdrawal and responded to medication assisted treatment. The patient did not have an inadequate response to pharmacotherapy at a lesser level of care. His presentation did not preclude treatment at a lower level of care. The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoglycemia.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a past medical history (PMH) of diabetes mellitus type 2 (DM2), hypertension (HTN), and hyperlipidemia (HL) who was admitted with complaints of (c/o) hypoglycemia and altered mental status (AMS); the patient received two doses of dextrose (D) 50 with minimal improvement in the AMS. Her vital signs were unremarkable. The physical exam was notable for lethargy, non-toxic appearance, and no apparent distress (NAD). Lab work was notable for glucose 31. Imaging studies included a chest x-ray (CXR) which showed no acute pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with recurrent hypoglycemia and treated with D50 and dextrose fluids. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The hospital stay was medically necessary at an acute inpatient level of care. This patient with a known history of diabetes on a sulfonylurea presented to the emergency department (ED) with complaints of (c/o) altered mental status and was found to have hypoglycemia. The patient received two doses of D50, once pre-hospital and another in the ED, with minimal improvement in altered mental status. As such, this patient had a new and persistent alteration in mental status with the intake of a long-acting oral hypoglycemic, with an inadequate decrease in symptoms with the administration of glucose, requiring the continuous administration of dextrose and close clinical and glucose monitoring. Overall, this patient could not have been safely and appropriately treated at a lower level of care.