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

Diagnosis: Psoriasis
Treatment: Skyrizi
The insurer denied Skyrizi.
The determination is upheld.

The patient is a male with psoriasis. He has failed Eucrisa and mometasone. Per the medical record, the plan is to concomitantly prescribe Skyrizi and Sotyktu. Per the plan denial, "For coverage, we ask that you are not taking Skyrizi with another targeted immunomodulator."  The medication under review for medical necessity is Skyrizi.

The requested health service/treatment of Skyrizi is not medically necessary for this patient.
Scientific evidence has not been established via well-designed, controlled studies with adequate follow-up that demonstrate the safety and efficacy of the proposed treatment.  There are no randomized-controlled studies that show the efficacy or safety of Skyrizi when administered concomitantly with an immunomodulator.  There are no psoriasis guidelines which support the use of these medications given together (1-2).  There is very limited data of prescribing Skyrizi with an immunomodulator. Further studies are necessary to determine the role and utility of co-administration of these medications for plaque psoriasis patients.
Appeal type: Medical necessity
Decision: Upheld

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


The patient is a female with a Class I occlusion with appropriate overbite and overjet. She has maxillary and mandibular spacing. She is treatment planned for 12-18 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces and monthly visits.

There is no medical reason to correct the patient's malocclusion with braces.
The patient has spacing. Her overbite is appropriate and there is no indication of damage to the incisors in the photographs. Her cephalometric radiograph shows she does not have a traumatic deep bite. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) for this patient. There is no indication from the photographs provided there is a severe overjet autoqualifier present.
While the patient has maxillary spaces, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. (2) If her teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Dementia.
Treatment: Personal Care Assistant (PCA) Services: 2-12 Hour Split Shifts per Day, 7 Days per Week.
The insurer denied Personal Care Assistant (PCA) Services 2-12 Hour Split Shifts per Day, 7 Days per Week.
The health plan's determination is overturned. 

This is a male patient with a history of coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus type 2 with diabetic polyneuropathy, Alzheimer's dementia, essential tremor, decreased hearing, spinal stenosis, bilateral knee osteoarthritis, insomnia, benign prostatic hyperplasia with urinary frequency and nocturia, and urinary incontinence due to overactive bladder. The patient lives alone. 

Personal Care Assistant (PCA) Services: 2-12 Hour Split Shifts per Day, 7 Days per Week are medically necessary for this patient.
There is documentation in the UAS (Uniform Assessment System) that the patient requires extensive assistance with tasks of transferring toilet and toilet use and limited assistance with walking, locomotion, and bed mobility. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. A tasking tool should not be used to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) of the medical necessity of increased PCA services. The patient does not have informal support for the entire time outside of the previously assigned PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Split-shift care requires proof that a PCA would be unable to receive 5 hours of uninterrupted rest. Per his PCP's letter, the patient must be turned and positioned every 2 hours. The patient's caregiver provided nighttime logs that document the patient's frequent need for assistance with toileting and walking overnight with no 5-hour uninterrupted periods documented. Therefore, the PCA would not be able to receive 5 hours of uninterrupted rest and also meet the requirements of turning the patient every 2 hours and providing assistance with ADLs overnight.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: feeding difficulty
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is male infant born at term that was evaluated in the office for decreased intake, switched to Alimentum. His oral intake decreased further over the next several days as did his urine output. He had no fevers. He had been spitting up for the past month and had no weight gain for the past one to two months. He presented to the emergency department (ED) for evaluation. Vital signs included temperature 36.5oC, heart rate 113, respiratory rate 36, and blood pressure 88/50. Examination was significant for no acute distress, flat anterior fontanelle, moist mucous membranes, no intraoral lesions, clear lungs, regular heart rate and rhythm, benign abdomen, good perfusion, baseline pallor, and some swelling on his thighs bilaterally from recent vaccines.

The inpatient hospital admission was not medically necessary. This male infant presented with feeding acute on chronic feeding refusal without significant dehydration. While he appeared well-hydrated, because he initially refused feeding in the ED (he eventually took four ounces of formula for his mother) the decision was made to admit for observation and evaluation. Radiographic testing revealed large stool burden indicative of constipation, and once he was started on lactulose with subsequent stooling, his oral intake normalized without any further difficulties. While it was not unreasonable to monitor this infant in the hospital for adequacy of oral intake, he was overall hemodynamically stable with no evidence of obstruction, serious illness such as sepsis, or significant dehydration. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Excessive skin and subcutaneous tissue. 
Treatment: Excision of Excessive Skin and Subcutaneous Tissue (lipectomy, panniculectomy, abdominoplasty). 
The insurer denied: Excision of Excessive Skin and Subcutaneous Tissue (lipectomy, panniculectomy, abdominoplasty). 
The denial is partially approved. 

The patient is an adult female patient that underwent bariatric surgery 6 years ago. She has lost 90 pounds. She has frequent rashes in her pannus fold that have persisted despite topical treatment with Lotrimin, Mycolog, nystatin, and Difllucan. Panniculectomy is planned. 

A panniculectomy is medically necessary, however, an abdominoplasty is cosmetic and not medically necessary. 

A panniculectomy (15830) is medically necessary. According to the American Society of Plastic Surgeons Position Paper "Treatment of Skin Redundancy for Obese and Massive Weight Loss Patients," "When surgery to remove extensive skin redundancy and fat folds is performed solely to enhance a patient's appearance in the absence of any signs or symptoms of functional abnormalities, the procedure should be considered cosmetic in nature and not a compensable procedure. For example, a panniculectomy to eliminate a large hanging abdominal panniculus and its associated symptoms would be considered reconstructive. In situations where a circumferential treatment approach is utilized to also treat the residual back and hip rolls or the ptotic buttock tissue, only the anterior portion of the procedures would be considered reconstructive, the remaining portion of the procedure would be considered cosmetic. Only in rare circumstances will buttock, thigh or arm lifts be needed to treat functional abnormalities. Typically, these procedures are performed to improve appearance and are therefore cosmetic in nature." 
The records indicate that the patient has failed conservative treatment for her longstanding rashes, including treatment by her primary care physician for several months. Photos show rashes and skin breakdown under the pannus fold. A panniculectomy will eliminate her rashes. The patient has failed medical management for months, and panniculectomy is now the most appropriate treatment for her rashes. Therefore, the requested health service is medically necessary. 
However, abdominoplasty is cosmetic. Removal of redundant upper abdominal skin, diastasis repair and umbilical transposition are component parts of an abdominoplasty that are not necessary to treat the rashes. According to the American Society of Plastic Surgeons, "In the case where a panniculectomy is combined with plication of the rectus abdominis muscle and/or translocation of the umbilicus, this may be completed as a single stage procedure but the plication of the rectus abdominis muscle and/or translocation of umbilicus should be considered purely cosmetic and separately billed to the patient." An abdominoplasty is a cosmetic body contouring procedure that will not confer any additional functional benefit for this patient. A panniculectomy with skin resection is sufficient to treat this patient's infections.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Bleeding
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a medical history of hypertension, asthma, chronic obstructive pulmonary disease, hyperlipidemia, and schizophrenia. She presented to the emergency department with rectal bleeding and abdominal pain. An electrocardiogram showed normal sinus rhythm. A computed tomography scan of the abdomen and pelvis showed colonic diverticulosis without acute diverticulitis. She was treated with intravenous ondansetron, pantoprazole, and magnesium. She was made nil per os (Nothing by mouth). She had some right upper quadrant abdominal pain.  A chest x-ray showed clear lungs and a spinal stimulator. A gastroenterology consultation noted likely lower gastrointestinal bleeding secondary to a diverticular bleed, hemorrhoid bleeding, or colonic Dieulafoy lesion, and minimal bleeding with stable hemoglobin; the recommendation was a clear liquid diet, bowel preparation, and nil per os after midnight.
She had a large bloody bowel movement with bowel preparation the night before, and improvement in the mild right upper quadrant pain. A colonoscopy showed poor preparation with stool in all blood throughout the colon, but no evidence of fresh blood or active bleeding, and pancolonic diverticulosis; the bleeding was assessed to be likely diverticular in nature, and the recommendation was to resume regular diet and medications, and discharged with high-fiber diet and plan for outpatient screening colonoscopy. She was discharged with a plan for Primary Care follow-up. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care is not medically necessary. In this case, the patient presented with rectal bleeding. There was no sustained tachycardia or hypotension. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-5]. She was found to have diverticulosis, but no active bleeding or high-risk findings on colonoscopy; bleeding resolved soon after presentation in this case, which is typical for diverticular bleeding [1-6]. All of the measures that were undertaken, including monitoring, Gastroenterology consultation, labs, and colonoscopy, could have been performed without acute inpatient level of care, at a lower level of care [1-6].
Appeal type: Medical necessity
Decision: Upheld

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

This is the case of a previously healthy young girl who presented to the emergency department (ED) with fever. Additional symptoms include malaise, stomach ache, dizziness, nausea, and headache. She was eating and drinking without vomiting or diarrhea. Emergency Medical Services (EMS) was called and noted an initial blood pressure (BP) 70/30 so they placed an intravenous (IV) and gave intravenous fluids (IVF) bolus with BP to 95/50.
The ED exam noted tachycardia but was otherwise normal. Electrocardiogram (EKG) showed sinus tachycardia. Blood work including electrolytes, complete blood count (CBC), and troponin was normal, and urinalysis (UA) was negative. 

The requested inpatient hospital admission was not medically necessary for this patient. According to the medical records and common practice guidelines, this patient could have safely and appropriately been managed at a lower level of care.
This otherwise healthy girl presented with acute fever and malaise, was transported by EMS and found to have hypotension in the field so an IVF bolus was given. By arrival to the ED, her blood pressure was stable, vital signs showed fever and tachycardia. Lab work-up was reassuring and the patient remained stable. Therefore, given the patient's age and health status she could have been monitored at a lower level of care with discharge to home and outpatient follow-up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult female patient admitted with a diagnosis of acute cholecystitis. She had abdominal pain in the right upper quadrant with positive Murphy's sign. Her white blood cell count was 8 and direct bilirubin was normal. Ultrasound showed evidence of cholecystitis. The patient was taken to the operating room for laparoscopic cholecystectomy. She was discharged soon after tolerating diet and pain was well controlled.

The requested health service was not medically necessary.

The patient had a diagnosis of acute cholecystitis. This was diagnosed via ultrasound, and she has had prior episodes of cholangitis. Her white blood cell count was normal, her liver function tests were normal, and she was taken to the operating room for laparoscopic cholecystectomy. She was then admitted and then discharged the next day. She tolerated her diet and there were no post-operative complications. There is no indication for inpatient admission per the documentation provided. The patient was not septic. Her vital signs were stable, there was no hypotension, and her surgical procedure was uncomplicated. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pancreatitis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned


The patient has a history of alcoholic pancreatitis and a pseudocyst and presented with epigastric tenderness. A recent computerized axial tomography (CAT) scan was read as acute pancreatitis but that the cyst was stable. There were increased hazy densities and nodular changes within the omentum. The patient was afebrile and the vital signs were stable. He was refusing an abdominal exam. The lipase was 589 (normal 11-83). Intravenous (IV) hydration and pain medications were given. 

The clinical history and physical documented that this patient had a diagnosis of recurrent acute pancreatitis. Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-250 for Pancreatitis. Clinical indications for admission for acute pancreatitis include having 2 of the following: abdominal pain, serum lipase greater than 3 times the upper limit of normal, and imaging findings indicative of acute pancreatitis. In this case, the patient had abdominal pain, the lipase was greater than 3 times the upper limit of normal, and the computerized axial tomography (CAT) scan was read as showing evidence of acute pancreatitis. This met Milliman Care Guidelines (MCG) criteria for admission for Pancreatitis. 

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 inpatient admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

 
Diagnosis: Chronic Low Back Pain

Treatment: Intracept/radiofrequency ablation, 2 units

The insurer denied coverage for Intracept/radiofrequency ablation, 2 units

The denial is upheld 

Reviewer #1:

This patient has chronic low back pain. The patient has had acupuncture, Physical therapy, Chiropractic as well as Epidural Steroid Injections (ESI) and radiofrequency ablation (RFA) of the medial branches.  The patient's medication trials have included Baclofen, Gabapentin, Naproxen, and Tizanidine. Magnetic resonance imaging (MRI) shows Modic Type I changes at L (lumbar) 4, L5 and S (sacral) 1.  The request is for RFA of the Basivertebral nerves at L4, L5 and S1.	

In 2018, Fischgrund and colleagues (1) published a double-blind, sham-controlled randomized controlled trials (RCT) evaluating the Intracept system and radiofrequency (RF) ablation of the Basivertebral nerve (BVN) for the treatment of chronic low back pain. A total of 225 participants with chronic (>= 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n=78) or treatment (n=147) intervention. In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85Celsius (C) for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Oswestry disability index (ODI) of 30 points (on 100 point scale) and a minimum visual analog scale (VAS) of 4 centimeters (cm) (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13%) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance.

Urits et al (6) also commented on the need for more research on this promising technique:  "reproducible large RCTs are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

In sum, this procedure is NOT likely to be more beneficial than the standard of care.

In summary, the denial of Intracept/radiofrequency ablation, 2 units and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity
Treatment: Victoza
The insurer denied Victoza.
The determination is upheld.

This is a female patient diagnosed with obesity. This request is for Victoza. As reported, she has autism and obesity secondary to polyphagia. She was previously on Victoza which was helpful in suppressing her appetite. She has gained 15 pounds (lbs) since Victoza was stopped. She is at risk of type 2 diabetes mellitus (T2DM) and metabolic syndrome.

She has gained weight. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

There is no documentation of a formulary alternative provided as the patient does not have an appropriate and approved diagnosis: type 2 diabetes.

The requested Victoza is not clinically appropriate.

Victoza is a long-acting glucagon-like peptide-1 (GLP1) agonist that improves glycemic control and has been shown to be beneficial in the treatment of type 2 diabetes. [1-4] The Food and Drug Administration (FDA) label [5] for Victoza is as follows:

Victoza is a GLP-1 receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Important Limitations of Use:

1) Not recommended as first-line therapy for patients inadequately controlled on diet and exercise (5.1). 2) Has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis (5.2). 3) Not for treatment of type 1 diabetes mellitus or diabetic ketoacidosis. 4) Has not been studied in combination with prandial insulin.

Victoza is indicated in patients who have type 2 diabetes as an adjunct to diet and exercise. The patient does not have a diagnosis of type 2 diabetes. The patient has a diagnosis of obesity. The request does not meet the standard of care and the requested Victoza is not clinically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Hip Avascular Necrosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

This is a patient with chronic medical problems including chronic hip pain and hepatitis. The patient presented to the hospital emergency department (ED) complaining of left hip pain. Imaging studies demonstrated "known" bilateral hip osteoarthritis and left hip avascular necrosis. Currently under review is the medical necessity of the inpatient admission.

The enclosed clinical information does not support a level of medical acuity or complexity that warranted acute inpatient hospital admission. The patient presented to the hospital emergency department (ED) with complaints of acute on chronic hip pain. There was no evidence of hemodynamic instability, sepsis, persistent mental status changes or other life-threatening event. Again, imaging studies demonstrated "known" bilateral hip osteoarthritis and left hip avascular necrosis. The patient had been seen by the orthopedic service several months prior to the ED presentation. Treatment was primarily oral and topical pain management. Physical and occupational therapy referrals could have also been provided as an outpatient. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).

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 the inpatient admission is not substantiated.