Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: Procedure 64628 and 64629: Intraosseous Basivertebral Ablation. 
The insurer denied: Procedure 64628 and 64629: Intraosseous Basivertebral Ablation. 
The denial is overturned. 

The patient is an adult female with chronic low back pain in whom 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 (PT), epidural steroid injections, facet injections, radiofrequency ablation (RFA), sacroiliac (SI) joint injections, and home exercises. The patient has failed multiple medications including opiate medications. Her magnetic resonance image (MRI) shows Modic changes. Her physical exam does not reveal any neurological injury. 

The health plan should cover the proposed treatment. 

The patient is an adult female who with chronic low back pain in whom 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, epidural steroid injections, facet injections, radiofrequency ablation (RFA), sacroiliac (SI) joint injections, and home exercises. The patient has failed multiple medications including opiate medications. Magnetic resonance image (MRI) shows Modic changes. Physical exam does not reveal any neurological injury. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. 

In this case, the patient has failed conventional treatments to the low back, including epidural steroid injection (ESI), radiofrequency ablation (RFA), sacroiliac (SI) joint injections, hip injections, physical therapy (PT), and medications. Therefore, the requested procedure is medically appropriate. The procedure is a Food and Drug Administration (FDA) approved procedure for axial low back pain. It has been shown effective in randomized controlled trial (RCT) with five-year results. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Other/Dental Issues
Treatment: Dental/Orthodontic Procedure/nerve treatment on teeth #24, #25 and #26 
The health plan denied the requested nerve treatment on teeth #24, #25 and #26 as not medically necessary. The health plan's determination is overturned.

This patient is a female who presented to the office for evaluation and treatment of teeth #24, 25, and 26. Provided for review are previous letters of appeal and denial, radiographic images, and information provided by the patient.
In question is the medical necessity for the health service/treatment for nerve treatment on teeth #24, #25 and #26.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of nerve treatment on teeth #24, #25 and #26 is medically necessary for this patient.
Previous denials were made based on New York State guidelines, stating that there must be records that show why the treatment is necessary, and thus they stated that the treatment was not medically necessary. From the provided documentation, teeth #24, 25, and 26 all have periapical periodontitis indicating pulpal pathology. The only therapy capable of addressing this condition without losing the teeth is that of endodontic therapy, both initial as well as re-treatment. Hence, the treatment of nerve re-treatment for #24 and 25, and nerve treatment for tooth #26 are all medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a girl who presented with right lower quadrant pain. She was well until 4 months prior to presentation when she developed pain in the right lower quadrant. The pain occurred approximately twice a week and was worse in the morning. She was seen by her primary doctor when the pain began, but no etiology was discovered. The day prior to presentation she had worsening pain with nausea, vomiting, and painful urination. She was seen at an outside emergency department and was found to have a 10 centimeter (cm) ovarian cyst. She had to leave due to a family emergency, but re-presented the following day with pain that was 10 out of 10 in intensity. The pain was worse with movement and she was unable to eat and was unable to urinate. She had not tolerated oral intake in the prior 2 days.

Inpatient Hospital Admission was medically necessary for this patient. She required pain management, Foley placement, intravenous fluids, specialist consultation, and surgical intervention to remove a large ovarian mass. This level of care required an inpatient hospital admission.

This is a young girl who presented with significant abdominal pain, urinary obstruction, and decreased oral intake and was found to have a large ovarian mass. She required Foley placement to relieve her urinary obstruction, and was not allowed to eat or drink and required intravenous fluids and pain control. She continued to have significant pain, and had surgery to remove the mass. After surgery, she required continued pain control and intravenous fluids until she could tolerate oral intake and oral pain medication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department with concerns for shortness of breath. Pertinent history included recent diagnosis of COVID-19 (Coronavirus disease) infection. Initial vital signs revealed a temperature of 99.3 degrees Fahrenheit, heart rate (HR) 88, blood pressure (BP) 128/87, respiratory rate (RR) 19, and peripheral capillary oxygen saturation (SpO2) 98% (percent) on room air. Initial examination documented the patient as alert, oriented, and in no acute distress.

Based on the clinical documentation provided, evidence based literature and standards of care, the inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient was diagnosed with a COVID-19 infection and presented one week later with shortness of breath. Initial evaluation found the patient to be hemodynamically stable and without hypoxia. Initial laboratory testing was relatively unremarkable. Initial computed tomography (CT) imaging revealed findings suggestive of bilateral multifocal pneumonia. Treatment plan initially included empiric antibiotics. Infectious disease consulted and recommended the initiation of Remdesivir for COVID-19. Following observation care, clinical improvement was achieved and antibiotics were discontinued. No hypoxia was noted during the hospital stay. It is unclear why the hospital stay was prolonged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine
Treatment: Acupuncture
The insurer denied Acupuncture.
The determination is overturned.

The patient has a defined history of right sided migraine with muscle spasms in the head, shoulder and neck, and upper extremity paresthesia for over 3 years. The patient has tried numerous medical interventions including oral medications, injections, and physical therapy as documented by their neurologist. It is noted that their schoolwork and daily activities were impacted by pain complaints. They began acupuncture in December 2017 and their pain notably decreased. The patient's insurance coverage changed in December of 2021 and the acupuncture coverage for their chronic condition is no longer covered. At issue is the medical necessity of the requested health service/treatment of Acupuncture.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis

Treatment: Adbry injection

The insurer denied coverage for Adbry injection

The denial is overturned

 
The patient is a young adult with severe atopic dermatitis, particularly affecting the face and scalp. The patient has failed therapy with Dupixent and topical steroids.  The request is for Adbry. 

The patient has atopic dermatitis which requires systemic therapy given the extent of involvement and the use of Adbry is reasonable given that it is Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis. Despite Dupixent therapy, the patient continues to experience episodic flares of the face and scalp which necessitate a change in systemic therapy. The request for Adbry is supported by the medical literature and specialty society guidelines. Adbry is an effective systemic therapy approved by the FDA for the management of atopic dermatitis. As summarized by Up to Date, Adbry "Tralokinumab is a fully human monoclonal anti-IL-13 antibody approved in Europe and the United States for the treatment of adults with moderate to severe atopic dermatitis that is not adequately controlled with topical prescription therapies."

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 Adbry injection is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis

Treatment: Adbry

The insurer denied coverage for Adbry

The denial is overturned

 
The patient is a young adult with severe atopic dermatitis, particularly affecting the face and scalp. The patient has failed therapy with Dupixent and topical steroids.  The request is for Adbry. 

The patient has atopic dermatitis which requires systemic therapy given the extent of involvement and the use of Adbry is reasonable given that it is Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis. Despite Dupixent therapy, the patient continues to experience episodic flares of the face and scalp which necessitate a change in systemic therapy. The request for Adbry is supported by the medical literature and specialty society guidelines. Adbry is an effective systemic therapy approved by the FDA for the management of atopic dermatitis. As summarized by Up to Date, Adbry "Tralokinumab is a fully human monoclonal anti-IL-13 antibody approved in Europe and the United States for the treatment of adults with moderate to severe atopic dermatitis that is not adequately controlled with topical prescription therapies."

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 Adbry injection is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Diabetes
Treatment: Mounjaro
The insurer denied: Mounjaro
The denial is: Overturned

The patient is a male with a history of diabetes requesting coverage for Mounjaro (tirzepatide). The records indicate that the patient has tried Ozempic, Rybelsus, and Trulicity, which either caused side effects or were ineffective. Samples of Mounjaro were prescribed to the patient, which is working well and is well tolerated.

Three out of the four formulary drugs, Ozempic, Rybelsus, and Trulicity have been ineffective and/or have caused adverse effects.
The patient has tried three out of the four formulary drugs which has been either ineffective or have caused side effects. He has been tolerating the non-formulary drug Mounjaro, which has been effective. Therefore, the patient has met the non-formulary approval process of trying three formulary alternatives in a class with three or more alternatives. Mounjaro is the most appropriate choice for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder pain
Treatment: Peripheral Nerve Stimulation (PNS)
The insurer denied: Peripheral Nerve Stimulation (PNS)
The denial is upheld

The patient is an adult male. The patient is diagnosed with shoulder pain. Records provided indicate the patient was recommended to undergo the SPRINT PNS (peripheral nerve stimulation) treatment. This was denied coverage by the health plan, as this treatment is considered not medically necessary, with insufficient evidence to support use for the patient's pain. This determination is under appeal, which is the subject of this review. The most recent appeal letter from the patient advocate 
is from the SPRINT manufacturer's facility. The letter states that the patient and doctor are seeking ways to improve the patient's pain. It was noted that the provider is requesting a one stage implantation of PNS (peripheral nerve stimulation) leads targeting the peripheral nerve and this device is FDA (United States Food and Drug Administration) approved. It was reported that the patient suffers from chronic intractable back pain bilaterally. The patient has tried lumbar radiofrequency ablation, physical therapy, medial branch blocks, epidural injections, NSAIDs (nonsteroidal anti-inflammatory drugs), Medrol Dosepak. The patient has had low back pain present for several years. Pain is rated at 3-8/10 and described as cramping, dropping and shooting. Pain is axial in nature and worse when sitting or standing for long periods of time. It was stated that palpation of the lumbar spine reveals pain at both sides in the lumbar three /sacral one (L3/S1) region. They are requesting reconsideration for approval of this treatment.

The requested peripheral nerve stimulation is not medically necessary.

This treatment would not be considered clinically appropriate in terms of type, frequency, extent, sight and duration or considered effective for the patient's illness, injury or disease. This treatment is not required for the direct care and treatment or management of that condition. The patient's condition would not be adversely affected if the services were not provided. This treatment would 
not be in accordance with generally accepted standards of medical practice. The treatment would be more intensive than alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results. 
The patient is noted to have complaints of chronic pain and has tried and failed conservative treatment including physical therapy, medial branch blocks, radiofrequency ablation, epidural injections, and medications. However, the requested treatment is considered unproven and is not considered standard of care in the general medical community, as there is insufficient evidence that this treatment is either effective or improves health outcomes over that of standard treatment options.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: sleep apnea
Treatment: Hypoglossal Nerve Stimulator 
The insurer denied Hypoglossal Nerve Stimulator. 
The health plan's determination is upheld. 

The patient is a male with sleep apnea. Apnea hypopnea index (AHI) is 64. Body mass index (BMI) is 30. A Sleep endoscopy did not reveal concentric collapse at level of oropharynx or hypopharynx. The patient cannot tolerate continuous positive airway pressure (CPAP). Per review of the notes, it appears that the patient had only attempted CPAP for 1 month.

The Implantation of a Hypoglossal Nerve Stimulator is not medically necessary for this patient.
The current standard of care for Hypoglossal nerve implant is to consider this surgery when a patient has attempted a reasonable trial of CPAP. A reasonable trial of CPAP is not documented for this patient. There was no documentation of alternative face masks or attempts at helping patient achieve CPAP compliance.
The Hypoglossal nerve implant has not been shown to be more effective than CPAP. CPAP is considered the gold standard treatment for obstructive sleep apnea.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult female with history of pre-diabetes and hypertension (HTN) who presented to the hospital with acute appendicitis signs and symptoms. The patient was hemodynamically stable and had a white blood cell (WBC) of 15. The patient's computed tomography (CT) scan showed uncomplicated appendicitis. The patient underwent uneventful appendectomy and was discharged.

The proposed treatment was not medically necessary.

After reviewing the medical records, this patient does not meet inpatient criteria per the Milliman Care Guidelines for uncomplicated acute appendicitis. This patient was hemodynamically stable on admission; the only significant laboratory value that was abnormal was a white blood cell (WBC) count of 15, and computed tomography that demonstrated uncomplicated appendicitis. The patient underwent uncomplicated appendectomy. There is no documentation supporting that this patient needed inpatient admission due to sepsis or other medical conditions. Inpatient 
admission is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied braces.
The determination is upheld.

This is a female patient with a Class I malocclusion, mild maxillary spacing and mild mandibular crowding, moderate overjet and mild overbite, and bi-maxillary protrusion with crossbite at the upper left second premolar. The issue for review is whether the requested health service/treatment of braces is medically necessary.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 6 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and the treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment of braces is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Increase in personal care assistance service to 24 hours per day 7 days per week (Monday through Sunday) split shift
The insurer denied: Increase in personal care assistance service to 24 hours per day 7 days per week (Monday through Sunday) split shift
The denial is: Upheld

The patient is a female with medical history notable for dementia. The patient is currently approved for 70 hours per week of personal care services. The patient and her care team requested an increase to 24 hours per day, 7 days per week (Monday through Sunday), split shift, and this request was denied by the health plan. The medical necessity for the increase is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was minimally impaired; she was alert and oriented times three but partially disoriented to time. She is able to make decisions about daily activities and describe an emergency plan. From a functional standpoint, she requires maximal assistance for meal preparation, housework, finances, shopping, and transportation. She requires extensive assistance for medications. For her activities of daily living (ADLs), she requires maximal assistance for bathing and dressing upper body. She requires extensive assistance for hygiene, dressing lower body, toilet transfer, toilet use, and bed mobility. She requires limited assistance for walking and locomotion. She was observed ambulating with a walker. She is frequently incontinent of urine and occasionally incontinent of stool. She uses pull-ups and requires a change 2-3 times per day. A task tool associated with the assessment recommended 34 hours per week to address her personal care needs.

The health plan's determination is upheld.

The requested health service of Personal Care Assistance services 24 hours per day 7 days per week (Monday through Sunday) split shift has not been demonstrated to be medically necessary for this patient.
The information provided for this appeal was a UAS. There is no supporting information provided regarding unmet personal care needs. The patient has been awarded hours which should be commensurate with her need demonstrated on the UAS. If she has had a change in clinical status, she should undergo an evaluation by her physician for further recommendations.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Neurodermatitis.
Treatment: Opzelura CRE (cream) 1.5%.

The insurer denied: Opzelura CRE 1.5%.  The denial is overturned.

The patient is an adult male diagnosed with moderate to severe atopic dermatitis. He has been treated with multiple topical and systemic agents including clobetasol, pimecrolimus, hydrocortisone, prednisone and antibiotics. He was started on Dupixent, achieving a positive response with occasional breakthrough lesions. The treating provider has requested Opzelura for those breakthrough areas, but the plan denied coverage. The denial of Opzelura is being appealed.

The requested Opzelura is medically necessary.

The request for coverage of Opzelura was denied because for this medication the plan requires a trial of Eucrisa, and the plan does not allow coverage when the patient will be using Opzelura with Dupixent. The treating provider has detailed why use of Eucrisa is not appropriate for the patient in the appeal letter. The patient has already tried both systemic and topical treatment options, yet he still has breakthrough lesions. Opzelura has demonstrated superior benefit for treating symptoms associated with eczema, particularly itching. Per Papp, K et al. (2021), "RUX [ruxolitinib] cream showed anti-inflammatory and prompt antipruritic effects with superior efficacy versus vehicle and was well tolerated."

The treating provider has determined that due to the refractory nature of the patient's atopic dermatitis, the patient required both Dupixent and Opzelura. There are no known contraindications when using the two medications together, and if the patient has tried and failed several topical agents, it is standard of care to use medications where studies show clinical benefit. Delaying effective therapy puts the patient at risk, and therefore use of Opzelura is medically necessary.