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

Diagnosis: Back pain. 
Treatment: Intraosseous basivertebral nerve ablation. 
The health plan denied: Intraosseous basivertebral nerve ablation. 
The determination is upheld. 

The patient is a male with low back pain. Prior treatments include chiropractic care, home exercises, medial branch blocks, physical therapy, radiofrequency ablation (RFA), and transforaminal epidural steroid injection (TFESI). Medications include Celebrex, Etodolac, Gabapentin, Oxycodone, and Percocet. The magnetic resonance imaging (MRI) shows mixed Modic type 1 and type 2 changes in lumbar vertebrae (L)4, L5. The suggestive diagnosis is vertebrogenic pain. 

The proposed health service or treatment of 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. According to Becker, et.al : "Seventeen patients with chronic, greater than 6 months, low back pain unresponsive to at least 3 months of conservative care were enrolled. Sixteen patients were treated successfully following screening using magnetic resonance imaging finding of Modic type I or II changes and positive confirmatory discography to determine the affected levels. The treated population consisted of eight male and eight female patients; the mean age was 48 years (34-66 years)." 
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. As cited above, the Becker. et.al. trial indicated only a 17 patient observational study. These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures. 
According to Smuck M , et. al., " Accordingly, longer-term follow-up may be needed to observe changes in opioid behaviors as demonstrated by a secondary analysis of data from the previous sham-controlled randomized controlled trial (RCT) of basivertebral nerve (BVN) ablation that showed opioid reduction in the subgroup reporting improvements in pain during long-term follow-up." 
Long term outcomes have not been elucidated demonstrating health outcomes, pain, and disability measures. Therefore, intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) is considered investigational as a treatment for low back pain. 

The health plan's determination regarding the proposed health service or treatment is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Intraosseous basivertebral nerve ablation. 
The health plan denied: Intraosseous basivertebral nerve ablation. 
The determination is overturned in part. 

The patient is a male with a past medical history of hyperlipidemia (HL), hemochromatosis, and chronic lower back pain for 20 years. Per the recent evaluation, he has low back pain which is worse with sitting and flexion, and the pain averages a 7/10. He has pain with lumbar flexion on exam. The treatment has included epidural steroid injection (ESI) and medial branch block (MBB)/radiofrequency ablation (RFA). Medications included Percocet, etodolac, meloxicam, metaxalone, Celebrex, oxycodone, and gabapentin. He has also pursued physical therapy (PT), chiropractic, and home exercise program (HEP) without durable benefit. He has magnetic resonance imaging (MRI) evidence of a disc bulge at Lumbar 4 - Lumbar 5 (L4-L5) with facet arthrosis and bilateral neural foraminal narrowing at that level. He also has a disc bulge at L5-Sacral 1 (S1) with right nerve root impingement. There are type 1 Modic changes at L5. A request for the Intracept procedure at L4, L5, and S1 was made. 
At issue is whether intraosseous basivertebral nerve (BVN) ablation (Intracept) is likely to be more beneficial than any standard treatment for this patient's condition. 
The health plan's determination regarding the proposed health service or treatment is overturned in part. 
The proposed health service or treatment of intraosseous basivertebral nerve ablation may be more beneficial than standard treatment for this patient. He has trialed prior injections, medications, and modalities without durable benefit. The pain has been present for greater than 20 years, and he has evidence of Modic 1 changes at L5 on MRI. It is medically reasonable to consider the Intracept procedure at the L5 level first, given the concordant findings of Modic type 1 changes at this level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy. The health plan's determination is overturned. 

This is a female diagnosed with obesity. This request is for Wegovy. As per the records, her body mass index (BMI) is 31.93 and she has elevated lipid levels.  

Wegovy is medically necessary for this patient.
Semaglutide is a GLP1R (glucagon-like peptide-1 receptor) agonist that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity. Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. This medication is now available for the treatment of obesity in the form of Wegovy. 
The standard of care requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension, hyperlipidemia. The patient has obesity and hyperlipidemia. The BMI is greater than 30. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure. 
Treatment: 7 days per week, 8 hours per day; 56 hours per week of Personal Care Worker (PCW) services. 
The insurer denied 7 days per week, 8 hours per day; 56 hours per week of Personal Care Worker (PCW) services. 
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for congestive heart failure, arthritis, coronary artery disease, and blindness. A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in-person. The patient lives alone in her apartment. Her cognition was minimally impaired; she was alert and oriented but forgetful. For her Instrumental activities of daily living (IADL), she required maximal assistance for meal preparation, housework, and shopping. She required extensive assistance for finances, stairs, and transportation. She required limited assistance for medications. For her activities of daily living (ADL), she required extensive assistance for bathing and dressing. She required limited assistance for all others. She is frequently incontinent of urine and infrequently incontinent of stool. A task tool associated with the UAS recommended 28 hours per week to address her personal care needs.

The requested 7 days per week, 8 hours per day; 56 hours per week of Personal Care Worker (PCW) services is medically necessary for this patient. 
The patient has several letters which detail the current state of her condition, which appears to have declined since her most recent Uniform Assessment System (UAS). She has several personal care needs which are not being met. The task tool associated with the UAS recommended 4 hours per day to meet her needs, but this tool should be viewed as a guideline and not the final determining factor in allocating PCW hours. Given that she has unmet personal care needs at 5 hours per day, the requested increase to 8 hours per day is medically reasonable and necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive Parkinson's Disease. 
Treatment: Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts. 
The insurer denied coverage for Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts. 
The denial is overturned. 

This is a patient with progressive Parkinson's disease. The patient lives alone. At the time of the Uniform Assessment System (UAS) assessment the patient "has a private aide from 11 am to 10 pm Monday to Sunday." The insurer approved Consumer Direct Personal Aide Services (CDPAS) 5 days x 11 hours and 1 day x 10 hours, total 65 hours/week and the request is for CDPAS 7 days x 12 hours x 2 shifts. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as independent. The patient is self-directing. The patient is reportedly totally dependent for performing much of their Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for dressing, bed mobility and toilet use. Extensive assistance is reportedly needed for bathing, personal hygiene, locomotion, toilet transfer and ambulation. Limited assistance is reportedly needed for eating. The patient is reportedly frequently incontinent of bladder and occasionally incontinent of bowel. The patient has reportedly fallen 2 more times over the prior 30 days. 

The letters from the patient's treating physician were  reviewed. The patient lives alone and needs toileting overnight. The patient is at maximal assistance for bed mobility and thus requires bed turning and positioning every 2 hours to prevent pressure sores. A live-in aide would not be able to get 5 hours of uninterrupted sleep. Based on the documents reviewed, the patient's progressive neurodegenerative condition does warrant an increase in CDPAS. Attention to the patient's functional needs are more appropriately provided and maintained by increasing to CDPAS 7 days x 12 hours x 2 shifts. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the 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. 
From a physical medicine and rehabilitation perspective, Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts is medically necessary. 

Based on the above, the insurer's denial must be reversed. 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 Consumer Direct Personal Aide Service (CDPAS) 7 days x 12 hours x 2 shifts is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Thyroid Eye Disease
Treatment: Tepezza
The insurer denied coverage for Tepezza.
The denial is overturned.

The patient has thyroid eye disease, and previously received an eight week of course of Tepezza.  The patient tried and could not tolerate intravenous (IV) Solumedrol.  Retreatment with Tepezza is being requested.  

The scientific evidence in peer-reviewed literature supports an improvement in health outcomes.  Tepezza is approved by the Food and Drug Administration (FDA) to reduce proptosis and improve quality of life in patients with thyroid eye disease.

The additional infusions of Tepezza does not have final approval from the FDA (Food and Drug Administration).  However, the use of Tepezza is FDA approved and studies have shown the retreatment with additional Tepezza is beneficial in improving vision and function in patients with recalcitrant thyroid eye disease.

This patient is a good candidate for additional Tepezza infusions. The patient continues to have active thyroid disease unresponsive to steroid therapy, and additional Tepezza infusions have been shown to be effective in treating patients with refractory thyroid eye disease (Douglas).

The additional infusions of Tepezza are the best available treatment for the patient at this time.  The patient continues to have active thyroid eye disease unresponsive to steroid therapy.  Studies have shown patients with thyroid eye disease with insufficient response benefits from additional Tepezza therapy.

The adverse risks are not increased over standard treatment.  Tepezza is the only disease-modifying treatment for thyroid eye disease and offers increased benefits over standard treatment with steroids.

Tepezza is more beneficial than any other standard treatments for this patient.

In summary, the denial of additional infusions of Tepezza and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Thyroid Eye Disease
Treatment: Tepezza
The insurer denied coverage for Tepezza.
The denial is overturned.

This is a patient with thyroid eye disease. The physician recommended Tepezza. The patient has had an initial 8 infusions with benefits per history. This request is for a second 8-week infusion cycle. There is an appeal application citing medical necessity. Coverage was denied. The patient was treated initially and her thyroid eye disease returned with a clinical activity score (CAS) of 5. The patient has recurrent constant bilateral eye pain with eyelid edema alongside retraction, injected conjunctiva, and inflamed caruncle. The request is for additional infusions of Tepezza, which is under review.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes.

Safety and efficacy of a second course of Tepezza has been demonstrated and supported in the literature by way of strong studies. 

Furthermore, Douglas et al have demonstrated that patients with thyroid eye disease of longer disease duration responded similarly to those treated earlier in the disease course and that patients with an insufficient initial response benefit from additional teprotumumab therapy.

Additional infusions of Tepezza do not have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is a good candidate for additional infusions of Tepezza.

The patient has responded before to Tepezza and has a CAS (clinical activity score) 5 score. There is literature support for additional therapy for recurrent disease symptoms.     

Additional infusions of Tepezza would be the best available treatment for this patient at this time.

This second course of Tepezza is well supported in the literature for patients with recurrent active thyroid eye disease whose condition has responded in the past to Tepezza.

There is strong clinical data available in the literature in terms of comparative cohort trials, supporting safety and efficacy of a second course of the treatment of thyroid eye disease. This clinical data is supportive of the standard of care, is clinically appropriate in this setting, and not done for the convenience of provider or patient. 

There is no indication that adverse risks are increased over other available treatment/services.     

Safety and efficacy of a second course of Tepezza has been demonstrated and supported in the literature by way of strong studies detailed below for this patient's condition.                                                    

In summary, the denial of additional infusions of Tepezza and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Thyroid Eye Disease
Treatment: Tepezza
The insurer denied coverage for Tepezza.
The denial is overturned.

According to the medical records, the patient has recurrent thyroid eye disease, for whom coverage of an additional course of Tepezza therapy is requested. Coverage was previously denied per policy, which considers treatment with Tepezza beyond a course of eight (8) infusions experimental. Upon appeal, the provider confirms that the patient developed thyroid eye disease and was treated with high dose intravenous (IV) Solumedrol before such treatment was stopped, due to side effects and lack of positive response. The patient was subsequently treated with Tepezza and reportedly responded well. However, the patient's condition recurred with a Clinical Activity Score (CAS) of 5 with constant bilateral eye pain, eyelid edema with retraction, eyelid erythema, conjunctival injection, and inflamed caruncles both eyes (OU). The provider cites literature supporting retreatment with Tepezza for these patients with recurrent disease. The request is for additional infusions with Tepezza.

Additional infusions of Tepezza do not have final approval from the appropriate regulatory bodies for this diagnosis.

Tepezza is Food and Drug Administration (FDA) approved for the treatment of Thyroid Eye Disease with the package insert recommending Initiating dosing with 10 milligrams per kilogram (mg/kg) for first infusion, followed by 20 mg/kg every 3 weeks for 7 additional infusions.     

This patient is a good candidate for additional infusions of Tepezza.

This patient has recurrent thyroid eye disease, with a CAS (Clinical Activity Score) of 5 identified, and prior positive response to Tepezza therapy. As noted above, there is a growing body of evidence for the efficacy of retreatment with Tepezza in patients with chronic TED (Thyroid Eye Disease) with low CAS, as well as those experiencing flare following prior Tepezza treatment.     

Additional infusions of Tepezza would be the best available treatment for this patient at this time. 

There are no other superior treatment options identified.     

It is not established that adverse risks are increased over other available treatment/services.     

Based on a review of the medical literature, the requested additional Tepezza therapy is likely to be more beneficial than any other available treatment option for this patient's disease.                                                    

In summary, the denial of additional infusions of Tepezza and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I malocclusion 
Treatment: Braces and monthly visits
The insurer denied braces and monthly visits.
The health plan's determination is overturned. 

The patient in question is a young male with an anterior crossbite on teeth 6 and 7. He presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. He is treatment planned for braces and monthly visits to address the crowding and crossbite. 

The braces and monthly visits are medically necessary. This patient presents with an anterior crossbite on teeth 6 and 7. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.

If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Digestive system
Inpatient hospital

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

The patient is a woman who presented with abdominal pain and nausea of one-day duration. At the time of presentation, the patient was without fever, heart rate was 61/minute, and blood pressure was 109/67. She was tender in the right upper quadrant. The white blood cell (WBC) count was elevated at 12.6. The complete metabolic panel identified elevated liver enzymes and normal bilirubin. Ultrasound showed a gallbladder with gallstones. No biliary ductal dilatation was seen.

She was admitted to the hospital and initially treated with intravenous (IV) fluid, antibiotics, and antiemetics. 

The inpatient hospital admission was medically necessary for this patient. In this case, the patient presented with acute upper abdominal pain. She had acute cholecystitis (leukocytosis, right upper quadrant tenderness, and the operative findings). She also had extensive inflammation of the gallbladder and extensive intra-abdominal adhesions such that the operation needed to be converted to open surgery. The clinical conditions in this case warrant an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Type 2 Diabetes.
Treatment:  Metformin modified release (Glumetza).

The insurer denied coverage for Metformin modified release (Glumetza).  The denial is overturned.

This an adult male diagnosed with Type 2 diabetes with hyperglycemia. This request is for Glumetza. As per visit note, he is on freestyle libre 3 sensor; Jardiance and Synjardy. As per letter, he has been on Synjardy but started to get side effects of muscle cramping and is not able to continue on it. Previously he has done well with taking Glumetza ER (extended release) 200 mg (milligrams) and Jardiance 25 mg. He tried and failed Glucophage; Glucophage ER; metformin ER; metformin IR (immediate release) in the past, due to pain in the joints that affected his walking. 

Metformin is still the best first line medication for treating type 2 diabetes (1).  There are some studies showing that patients, who do not tolerate immediate release metformin, have fewer adverse events and better compliance with extended-release metformin (2-4). The patient has failed Glucophage; Glucophage ER; metformin ER; metformin IR. The patient also failed synjardy, which includes metformin. The patient was previously successful with Glumetza. Given the failure of multiple formulations of metformin and trial and efficacy of Glumetza, the request is medically necessary.

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 Metformin modified release (Glumetza) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/orthodontic

Diagnosis: Class I occlusion 
Treatment: Full Braces and Monthly Brace Adjustment Visits 
The insurer denied Full Braces and Monthly Brace Adjustment Visits. The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion and normal overjet and a slightly deep overbite. Both arches have minor crowding. Tooth 14 is in crossbite but there is no functional shift detectible from the records. 

Full Braces and Monthly Brace Adjustment Visits are not medically necessary for this patient.
The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another. Deep bites may be corrected in adulthood, so it is not as if she will lose the ability to correct her malocclusion should she choose to do so as an adult. There is a single tooth posterior crossbite on the left. Despite this, her midlines are coincident indicating there is no functional impairment as a result of the crossbite. If this condition is left untreated studies have shown that adults with unilateral posterior crossbite have adaptations that compensate for the crossbite and maintain normal function. For these reasons, the requested orthodontic treatment is not medically necessary.