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

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

The patient is a female with a past medical history of hypertension, mild bilateral hip osteoarthritis, migraine, gastroesophageal reflux disease (GERD), hyperlipidemia, and low back pain who was prescribed Wegovy 0.25 milligrams (mg) /0.5 milliliter (ml) injection weekly. The insurer sent an initial adverse determination stating in order for the medication to be approved, the patient must meet the following requirements: body mass index (BMI) must be at least 30, along with counseling and monitoring by the patient's doctor's office, the patient must also be enrolled in a qualified complete weight loss program for at least the past 3 months, with proof of current and prior enrollment. There was a copy of a receipt  from Weight Watchers for payment of a 6-month membership. The patient had an office visit noting the patient's blood pressure was 144 over 80 (144/80), BMI 39.44, and there was a recommendation to return again in four weeks. The patient's primary care physician (PCP) provided a letter requesting consideration for coverage of weight loss therapy, Wegovy, for the patient with current BMI 39.44, comorbidities of hypertension, hyperlipidemia, and chronic low back pain. The provider noted the patient had made lifestyle changes including exercise and structured diet plans without successful weight loss. At issue is the medical necessity of Wegovy.
The Wegovy is not medically necessary. The most recent denials stated the lower doses of Wegovy are not available due to a national shortage and therefore the patient could not be properly titrated with lower to higher doses of Wegovy as recommended by manufacturer in package insert approved by Food and Drug Administration (FDA). In addition, per updated guidelines for the treatment of obesity "The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of diet, exercise, and behavioral modification. All patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. The behavioral modification component facilitates adherence to diet and exercise regimens, and includes regular self-monitoring of food intake, physical activity, and weight". Although the patient has participated in Weight Watchers, there is no specific documentation of online or in person attendance over the last three months. There was no documentation of an exercise regiment or reasoning as to why the patient could not participate in an exercise regimen. In summary, the patient did not provide proof of attendance in a qualified complete weight management program over a several month period of time, nor have unsuccessful weight loss while adhering to a Weight Management program and therefore Wegovy is not medically necessary for the patient. Furthermore, Wegovy is not available due to manufacturing shortage and the patient would not be able to safely titrate dosing as recommended by the manufacturer.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Radiofrequency Ablation (2 units) (CPT Codes 64628 and 64629)
The insurer denied: Radiofrequency Ablation (2 units) (CPT Codes 64628 and 64629)
The denial is overturned.

The patient is an adult female who presented with a primary diagnosis of vertebrogenic low back pain. The patient continues to have chronic axial back pain for greater than five years. The pain is aggravated with sitting and standing for prolonged periods of time. The patient has tried epidural injections without any meaningful relief. The patient previously had extensive courses of physical therapy and has been compliant with her home exercise program without relief. The patient had also tried non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxers as well as acetaminophen. Magnetic resonance imaging (MRI) demonstrated endplate edema as well as mild irregularity of adjacent plates. It also demonstrated facet changes.

The health plan should cover the requested health service.

Based on the documentation provided, the health plan should cover the requested procedure. The patient has a history of continued pain and despite prior treatments including physical therapy, home exercise, medication, and injections, the patient continues to be symptomatic. Magnetic resonance imaging had demonstrated Modic type changes, which is supported by the US Food and Drug Administration (FDA) for the requested procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Radiofrequency Ablation (2 units) (CPT Codes 64628 and 64629)
The insurer denied: Radiofrequency Ablation (2 units) (CPT Codes 64628 and 64629)
The denial is upheld.

The patient is an adult female with low back pain that began over five years ago. Past treatments include home exercise, epidural steroid injections, physical therapy, Tylenol, aspirin, gabapentin, non-steroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. Her pain ranges from 7/10 to 9/10. Magnetic resonance imaging (MRI) of the lumbar spine shows mild degenerative changes with disc bulges and facet arthropathy at L3-5 as well as high T2 and inversion recovery signal within the L4-5 disc space with endplate edema and mild irregularities of the adjacent endplates. The request for L4-S1 Intracept was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested health service.

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. In this clinical case, the magnetic resonance imaging findings do not support the use of Intracept. This patient does not have Modic changes on magnetic resonance imaging per radiologist report. This patient does have other causes of low back pain that have not been excluded on magnetic resonance imaging as likely causes of her pain. Furthermore, the patient does not meet inclusion and exclusion criteria in the current published studies. As such, the health plan should not cover the requested health service. Other standard treatment options that exist in the medical literature may include non-opioid medications (i.e., non-steroidal anti-inflammatory drugs, membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., physical therapy, home exercise program, chiropractor treatments), and interventions (i.e., epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Radiofrequency Ablation (2 units) (CPT Codes 64628 and 64629)
The insurer denied: Radiofrequency Ablation (2 units) (CPT Codes 64628 and 64629)
The denial is upheld.

The patient is an adult female who has chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy and epidural steroid injections. The patient has failed medications, including non-steroidal anti-inflammatory drugs (NSAIDs). Magnetic resonance imaging (MRI) shows Modic changes. Physical exam does not 
reveal any neurological injury.

The health plan should not cover the requested health service.

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is no likely to be more beneficial than standard treatments. The patient is an adult female who has chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy and epidural steroid injections. The patient has failed medications, including non-steroidal anti-inflammatory drugs (NSAIDs). Magnetic resonance imaging (MRI) shows Modic changes. Physical exam does not reveal any neurological injury. The Intracept procedure (interosseous basovertebral 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 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 facet joint/medial branch blocks or sacroiliac joint injections, which are common treatments 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 of 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: Hyponatremia
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital STay.
The determination is upheld.

The patient is a female with a history of B-cell (white blood cells) lymphoma with associated with thrombocytopenia, hypothyroidism, hypogammaglobulinemia and peripheral neuropathy who was referred to the emergency room (ER) with hyponatremia. She was recently diagnosed with a urinary tract infection (UTI) and started on Bactrim. The patient developed nausea, vomiting and poor by mouth (PO) intake. She had multiple episodes of vomiting and a decreased appetite. She was switched to Keflex on the day of admission. She was hemodynamically stable otherwise. Her lab results showed a sodium (Na) of 128. She was started on intravenous (IV) fluids and her hydrochlorothiazide was held. She was switched to amlodipine. Her potassium was low and was repleted. She improved and was eventually discharged. At issue is the medical necessity of an inpatient admission.
The requested inpatient admission was not medically necessity.
This is a female with a history of B-cell lymphoma who developed nausea, vomiting and poor by mouth (PO) intake. She had multiple episodes of vomiting and decreased appetite. She was switched to Keflex on the day of admission. She was hemodynamically stable otherwise. Her labs showed a Na (Sodium) of 128. She was started on IV fluids and her hydrochlorothiazide was held. She was switched to amlodipine. Her potassium was low and was repleted. She improved and was eventually discharged.
The patient had mild to moderate hyponatremia, and she was largely asymptomatic. She has no dizziness, lightheadedness, hemodynamic instability, obtundation, seizure, persistent hyponatremia that would make her a candidate for inpatient admission [1]. She had mild hyponatremia from dehydration due to nausea, vomiting and poor PO intake. She needed IV hydration with slow improvement in her Na that was possible to achieve at a lower level of care [2]. Inpatient admission was not indicated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a medical history of hypertension, umbilical hernia and asthma was admitted for an asthma exacerbation with symptoms shortness of breath, wheezing, cough, sneezing and diarrhea. Her chest x-ray did not demonstrate any evidence for acute infiltrates, consolidations, pneumothorax, pleural effusions, or fractures. She was treated with systemic steroids and DuoNeb nebulizers. Under review is the inpatient hospital admission. 

Inpatient Hospital Admission was not medically necessary for this patient. This patient was admitted for asthma exacerbation with symptoms shortness of breath, wheezing, cough, sneezing and diarrhea. In the emergency room, the patient was afebrile, hemodynamically stable, had an oxygen saturation of 97% on room air, was in no acute distress but on chest auscultation had wheezing. Although the patient still had wheezing, she was in no acute distress, she was alert and awake, was hemodynamically stable, had a respiratory rate of 20 breaths per minute, had an oxygen saturation of 97% on room air. She was treated with DuoNebs and intravenous methylprednisolone. She did not have documented hypercapnia or documented hypoxemia, she did not require any ventilatory support, she did not have a sustained respiratory rate > (greater than) 30 breaths per minute or heart rate >140 beats per minute, she had no reported cyanosis or increased work of breathing, there were no peak flow measurements reported and her chest x-ray did not demonstrate evidence for acute infiltrates, consolidations, pneumothorax, pleural effusions, or fractures. Therefore, based on the clinical documentation, the Inpatient Hospital Admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III malocclusion
Treatment: Comprehensive Treatment of the Adolescent 
Dentition (Braces and Adjustments of Braces and Retainer)
The insurer denied: Comprehensive Treatment of the Adolescent 
Dentition (Braces and Adjustments of Braces and Retainer)
The denial is overturned.

This is an adolescent female patient. The request is for orthodontic benefits with adjustments and retainer. She has a Class III malocclusion with a narrow upper arch and an edge-to-edge bite. Also, the patient has an open bite. The prior denial was due to a score of 17 points on the handicapping index scale.

The requested health service is medically necessary.

The patient has a crossbite of a permanent anterior tooth (#7) with gingival margin recession and clinical attachment loss. She also has impacted anterior teeth (teeth #6 and 11) where extraction is not indicated. Both of these conditions are automatic qualifiers for orthodontic benefits. The adjustments are needed for proper progression of the case and a retainer at the end of treatment is needed to prevent relapse. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: recurrent pregnancy loss
Treatment: Intravenous Immunoglobulin (IVIG; Gamunex-C) 
The insurer denied Intravenous Immunoglobulin (IVIG; Gamunex-C) 
The health plan's determination is upheld. 

The patient is a female with a history of recurrent pregnancy loss. She consulted a reproductive endocrinologist who performed an evaluation. The patient has positive antiphospholipid antibodies and a "relatively elevated NK (natural killer) killing capacity intravenous immunoglobulin (IVIG) treatment was prescribed. 

Intravenous Immunoglobulin (IVIG; Gamunex-C) is not medically necessary for this patient. Although a few early non- randomized, uncontrolled studies may have shown modest benefit in properly characterized patients with repeated pregnancy loss, most others that have used randomized controlled methods have not. Thus, there is no clear efficacy as yet shown up to the current literature. The American Society for Reproductive Medicine, in their Practice Committee Opinion, states: "Treatment with intravenous immunoglobulin (IVIG) has also been proposed for unexplained pregnancy loss. However, several trials and meta-analyses concluded that IVIG is ineffective for primary recurrent pregnancy loss; thus, this treatment is not recommended...There is insufficient evidence to recommend IVIG administration as part of IVF to improve in vitro fertilization (IVF) outcomes. Subpopulations that benefit from treatment may exist, but additional high-quality experimental RCTs (randomized controlled trials) are needed to define indications and explore risks and benefits". There is little to no data published on its performance compared with established treatments. This is, most likely, partly due to the lack of any reliable data supporting a clinically effective association between the screening tests used for the etiology and the treatments directed at the abnormal tests, such as the natural killer cell testing performed in this patient. Therefore, the requested Intravenous Immunoglobulin (IVIG; Gamunex-C) is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hepatic encephalopathy

Treatment: Kristalose 10 gram (g) packet

The insurer denied coverage for Kristalose 10 gram (g) packet

The denial is overturned.
 

The patient was diagnosed with cirrhosis. He has hepatic encephalopathy, gastric and esophageal varices, and iron deficient anemia. He was treated for years with Nadolol, Kristalose, and Xifaxan. The regimen of Kristalose and Xifaxan has controlled the encephalopathy. The progress note states that he was having difficulty with liquid lactulose including nausea and vomiting and was therefore not compliant with it. At that time, he was started on Kristalose. He has been able to tolerate the Kristalose without problems. The medical record notes that Constulose and Enulose were tried when there were insurance problems with the Kristalose but it also caused nausea and vomiting. 

UpToDate has an article titled "Hepatic encephalopathy in adults: Treatment." The article states that for patients with encephalopathy, continued administration of lactulose or lacitol should be given. It is noted that many patients have problems with adherence with the lactulose. 

This patient has advanced cirrhosis with a diagnosis of hepatic encephalopathy. For a prolonged period of time, he was doing well on the combination of Kristalose and Xifaxan. The medical record documents that he has failed the alternative drugs of lactulose liquid, Constulose, Generlac, and Enulose. In view of the fact that he has tried multiple formulary alternatives and has found that Kristalose is the only form of lactulose that he is able to tolerate, giving Kristalose 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 Kristalose 10 gram (g) packet is substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female with impacted teeth number (#) 20 and #29. These teeth are unable to fully erupt due to crowding. She presents with a skeletal Class II malocclusion and severe maxillary and mandibular crowding. She is treatment planned for 30-36 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to address the crowding and to create space to bring the impacted teeth into the arch. At issue is the medical necessity of braces and monthly visits. 

Approximately 10 percent (%) of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. (2) The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. (2) Given the proximity of 20 and 29 to the roots of the adjacent teeth, there is already concern that the mandibular first molars may be damaged. If left untreated, the damage that can occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation (AF)
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This male patient presented to the emergency department (ED) complaining of chest pain, dyspnea, and lightheadedness. His medical history was remarkable for hyperlipidemia. On physical exam, his chest was clear. There was no peripheral edema. An electrocardiogram showed atrial fibrillation (AF) with a ventricular rate of 112 beats/minute; there were no acute changes. His serum troponin level was normal and remained normal when re-measured. His brain (or B-type) natriuretic peptide (BNP) level was 141 picograms per milliliter (pg/ml). A chest x-ray showed no acute pathology. The patient was treated with apixaban and was admitted to the hospital. Oral metoprolol was prescribed with good ventricular rate control. The patient's symptoms were improved but not completely resolved. He remained in AF with a controlled ventricular rate. He had no complaints. A transthoracic echocardiogram showed a left ventricular ejection fraction of 35 percent (%) with global hypokinesis. There was mitral valve prolapse with mild to moderate mitral regurgitation and mild aortic regurgitation. Transesophageal echocardiography showed no intra-atrial thrombus. The patient's rhythm was converted to sinus with direct current (DC) cardioversion. He was discharged. At issue is the medical necessity of an inpatient hospital stay.

Based on the documentation provided, an inpatient level of care was not medically necessary.

This patient presented with new onset AF. He was hemodynamically stable, there was no evidence of acute ischemia or decompensated heart failure, and he was not at high short-term risk for thromboembolism. His ventricular rate was easily controlled with low dose oral metoprolol. For patients presenting with acute AF, the safety of observation level care or discharge to home with close follow-up has been well demonstrated. As stated by Lin, et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization." Likewise, Conti, et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations."