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

Diagnosis:  Obesity.
Treatment:  Mounjaro.

The insurer denied coverage for Mounjaro.  The denial is overturned.
 
The patient has a history of obesity, cardiomyopathy, and transient ischemic attack (TIA) and wanted pharmacological treatment for obesity. He was started on Ozempic. His weight was 242 pounds, but he only had a weight loss of 4 pounds on the Ozempic. There was a discussion about proceeding with bariatric surgery. However, it was decided to instead try Mounjaro. 

UpToDate has an article titled "Obesity in Adults: Drug Therapy." The article discusses the choice of pharmacologic agents. Options include GLP-1 agonists, such as semaglutide and liraglutide. Semaglutide has demonstrated efficacy in weight loss, as well as improvement in glycemia and lipids. There is also another category of approved drugs, which are the dual acting GLP-1 and GIP receptor agonists. 

The insurance company has offered other formulary GLP-1 receptor agonists. These include Victoza, Rybelsus, and Trulicity. However, there is another category of approved drugs for weight loss. These are dual-acting GLP-1 and GIP receptor agonists. Mounjaro (Tirzepatide) is a novel GLP-1 and GIP receptor agonist that is effective in the treatment of obesity in patients with or without diabetes. In an open-label trial, including over 1800 patients comparing semaglutide with tirzepatide, reduction in body weight with all doses of tirzepatide was greater compared with semaglutide. 

This patient has obesity and has failed treatment with a GLP-1 receptor agonist. It would be appropriate to try a medication with a different mechanism of action rather than giving the patient another GLP-1 receptor agonist. Mounjaro is both a GLP-1 and GIP receptor agonist. The formulary drugs offered are only GLP-1 receptor agonists. They did not cause an adverse reaction, but the Ozempic was not effective. Based on the UpToDate article, it is likely that the combination of GLP-1 and GIP receptor agonists would be more effective than the GLP-1 receptor agonist alone. Therefore, the denial of Mounjaro is reversed.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The not formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Mounjaro is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Hepatitis B (HBV)
Treatment: Vemlidy
The insurer denied: Vemlidy
The denial is Overturned.

The patient is an adult male with chronic hepatitis B. He was treated with tenofovir for three years, at which time he was changed to Vemlidy to prevent the risk of osteoporosis and renal insufficiency. He is doing well on Vemlidy with an undetectable hepatitis B virus (HBV) viral load. The physician (MD) is requesting to continue Vemlidy.

Vemlidy is medically necessary.

Tenofovir can be used as first-line therapy in treatment-naive patients and also in those who have had prior exposure, or developed drug resistance, to other nucleos(t)ide analogs (e.g., lamivudine). In clinical trials of patients receiving tenofovir disoproxil fumarate, no signature mutation for tenofovir resistance has been identified, even among those who have been treated for up to eight years. 
There are two formulations of tenofovir, TDF and tenofovir alafenamide. For most patients, Vemlidy, tenofovir alafenamide (25 milligrams daily), is recommended rather than TDF (300 milligrams daily), if available. For those who were originally started on TDF, we generally suggest switching to tenofovir alafenamide (Vemlidy), particularly in older patients and those with risk factors for renal impairment or osteoporosis. Although there is more experience with TDF compared with tenofovir alafenamide, tenofovir alafenamide may be equally effective and is associated with less renal and bone toxicity. Therefore, the requested Vemlidy is clinically appropriate, accepted standard of care, and is medically necessary in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: Braces and Monthly Visits.
The insurer denied: Braces and Monthly Visits.
The denial is Overturned.

The patient is a teenaged female. The request is for orthodontic benefits and monthly visits. The patient has a class I skeletal bite with a class II malocclusion. There is severe upper and moderate lower arch crowding with a deep bite. The prior denial was due to a handicapping index score of 21.

The proposed treatment is medically necessary.

The patient has an anterior tooth (#22, lower left permanent canine) in crossbite, or "reverse bite". It is outside of the upper teeth which is backwards to what is normal. When there is an anterior tooth in crossbite with clinical attachment loss and recession of the gums, that is an automatic qualifying event. This is what the patient has and there is medical necessity to correct this problem. Orthodontic treatment is needed to correct things and the monthly visits are needed for follow up to make sure there is progress in the treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 braces and D8670 monthly visits x 12
The insurer denied coverage for D8080 braces and D8670 monthly visits x 12
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment notes as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite, posterior crossbite and anterior crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD)  index attaining 30 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining only 19 points on the HLD index by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist completes the second portion of the index arriving at 30 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this. is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

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 D8080 braces and D8670 x 12, monthly visits is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who was brought by Emergency Medical Services (EMS) to the emergency department (ED) with chest pain. The patient continued to have chest pain which worsened upon arrival and abdominal pain, pelvic and left hip pain. His chest pain was diffuse, all over his chest, not radiating, not associated with shortness of breath, diaphoresis or syncope. 

The Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with chest pain and body pain, and his chest pain was non cardiac. His troponin was negative. He was hemodynamically stable, His ICD (implantable cardioverter defibrillator) was functioning fine. The patient also had multiple ongoing problems, including elevated international normalized ratio (INR), elevated creatinine. He received IV (intravenous) hydration with small bolus. His condition improved. He also was diagnosed with liver cirrhosis, but no significant work up was done. Psychiatry did not believe that the patient is a threat to himself and recommended medical management without supervision. The patient, with multiple chronic medical problems, was not diagnosed with an acute condition which would warrant inpatient admission. A lower level of care was appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Back pain.
Treatment:  Outpatient Intracept System (thermal heat destruction of a nerve in spine).

The insurer denied outpatient Intracept System (thermal heat destruction of a nerve in spine).  The denial is upheld.

The patient is an adult male with low back pain which began nine years ago after falling down a flight of stairs. Past treatments include physical therapy, chiropractor treatment, epidural steroid injections, hydrocodone, hydromorphone, tramadol, Robaxin, Flexeril, Meloxicam, Lidocaine patches, Ketorolac, and methylprednisolone. The patient's magnetic resonance image of the lumbar spine shows a small disc bulge at L (lumbar) 4-5 with an annular tear and right disc protrusion as well as a L5-S1 disc bulge with bilateral foraminal stenosis at this level. The request for L5 Intracept was denied as experimental/investigational.

The health plan should not cover the proposed treatment.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such, the health plan should not cover the proposed treatment. 

Other standard treatment options that exist in the literature include: nonopioid medications (i.e., non-steroidal anti-inflammatory drugs [NSAIDs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., physical therapy, home exercise program, chiropractor treatments), 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:  Back pain.
Treatment:  Outpatient Intracept System (thermal heat destruction of a nerve in spine).

The insurer denied outpatient Intracept System (thermal heat destruction of a nerve in spine).  The denial is upheld.

The patient is an adult male 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 (PT), epidural steroid injections, and home exercises. The patient has failed multiple medications including potent opiate medications. Magnetic resonance image (MRI) shows degenerative endplate changes, which can be taken to mean Modic changes. The patient's physical exam does not reveal any neurological injury.

The health plan should not cover the proposed treatment.

The requested Intracept procedure should not be covered. The requested health service or procedure is not likely to be more beneficial than standard treatments. The patient is an adult male who with chronic low back pain for 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, and home exercises. The patient has failed multiple medications including potent opiate medications. Magnetic resonance image shows degenerative endplate changes which can be taken to mean Modic changes. The patient's 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 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. The procedure is a Food and Drug Administration (FDA) approved procedure for axial low back pain. It has been shown effective in randomized clinical trials (RCT) with five-year results. 

However, this patient has not failed or attempted all conventional and typical options for common causes of axial low back pain. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis

Treatment: Taltz Autoinjector 80mg/ml Auto inject

The insurer denied coverage for Taltz Autoinjector 80mg/ml Auto inject

The denial is upheld

The patient is an adult with psoriasis affecting the elbows, ankles, and face. The patient was treated with Otezla samples briefly per the documentation but "did not take for long enough to know if effective or not." The total body surface area (TBSA) is reported as 10% with the disease classified as "Mild" per the documentation. The requested medication is Taltz. 

There is no documentation of a contraindication nor a specific Taltz indication which would reasonably favor the use of Taltz over multiple formulary alternatives, including Enbrel, Humira, Stelara, cosentyx, skyrizi, and tremfya. Taltz and Cosentyx are both within the IL-17 inhibitor class and would be expected to have similar efficacy and safety. Without blinded, controlled studies evaluating the safety and efficacy of Cosentyx with Taltz it is reasonable to assume that both medications have a similar safety and efficacy profile given their similar mechanism. There is no documentation provided which would warrant the use of Taltz over formulary alternatives, including Cosentyx. The use of Taltz would not be medically necessary over approved formulary alternatives in a patient who has not tried any prior biologic and with no contraindication to available reasonable alternatives.

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 Taltz Autoinjector 80 milligrams per milliliter (mg/ml) Auto inject is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who presented to the emergency department (ED) with worsening chest pain. The chest pain was described as sharp/tightness, 8/10, non-radiating and associated with shortness of breath and diaphoresis. The patient was not complaint with medications. The patient underwent coronary artery bypass graft (CABG) recently. 

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient with history of coronary artery disease (CAD) and recent coronary artery bypass graft (CABG) presented with chest pain. His pain did not have angina features. His serial troponin was negative and electrocardiogram (ECG) was unchanged. His telemetry revealed stable rhythm. 

The patient, from chest pain prospective, did not have indications for inpatient admission. He ruled out for myocardial infarction (MI) and further work up for chest pain could have been accomplished at a lower level. His BP was elevated, but it normalized with oral medications, and there were no reasons to assign inpatient status for transient BP elevation. 

His brain (or B-type) natriuretic peptide (BNP) was elevated and cardiology documented diagnosis of heart failure and gave him intravenous (IV) Lasix. However, the diagnosis was established solely based on elevated brain (or B-type) natriuretic peptide (BNP) level. He did not have features of heart failure on physical examination (no jugular vein distention (JVD), crackles, cardiac gallop, murmur, edema orthopnea or paroxysmal nocturnal dyspnea (PND)). His CXR was negative for congestive heart failure (CHF).
BNP can be non-specific in the setting of acute infection, such as viral infection, it is acute phase reactant and could be false positive, as in this case. The patient did not have CHF and inpatient admission was not medically necessary. 

The patient presented with pleuritic type of chest pain and he was COVID positive. However, he did not have symptoms or signs of severe COVID infection. No fever, severe dyspnea, myalgia, weakness was noted. His O2 (oxygen) saturation on room air was 93%, probably due to chronic obstructive pulmonary disease (COPD), heavy smoking. His CXR was negative. 

Based on that, the patient did not have indications for inpatient admission based on positive COVID infection. The patient left against medical advice (AMA), but even if he stayed, there were no indications for inpatient admission. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Essential Hypertension, Type 2 Diabetes, Short Term Memory Loss, History of CVA (cerebral vascular accident)
Treatment: Increase Home Health Care (HHC) - level 2 per 15 minutes to 70 hours/week
The insurer denied an increase in HHC - level 2 per 15 minutes to 70 hours/week.
The denial is overturned.

This elderly female patient has hypertension, diabetes, osteoarthritis, history of cerebral vascular accident (CVA), and short-term memory loss. The patient has a history of a fall 5 months ago due to weakness and poor balance. She was hospitalized for 5 days. The denial of an increase in home health care (HHC) to 70 hours/week is being appealed. The plan approved an increase from 25 hours/week to 32 hours/week. Uniform Assessment System (UAS) completed 4 months ago shows modified independent cognition and functional status: total dependence with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, phone use, stairs, transportation, bathing dressing and toilet use; limited assistance with locomotion waking, toilet transfer, and bed mobility; and supervision with eating. She has frequent bladder incontinence. 

Compared to UAS evaluation completed last year, there has been a decline with meal preparation, housework, shopping, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility. A letter from the patent's physician recommends an increase in hours to accommodate her nighttime routine.

The proposed treatment is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs), health maintenance activities, and routine support services. This patient has multiple chronic conditions. She was hospitalized 4 months ago after a fall. The denial of an increase in HHC to 70 hours/week is being appealed. The plan approved an increase from 25 hours/week to 32 hours/week. UAS completed 4 months ago shows the patient requires assistance with all ADLS, except eating. Compared to UAS evaluation completed last year, there has been a decline with meal preparation, housework, shopping, personal hygiene, dressing, walking, locomotion, toileting, and bed mobility. The patient has a history of falls. Her condition has deteriorated since a recent hospitalization. The appeal statement notes the patient needs assistance with nighttime needs. The information provided shows that this patient has significant limitations in functioning with significant decline between UAS evaluations. The approved HHC 32 hours/week is insufficient to meet this patient's needs for assistance with ADLs. The proposed increase to 70 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an elderly female with a known history of spinal stenosis. She presented with exacerbation of pain. She complained of progressive pain from low back radiating to her right hip and associated with paresthesia in her feet. She was unable to ambulate. The patient's vital signs were stable. Exam showed symmetrical strength in extremities, normal reflexes and normal sensation. The patient's pertinent labs included hemoglobin 11.6 and BUN/Cr (blood urea nitrogen/creatinine) 31/1.29. Lumbar CT (computed tomography) showed moderate canal stenosis with severe multilevel foraminal stenosis. The patient was admitted. Plan of care included oxycodone for pain and orthopedics consult. On Day #2, orthopedics consultant noted no evidence of caudal equina. MRI (magnetic resonance imaging) of cervical spine was recommended. Pain management was recommended. The patient's pain was controlled with hydromorphone. On Day #3, the patient was able to get up from bed to chair. Medrol dose pack was started. She was referred for physical therapy. She complained of nausea, vomiting and constipation on Day #4. The patient's sciatic pain improved during the remainder of her stay. She was cleared for discharge to subacute rehab on Day #7. 

The Inpatient Hospital Admission was not medically necessary. 

This patient with chronic low back pain was admitted for conservative pain management. She was hemodynamically stable and afebrile. She did not have loose bowel or bladder function. Musculoskeletal and neurologic exams were normal. The patient was able to tolerate oral intake. She did not have intractable pain. She did not have findings that required an acute inpatient level of care for pain management. The MCG (Milliman Care Guidelines) Guideline for Back Pain is not met for inpatient admission. The patient did not have an associated neurologic deficit, severe pain requiring acute inpatient management, etiology that requires inpatient treatment, or inpatient surgery needed. 

Therefore, given the above, the Inpatient Hospital Admission was not medically necessary.