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

Immunologic disorders
Pharmacy/prescription drugs

Diagnosis: erosive tophaceous gout 
Treatment: Krystexxa (pegloticase)
The insurer denied Krystexxa (pegloticase). The health plan's determination is overturned. 

The patient is a male with a history of erosive tophaceous gout of multiple locations including hands and feet, requiring prior surgery to remove tophi from right 4th finger and also leading to carpal tunnel syndrome. The physician requested Krystexxa for rapid clearance of tophi to prevent ongoing damage to joints, with plans to add methotrexate for prevention of antibodies against Krystexxa. A dual energy computed tomography (CT) of right and left foot and ankle demonstrated extensive uric acid crystal deposition both intra-articularly and peri-articularly including of tendons and with large tophus noted about the first MTP (metatarsophalangeal) and subtalar joints. Erosions of joints were noted. Similarly, dual-energy CT of upper extremities was compatible with tophaceous gout including joints and tendons. Per notes, the patient has normal G6PD (Glucose-6-phosphate dehydrogenase) activity. 

Krystexxa is medically necessary for this patient for rapid resolution of tophi which have previously required surgical intervention, and prevention of further erosive disease. Additionally, the patient has no contraindication, namely no G6PD deficiency.
The patient has a uric acid of greater than 6, the patient is greater than 18 years of age, and he has no deficiency of G6PD. He has ongoing severe tophaceous gout of multiple locations, having previously undergone surgery for removal of tophus, and has active erosive disease. There is no documentation of prior use of allopurinol or Uloric, though as noted by physician note of appeal, resolution of tophi would occur much more rapidly with Krystexxa, thus decreasing future risk of damage. Given burden of disease in this relatively young patient with the potential for years of further damage ahead of him, Krystexxa would be ideal for rapid resolution of current tophi prior to initiation of a xanthine oxidase inhibitor.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Ozempic
The insurer denied the request for Ozempic.
The health plan's determination is upheld.

The patient is a female who is diagnosed with obesity. As per the visit note she has a history of obesity status/post (s/p) gastric bypass and she also had an endoscopic ultrasound (EUS) jejunocolostomy. She has a medical history of pre-diabetes, hypertension (HTN) and hyperlipidemia. She is unable to tolerate Metformin due to gastrointestinal (GI) side effects. She is tolerating Ozempic 0.25 milligrams (mg) weekly.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The requested health service/treatment of Ozempic 1/0.75 (3) Pen Injector is not medically necessary. Semaglutide is a Glucagon-like peptide-1 receptor agonists (GLP1R) agonist [1] that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity [2-4]. Recent studies published in major peer reviewed medical journals have shown the safety and efficacy of Semaglutide for the treatment of obesity [5-7]. This medication is now available for the treatment of obesity in the form of Wegovy. There are no studies showing the safety or efficacy of the requested medication for patients who do not have diabetes. 

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Thermal Destruction of Intraosseous Basivertebral Nerve
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve.
The health plan's determination is upheld.

This is a female with a history of low back pain. She has had physical therapy and medications without relief. She is a non-smoker. The neurologic exam shows no motor, sensory or reflex abnormalities. The lumbar MRI (magnetic resonance imaging) shows degenerative changes, worse at L (lumbar) 4-5. 

The Thermal Destruction of Intraosseous Basivertebral Nerve is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

While this is a promising technology, further research has been recommended. Urits, et al cite "CLBP (chronic low back pain) is a difficult yet common diagnosis that affects a significant portion of patients worldwide. In efforts to combat this debilitating disease, researchers have made great progress in understanding the pathophysiology of lower back pain (LBP) in addition to unveiling the anatomy of the vertebrae in search of appropriate treatment options. As a result, with the growing evidence supporting the vertebrogenic model that involves the BVN (basivertebral nerve), RF (radiofrequency) ablation of the BVN has emerged as a possible minimally invasive procedure to treat LBP. Several studies have supported the safety, durability, and efficacy of RF ablation of the BVN. There is also convincing evidence that BVN ablation is more beneficial than the current standard of care for the treatment of CLBP. However, reproducible large RCTs (randomized controlled trials) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of CLBP and improve the quality of life of CLBP patients in the near future".
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Thermal Destruction of Intraosseous Basivertebral Nerve
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve.
The health plan's determination is upheld.

The patient is a female with severe chronic low back and leg pain. She has failed physical therapy (PT) and analgesics. Magnetic resonance imaging (MRI) of the L (lumbar) spine shows L3-5 mild foraminal narrowing with degenerative disc disease.

Thermal Destruction of Intraosseous Basivertebral Nerve is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

There are no large long-term studies showing clear benefit of this procedure in this patient cohort with imaging showing ongoing foraminal stenosis over multiple levels. Therefore, at this time more studies are needed showing benefit in patients with this pathology.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Thermal Destruction of Intraosseous Basivertebral Nerve
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve.
The health plan's determination is upheld.

This is a female who has a long history of chronic pain since a motor vehicle accident (MVA) 20 years ago. Her pain has become progressively worsening in the past few years. She has diagnosis of cervical and lumbar radiculopathy. She states that she has some mild achy pain in the back, but more burning pain and radiating pain in both lower extremities and numbness in the feet. Her pain is worse with prolonged sitting and standing. She had tried physical therapy (PT), epidural injections and nerve ablation without much improvement. 

Thermal Destruction of Intraosseous Basivertebral Nerve is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The requested procedure was designed to treat low back pain from the vertebral body by ablating Basivertebral nerves. This patient has significant radiating pain and burning pain in the lower extremities, which is not consistent with vertebrogenic pain. The magnetic resonance imaging (MRI) report documented multilevel disc bulges and facet joint arthropathy without Modic changes. Truumees's study supported the efficacy of Intracept procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded.

Given this patient's medical history, MRI reading, and the current clinical evidence, the proposed procedure is not likely to be more beneficial than any standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and monthly visits
The insurer denied coverage for braces and monthly visits.
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 noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified impacted mandibular left canine among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index, choosing the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated on the HLD index. 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 on the HLD index by internal reviewers attaining a score of 13 points. The orthodontist is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review), it is evident that the patient exhibits a 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 Labio-Lingual 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 HLD index, choosing the impacted permanent anteriors criterion to justify orthodontic care. The clinical circumstance as documented (mandibular canine) meets this criterion for approval of care. 

Regarding the validity of the HLD 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, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for adjustment of braces (periodic orthodontic treatment visit) and insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intraosseous Nerve Ablation (Intracept Procedure).

The insurer denied the Intraosseous Nerve Ablation (Intracept Procedure).  The denial is upheld.

The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as not medically necessary. 

The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, RFA (radiofrequency ablation), and home exercises. The patient has failed multiple 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 requested Intracept procedure is not medically necessary.

The requested Intracept is not likely to be more beneficial than standard treatments. The patient is an adult male with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as not medically necessary. The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, RFA (radiofrequency ablation), and home exercises. The patient has failed multiple 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 necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Broken restoration on tooth #17.
Treatment: Inlay - Metallic - Two Surfaces (D2520).
The insurer denied: Inlay - Metallic - Two Surfaces (D2520).
The denial is overturned.

The patient is an adult male requesting dental benefits for a two-surface gold inlay on tooth #17. The prior denial was due to non-coverage for the gold inlay (only an alternative benefit).

The gold inlay was medically necessary.

There are several ways to restore tooth #17. Both an amalgam and composite restoration broke after being placed. The only other way to restore this tooth was with a lab fabricated restoration, either a gold or porcelain inlay. A gold inlay is the better restoration since the margins (edges) can be made so they cannot be detected, which will improve the hygiene on the tooth. Less plaque will build up in this area. Gold is very strong and will not break under biting pressures.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left groin wound infection.
Treatment: Inpatient Emergency Admission.
The insurer denied: Inpatient Emergency Admission.
The denial is overturned.

This adult female was admitted to the hospital because of left groin wound infection. She had previously undergone bilateral iliofemoral endarterectomy and left to right femoral-femoral bypass with prosthetic, roughly one month prior to the current admission. She had a medical history notable for diabetes, smoking, chronic obstructive pulmonary disease, and hypertension. She had been seen five days prior to the current admission at an Urgent Care Center for fever and was started on ciprofloxacin. However, while on ciprofloxacin, she developed chills and rigors, prompting the current admission. On admission examination, she had sutures in place from her recent surgery with wound dehiscence. She had drainage of pus, surrounding erythema, and abdominal tenderness. Her C reactive protein was elevated at 6.46 with left shift. She was admitted for intravenous antibiotics, blood cultures, hydration, and further workup. Over the next two days, the erythema resolved, and her C reactive protein trended down. Blood cultures were negative. A CT (computed tomography) scan did not show a deep underlying abscess. She was discharged on Day #3 on oral antibiotics.

The proposed treatment "is medically necessary". 

The patient's inpatient admission was medically necessary because her presenting scenario was concerning for vascular graft infection. The patient had undergone major vascular reconstructive surgery with prosthetic conduit one month prior to the current admission, and she now presented with wound breakdown, erythema, and purulent drainage. She had already failed a five-day trial of oral antibiotics. Just prior to presentation, she had rigor and chills. Admission laboratory studies were consistent with an acute inflammatory process, because she had elevated C reactive protein and left shift. In this clinical scenario, intravenous antibiotics are mandatory, along with further workup to determine whether there is underlying graft infection. Graft infection can be limb- and or life-threatening. Outpatient management is not appropriate in this situation because of risk of hemorrhage and/or sepsis. Fortunately, the patient's work up and her response to intravenous antibiotics argued against graft infection, suggesting that her infection was more superficial in nature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Croup	
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This is a toddler with a one-day history of noisy breathing and a barking cough. His mother was concerned about the cough and his difficulty breathing so she brought him to the emergency room (ER) for treatment.

In the ER the child was noted to be anxious and in respiratory distress with increased work of breathing. He had a harsh barking cough and audible stridor. On physical examination he was described as having increased work of breathing with inspiratory stridor and wheezing, there were subcostal and intercostal retractions. A pulse oximeter reading was 89% (percent) on room air and he required supplemental oxygen. He was administered 2 treatments with racemic epinephrine and dexamethasone. A chest x-ray was reported to show a right lower lobe infiltrate. A respiratory viral panel was negative. Following treatment in the ER he continued to have stridor and increased work of breathing and he required oxygen supplementation. Because he had failed to improve with treatment in the ER the decision was made to admit him to the Pediatric Intensive Care Unit (PICU) for ongoing treatment with oxygen, dexamethasone, albuterol and racemic epinephrine with a diagnosis of croup.

The insurer denied the need for admission to the hospital and indicated that the child could have been safely discharged.

The patient was treated appropriately in the emergency room for an acute illness with croup. He had been treated with intravenous (IV) steroids, albuterol and 2 doses of racemic epinephrine and he continued to have stridor and wheezing. The medical record does support the need for admission to the hospital for oxygen supplementation and continued treatment. The admission was consistent with the standard of care for a toddler in respiratory distress with stridor and hypoxemia which did not improve with 2 doses of racemic epinephrine and steroids in the ER.

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 the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg weakness
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient was seen in the emergency department with complaints of left-sided chest pain that started 1 hour prior without radiation. The patient also reported a 2-week history of feeling unsteady in the bilateral legs as well as urinary retention and difficulty moving bowels. Past medical history was significant for Guillain- Barre syndrome. The patient also had a history of a stroke. The patient reported the main cause of presentation was willingness to go on subacute rehab (SAR).  It was noted the patient did not want to be placed on SAR where he was located so he left against medical advice (AMA) and came to current facility. The patient was admitted for diagnosis of leg weakness. It was noted that his chest pain was not resolved. It was also reported the patient had a longstanding issue with neurological conditions and would likely need admission for SAR placement.  

The patient received treatment and magnetic resonance imaging (MRI). The patient left against medical advice and without completion of the physician's evaluation and monitoring. The patient pulled out his intravenous (IV) access and left the hospital. It was noted that the patient required an inpatient admission for urgent evaluation given a new onset of weakness.  

Milliman Care Guidelines (MCG) recommends hospital admission for ataxia, weakness that is progressive or severe, and/or Guillain-Barre syndrome amongst other neurological conditions. In this case, the patient presented with a 2-week history of feeling unsteady in the bilateral legs. The patient had a history of Guillain-Barre syndrome as well as a stroke. It was noted that the patient left AMA at another facility as he wanted to go on subacute rehab at a different location. It was also reported the patient had longstanding issue with neurological conditions and would likely need admission for SAR placement. Given the findings, there was a history of neurological issues with plan for rehab placement. There is a lack of findings to support inpatient admission versus observation status. 

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 inpatient admission is not substantiated.