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

Diagnosis: Back pain. 
Treatment: 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT [computed tomography]), single or multiple levels, unilateral or bilateral; lumbar. 
The insurer denied 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar. 
The health plan's determination is upheld. 

This is a patient diagnosed with Spinal Stenosis, Lumbar Region with Neurogenic Claudication; Bulging of Lumbar Intervertebral Disc; Cervical Radiculopathy; Chronic Lumbar Radiculopathy; Lumbar Spondylosis. According to the records provided, the patient was recommended to undergo percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements under image guidance, which was denied by the health plan.

Percutaneous Laminotomy/Laminectomy (Interlaminar Approach) for Decompression of Neural Elements is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Mild (minimally invasive lumbar decompression), from Vertos Medical, Inc., describes a percutaneous procedure for decompression of the central spinal canal in patients with lumbar spinal stenosis. In contrast to surgical decompression, the mild procedure is a percutaneous decompressive procedure performed solely under fluoroscopic guidance (eg, without endoscopic or microscopic visualization of the work area)." 
Per Ohara et al, "Percutaneous endoscopic lumbar laminectomy or laminotomy (PELL) is a minimally invasive surgical technique to treat lumbar canal stenosis. The procedure is undertaken using a single port endoscope, as with percutaneous endoscopic lumbar discectomy (PED)...Conclusion: PELL requires much more skill than PED and the learning curve is not steep. PELL is minimally invasive for the patient, but further developments of the endoscope or procedures are required to achieve widespread use." 
The patient is noted to have a history of chronic back pain that has reportedly failed conservative treatment and epidural injections. However, there is no evidence to support the MILD procedure is equivalent or superior to that of standard treatments for this patient's condition. Currently, this procedure is not standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT [computed tomography]), single or multiple levels, unilateral or bilateral; lumbar. 
The insurer denied 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar. 
The health plan's determination is upheld. 

The patient is a female with lumbar spinal stenosis and neurogenic claudication. She has failed conservative treatments, including medication therapy and epidural steroid injections. Magnetic resonance imaging (MRI) of the L (lumbar) spine reported slight spondylolisthesis of L4 and L5 along with mild to moderate stenosis.  

Percutaneous Laminotomy/Laminectomy (Interlaminar Approach) for Decompression of Neural Elements is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Mild (minimally invasive lumbar decompression), from Vertos Medical, Inc., describes a percutaneous procedure for decompression of the central spinal canal in patients with lumbar spinal stenosis. In contrast to surgical decompression, the Mild procedure is a percutaneous decompressive procedure performed solely under fluoroscopic guidance (eg, without endoscopic or microscopic visualization of the work area). This procedure is indicated for central stenosis only, without the capability of addressing nerve root compression or disc herniation, should it be required. Due to the unknown impact of these limitations on health outcomes, randomized controlled trials (RCTs) in appropriate patients are needed to compare this new procedure with established alternatives. Therefore, this procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT [computed tomography]), single or multiple levels, unilateral or bilateral; lumbar.
The insurer denied 0275T Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar. 
The health plan's determination is overturned. 

The patient is a female with a history of low back pain and radiculopathy. She was treated with anti-inflammatories, physical therapy, home exercise program and lumbar epidural steroid injections. Magnetic resonance imaging (MRI) of the lumbar spine revealed spondylosis, listhesis, stenosis. disc displacement and degeneration. Their treating provider recommended Percutaneous Laminotomy/Laminectomy (Interlaminar Approach) for Decompression of Neural Elements. 

The proposed Percutaneous Laminotomy/Laminectomy (Interlaminar Approach) for Decompression of Neural Elements is 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 is a minimally invasive procedure for treatment of degenerative LSS (lumbar spinal stenosis) with ligamentum flavum hypertrophy through percutaneous decompression of the hypertrophic ligamentum flavum. The effect is debulking of tissue that is a contributor to lumbar canal narrowing with minimal trauma to surrounding tissue. The requested procedure is a safe, durable, minimally invasive procedure that has been shown to be effective as an early interventional therapy for patients suffering from symptomatic lumbar spinal stenosis. 

It has been shown to be statistically superior to ESIs (epidural spinal injection) in the treatment of LSS patients with neurogenic claudication and verified central stenosis due to ligamentum flavum hypertrophy. Patients with spinal co-morbidities also experienced statistically significant improved function that was durable through 1 year.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic short stature

Treatment: Omnitrope 10/1.5 ML (milliliter) INJ (injection)

The insurer denied coverage for Omnitrope 10/1.5 ML (milliliter) INJ (injection)

The denial is upheld

 
This is a teenage male diagnosed with Idiopathic short stature (ISS). This request is for Omnitrope. As reported he is taking methylphenidate for attention deficit hyperactivity disorder (ADHD). 

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

Classic GH deficiency

The patient did not meet biochemical criteria. Growth hormone (GH) stimulation testing peaked at greater than 10. His GH stimulation test with clonidine and arginine peaked at 43. Growth factors are normal.

The patient does not meet growth hormone deficiency criteria.

Idiopathic Short stature

The patient's height velocity and bone age would allow the patient to reach a normal adult height. 

The patient does not meet idiopathic short stature criteria.

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.

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 Omnitrope 10/1.5 ML INJ is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Crohn's Disease.
Treatment:  Inflectra.

The insurer denied: Inflectra.  The denial is upheld.

The patient is an adult male with moderate to severe fistulizing Crohn's. He was doing well on Remicade and changed to Inflectra. The physician (MD) is requesting continuation of Inflectra. Inflectra was denied, as the plan preferred agents are Remicade, Stelara and Skyrizi.

The requested Inflectra is not medically necessary. 

The patient has Crohn's and has previously done well on Remicade and is now doing well on Inflectra. Medical literature supports that patients can be changed between Remicade (Infliximab), and Infliximab biosimilars without loss of efficacy or risk. As the patient is doing well on Inflectra (an Infliximab biosimilar), it would not be medically reasonable to change to a drug with a different mechanism of action, such as Stelara or Skyrizi. While the appeal letter states that the patient is at risk for a delayed hypersensitivity reaction if he resumes Remicade, literature to support this is not found, as the delayed hypersensitivity would be to infliximab, which he has been on continuously. Therefore, as the patient can safely change to Remicade, the requested Inflectra is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and Vomiting
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This patient is a toddler female. She had vomiting and was hospitalized. A brief summary of the hospital stay includes an emergency department note and admission history and physical documenting that the patient was seen in the emergency department for vomiting more than twenty times. She was admitted for acute gastroenteritis or food poisoning and dehydration. A discharge summary on day #2 states no fever, and no more vomiting. The patient had a normal exam, tolerated Pedialyte, and was on intravenous fluids. A discharge summary on day #3 stated the patient was doing well and tolerated by mouth intake. She was discharged home.

The requested health service was not medically necessary.

As documented in the clinical notes, this patient had acute vomiting. The patient was suspected to have acute gastroenteritis (acute gastritis) or food poisoning. During the hospital stay the patient received intravenous fluids and oral intake. At the time of admission, the patient was stable. The patient stopped vomiting after admission and tolerated by mouth intake. There was no documentation of any acute events. Thus, the acute inpatient care was not medically necessary. Acute infectious gastroenteritis may require intravenous fluids for dehydration and can be managed at observational level of care (1-3).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection
Treatment: Inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This is the case of a young female with a history of pyelonephritis who presented to the emergency department (ED) with vomiting, sore throat, and fever. She was previously seen at an outside facility for fever and abdominal pain, had urinalysis (UA) and was placed on Cefdinir. The Fever and throat pain persisted, so the patient was seen earlier the same day in the ED and discharged with Augmentin and ibuprofen. However, vomiting continued so she returned to ED.

Based on the patient's age, underlying health, and stable presentation, inpatient hospital admission was not medically necessary. Her care could have been safely and appropriately managed at a lower level of care.
This young female with 1 prior episode of urinary tract infection (UTI) /pyelonephritis and negative imaging of the kidneys presented to the emergency department (ED) with vomiting and clinical findings of acute pharyngitis. Vital signs were stable and laboratory studies indicated possible UTI. The patient received intravenous fluids (IVF) and intravenous (IV) antibiotics in the ED and was admitted to the hospital for similar care. Given the patient's age, lack of underlying medical conditions, and stable presentation, she could have been treated at a lower level of care and discharged home.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Migraines.
Treatment:  Aimovig.

The insurer denied Aimovig.  The health plan's determination is upheld.

The patient is a female with chronic migraines who is requesting treatment with Aimovig. The drug was denied because the patient has not tried and failed Ajovy, Emgality and/or Qulipta. 

A formulary exception is not indicated in this case. There is no documentation that the patient has tried and failed any of the formulary drugs including Ajovy, Emgality, and Qulipta. All of these drugs are CGRP (Calcitonin gene-related peptide) inhibitors. All of these drugs are Food and Drug Administration (FDA) approved and literature supported for prevention of chronic migraine. As such, there is no reason to believe that any of these drugs would not be effective for the patient's condition. Additionally, the adverse effects of these injection medications are expected to be similar to Aimovig, which is also an injection medication.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atopic dermatitis
Treatment: Adbry
The insurer denied Adbry
The health plan's determination is upheld. 

The patient is a male with moderate to severe atopic dermatitis located on his body throughout (arms, legs, face, and trunk). The patient has chronic lymphopenia of an unknown cause, and is being closely monitored by Hematology/Oncology. The two formulary-preferred medications are Rinvoq and Dupixent. As per the clinic notes, the patient consumes less than one drink per day of alcohol. The patient has tried and failed topical steroids, pimecrolimus, and tacrolimus.

A formulary exception is not indicated. The patient has no documented treatment failure with, or true medical contraindication to, either Dupixent, or phototherapy. Adbry is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. There is significant contraindication of the patient (because of his low white blood cell, followed by Heme/Onc) to any oral/systemic therapy that could affect his white blood cell count, including first-line oral immunosuppressants/immunomodulators (methotrexate, cyclosporine, mycophenolate mofetil, or azathioprine) or to second-generation immunomodulator Rinvoq. Dupixent and Adbry have very similar levels of efficacy and tolerability, and neither are deemed significantly more effective or safe than the other, consistent with current evidence to date.

Therefore, as consistent with current standards of care, Adbry is not indicated and is not more effective than all formulary alternatives.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Overactive bladder
Treatment: Myrbetriq
The insurer denied Myrbetriq.
The determination is upheld.

This is a patient with a history of overactive bladder. Non-clinical documentation from the patient states that he tried oxybutynin in the past. The patient has now been prescribed Myrbetriq. The clinical documentation states the patient has taken oxybutynin just like the patient information has stated. However, it does not explain the rationale as to why the patient cannot take other anticholinergic medications or Gemtesa. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Mybetriq, or would have adverse effects.
The formulary drugs darifenacin ext rel (extended release), oxybutynin ext rel, solifenacin, tolterodine, tolterodine ext rel, trospium, trospium ext rel, Gemtesa will not be ineffective, or would not be as effective as the non-formulary drug, Mybetriq, or would have adverse effects.
While many of the medications on the formulary list are anticholinergic and have the same risk of adverse effects within that class, Gemtesa and Myrbetriq have a similar side effect and efficacy profile. Therefore, the patient could try the formulary alternative Gemetesa.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: weakness
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld.

The patient is a man with a history of epilepsy, anxiety, and paroxysmal atrial fibrillation. He presented to the emergency room with an altered mental status, shortness of breath, chest pain, and headache. Vital signs showed a blood pressure 110/92 and pulse 164. He was alert and in no acute distress. Physical exam was otherwise normal. Labs were notable for an elevated troponin, mildly decreased calcium, glucose 174, and a white blood cell (WBC) count 22,600. The chest x-ray was normal and there were no acute intracranial abnormalities on head computed tomography (CT) scan. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further evaluation and treatment.

The inpatient hospital admission was not medically necessary for this patient.
Based on a thorough review of the information provided, the inpatient hospital admission was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, persistent hypoxia, EKG evidence of an acute coronary syndrome (ACS), or severe metabolic disarray. The altered mental status had cleared in the emergency room and the leukocytosis improved considerably. The clinical presentation was consistent with the aftereffects of a seizure. The services provided - oral medications, echocardiogram - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the inpatient hospital admission was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent urinary tract infections
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.


The patient is a female with a history of recurrent urinary tract infections (UTIs), ventral hernia and right staghorn calculus. She underwent a nephrectomy along with hernia repair, abdominoplasty, cholecystectomy, wall closure involving multiple surgeons. She was admitted postoperatively after the surgery. Her Foley catheter was removed. She was evaluated by physical therapy and cleared for discharge home. She was off oxygen and her heart rate was within normal limits. She continued to require intravenous (IV) pain medications. She was cleared for discharge home. The medical necessity for inpatient stay is under review.
The majority of patients who undergo nephrectomy and hernia repair can be discharged within 24 hours of the procedure. The procedure was an elective, scheduled procedure. The patient did not have any significant risk factors which increase the risk of post-operative complications. The post-operative course was essentially normal without any significant complications or significant issues with pain control. Observation status for this patient's clinical presentation and post-operative course was safe. A lower level of care is the generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a male who was hospitalized secondary to the presence of swelling and pain of his bilateral upper extremities. His medical history includes injection drug use, opiate dependence, and distant nephrectomy.  A computed tomography (CT) scan of the right upper extremity demonstrated cellulitis with associated abscesses in the volar soft tissues of the forearm and hand although no evidence of osteomyelitis. Initial treatment included the provision of intravenous antibiotic therapy and methadone. He underwent surgical debridement of the upper extremities. Blood cultures were without growth. Surgical swab cultures grew Streptococcus pyogenes and Streptococcus agalactiae. At the patient's request, he was discharged home with prescribed oral antibiotic therapy. At issue is the medical necessity of an inpatient stay.

Based on the information provided, the requested health service (that is (i.e.) acute inpatient care) was not medically necessary for this patient. On the date of admission, this patient was afebrile, hemodynamically stable, and able to tolerate oral medications. He had not received prior treatment for cellulitis or soft tissue abscesses. While it is clear this patient required medical treatment, including incision and drainage of soft tissue abscesses, acute inpatient care was not medically necessary. The medical care provided could have safely and effectively been delivered at a lower level of care.
There is no evidence this patient was septic and/or bacteremic. There was no evidence of osteomyelitis or necrotizing fasciitis. While medical care was warranted (i.e. incision and drainage of soft tissue abscesses, early provision of intravenous antibacterial therapy), acute inpatient care was not medically necessary.