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

Diagnosis: low back pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure. 
The health plan's determination is overturned.

This is a male patient who has one year history of chronic axial low back pain. His pain is constant, sharp, and achy without any radiation to the lower extremities. Pain is increased with prolonged sitting and changing positions. Pain level is 5/10 with negative impact on his function and activities of daily living (ADL). He had tried physical therapy (PT), NSAIDs (non-steroidal anti-inflammatory drugs) and facet joint radiofrequency ablation, but without adequate improvement. A spine surgeon evaluated the patient and recommended the Intracept procedure. Physical exam (PE) was unremarkable except for decreased lumbar spine range of motion (ROM) and pain with flexion and extension. Magnetic resonance imaging (MRI) revealed degenerative disease at L4/5 with Modic changes at L4 and L5 levels.

The Intracept Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intraosseous nerve ablation procedure (INTRACEPT) was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. He had tried PT, NSAIDs and facet joint radiofrequency ablation without adequate improvement. Further interventions are indicated to improve his pain and function. Other potential treatment options are long-term use of medications (opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the Intracept procedure is appropriate as the next step intervention.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: family history of cancer
Treatment: genetic testing
The insurer denied genetic testing. 

The health plan's determination is upheld.

The patient is a female with family history of cancer in her mother (colorectal). Genetic Testing was ordered for deoxyribonucleic acid (DNA) Sequence Analysis. The health plan denied it as not medically necessary.

No, the patient did not meet minimal clinical criteria for Lynch testing and therefore genetic testing would have a low yield and would not be indicated or medically necessary. Moreover, the Lynch testing may potentially be harmful if it results in a variant of unclear significance (VUS) which would be difficult to interpret and may necessitate further unnecessary testing of the patient and family members. The patient did not fulfill either Amsterdam I or Amsterdam II criteria:
Amsterdam I criteria (all 4 must be met):
1)	Three or more family members, one of whom is a first-degree relative of the other two, with a confirmed diagnosis of colorectal cancer (not met since only her mother had colorectal cancer based on the pedigree)
2)	Two successive affected generations (not met)
3)	One or more colon cancers diagnosed before age 50 years (not met)
4)	Exclusion of familial adenomatous polyposis (met)
Amsterdam II criteria (all 4 must be met):
5)	Three or more family members (one of whom is a first-degree relative of the other two) with HNPCC (Hereditary nonpolyposis colorectal cancer)-related cancers (not met)
6)	Two successive affected generations (not met)
7)	One or more of the HNPCC-related cancers diagnosed before age 50 years (not met)
8)	Exclusion of familial adenomatous polyposis (met).

The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever.
Treatment: Inpatient Hospital Admission.

The insurer denied Inpatient Hospital Admission.  The denial is overturned.

The patient is an adult male who was admitted to the hospital. The patient has a past medical history significant for myocardial infarction and cardiac arrest. He also has a history of a mitral valve replacement. The patient came to the emergency department reporting six weeks of intermittent fever. In the emergency department, the patient was afebrile but was noted to be tachycardic. His white blood cell count was elevated at 22,000. He had an elevated procalcitonin level. The patient was found to have acute kidney injury with a creatinine level of 1.7. The patient was diagnosed as having sepsis in the emergency department. The source for his infection was unclear at that time. The patient was treated with intravenous fluids along with broad-spectrum antibiotics. Blood cultures were obtained. Following his emergency department evaluation, the patient was admitted to the hospital as an inpatient. Over the next several days, he continued to receive intravenous antibiotics. Numerous tests were performed in order to determine the source for his fever. No source for the fever was identified. The patient was discharged home to finish a course of oral antibiotics. The patient later was diagnosed as having endocarditis requiring a prolonged hospital stay and multiple surgeries. The patient's health plan denied coverage for an inpatient admission on the grounds that it was not medically necessary. The health plan argues that the patient was clinically stable and could have been managed at a lower level of care. The patient has appealed this denial.

The proposed treatment (inpatient admission) was medically necessary.

On admission the patient was diagnosed as having sepsis. He had an elevated heart rate and an elevated white blood cell count in the setting of suspected infection. The patient met accepted criteria for diagnosing sepsis (reference below). It is recognized in the medical literature that sepsis places patients at risk for cardiovascular collapse and organ failure. An inpatient admission was medically necessary to treat this patient with sepsis. At the time the patient was admitted, the patient had a severity of illness to justify an inpatient admission. He had sepsis, and, as such, was at risk for rapid clinical deterioration. The patient had an intensity of required services to justify an inpatient admission. The patient required intravenous fluid along with broad-spectrum intravenous antibiotics. Multiple tests were performed on this patient and many consultations were obtained in order to determine the source of his sepsis. Later on, the patient was found to have endocarditis.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
Inpatient hospital

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

The patient is a man who was evaluated with complaint of abdominal pain of 2-days duration. Comorbid health conditions included hypertension, hyperlipidemia, diabetes, and a known history of gallstones. Vital signs were normal at the time of presentation. He was tender in the right upper quadrant. The white blood cell (WBC) count was elevated at 12 and liver enzymes were normal with normal bilirubin. An Ultrasound showed findings consistent with acute cholecystitis. He was started on intravenous (IV) antibiotics. The surgical history and physical (H&P) states that the patient had cholecystitis for which laparoscopic cholecystectomy was recommended.

An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with complaint of abdominal pain. Imaging and surgical consultation was performed and established the diagnosis of cholelithiasis/cholecystitis. At the time of presentation and at the time of surgical assessment, the patient had normal vital signs and was without fever. Ultrasound confirmed cholelithiasis/cholecystitis. Lab data identified an elevated white blood cell (WBC) count and normal serum transaminases. Surgery (cholecystectomy) was performed. The perioperative and early post-surgical recovery were uncomplicated, and the patient was stable for discharge from the hospital on the first post-surgical day. An acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease.
Treatment: Risankizumab (Skyrizi).
The insurer denied Risankizumab (Skyrizi). 
The health plan's determination is overturned. 

The patient is a female with ileocolonic Crohn's disease. She has failed Humira and then Renflexis 12.5 mg/kg (milligrams/kilogram) every 6 weeks, with persistent abdominal pain. She has developed a severe psoriaform rash. Wireless capsule endoscopy showed two small bowel ulcers consistent with Crohn's disease.
Under review is Risankizumab (Skyrizi) for the treatment of Crohn's disease.

Skyrizi is medically necessary in this case. Large, high-quality randomized controlled trials have demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease; Skyrizi achieved high rates of clinical and endoscopic remission. Lack of effective therapy may result in Crohn's disease symptoms and complications such as disease flare, hospitalization, need for surgery, fistula, and stricture; subcutaneous dosing cannot be used without intravenous induction doses. The use of Skyrizi is supported over the formulary alternative. The patient has psoriaform rash, for which Entyvio (which is only active in the gastrointestinal tract) would be ineffective; additionally, Skyrizi is supported as more effective than Entyvio for the treatment of Crohn's disease. For these reasons, Skyrizi is supported as medically necessary for the treatment of this patient's Crohn's disease.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Tacrolimus-induced nephrotoxicity
Treatment: Envarsus XR (extended release) 4 MG (milligrams) tablet
The insurer denied coverage for Envarsus XR 4 MG tablet.
The denial is overturned.

The patient is an adult female who has received a heart and lung transplant. Other past medical history includes congestive heart failure (CHF), Amyloidosis, myocardial infarction, hypothyroidism, pulmonary hypertension, status post Tracheostomy and chronic kidney disease (Creatinine clearance 15 -29).

As per her physician's note, the patient's medical course was complicated by Tacrolimus induced Nephrotoxicity. Her doctor has requested Envarsus XR (extended release) 4 mg (milligrams) and 1 mg Tabs (tablets).

Given the information that this patient suffered from Tacrolimus induced nephrotoxicity - acute kidney injury (AKI) during hospitalization and also has residual chronic kidney disease (CKD) Stage IV with impaired renal function (with Creatinine Clearance of 15-29) it was safer to prescribe the extended release form of the drug.

This patient has had prolonged use of Tacrolimus and prolonged exposure to high doses of Tacrolimus require further higher doses to maintain appropriate therapeutic levels. Envarsus XR has a narrow therapeutic index. Hence the drug on the formulary Tacrolimus is likely to cause further adverse reactions in this patient.

The extended release form of the drug which is Envarsus has a higher bio availability and lower peak concentrations and has a longer time to maximum concentration compared to the immediate release form.

This may be beneficial especially in a patient like this one who already had suffered from Tacrolimus induced AKI and now has Stage IV CKD.

Based on the above, Envarsus XR should be approved for this patient.

The formulary drugs are expected to cause adverse effects. 

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

The formulary drug is not expected to be effective.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a formulary exception for Envarsus XR 4 mg tablet is overturned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Nephrotoxicity
Treatment: Envarsus XR (extended release) 1 MG (milligram)
The insurer denied coverage for Envarsus XR 1 MG.
The denial is overturned.

The patient is an adult female who has received a heart and lung transplant. Other past medical history includes congestive heart failure (CHF), Amyloidosis, myocardial infarction, hypothyroidism, pulmonary hypertension, status post Tracheostomy and chronic kidney disease (Creatinine clearance 15 -29).

As per her physician's note, the patient's medical course was complicated by Tacrolimus induced Nephrotoxicity. Her doctor has requested Envarsus XR (extended release) 4 mg (milligrams) and 1 mg tablets.

Given the information that this patient suffered from Tacrolimus induced nephrotoxicity - acute kidney injury (AKI) during hospitalization and also has residual chronic kidney disease (CKD) Stage IV with impaired renal function (with Creatinine Clearance of 15-29), it was safer to prescribe the extended release form of the drug.

This patient has had prolonged use of Tacrolimus and prolonged exposure to high doses of Tacrolimus require further higher doses to maintain appropriate therapeutic levels. Envarsus XR has a narrow therapeutic index. Hence the drug on the formulary Tacrolimus is likely to cause further adverse reactions in this patient.

The extended release form of the drug which is Envarsus has a higher bio availability and lower peak concentrations and has a longer time to maximum concentration compared to the immediate release form.

This may be beneficial especially in a patient like this one who already had suffered from Tacrolimus induced AKI and now has Stage IV CKD.

Based on the above, Envarsus XR should be approved for this patient.

The formulary drugs are expected to cause adverse effects. 

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

The formulary drug is not expected to be effective.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a formulary exception for Envarsus XR 1 mg tablet is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Rheumatoid Arthritis
Treatment: Formulary exception for Rasuvo
The insurer denied the formulary exception for Rasuvo.
The denial is upheld.

The patient is an adult female with a diagnosis of Raynaud's syndrome. The patient's diagnosis is not established at this point, and the working diagnosis is possible relapsing polychondritis. The patient has tried and failed Ilaris, Enbrel, Xolair, Chromium sodium for previously presumed diagnosis of TRAPS (tumor necrosis factor receptor-associated periodic syndrome). The patient responded well to steroid treatment and her rheumatologist wants to start her on Rasuvo. Rasuvo was denied coverage by the health plan, as the current plan-approved criteria does not allow coverage of Rasuvo unless the patient has tried generic methotrexate by mouth and it either did not work or caused a bad side effect. The patient's rheumatologist is appealing the determination, as the patient has chronic nausea and emesis and cannot take oral methotrexate.

The health plan should not cover the formulary exception for Rasuvo.

The patient has a diagnosis of a presumed inflammatory arthritis, possible relapsing polychondritis. The patient has shown response to steroid treatment. Her rheumatologist wants to start her on Rasuvo. Studies have shown that the bioavailability can vary up to 30% (percent) with oral methotrexate, and some experts do recommend injectable methotrexate over oral if patient can tolerate it. There are also less documented side effects from injectable methotrexate versus oral methotrexate. That being said, use of generic methotrexate vials with syringes would be a reasonable choice for treatment and is recommended by healthcare policy guidelines. There is no clinical documentation that the patient would have inability to use vials and syringes due to dexterity. There are no clinical studies that have shown that generic methotrexate will be less effective than brand name. Generic methotrexate would reasonably be expected to be as effective as the requested non-formulary drug. There are no differences in adverse effects with the generic methotrexate compared with Rasuvo. Therefore, given the above, the health plan should not cover the formulary exception for Rasuvo.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient hospital stay
The insurer denied the Inpatient hospital stay.
The determination is upheld.

This is a male patient with a history of hypertension, hyperlipidemia, coronary artery disease (CAD), percutaneous intervention, diabetes, and chronic obstructive pulmonary disease (COPD). He was admitted for an elective staged percutaneous intervention of his right coronary artery. The patient's left ventricular ejection fraction (LVEF) was normal. The vital signs and the creatinine were normal. He underwent a successful and uncomplicated intervention. He remained stable and was discharged. At issue is the medical necessity of an inpatient stay.

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to for example observation or outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of coronary artery disease (CAD), hypertension, hyperlipidemia, diabetes, congestive heart failure (CHF), cardiomyopathy, and kidney disease. He presented with chest and jaw pain while performing activities of daily living. This was resolved with rest. A recent echocardiogram demonstrated an ejection fraction (EF) of 45-50 percent (%). He was admitted electively for a cardiac catheterization. The patient's blood pressure (BP) was elevated. His other vital signs and the oxygen saturation were normal. He was in no distress. He underwent an uncomplicated cardiac catheterization. There was an occluded left circumflex artery with left to left and right to left collaterals. There was a plan for a near future brachytherapy therapy. He remained stable and was discharged. At issue is the medical necessity of an inpatient stay.

This patient underwent a successful elective and non emergent cardiac catheterization without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care toward catheterization or overall cardiac outcomes.
It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient was a young adult who has a history of (H/O) Asthma. She presented to the emergency department (ED) with complaints of (C/O) increasing shortness of breath (SOB) which was not relieved by use of inhalers. The patient reported some C/O palpitations and Chest pain last week when she heard the news of her father's demise. She was treated with Steroids and inhalers. She was also treated for some anxiety symptoms at that time.

On presentation to the ED vital signs were normal except for an elevated heart rate (103).  Oxygen saturation on room air was 95% The patient was in no acute distress. She had bilateral wheezes. Heart sounds were normal and she was alert and oriented x  3.  Her lab results were normal except for mild hypokalemia of 3.4.  She was treated with Albuterol, Ipratropium via nebulizer, Dexamethasone , and Magnesium.  Chest x-ray was unremarkable.

This patient was continued on Dexamethasone, inhaled corticosteroids (ICS), bronchodilators (BD) and Montelukast. The next day she remained afebrile and stable, not hypoxic, in no distress, ambulatory and labs were stable.

Patient remained stable after admission. Was tolerating food and fluids. 

This patient did not need acute inpatient hospitalization. She could have been placed in Observation status - which could be for up to 48 hours. During this period diagnostic testing and treatment could have been done. She was stable for discharge after a period in observation ( which could be for up to 48 hours ). She could have been switched to oral (PO) steroids and discharged home on ICS, Singulair and BD with close follow-up in an outpatient setting.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Decay. 
Treatment: Cleaning inside roots of a premolar tooth (root canal) for teeth #'s 28 and 29, tooth colored cap (crown) for teeth #'s 7, 8, 28, and 29, and plate replacing some upper teeth (partial denture). 

The insurer denied coverage for cleaning inside roots of a premolar tooth (root canal) for teeth #'s 28 and 29, tooth colored cap (crown) for teeth #'s 7, 8, 28, and 29, and plate replacing some upper teeth (partial denture). 

The denial is upheld. 

Upon review of the submitted documentation which includes copies of undated full mouth series radiographs and undated panoramic radiograph and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment. Based on the documentation, multiple endodontic procedures and post and crowns were recommended in addition to a maxillary removable partial denture. The insurer has denied the services stating that these services are not medically necessary treatment as the clinical documentation does not support it insofar as the patient does not meet the conditions of the New York State Medicaid program for approval of the requested services. The patient is appealing. 

Based on the submitted objective information for review, which consists solely of the radiographic examinations, there is evidence of endodontic therapy on teeth #7 and #8. However, the radiographic documentation does not support the extensive dental treatment recommended by the dentist. There are no dental treatment notes, no dental charting, nor periodontal charting provided for review. As the documentation is inadequate to support the treatment, these services are considered 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 cleaning inside roots of a premolar tooth (root canal) for teeth #'s 28 and 29, tooth colored cap (crown) for teeth #'s 7, 8, 28, and 29, and plate replacing some upper teeth (partial denture) is not substantiated.