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

Diagnosis: Vertebrogenic Low Back Pain. 
Treatment: Intracept Intraosseous Nerve Ablation System 
(64628, 64629). 

The insurer denied: Intracept Intraosseous Nerve Ablation System (64628, 64629). 
The denial is upheld. 

The patient is an adult male with low back pain that began nine years ago after a 13 to 14 foot fall. Past treatments include acupuncture, chiropractor, epidural steroid injections, and physical therapy. Pain ranges from a 3/10 to 10/10. Magnetic resonance imaging (MRI) of the lumbar spine shows L4-S1 bulging discs and facet arthropathy as well as moderate degenerative disc disease. The request for Intracept procedure was denied coverage by the health plan, as not enough published medical studies to show this treatment is effective or improves health outcomes. Therefore, it was deemed to be experimental/investigational. The denial is being appealed.

The health plan should not cover the Intracept procedure. 

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 Intracept procedure. Other standard treatment options that exist in the medical literature may include non-opioid 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), and interventions (i.e., epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Vertebrogenic Low Back Pain. 
Treatment: Intracept Intraosseous Nerve Ablation System (64628, 64629). 

The insurer denied: Intracept Intraosseous Nerve Ablation System (64628, 64629). 
The denial is upheld. 

The patient is an adult male. He has chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, chiropractic, acupuncture, and home exercises. The patient has failed multiple medications, including potent opiate medications. Magnetic resonance imaging (MRI) shows Modic changes. Physical exam does not reveal any neurological injury. 

The health plan should not cover the Intracept procedure. 

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is not likely to be more beneficial than standard treatments. The patient is an adult male with chronic low back pain. 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, chiropractic, acupuncture, and home exercises. The patient has failed multiple medications including potent opiate medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury.
The Intracept procedure (interosseous basivertebral nerve ablation) is not an Intradiscal procedure. It is a new intraosseous nerve ablation approved by the United States Food and Drug Administration (FDA) for the treatment of chronic low back pain in the treatment of vertebrogenic-related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. 

However, the patient has not failed or attempted facet interventions or sacroiliac joint injections, which are common treatments for 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 alternative sacroiliac injections do show favorable outcomes in the literature and have lower risk and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial flutter. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The health plan's determination is overturned. 

This woman presented to the emergency department (ED) complaining of fever, chills, cough, dyspnea, chest pain, headache and rigors. Her medical history was remarkable for paroxysmal atrial fibrillation, coronary artery disease, percutaneous coronary intervention, peripheral arterial disease, left below knee amputation, heart failure with preserved ejection fraction, diabetes, asthma, anemia, mesenteric ischemia, chronic myelogenous leukemia and obesity. 

The inpatient hospital admission was medically necessary. 
This woman, with multiple medical problems, was admitted to the hospital with COVID-19 (coronavirus disease) infection and atrial flutter with a rapid ventricular rate. She developed a type 2 myocardial infarction (MI) from demand ischemia. Her hospital course was complicated by persistent, worsening anemia and acute kidney injury. During that time period in question, the patient required repeated red blood cell transfusions for decreasing hematocrit. Given her recent type 2 MI, significant anemia placed her at risk for further myocardial injury. Thus, careful and frequent monitoring of her hemoglobin with transfusions as needed was required. The patient also developed abdominal pain with marked leukocytosis. Given her history of mesenteric ischemia, as well as her immunosuppressed state due to her chronic myelogenous leukemia, this was a very concerning situation with the potential for catastrophic outcomes. This patient was at substantial risk for major adverse events. She required frequent monitoring of her clinical status and various laboratory studies with the ability to intervene emergently, if needed. This could only have been accomplished safely in an inpatient setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Elevated lipoprotein(a)
Treatment: Blood test - lipoprotein(a) (code 83695)
The insurer denied: Blood test - lipoprotein(a) (code 83695)
The denial is upheld.

The patient is an adult male with a family history of premature coronary artery disease. For further risk stratification, a lipoprotein(a) level was obtained and was noted to be elevated. The patient has been followed by a cardiologist for further evaluation of this.

The health plan should not cover the proposed treatment.

Based on a review of the current literature regarding atherosclerotic coronary vascular disease (ASCVD) risk reduction and prevention, there are no large, randomized control trials to prove improve health outcomes by checking lipoprotein(a) levels. This specially holds true in patients who are younger than 40 years of age. The current request is considered investigational and is not medically appropriate. 
The requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease. Standard therapy would be traditional atherosclerotic coronary vascular disease risk reduction strategies.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Elevated lipoprotein(a)
Treatment: Blood test - lipoprotein(a) (code 83695)
The insurer denied: Blood test - lipoprotein(a) (code 83695)
The denial is upheld.

The patient is an adult male with history of a low-density lipoprotein (LDL) of 107. There was no evidence of cardiovascular disease. Lipoprotein(a) assay is under review.

The health plan should not cover the proposed treatment. 

The requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease. Lipid subfraction analysis, including lipoprotein(a) (Lp[a]), may provide additional information regarding lipid status. However, it has not been demonstrated that this information, or targeted therapy for these subclasses, is established as standard of care towards improved risk assessment or clinical outcomes above that of assessment and treatment of the known lipid classes (low-density lipoprotein [LDL] and high-density lipoprotein [HDL]). As such it is considered not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Elevated lipoprotein(a)
Treatment: Blood test - lipoprotein(a) (code 83695)
The insurer denied: Blood test - lipoprotein(a) (code 83695)
The denial is upheld.

This adult male patient was referred for blood test - lipoprotein(a) (code 83695) for cardiovascular risk assessment, in the setting of elevated lipoprotein(a) and family history of premature coronary artery disease and fatal myocardial infarct (MI) involvinghis maternal grandfather at age 49. The patient's lipid profile showed total cholesterol (TC) 174, low-density lipoprotein (LDL) 107, high-density lipoprotein (HDL) 46, triglycerides 103 and lipoprotein(a) 248. A, repeat lipoprotein(a) was 199. Thepatient's coronary artery calcium score was zero. The requested coverage of the lab test has been denied as investigational by the patient's Policy and the patient is appealing the decision.

The health plan should not cover the proposed treatment.

The proposed treatment is experimental/investigational and not medically appropriate. 

According to the current peer-reviewed medical literature, advanced or expanded cardiovascular (CV) risk panels, including testing for lipoprotein(a) and other than standard lipid profiles, are considered investigational because there is insufficient evidence that the testing results in improved patient health outcomes. Using newer lipid markers to either replace or supplement conventional lipid measurements does not improve cardiovascular risk prediction. Adding information on various "emerging" lipid markers to existing risk assessments only improved prediction slightly and none of the newer lipid markers significantly changed classification of subjects across the clinical risk cutoff levels that are currently used to inform treatment decisions. There is insufficient published scientific data showing that expanded cardiovascular risk panels, including lipoprotein(a) testing helps in the decision making for patients and that it 
has been shown to improve the health outcome of patients compared to conventional risk factor modification and medical therapy, including statin therapy, which have proven benefits and are published extensively in the scientific literature. Improved risk prediction does not necessarily result in improved health outcomes. A common limitation to all the so-called novel cardiovascular risk markers are that no data yet exist that optimizing levels, beyond proven low-density lipoprotein (LDL) reduction, leads to reduced cardiovascular risk, and thus their use is largely limited to risk identification and motivation for life-style change. Until there are outcome studies demonstrating a clinical benefit from measurement of expanded cardiovascular risk panels, including lipoprotein(a) testing for cardiac risk assessment and management, the requested health service is not more beneficial than any standard treatment for the patient's condition. Its clinical utility remains undefined in the published literature, investigational and not medically appropriate, based on the submitted information and the current published medical literature evidenced-based standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pelvic pain
treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with pelvic pain. She presented to the emergency department with chest pain, breast heaviness and generalized abdominal pain. She also had nausea and vomiting. On exam, she had a vaginal discharge and voluntary guarding with right lower quadrant tenderness. Her vital signs were not contributory. A computed tomography (CT) scan showed a right ovary with multiple cysts. Pelvic ultrasound showed multiple cysts. She was empirically treated for pelvic inflammatory disorder with intravenous antibiotics and pain control. 

Inpatient hospital stay is not medically necessary for this patient.
There are clear criteria for inpatient hospital admission with PID (pelvic inflammatory disease). They include surgical emergencies when appendicitis cannot be excluded, tubo-ovarian abscess, pregnancy, severe illness with nausea, vomiting and high fever of 101oF, unable to tolerate oral regimen, and no clinical response to oral antibiotics. The patient in this case did not have documentation of this and therefore, inpatient admission was not medically necessary. The patient could have been provided oral antibiotics for home use and follow up in the clinic for evaluation of treatment at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough
Treatment: Computed tomography, thorax
The insurer denied the computed tomography, thorax. 
The denial is upheld.

The patient is a female who presented for an office visit with noted cough and dyspnea. A computed tomography (CT) scan of the chest was ordered at this time along with a chest x-ray. The patient left the office, against medical advice (AMA) to have the chest x-ray (CXR) and the CT scan done. Transfer to the emergency department (ED) was recommended for further evaluation of her respiratory status, and the patient refused. The patient was then sent a prescription for oral antibiotics and an albuterol inhaler. The chest x-ray was normal, and the CT scan of the chest was normal. An electrocardiogram (EKG) was done and showed normal sinus rhythm (NSR).
At issue is the medical necessity of Computed tomography, thorax.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Computed tomography, thorax is not medically necessary for this patient.
Typically, with cough and dyspnea for only a few days, is more consistent with infection or bronchitis or the like that requires acute treatment and evaluation. If these symptoms are persistent after that time, then a CT scan may be indicated. The patient had a normal initial chest x-ray and no indication for a CT scan to follow up. Per current literature the patient did not have any indication of pneumonia on imaging or any other concerning features that would require a CT scan.
Therefore, the health service/treatment of Computed tomography, thorax is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Overweight
Treatment: Formulary exception for Wegovy
The insurer denied: Formulary exception for Wegovy
The denial is upheld.

The patient is an adult male with elevated body mass index in the overweight category. The request for Wegovy is under review. The prior request was denied because, "Your records with us and the information submitted by your doctor do not show you meet the following criteria: (1) documentation of BMI (body mass index) greater than or equal to 30 kilograms per square meter, or a BMI [body mass index] greater than or equal to 27 kilograms per square meter with at least one weight-related comorbid condition (such as high blood pressure, high cholesterol, high blood sugar) within the last month. Additionally, the information submitted by your doctor does not show the 
following: (1) been evaluated for potential medical causes of weight gain (such as low thyroid level, depression) and for medications that cause weight gain (such as steroids, antipsychotics, antidepressants, antiepileptics, beta-blockers) (2) documentation of baseline body weight within the last month (3) trial of at least six months of lifestyle modification (such as dietary changes as instructed by nutritionist or physician, exercise, and behavior modifications) with failure to lose more than 5% of body weight (4) documentation of body weight before and after lifestyle modifications (5) documentation you will be taking the requested medication with lifestyle modifications (6) the medication will not be used at the same time with other weight loss products such as prescription/non-prescription medications or herbal preparations." The denial is being appealed.

The health plan should not cover the Formulary exception for Wegovy.

This request is for Wegovy for weight loss in a patient that is overweight. No clinical documentation was provided to document the patient's body mass index or to document if the patient has a weight-related co-morbidity or if he has tried and failed lifestyle changes. Given the lack of documentation, it is unknown if Wegovy is being requested in a manner consistent with the Wegovy prescribing information. Wegovy has risks, including nausea and vomiting. Therefore, no, the health plan 
should not cover the formulary exception for Wegovy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malpositioned Teeth. 
Treatment: Comprehensive Orthodontic treatment (braces & monthly visits). 

The health plan denied: Comprehensive Orthodontic treatment (braces & monthly visits). 

The determination is overturned. 

The patient is a male with a Class II Division 1 malocclusion with maxillary and mandibular crowding. He has an 8-millimeter (mm) overjet and a 6-mm overbite. He is treatment planned for 30-36 months of orthodontics to correct his malocclusion, but his insurance denied the claim due to a lack of medical necessity. 
At issue is the medical necessity of comprehensive orthodontic treatment (braces and monthly visits). 

The health plan's determination of medical necessity is overturned in whole. 

The requested health service/treatment of comprehensive orthodontic treatment (braces and monthly visits) is medically necessary for this patient. Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. This patient, like fifteen percent of the population, exhibits an Angle's Class II bite.[1] Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma.[2] Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6-mm and greater overjet, which this patient has.[3] For these reasons, orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Asthma exacerbation secondary to influenza B infection.
Treatment:  Inpatient Admission.

The health plan denied the Inpatient Admission.  The determination is overturned.

The patient is a male with a history of asthma who presented with a cough, fever, and ear drainage. He was brought to his primary doctor due to excessive coughing, fever, and purulent drainage from his left ear. At that time, he was noted to have decreased breath sounds at the lung bases and was found to have influenza B infection. He was also brought to the emergency department (ED) due to fevers, cough, and a rash, and was discharged with albuterol, acetaminophen, and ibuprofen. However, he continued to be sick and had increased wheezing at home, so he was brought back to the ED for care.

On examination, he was noted to have shallow breathing with a temperature of 99.3 Fahrenheit, a heart rate of 155 beats per minute (bpm), and a respiratory rate of 20/minute. His left ear had otorrhea with a mildly erythematous tympanic membrane. His lung exam revealed rhonchi and wheezes with decreased breath sounds at the bases. He was given intravenous (IV) methylprednisolone, 2 albuterol/Atrovent nebulized treatments, and 4 doses of Atrovent. He was subsequently admitted to the hospital for an asthma exacerbation secondary to influenza B infection.

In the hospital, he initially continued to have tachypnea and was treated with albuterol every 2 hours, IV methylprednisolone, and Augmentin with ciprofloxacin drops. Over time he improved and was able to wean to every 3 and then every 4-hour treatments. He was able to switch to oral prednisone and was felt to be stable for discharge to home with continued treatment and follow up as an outpatient.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of inpatient admission was medically necessary for this patient.

This is a young boy who presented with an asthma exacerbation in the setting of influenza B infection. He continued to have tachypnea and wheezing despite appropriate and intensive treatment in the ED setting, and initially required bronchodilator treatment every 2 hours along with parenteral corticosteroid treatment with monitoring and additional treatments as needed.

The decision making at the time of admission for this patient was consistent with his young age, the presence of persistent symptoms despite appropriate treatments, and the need for ongoing intensive treatments along with close monitoring for potential deterioration of clinical status.

According the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 26th edition, Asthma, Pediatric, hospital admission is indicated for patients with respiratory findings, including moderate wheeze, which persist despite observation care, with beta agonist response not sustained for at least 3 hours.

This patient continued to have tachypnea and wheezing despite appropriate treatments, and initially required beta agonist treatment every 2 hours. Therefore, inpatient care was necessary and appropriate.