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

Diagnosis: Abdominal/Stomach Pain. 
Treatment: Inpatient admission. 

The health plan denied: Inpatient admission. 
The determination is upheld. 

The patient is a female with a medical history of significant alcohol use. She presented to the emergency department (ED) with abdominal pain, nausea, and vomiting after significant alcohol intake for two days; she also had a fall on a radiator, striking her head and reported progressively worsening diffuse headache. Her vital signs were notable for tachycardia with a pulse rate of 127 beats per minute. The physical examination was notable for a flat abdomen with epigastric tenderness and normal bowel sounds. The labs showed an unremarkable complete blood count, a low sodium of 128, an elevated creatinine of 1.5, an elevated aspartate aminotransferase of 362, an elevated alanine aminotransferase of 84, and an elevated lipase of 291. A computed tomography (CT) scan of the head was unremarkable. A CT scan of the abdomen and pelvis showed hepatomegaly and hepatic steatosis, no bowel obstruction or wall thickening, and normal appendix. An ultrasound of the abdomen showed a normally distended gallbladder without shadowing stone, no biliary ductal dilation, and findings typical of hepatic fatty change. She was treated with intravenous (IV) fluids, thiamine, famotidine, morphine, and oral Maalox. She was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol. The following day, her abdominal pain, nausea, and vomiting had resolved, and she was tolerating oral intake. Her labs showed an unremarkable complete blood count, a normalized sodium, an elevated aspartate aminotransferase of 164, and an elevated alanine aminotransferase of 55. She was then discharged. At issue is the medical necessity of the inpatient admission. 

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

The requested health service/treatment of inpatient admission is not medically necessary for this patient. The patient presented with symptoms consistent with alcoholic gastritis, and symptoms and labs consistent with acute pancreatitis [1]. She was appropriately treated with IV fluid administration and gradual advancement of diet [1-5]. However, there was no hemodynamic instability or other complications such as pseudocyst, pancreatic necrosis, thrombosis, ascending cholangitis, abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care [4-5]. There was concern for alcohol withdrawal, but no complicated or severe acute alcohol withdrawal was documented; she was appropriately maintained on a CIWA protocol [6,7]. Her liver enzymes were elevated, but there was no acute liver failure or alcoholic hepatitis [8,9]. All of the measures that were undertaken, including labs, imaging, IV fluids, monitoring, and CIWA protocol, could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep vein thrombosis
Treatment: Acute inpatient admission
The insurer denied: Acute inpatient admission
The denial is upheld.

The patient is an adult female with hemoglobin SS (two copies of sickle hemoglobin gene) sickle cell disease and a recent cerebrovascular accident (CVA). She was not on anticoagulation and was sent to the emergency room for leg swelling and pain. She was found to have venous thromboembolism and was admitted. The deep venous thrombosis (DVT) was stated to be small. She was paced on anticoagulation and discharged the following day on Lovenox.

The acute inpatient admission was not medically necessary.

Multiple studies have shown that outpatient therapy for venous embolism is safe and feasible. Clinical indications for admission include: Massive DVT (deep venous thrombosis) (e.g., 
iliofemoral DVT [deep venous thrombosis], phlegmasia cerulea dolens); Concurrent symptomatic pulmonary embolism; High risk of bleeding on anticoagulant therapy; Comorbid conditions or other factors that warrant in-hospital care. This patient had what was described as a small DVT (deep venous thrombosis) in the lower leg. There was no hemodynamic instability, no concurrent pulmonary embolism, and she was not high risk for bleeding. A history of hemoglobin SS (two copies of sickle hemoglobin gene) and CVA (cerebrovascular accident) does not warrant acute level care. As such, she could have received therapy with Lovenox in a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes. 
Treatment: Ozempic (semaglutide). 
The insurer denied coverage for Ozempic (semaglutide). 
The denial is overturned. 

This is an adult female diagnosed with Type 2 Diabetes in 2022. This request is for Ozempic. She has obesity, and she is on Weight Watchers. She is on stable doses of metformin but her glycated hemoglobin (HbA1c) was 7.2 %. She also has hypertension and coronary artery disease. 

Ozempic is considered medically necessary for this patient. Ozempic is a glucagon like peptide 1 (GLP) agonist that is Food and Drug Administration (FDA) approved in the treatment of Type 2 Diabetes (2-6). 
 
The patient's goal glycated hemoglobin (HbA1c) is less than 6.5% (The patient's glycated hemoglobin (HbA1c) was documented 7.2%). The American Association of Clinical Endocrinologists recommends a goal glycated hemoglobin (HbA1c) of less than 6.5%. The patient needs additional treatment. The request for Ozempic is medically necessary. 

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 Ozempic (semaglutide) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Growth Hormone Deficiency.
Treatment:  Norditropin flexpro 10 mg (milligrams) /1.5 ml (milliliter) pen injector.

The insurer denied coverage for Norditropin flexpro 10 mg (milligrams) /1.5 ml (milliliter) pen injector.  The denial is upheld.

This is a male child diagnosed with Growth Hormone Deficiency (GHD). The Provider states that at the time of the original approval from insurance, Norditropin had a nation-wide shortage. They applied for Genotropin and received approval for use. Unfortunately, the Genotropin pen device (which was on manufactures back order) did not arrive until about 5 weeks ago when medication began, so he shows no improvement in his height velocity with the short duration of treatment.

The patient's Growth Hormone stimulation test with arginine and clonidine peaked at 9.4. His Insulin-like Growth Factor 1 (IGF1) was 139; Insulin-like Growth Factor-Binding Protein 3 (IGFBP3) was 4.7. His testes were 8-12 cc (cubic centimeters) bilaterally, and pubic hair was at Tanner 1 (level of puberty score). 

The patient's predicted adult height is 170.18 centimeters (cm) (-0.93 SDS [Standard Deviation Score]).

The request for Norditropin flexpro 10 mg was denied because the patient's stature and growth velocity data did not meet the policy criteria. 

The patient does not have a pretreatment height less than or equal to -2.25 standard deviations (SD). His height Velocity is normal. The patient therefore does not meet idiopathic short stature criteria. The patient's pretreatment height was 136.04 cm (-1.58 SDS) with height velocity over 4.8 cm/year.

The request does not meet any nationally accepted criteria for use of growth hormone. 

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 Norditropin flexpro 10 mg (milligrams) /1.5 ml (milliliter) pen injector is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertension and syncope
Treatment: inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld. 

This is an adult male with a medical history of hypertension, chronic kidney disease, and diabetes.  

The patient was admitted with hypertensive emergency and syncope. The patient was aphasic with left facial droop and syncope. It was noted the patient returned to baseline upon arrival to the Emergency Department (ED). It was noted the patient has elevated blood pressure and missed his morning medications. The diagnosis was syncope versus seizure. Exam with no neurologic abnormalities was noted. The patient had no signs of stroke, seizure or persistent altered mental status that was different than baseline.

Patient had elevated blood pressure with normal heart rate, intravenous fluids (IV) and home Blood Pressure medication (morning medication not taken at home) was given. Computerized tomography (CT) of the head indicated no acute bleed. Upon medical evaluation (neurological), the patient had no focal neurologic deficits, facial droop, fluctuating mental status, or altered mental status from baseline that would require inpatient admission.

Per the MCG (Milliman Care Guidelines) Hypertension M-197 Guidelines, Clinical Indications for Admission to Inpatient Care is supported when there is a Hypertensive emergency, Hypertensive encephalopathy, Cerebral infarction, Intracranial hemorrhage, Myocardial ischemia or infarction, Heart failure, Aortic dissection, Increased creatinine (new) from baseline, Papilledema, Retinal hemorrhage, Microangiopathic hemolytic anemia or Seizure.

The medical records provided for review support that services could have been rendered in observation unit. There was no medical necessity documented to support the inpatient level of care.

"Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA)". (Mendelson, S. J., & Prabhakaran, S.).

Per Majidi, S., et al., "Routine hospitalization of all patients with TIA (transient ischemic attack) or minor ischemic stroke may not positively affect short-term clinical outcome."

Per Homoya, B. J., et al., "Many factors contributed to decisions regarding admitting a patient with TIA (transient ischemic attack); however, clinicians' uncertainty appeared to be a key driver. Further quality improvement interventions for TIA care should focus on facility adoption of TIA protocols to address uncertainty in TIA admission decision-making and to standardize timely evaluation of TIA patients and delivery of secondary prevention strategies." 

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: Dementia, arthritis, major depressive disorder, and generalized anxiety disorder.
Treatment: Personal Care Assistance Services 6 Hours per Day, 7 Days per Week (Monday through Sunday) for a Total of 42 Hours per Week.

The insurer denied: Personal Care Assistance Services 6 Hours per Day, 7 Days per Week (Monday through Sunday) for a Total of 42 Hours per Week.  The denial is upheld.

This patient is an adult female patient with medical conditions that include dementia, arthritis, major depressive disorder, and generalized anxiety disorder. The denial of personal care assistance services six hours per day, seven days per week, for a total of 42 hours per week is being appealed. The health plan approved a total of 40 hours per week. Uniform Assessment System (UAS) evaluation completed 4 months ago shows minimally impaired cognition and functional status: maximal assistance with meal preparation and housework; extensive assistance with bathing and lower body dressing; limited assistance with managing finances and medications, phone use, personal hygiene, upper body dressing, walking, locomotion, and toileting; and independent with bed mobility and eating. The patient has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been a decline with managing finances and medications. A letter from the patient's physician notes the patient's husband passed a few weeks ago. This has significantly impaired her activities of daily living (ADLs).

The proposed treatment is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. Denial of personal care assistance services six hours per day, seven days per week, for a total of 42 hours per week is being appealed. The health plan approved a total of 40 hours per week. Uniform Assessment System (UAS) evaluation completed 4 months ago shows the patient needs assistance with all activities of daily living, except bed mobility and eating. Compared to Uniform Assessment System evaluation completed last year, there has been a decline only with managing finances and medications. The appeal statement notes a significant impairment in activities of daily living since her husband passed a few weeks ago. The information provided is inadequate to support a significant decline in the patient's functional status. There is no significant change between Uniform Assessment System evaluations. Therefore, the proposed increase personal care assistance services from a total of 40 to 42 hours per week is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: A procedure to treat low back pain, code 64628, 64629.

The insurer denied coverage for a procedure to treat low back pain, code 64628, 64629.   
The denial is upheld. 

This patient has chronic low back pain [CLBP]. The patient is status post laminectomy. The patient is doing Physical Therapy. Their medications are OTC [over the counter] meds, Tylenol and NSAID [non-steroidal anti-inflammatory drugs. The patient's MRI [magnetic resonance imaging] shows Modic changes at L[lumbar]1/L2, L2/L3 and L3/L4 and L4-L5 according to the official radiology report.  It also shows disc herniation at L4-L5 and a disc bulge at L5-S[sacral]1 along with facet arthropathy.  The physician is asking to perform RFA [radiofrequency ablation] on the Basivertebral nerves [BVN] at L3, L4, L5 and S1, which is different from the Modic changes in the official report. 

Conger et al. (4) pointed out that all of the major studies while supportive, have been funded by the company: 

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings." 

Similarly, a clinical practice guideline (5) while favorable pointed out the limitations of the current literature: 

1)  Industry funding is a potential source of study bias for the available data reviewed.
2)  Limited number of studies. 
3)  Short-term follow up for the majority of studied patients. 
4)  Unknown effect on the primary degenerative process. 

Urits et al. (6) also commented on the need for more research on this promising technique:  "reproducible large randomized controlled trials (RCTs) 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 radiofrequency (RF) ablation in the management of CLBP and improve the quality of life of CLBP patients in the near future." 

In sum, this procedure is not likely to be more beneficial than the standard of care. 

In summary, the denial of a procedure to treat low back pain, code 64628, 64629, is upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Basivertebral Nerve Radiofrequency Ablation
The insurer denied: Basivertebral Nerve Radiofrequency Ablation
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 experimental/investigational. The patient has failed conservative treatment in the form of chiropractic care, home exercises, medial branch block injections, physical therapy, radiofrequency ablations, and transforaminal epidural steroid injections. Medications have included Ibuprofen and Pregabalin. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury.

The health plan should not cover the requested health service.

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 in whom 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 chiropractic care, home exercises, medial branch block injections, physical therapy, radiofrequency ablations, and transforaminal epidural steroid injections. Medications have included Ibuprofen and 
Pregabalin. 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 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 has been shown effective in RCT (randomized controlled trials) with 5-year results. 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, in this case, the patient has not failed or attempted sacroiliac joint injections, which are 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 sacroiliac injections do show favorable outcomes in the literature, have lower risk, and 
morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Basivertebral Nerve Radiofrequency Ablation
The insurer denied: Basivertebral Nerve Radiofrequency Ablation
The denial is upheld.

The patient is an adult male with low back pain for over five years. His past treatments include chiropractor care, home exercises, medial branch block injections, physical therapy, 
radiofrequency ablations, transforaminal epidural steroid injections, ibuprofen, and Pregabalin. His pain ranges from a 2/10 to a 9/10. The patient's MRI (magnetic resonance imaging) of the lumbar spine shows multilevel disc and facet changes in the lower spine, worse at lumbar five to sacral one (L5-S1) and a new small disc protrusion at lumbar three to four (L3-4). The request for Intracept was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested health service.

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 requested health service. 
Additional studies/trials are necessary to determine efficacy as compared to other conventional therapies. Other standard treatment options that exist in the medical literature may include non-opioid medications (i.e. NSAIDs [nonsteroidal anti-inflammatory drugs], 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: Back Pain
Treatment: Basivertebral Nerve Radiofrequency Ablation
The insurer denied: Basivertebral Nerve Radiofrequency Ablation
The denial is upheld.

The patient is an adult male. Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease that has resulted in development of vertebrogenic pain identified by degenerative endplates changes (Modic) on MRI (magnetic resonance imaging). The patient has pain and failed treatment for greater than six months. Prior treatments include chiropractic care, home exercises, medial, branch block, physical therapy, radiofrequency, ablation and transforaminal epidural steroid injections. The patient's pain is aggravated with bending, lifting, standing and walking. The pain is averaging 5-9/10.

The health plan should not cover the requested health service.

Based on the documentation provided, the requested procedure is not recommended at this time. Although the patient has a history of chronic back pain and has tried other conservative therapy and injections, and although the appeal letter notes Modic changes, there was lack of documentation of Modic type changes noted on MRI (magnetic resonance imaging). The requested procedure is recommended for such findings. As such, is not recommended at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Taltz. 

The insurer denied Taltz. 
The determination is upheld. 

The patient is a male with psoriatic arthritis and moderate to severe psoriasis (40% (percent) body surface area involvement) of the malar area, nasolabial folds, eyebrows, ears, trunk, elbows, hands, and lower extremities. At issue is the medical necessity of Taltz.
Taltz is not medically necessary for this patient. 

The patient has no documented treatment failure with, or true medical contraindication to, either Cimzia, Humira, Skyrizi, Stelara, or Tremfya, all of which are of similar potency and efficacy to the requested Taltz. These alternative medications are as medically appropriate for the treatment of this patient's particular clinical condition as is the requested Taltz. Therefore, Taltz is not medically necessary.