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

Diagnosis: Chronic Low back Pain. 
Treatment: 22899, unlisted procedure, spine. 

The insurer denied coverage for 22899, unlisted procedure, spine.  The denial is upheld. 

This is a patient with a history of hyperlipidemia, coronary artery disease (CAD), sacroiliitis, and spondylosis. She presented to the Pain Management physician's office for an evaluation of back pain that continued to worsen. She has tried and failed conservative treatment options including physical therapy (PT), home exercises, and chiropractic adjustments. She underwent a left sided L(lumbar)4-L5 discectomy and hemilaminectomy. Pain persisted. The patient may be a candidate for the Intracept procedure. 

The Intracept procedure is "intraosseous ablation of the basivertebral nerve". It has been proposed to address low back pain identified by Mobic changes. The procedure is performed within the vertebral body. It has been proposed that pain relief is manifested by patients who no longer require their narcotics. For one level of disc disease each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeon nor spine surgeon. There are no National Organizations which provide guideline nor indication. 

A search was performed using PubMed. The key word was Intracept Lumbar. There were two references. The articles submitted by appeal were also reviewed. There were small numbers of people evaluated for a short duration. The procedure is currently being performed by an investigative group and likely IRB (Investigational Review Board). The procedure is not mainstay nor current accepted treatment by the practicing medical community. 

The procedure is essentially a thermoablation performed within the vertebral body. 
There are several level 1 studies showing the benefit of this procedure years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer. 

The scientific evidence in peer-reviewed literature did not support the result of improvement in health outcome. It is FDA (food an drug administration) approved, but no recommendations have been made for use of the device. This is not the best available treatment for this patient at this time. It is unclear if the adverse risks are increased over standard procedures. The Intracept Procedure is not likely to be more beneficial than any of the standard treatments for this patient. 

The carrier's denial of 22899, unlisted procedure, spine should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dysphagia 
Treatment: Inpatient Hospital Services 
The insurer denied coverage for inpatient hospital services. 
The denial is overturned. 

According to the medical records, the patient has a history epilepsy and recent tonsillectomy. Following tonsillectomy, the patient had continued pain and difficulty swallowing. She presented to the emergency department (ED) for evaluation of difficulty eating, drinking and dysphonia. She failed an oral swallowing challenge in the emergency department (ED) and was admitted for further oral monitoring and pain control. She was evaluated by Pediatric Otolaryngology, her pain was managed and her intake improved. The patient was discharged home with outpatient follow up planned. 

According to Guntinas-Lichius, O., et al (2016), "Conclusion: Many patients seem to receive insufficient or ineffective analgesia after tonsillectomy. Further research should address if populations at risk of higher postoperative pain such as females, younger patients or those with preexisting pain might profit from a special pain management protocol. Beyond classical demographical and process parameters the large variability between different hospitals is striking and indicates the existence of other unknown factors influencing postoperative pain after tonsillectomy." 

The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The patient underwent tonsillectomy and presented to emergency department (ED), brought in by ambulance (BIBA) with inability to tolerate by mouth and poor pain control. She had only had 1 bottle of water since surgery. After ED hydration and intravenous (IV) steroids/pain medication/anti-nausea medication, she continued to be unable to tolerate by mouth. Her hospital admission was medically necessary and standard of care. 

Based on the above, the medical necessity for the inpatient hospital services is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tingling and Numbness.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The patient is a male. He presented with left face numbness and left eye twitching.

At presentation, the patient was noted to have left ptosis and left hemibody paresthesia. CT (computed tomography) brain and CT (computed tomography) perfusion were negative for acute intracranial pathology. He was admitted for possible TIA (transient ischemic attack). Subsequent MRI (magnetic resonance imaging) was negative for stroke. 

No, the Inpatient admission was not medically necessary.

The patient did not have any significant neurological deficit at presentation, and CT (computed tomography) scan was negative for acute stroke. Moreover, the clinical presentation, left eye twitching, was unlikely to represent an acute stroke. The diagnostic studies, clinical evaluation, monitoring and treatment could have been safely and effectively provided at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Skilled Nursing Facility. 

The insurer denied skilled nursing facility.  The denial is upheld.

The patient is a male with right foot osteomyelitis. He was admitted to a skilled nursing facility. It was noted that intravenous (IV) antibiotics were required, and he obtained wound care every Thursday. The health plan denied skilled nursing facility as the patient did not meet criteria. The subject under review is the medical necessity for the skilled nursing facility.

No, the requested skilled nursing facility stay was not medically necessary nor appropriate for this patient. The patient did not have any skilled needs.
The patient is a male who was admitted to a hospital related to right foot osteomyelitis. He was subsequently admitted to a skilled nursing facility. The patient was medically stable. He was not requiring any IV antibiotics. He was seen by a wound team once a week and dressing changes were not more than once a day.  The patient was more than ready to be discharged to a lower level of care since, despite being non-weight bearing (NWB) to his right lower extremity (RLE), he was ambulating over 100 feet with rolling walker and stand by assist (SBA) with wheelchair following via hopping and was also SBA for bed mobility, transfers, toileting, car/tub-shower transfer and lower extremity dressing. He was independent over 150 feet with wheelchair mobility, upper extremity activities of daily living (ADLs), hygiene/grooming and feeding.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

The patient is a male. He was hospitalized for chest pain. He presented to the ED (emergency department) for evaluation of non-exertional chest pain associated with nausea, vomiting, and shortness of breath. His past medical history is pertinent for HTN (hypertension), a normal stress test a month prior, severe smoking and substance abuse. He admitted to taking PCP (phenylcyclohexyl piperidine).

The patient's vital signs were stable. His troponin was slightly elevated, but felt to be from his AKI (acute kidney injury) from dehydration. His treatment included hydration, repeat troponin and methimazole for his hyperthyroidism. Echocardiogram was normal, and nuclear stress test was noted to have technical limitations and equivocal for ischemia. Possible OP (outpatient) catheterization was going to be considered. There were no arrhythmias.

No, the Inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, there was not a medical need for the acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient hospital stay are not met. The patient was not evidenced to have hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome (ACS), chest pain that is indicative of a serious cardiac condition like pulmonary embolism (PE) or aortic dissection, acute myocardial infarction (AMI), pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care he received, including IV (intravenous) hydration for AKI (acute kidney injury), which explained the and nuclear stress test, is routinely provided safely and effectively at a lower level of care, such as in the hospital's Observation unit.

Therefore, the Inpatient admission was not medically necessary, based on the submitted information and the current published medical literature.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abscess.
Treatment: Current procedural terminology (CPT) code 10060 [incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single] and CPT code 70355 [orthopantogram (e.g., panoramic x-ray)].

The insurer is denied coverage for current procedural terminology (CPT) code 10060 [incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single] and CPT code 70355 [orthopantogram (e.g., panoramic x-ray)].  The denial is overturned. 

This female patient has no documented history.

The indication for surgery in this case is unsuccessful endodontic treatment. The main objective with surgical retreatment is to eliminate and prevent bacterial infection in the root canal system from causing an inflammatory reaction in the periradicular tissue. A basic prerequisite for successful treatment is the diagnosis, case selection, and treatment planning. This is particularly important since the primary treatment has failed. The radiograph (70355) is needed to evaluate the area, plan and document treatment.

The patient had an infection from tooth number (#) 3, which previously had a root canal. This required treatment. The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for current procedural terminology (CPT) code 10060 [incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single] and CPT code 70355 [orthopantogram (e.g., panoramic x-ray)]  is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Skyrizi. 
The denial is upheld.

The patient is a male with psoriasis. Body surface area affected is 1% (percent). His scalp is affected. He has failed Lidex solution, ketoconazole shampoo, and mometasone. The medication under review is Skyrizi 150 milligrams per milliliter (MG/ML) subcutaneous (SC) solution prefilled syringe (SOSY).
The subject under review is the medical necessity for the requested medication.

The health plan's determination is upheld.

The requested health service/treatment of Skyrizi 150MG/ML SC SOSY is not medically necessary based on the current peer-reviewed literature. There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the formulary alternatives, such as methotrexate, which has been shown to be effective for psoriasis.

According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the formulary alternatives such as methotrexate are effective treatments for the management of psoriasis. (1, 2)
Within the peer-reviewed literature, West et al. 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis. (3)
The evidence-based literature is consistent. The formulary medications are appropriate agents for the treatment of the patient's psoriasis.
It is noted that the patient has tried and failed topical steroids. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Skyrizi prior to the formulary alternatives.

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

Diagnosis: Dental Disorder.
Treatment: Braces and monthly visits times (x) 12.
The insurer denied Braces and monthly visits times (x) 12.
The determination is overturned.

The patient has a Class I malocclusion and anterior crossbite of tooth number (#) 7. Tooth #27 is barely erupted but due to its position it can be anticipated that there will be gingival recession on this tooth if it is not moved into a more favorable position. She is treatment planned for 30-36 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to correct her malocclusion. At issue is the medical necessity of braces and monthly visits times (x) 12.
The patient has significant maxillary anterior crowding with #7 in crossbite. This tooth has a high risk for restorative problems in the future due to the traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time (4), which will make treating this occlusion at a later time more difficult. Tooth #27 already has slight recession, and further movement of #27 will likely lead to the need for future for periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer. 
Treatment: Selective internal radiation therapy (SIRT). 

The insurer denied the selective internal radiation therapy (SIRT). 
The determination is overturned. 

The patient has metastatic left breast cancer with dominant liver disease after an original cancer diagnosis. She has a history of metastatic lesions. She has had multiple treatment regimens over the years. She was evaluated for palliative care. She is now on Alpelisib. She has a reasonable performance status currently. Lab work is stable.
Liver lesions were confirmed by recent positron emission tomography (PET) / computed tomography (CT) imaging and are progressing. There are other metastatic foci in bone and lymph nodes as well. 
The plan is for SIRT (selective internal radiation therapy) to the liver via the hepatic arteries. 
Pertinent past medical records include several treatments with surgery, chemotherapy and radiation therapy. Also, she has a past medical history of hypertension, diabetes and depression with anxiety. Life expectancy is not documented but should be expected to be greater than 3 months. 
Additional systemic chemotherapy is not a viable option nor is image guided ablation.
At issue is the medical necessity of selective internal radiation therapy (SIRT). 
The requested health service/treatment or procedure of SIRT (selective internal radiation therapy) is medically necessary for this patient. 
Palliative loco-regional therapy is well tolerated and efficacious. This patient's hepatic dominant metastatic tumors require Yttrium-90 (Y-90) radio-embolization (SIRT) for control of unresectable liver metastases from a breast cancer primary. This will prolong life, control intrahepatic disease and diminish future symptoms. Liver directed therapy is the treatment of choice. This patient has liver dominant metastatic breast cancer and requires liver directed loco-regional therapy to control disease and preserve liver function. The lesions are refractory to systemic chemotherapy. Eastern Cooperative Oncology Group (ECOG) 2 performance status is documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Maxillary and mandibular crowding.
Treatment: Braces/Monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is upheld. 

The patient is a male with maxillary and mandibular crowding and several unerupted permanent teeth. The orthodontist mentioned in the diagnosis that tooth # (number) 6 is impacted. The patient was treatment planned for Braces and Monthly Visits (x12) with palatal expansion and surgical canine exposure. This is the subject under review.

Braces and Monthly Visits (x12) are not medically necessary for this patient at this time. He is in the process of losing his remaining primary teeth as they are replaced with permanent teeth. Neither teeth #6 nor #11 appear to be erupting at a poor angle on the radiograph, and it is too early to determine if it will require an exposure as maxillary canines usually erupt at 11-12 years of age. There is still much time to see if the tooth will erupt successfully on its own without orthodontic intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Fibrillation, Hypertension, Osteoarthritis. 
Treatment: Consumer and self-directed personal assistance services (CDPAS), 84 hours per week. 

The insurer denied coverage for consumer and self-directed personal assistance services (CDPAS), 84 hours per week. 

The denial is overturned. 

According to the documentation submitted, this is the case of an elderly patient with a medical history inclusive of atrial fibrillation, hypertension, osteoarthritis, gait instability, falls, fractures, cognitive impairment and bilateral renal cysts. Per the letter of medical necessity, the doctor writes that the patient needs assistance with bathing, dressing, toileting, transfers, ambulating and personal hygiene. The patient lives with her son who needs rest at night. Night-time logs submitted indicate the patient receives assistance during the night. UAS (Uniform Assessment System) done shows need for limited assistance with ADLs (activities of daily living). 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; noted 

"(a) Definitions and scope of services. 

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse. 

The patient is an elderly patient who needs assistance with activities of daily living (ADLs). She has dementia with significant changes in mentation (as well as behavioral changes). She is incontinent. She has been provided with diapers and durable medical equipment (DME) but has not demonstrated the ability to use them independently, from a physical or cognitive viewpoint. Nighttime logs show unscheduled nighttime needs. The patient's physicians, children, and others note decline in function. 

The provision of diapers and alternate pressure beds is not by itself adequate for prevention of pressure sores; changing diapers regularly and positioning are also necessary. 

The increase in hours is supported by the documentation. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for consumer and self-directed personal assistance services (CDPAS), 84 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure.
The denial is upheld.

The patient is a male. He has history of chronic lower back pain. He has tried medications, physical therapy and injections. MRI (magnetic resonance imaging) lumbar spine showed Modic changes at L3-4 (third lumbar spine vertebra-fourth lumbar spine vertebra).

No, the health plan should not cover the Intracept procedure.

No, the Intracept procedure is not more beneficial.
The patient has history of chronic lower back pain and has failed conservative therapies.

While BVN (basivertebral nerve) RFA (radiofrequency ablation) is evidenced to be an effective and durable treatment option when applied to a select patient population based on defined clinical and radiographic criteria, non-industry-funded trials need to be pursued to confirm the results of currently published clinical studies. All studies performed to date have been industry sponsored.

BVN (basivertebral nerve) ablation may provide a treatment option to treat patients that fail nonsurgical treatment. However, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results.

Therefore, as the health plan asserts, the Intracept procedure is considered experimental/investigational.