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

Reviewer #2:

Diagnosis: pelvic venous disease.

Treatment: endovascular occlusion of the ovarian and/or internal veins

The insurer denied coverage for endovascular occlusion of the ovarian and/or internal veins

The denial is upheld

This is a patient who is Gravida (G) 4 Para (P) 4 with multiyear history of severe pelvic pain. Endometriosis and pelvic inflammatory disease (PID) have been ruled out. A computed tomography arteriography and venography (CTV) showed a dilated right ovarian vein with many dilated parauterine vessels. The treating provider has requested to perform ovarian vein embolization, which is under review.

The peer-reviewed literature does not support a result of improvement in health outcome.

The body of evidence in the peer-reviewed medical literature regarding embolization of the Ovarian Vein or Internal Iliac Veins for the treatment of pelvic congestion syndrome (PCS) is insufficient and poor quality. While some studies suggest favorable results of embolization for the treatment of pelvic congestion syndrome (PCS), additional well-designed randomized controlled trials are necessary to establish the relative safety and efficacy of the embolization procedure.      

Society for Vascular Surgery (SVS)/ American Venous Forum (AVF):

In a guideline published by the SVS and the AVF in 2011, guideline authors suggest "treatment of pelvic congestion syndrome and pelvic varices with coil embolization, plugs, or transcatheter sclerotherapy, used alone or together (2B)." The 2B recommendation indicates a "weak" recommendation based on moderate quality evidence, where the benefits of the technology are considered closely balanced with risks and burdens (Gloviczki et al., 2011).

This patient is not a good candidate for endovascular occlusion of the ovarian and/or internal veins.

The long term outcome of the proposed embolization procedure has not yet been shown to be superior to standard medical treatments.     

The endovascular occlusion of the ovarian and/or internal veins is not the best available treatment for this patient currently .

The long term outcome of the proposed embolization procedure has not yet been shown to be superior to standard medical treatments     
  
The adverse risks are increased over standard treatment/services.  

There are increased risks of the proposed embolization procedure verses standard medical treatments of physical therapy, hormonal therapy, compression therapy, etc.     

There is a lack of sufficient peer-reviewed data that supports the requested embolization procedure as more beneficial that standard medical treatments, such as physical therapy, hormonal therapy, and compression therapy  for this patient. 

In summary, the denial of (37241) endovascular occlusion of the ovarian and/or internal veins and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1:

Diagnosis: pelvic venous disease.

Treatment: endovascular occlusion of the ovarian and/or internal veins

The insurer denied coverage for endovascular occlusion of the ovarian and/or internal veins

The denial is overturned

This case involves a patient seeking authorization for the coverage of endovascular occlusion of the ovarian and/or internal veins with current procedural terminology (CPT) code 37241.

CT venogram abdomen/pelvis revealed minimal compression of the left common iliac vein between the vertebral body and the right common iliac artery.  Multiple enlarged tortuous peri uterine pelvic and vaginal vessels bilaterally with dilatation of the right ovarian vein were suggestive of underlying pelvic venous disease.

The Milliman Care Guidelines (MCG) indicates pelvic congestion syndrome (PCS) is characterized by chronic pelvic pain of greater than 6 months' duration that is unexplained by other etiologies, is worse with postural changes, and may be accompanied by dyspareunia due to pelvic varices or valvular incompetence within pelvic veins. Based on review of existing evidence, there are currently no clinical indications for ovarian and Internal Iliac Vein Embolization.

Per the cited literature, pelvic venous insufficiency (PVI), defined as retrograde flow in the gonadal and internal iliac veins, is the underlying cause of pelvic congestion syndrome (PCS), a common cause of disabling chronic pelvic pain in women of child-bearing age. PCS is a chronic pain syndrome characterized by positional pelvic pain that is worse in the upright position and is associated with pelvic and vulvar varicosities as well as symptoms of dyspareunia and postcoital pain. Endovascular and endoscopic interventions on the gonadal veins are highly effective and safe in eliminating pathologic blood reflux along the gonadal veins.

Peer-reviewed literature indicates that embolotherapy of the internal iliac and ovarian veins is a safe and effective technique for treating pelvic venous incompetence (PVI) and has been shown to reduce or alleviate pelvic pain in most women undergoing treatment for PCS. The records showed how complex the patient's condition is and that it is significantly affecting their quality of life due to the chronic debilitating pain. Given the high risk of progression of disease and morbidity, support in current literature, and the paucity of available treatment options, proceeding with the request is appropriate for this patient. As such, the denial for endovascular occlusion of the ovarian and/or internal veins is overturned.

In summary, the denial of (37241) endovascular occlusion of the ovarian and/or internal veins and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left knee pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient has a benign past medical history who presented to the emergency department with complaints of left knee and calf pain. Vitals on presentation included: temperature (T) 98.1 (degrees) Fahrenheit, blood pressure (BP) 126/72, pulse (P) 111, respiratory rate (RR) 18, and oxygen (O2) saturation 98% (percent). Laboratory results showed the following: white blood cell (WBC) 14.8, hemoglobin (Hgb) 11.9, hematocrit (Hct) 36.6, creatinine 0.75, and glucose 188. 

The patient was admitted for possible left knee infection. The patient was empirically treated with intravenous (IV) antibiotics (vancomycin and Zosyn). X-ray of knee showed no acute fracture, no destructive or lytic lesion. Venous duplex ultrasound was negative for deep vein thrombosis (DVT). A computed tomography (CT) scan showed mild to moderate left ankle joint effusion with diffuse surrounding synovial enhancement. Magnetic resonance imaging (MRI) showed left knee mild to high myotendinous medial gastrocnemius strain with adjacent subcutaneous edema. Antibiotics were discontinued. The patient remained afebrile, hemodynamically stable, and was discharged to follow-up with Orthopedics. 

According to documentation, the patient was admitted to the hospital for left knee discomfort. The patient was afebrile, hemodynamically stable, and laboratory results were only notable for mild leukocytosis. Imaging studies were suggestive of inflammation secondary tendon strain. Antibiotics were subsequently discontinued. The patient had no co-morbid conditions, no evidence of disseminated infection and no surgical intervention was required. Based on the above findings, the patient met criteria for observation level of management. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Outpatient Services (Pain Injections 64484 x1, 64483 x1). 
The insurer denied: Outpatient Services (Pain Injections 64484 x1, 64483 x1). 
The denial is upheld. 

The patient is an adult female with acute on chronic low back and right lower extremity pain. The pain is an 8/10 as of 4 months ago. Notes state the patient previously had an epidural steroid injection 8 months ago that provided more than 80% relief for almost 2 months. The patient's past treatment includes 3 months of physical therapy, home exercise, chiropractor, ice, rest, stretching, Tylenol, ibuprofen, and aspirin. Examination shows a positive straight leg raise. Addendum from 2 months ago indicates this was the first lumbar transforaminal epidural steroid injection on the right side; she denied having this type of procedure in the past. The request for right L (lumbar) 5-S (sacral) 1 transforaminal epidural steroid injection was denied as not medically necessary as the previous injection did not provide at least 50% relief for at least 2 months, no more than 4 injections at the same site within the past 12 months, and continuation of injections beyond 12 months. 

The requested health service is not medically necessary. 

The clinical information provided indicates initially that this is the second transforaminal epidural steroid injection (TFESI) the patient has received but this is the first transforaminal epidural steroid injection on the right side of this type. As such, current published literature and standard of care within the medical community have certain criteria for which this injection would be considered medically necessary. Diagnostic magnetic resonance image (MRI) imaging showing appropriate pathophysiology is one of such criteria. The clinical information provided did not include diagnostic imaging to support persistent radicular pain caused by disc herniation in a defined nerve root level, or spinal stenosis. As such, the requested right L5-S1 transforaminal epidural steroid injection is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Reflex Sympathetic Dystrophy of the Right Leg.
Treatment: Personal Care Aide (PCA) Hours: 7 Days per Week, 12 Hours per Day (or 84 Hours per Week).

The insurer denied Personal Care Aide (PCA) Hours: 7 Days per Week, 12 Hours per Day (or 84 Hours per Week).  The health plan's determination is overturned.

The patient is a female with past medical history of complex regional pain syndrome, spinal stenosis, deep vein thrombosis (DVT), hypertension, hyperlipidemia, hypothyroidism, diabetes mellitus type 2, anxiety, depression, urinary incontinence, neuropathy, osteoarthritis, obesity, and nicotine dependence, who had active PCA (personal care aide) services.

Personal Care Aide (PCA) Hours: 7 Days per Week, 12 Hours per Day (or 84 Hours per Week) are medically necessary for this patient.

There is documentation from the patient's medical providers, including her primary care provider, neurologist, and orthopedic provider, of the medical necessity of increased PCA services. There is documentation that the patient requires at least maximum assistance with transfer toilet, toilet use, walking, and locomotion; therefore, the patient has unscheduled and unpredictable care needs. The insurer has not documented a plan to meet the patient's unscheduled and unpredictable care needs when she does not have informal help between the hours of 8 AM and 8 PM. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The patient's current hours ended this month. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Migraine
Treatment: Emgality
The insurer denied: Emgality
The denial is upheld.

The patient is a teenage female with migraine headache disorder. The provider has requested Emgality for migraine prevention. This was denied coverage by the health plan, as she is not at least 18 years old. The denial is being appealed.

The health plan should not cover the treatment with Emgality.

The requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease. There are no high-quality clinical trials to support the safety or efficacy of this medication in persons under the age of 18. The extent of the medical literature includes only one retrospective trial (Greene et al., 2021). This does not breach the threshold of evidence required to conclude that this medication is effective in this clinical context. Therefore, Emgality is not considered an appropriate treatment for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Migraine
Treatment: Emgality
The insurer denied: Emgality
The denial is overturned.

The patient is a teenage female with migraines. She is currently on Emgality with migraines improved from daily to two to three per month. She was previously on propranolol and Topamax. Her provider wishes to continue Emgality. The request was denied coverage by the health plan, as the patient is under the age of 18 and is not FDA (Food and Drug Administration) approved for use under this age.

The health plan should cover the treatment with Emgality.

Although the patient is under the age of 18, there is data in the medical literature that shows that anti-CGRP (calcitonin gene-related peptide) is safe and effective in adolescents who have migraines that are refractory to treatments, which is the case here. Furthermore, the patient is tolerating Emgality, and it is effective. Lastly, she has tried and failed two oral preventative medications, and therefore anti-CGRP (calcitonin gene-related peptide) is recommended by the American Headache Society.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Migraine
Treatment: Emgality
The insurer denied: Emgality
The denial is overturned.

The patient is a teenage female with chronic migraines. She started Emgality 6 months ago. Her last clinic visit note is dated last month. Her prior visit was the month before that. Her headache frequency improved to three to four total from the last visit, down from daily headaches. This headache improvement occurred while receiving Emgality. She previously tried and failed Prozac, propranolol, topiramate, and MigreLief. Her neurologist requested continued Emgality use. The request was denied coverage by the health plan as experimental due to not meeting off-label use policy requirements. This was appealed by the treating physician, with a letter noting the patient benefitted from Emgality after prior preventative medication treatment failures. This review is in regard to Emgality use.

The health plan should cover the treatment with Emgality. 

The treatment with Emgality is more beneficial. The patient has chronic migraines. She has tried and failed first-line migraine preventative treatment options. The patient received a CGRP (calcitonin gene-related peptide) inhibitor (Emgality) with marked improvement in headache frequency. There is some efficacy and safety data for CGRP (calcitonin gene-related peptide) inhibitors in the patient's age group. There is a retrospective study of CGRP (calcitonin gene-related peptide) inhibitors used for 
prevention of migraine in adolescent patients, which showed an improvement in the number of headache days and functioning compared to their baseline (Greene). Another retrospective study specific to Vyepti (Eptinezumab) showed a reduction in headaches and good tolerability in 11 patients (Zorrilla). Vyepti is analogous to the other CGRP (calcitonin gene-related peptide) monoclonal antibodies medications, including Emgality, so the results are pertinent. This patient has special circumstances for which CGRP (calcitonin gene-related peptide) inhibitors would be appropriate, as the patient has failed first-line treatments and has already shown a significant clinical benefit since starting Emgality. The patient should be considered as having special circumstances where CGRP (calcitonin gene-related peptide) inhibitors could be considered (Szperka). Other standard treatments for migraine prevention are similar to the failed medications. Emgality has a different mechanism of action which none of the standard options provide. Therefore, CGRP (calcitonin gene-related peptide) inhibitor use is supported in this specific case based on current medical literature and is thus more beneficial than any standard treatment for the patient's migraines. Emgality is medically appropriate per current standards of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Axenfeld's Rieger Anomaly

Treatment: eye surgery (procedure code 0617T)

The insurer denied coverage for eye surgery (procedure code 0617T)

The denial is overturned


The patient has Axenfeld's Rieger Anomaly, resulting in significant iris defects in the right eye and extreme glare symptoms affecting daily activities.  The request was for surgical implantation of an artificial iris prosthesis.

On assessment, visual acuities were 20/100 in the right eye (OD) and 20/20 in the left eye (OS).  Examination showed temporal iridoplasty left eye (OS), early cataract right eye (OD) and posterior chamber intraocular lens left eye (OS).  The patient's Axenfeld's Rieger Anomaly and iris defect is beyond treatment with primary iris repair.  

The patient has a significant iris defect in the right eye as a result of a congenital condition called Axenfeld's Rieger Anomaly. As a result, this has caused glare symptoms and visual disturbance affecting daily activities.  Since the iris defect is too large to repair, an iris prosthesis is medically necessary to minimize the glare symptoms associated with the iris defect.

Based on the above, the insurer's denial must be reversed. 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 eye surgery (procedure code 0617T) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis. 
Treatment: Cibinqo. 
The insurer denied Cibinqo. 
The determination is upheld. 

The patient is a male with nummular dermatitis located all over the body (trunk, upper extremities, and lower extremities). The patient has tried and failed topical triamcinolone cream, and clobetasol ointment, as well as a prednisone taper. The patient was more recently prescribed tacrolimus ointment. Anaphylactic shock is reported for this patient between (four episodes), two of which required emergency room treatment. Because Dupixent and Adbry have risks of anaphylactic shock, these agents have been avoided. At issue is the medical necessity of Cibinqo.
 Although the concerns of the patient's provider about anaphylactic shock from either Dupixent or Adbry are noted, the patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil). Cibinqo is not proven to be superior to all other formulary alternatives as per comparative, controlled studies, and is only Food and Drug Administration (FDA)-approved for second-line systemic therapy behind the other, aforementioned systemic therapies. Therefore, consistent with current medical literature, the requested Cibinqo is not medically necessary.
Modern dermatology literature supports use of the preferred medications as similarly efficacious to the requested Cibinqo, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and this literature recommends use of these preferred agents as appropriate for this patient's clinical scenario. The provider is prescribing and requesting Cibinqo out of convenience and/or preference of the provider and/or patient, and neither convenience nor preference are the same as true medical necessity. Therefore, as per current medical standards of care, Cibinqo is not medically necessary. Cibinqo is not being used as a second-line systemic therapy consistent with Food and Drug Administration (FDA) approval.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Gastrointestinal Bleeding. 

Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient had a history of diverticulosis and presented with left lower quadrant (LLQ) abdominal pain and bleeding. The patient had a mild tachycardia but was hemodynamically stable. By the time of admission the tachycardia had resolved. The abdominal exam was benign. The hemoglobin was 14.9. The abdominal computed tomography (CT) scan was negative for acute findings. The consult note describes brown stool on the rectal exam. The surgeon advised that the bleeding had resolved and advised an outpatient workup. No blood transfusions were needed. The patient was found to have a Meckel's diverticulum. A colonoscopy revealed diffuse diverticulosis with blood in the colon and terminal ileum but no active bleeding. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-182 for Lower Gastrointestinal (GI) Bleeding. Clinical indications for admission include hemodynamic instability, ongoing active bleeding, failure to control bleeding after a colonoscopy, severe coagulopathy, severe anemia with signs of cardiac ischemia, peritoneal signs, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had lower gastrointestinal bleeding that was due to either diverticulosis or a Meckel's diverticulum. The patient was not actively bleeding while in the hospital. The colonoscopy found residual blood in the intestine but no active bleeding. This exam could have been performed during observation care. The patient had a drop in hematocrit but did not require any transfusions. The patient did not meet MCG criteria for admission for Lower GI Bleeding. 

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 a full hospital admission is not substantiated.