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

Diagnosis: Lewy body dementia, catatonic disorder and depression

Treatment: An increase in Patient Care Aide (PCA) services, Level 2, 24 hours per day- live in per diem, 7 days a week.

The insurer denied coverage for increase Patient Care Aide (PCA) services, Level 2, 24 hours per day- live in per diem, 7 days a week
The denial is overturned.

This is a female with Lewy body dementia, catatonic disorder and depression. She is temporarily living with a sibling as her (primary care giver) mother has recently died. The insurer approved PCA services 9 hours/day, 7 days a week. Under review is the requested increase in Patient Care Aide (PCA) services, Level 2, 24 hours per day- live in per diem, 7 days a week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as "severely impaired." She requires maximal assistance for activities of daily living including bathing, dressing and personal hygiene. Toilet transfers/use requires maximal assistance. The patient is bowel and bladder incontinent. Her activity level has "deteriorated" over the past 90 days. In addition, the patient's mother died and was the primary care giver, when the PCA was not present. The combination of the patient's progressive dementia, functional decline and significant change in her home care circumstances support the requested increase in Patient Care Aide (PCA) services, Level 2, 24 hours per day- live in per diem, 7 days a week, as medically necessary.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  

From a physical medicine and rehabilitation perspective, Patient Care Aide (PCA) services, Level 2, 24 hours per day- live in per diem, 7 days a week, is medically necessary.  

The insurer's denial of coverage for personal care aide (PCA) services, Level 2, 24 hours per day - live-in per diem, 7 days a week is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 

The insurer denied thermal destruction of intraosseous basivertebral nerve. 
The denial is upheld. 

The patient is a male with a history of low back pain. The pain has been present for over 10 years. Prior treatments have included exercises, injections, as well as medications. Patient has trialed non-steroidal anti-inflammatory drugs (NSAIDs) and other agents. activities of daily living (ADLs) are restricted. The patient's pain is rated 8 out of 10. Magnetic resonance imaging (MRI) lumbar spine reported lumbar (L)4-5 and L5-sacral (S)1 degenerative changes. The patient is noted to have chronic low back pain, from the vertebrogenic changes. The subject under review is whether the requested procedure requested is likely to be more beneficial for this patient's back pain then any standard treatment. 

The health plan's determination is upheld. 

The proposed health service or treatment thermal destruction of intraosseous basivertebral nerve is not likely to be more beneficial than any standard treatment or treatments for the patient's back pain. 

The patient has complaints of low back pain. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. Given the above, the proposed treatment thermal destruction of intraosseous basivertebral nerve is not likely to be more beneficial than any standard treatment or treatments for the patient's back pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 

The insurer denied thermal destruction of intraosseous basivertebral nerve. 
The denial is upheld. 

This is a male with diagnoses of low back pain and vertebrogenic low back pain. The patient was recommended to undergo the Intracept procedure, which was denied by the insurance carrier as experimental and investigational. 
The letter of appeal from the provider states that the denial was not appropriate. The provider states that this is an innovative procedure to address chronic low back pain identified by Modic changes and fulfills a treatment gap for patients with chronic low back pain. The provider states that the patient has had low back pain that began over 10 years ago and has had multiple treatments including home exercises, lumbar epidural steroid injections and medication management. Medications have included non-steroidal anti-inflammatory drugs (NSAIDs) and over-the-counter (OTC) medications. Nothing has provided significant relief and the patient's pain is rated at 8/10. The provider states that the patient's magnetic resonance imaging (MRI) shows mixed Modic type I and II changes at disc spaces lumbar (L)4 - L5 and L5 - sacral (S)1 and therefore the patient's pain is coming from vertebrogenic changes at these levels. The provider is requesting that the denial be overturned. The subject under review is whether the requested Intracept procedure is likely to be more beneficial for this patient's back pain than any standard treatment. 

The health plan's determination is upheld. 

The patient is noted to have a history of chronic back pain and radicular symptoms that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). However, there were multiple findings on MRI that are likely pain generators including subarticular stenosis, neural foraminal narrowing, and facet arthropathy at multiple levels. Additionally, it appears the patient has only used OTC NSAIDs/Tylenol with no indication of having exhausted prescription strength medications. This procedure remains unproven as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. 
This treatment is not currently considered standard of care in the general medical community. There is a lack of high-grade evidence and large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure. There is no evidence to suggest that this treatment is likely to be more beneficial than other standard treatments for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 

The insurer denied thermal destruction of intraosseous basivertebral nerve. 
The denial is upheld. 

The patient is a male who has a medical history of neck pain and low back pain. His low back pain is in the left side with radiating pain down to left buttock and left lateral thigh into the knee and calf. He had a caudal epidural injection with 50% pain relief. He takes nonsteroidal anti-inflammatory drug (NSAID) and Tylenol with mild relief. The intensity of low back pain is 5/10. Physical exam (PE) revealed decreased range of motion (ROM) of lumbar spine, bilateral paraspinal tenderness, and positive straight leg raise test on the left and positive facet loading. Magnetic resonance imaging (MRI) reveal multilevel degenerative disc disease worse at lumbar (L) 4-5 and L5-S1 with Modic type 1 and type 2 changes, facet arthropathy at L4-5 and L5-S1 levels, a disc bulge asymmetric to the left with severe left neuroforaminal narrowing and moderate subarticular stenosis at L5-sacral (S)1 level. The treatment plan was to consider left L3, L4, L5 medial branch blocks and schedule Intracept procedure. The subject under review is whether the Intracept procedure is likely to be more beneficial for the patient than any standard treatment. 

The health plan's determination is upheld. 

The Intracept system was designed to treat low back pain from vertebral body by ablating basivertebral nerves. Reviewing of the available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. This patient responded to a prior lumbar epidural injection, which indicated lumbar radiculopathy is a significant pain generator. In addition, he has signs and symptoms consistent with lumbar facet arthropathy. MRI revealed findings of multilevel disc bulges, facet joint arthropathy, and moderate spinal stenosis. Truumees's study supported the efficacy of Intracept procedure. However, the patients with clinical evidence of other pain etiologies including disc bulge, facet arthropathy and radicular pain were excluded from the study. (1) 

Given this patient's medical history, MRI reading, and the current clinical evidence, he is not an appropriate candidate for this Intracept procedure. The proposed Intracept procedure is unlikely to be more beneficial than any standard treatment for this patient's back pain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is overturned. 

The patient is a female who presents for evaluation and treatment of her entire dentition. Provided for review are previous letters of appeal and denial, a treatment plan with diagnosis explaining the presence of deep impinging overbite with severe soft tissue damage.

Braces and Monthly Visit (x12) are medically necessary for this patient. Based on the provided documentation, there is deep impinging overbite and soft tissue damage according to the provider which is an automatic qualifier for the requested treatment. According to the HLD (Handicapping Labio-Lingual Deviations) index, there is not a need to calculate a score once there has been a diagnosis of deep impinging overbite with severe soft tissue damage as is the case here. Hence, braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Temporal Pain, Blurred vision.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of Parkinson's disease, cerebrovascular accident (CVA), hypertension (HTN) and hyperlipidemia (HLPD) who was admitted with complaints of (c/o) right-sided temporal pain associated with blurred vision. Vital signs were unremarkable. The physical exam was notable for right temporal tenderness to palpation (TTP), no focal deficits. Lab work showed a slightly elevated troponin and normal C-reactive protein (CRP), normal erythrocyte sedimentation rate (ESR). A temporal artery ultrasound (US) showed bilateral patent temporal arteries. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with headache/possible temporal arteritis and treated with steroids and acute coronary syndrome (ACS) rule-out. Rheumatology evaluated the patient and determined giant cell arteritis (GCA) was unlikely. For the chest pain, a nuclear stress test (NST) was deemed appropriate for outpatient work-up. The patient was discharged against medical advice. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. 

This patient presented to the emergency department (ED) with complaints of (c/o) a headache associated with blurred vision. A computed tomography (CT) scan in the ED did not demonstrate any acute intracranial pathology. This patient did not have a life-threatening cause of the headache, evidence of increased intracranial pressure (ICP), tumor, hydrocephalus, intracranial bleed, acute or subacute cerebrovascular accident (CVA), acute central nervous system (CNS) infection (encephalitis, brain abscess) or bacterial meningitis. In addition, the patient did not require immediate surgical intervention, have a hypertensive emergency, acute alteration in mental status, co-existing seizures, nuchal rigidity, acute visual loss, new focal neurologic deficits, apnea, abnormal respiratory pattern, or significantly abnormal vital signs. There was clinical concern for GCA on admission, which was felt unlikely by rheumatology after biochemical and imaging work-up. Overall, this patient was admitted for clinical concern of GCA, which was ultimately deemed unlikely, and treated with ACS rule-out and steroids with expert consultations, and this uncomplicated hospital stay could have safely occurred at an observation level of care.
Regarding the Milliman Care Guidelines for Headaches, the patient did not have severe headache, severe altered mental status (AMS), severe vomiting, severe dehydration, aneurysm, arterial dissection, venous sinus thrombosis, increased ICP, cerebrospinal fluid (CSF) leak, medication over-use headache, vasculitis requiring inpatient monitoring, severe (new) neurologic findings requiring inpatient care, or new-onset focal neurologic deficit.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient stay.
The insure denied the inpatient stay. 
The health plan's determination is upheld.

This case involves a patient with known asthma, multiple emergency department (ED) visits and multiple admits, including 2 Pediatric Intensive Care Unit (PICU) stays, who was admitted to the pediatric floor. In the ED, he received, intravenous (IV) magnesium sulfate, and IV steroids. Following admission, he was placed on albuterol via nebulizer q (every) 3h (hours), oral steroids, and IV fluids. Albuterol was changed from nebulizer q3h to q4h. Per the notes, he had equal air entry bilaterally, scattered rhonchi, no acute distress, normal breath sounds, and/or bilateral expiratory wheezes. Per the notes, IV fluids were started for spitting after coughing. 

The inpatient hospital admission is not medically necessary for this patient. 

Based on the records provided, there was not decreased breath sounds with tight chest, and no signs of respiratory distress. The patient was reported to be comfortable on room air and has normal pulmonary effort. The oxygen saturations were all above 92% on room air. The patient received by mouth (PO) steroids. IV fluids were given overnight for excessive cough with post-tussive spitting. Per the history and physical (H&P), the patient was not seen by the attending physician, as the parent refused them access. The patient was only seen by the resident, and later, a consultant. Although this patient had severe symptoms in the ED and had previous PICU admissions, he did not exhibit any more signs or symptoms of respiratory distress in the hospital. There were no examination findings inpatient that supported the frequency of breathing treatments that are generally reserved for the inpatient setting. A lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was brought to the emergency department (ED) with three weeks of looser, non-bloody stools and two days of non-bilious, non-bloody vomiting. He had been seen by his pediatrician three days prior, who thought he had viral gastroenteritis. The next day, he went to an urgent care where he received some intravenous (IV) fluid and appeared improved, but on the day he was brought to the ED, the parents were concerned by 2-3 episodes of diarrhea and decreased oral intake. In the ED, he was thought to be dehydrated, so he received two normal saline boluses. Lab results were normal except for a bicarbonate (bicarb) of 16. The blood urea nitrogen (BUN) was 7. An ultrasound was consistent with enteritis. He was admitted for further management. On arrival to the pediatric ward, his exam was normal except for a mild diaper rash. He had normal perfusion and moist mucus membranes. The admitting impression was that he had viral gastroenteritis. He was continued on IV fluid as well as offered food and drink by mouth, which increased in amount and toleration. He was discharged home.
At issue is the medical necessity of an inpatient stay.

No, the acute inpatient stay was not medically necessary. The patient was not significantly dehydrated based on the physical exam (he had moist mucus membranes, normal perfusion) or laboratories (although his bicarb was 16, his BUN was low; the mildly low bicarb was less likely an acidosis due to dehydration than it was due to hydrogen (H+) loss in the vomit). Although he was vomiting, he was still taking fluids by mouth, and there was no indication that he could not sustain his hydration. To whatever extent he was "dry," he was completely fluid repleted after two normal saline boluses. Care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease. 
Treatment: Stelara. 

The insurer denied the Stelara. 
The determination is overturned. 

The patient has stricturing Crohn's disease complicated by ileocolic resection. He failed Humira, with testing showing undetectable Humira and a high anti-Humira antibody level. A colonoscopy showed ileal and ileocecal valve stenosis requiring dilation, as well as ileal inflammation and ulceration. He had an ileocolic resection, showing strictures, adhesions, and abscess. Stelara is requested for the treatment of Crohn's disease. The request was not approved as infliximab biosimilars and Entyvio have not been attempted.
At issue is the medical necessity of Stelara. 

Yes, current medical literature supports the medical necessity of Stelara in this case over the formulary alternatives of infliximab and Entyvio. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al). Another study showed a 73% response in patients with anti-TNF-resistant Crohn's disease, and 80% of responders maintained remission for 1 year (Kopylov, et al). A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed (Tuskey, et al). A recent study demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara (Wils, et al). Furthermore, the most recent guidelines for the treatment of Crohn's disease (2021 American Gastroenterological Association guidelines) state that, "In adult outpatients with moderate to severe Crohn's disease who previously responded to infliximab (secondary nonresponse), the American Gastroenterological Association (AGA) recommends the use of adalimumab or ustekinumab and suggests the use of vedolizumab over no treatment for the induction of remission. Comment: If adalimumab was the first-line drug used there is indirect evidence to suggest the option of using infliximab as a second-line agent." - Stelara is recommended, whereas Entyvio is suggested, and infliximab is suggested as second-line (Feuerstein, et al). Additionally, there is prospective study data which supports the greater efficacy of Stelara compared with Entyvio when used for the treatment of Crohn's disease (Biemans, et al). Another larger study concurred (Manlay, et al). 

In this patient with severe disease (given the need for surgical resection), and risk for complications such as fistula, stricture, and need for further surgery, the use of Stelara is more appropriate than Entyvio. For these reasons, the request for Stelara should be considered medically necessary for the treatment of his Crohn's disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Surgical Services. 
The insurer denied trigeminal nerve stimulation. 
The denial is overturned.

The patient is a female with a long-standing history of trigeminal neuralgia. She is status post craniectomy and cranioplasty. She underwent a psychological evaluation and was deemed a surgical candidate for stimulator trial. She was seen by a neurosurgeon after failing the best medical management and continues to have severe, intractable pain that interferes with her quality of life and activities of daily living. She currently takes Cymbalta and Neurontin. She is a non-smoker and non-drinker. Her exam is normal. She has pain in the left scalp, left periorbital and left perioral region. She underwent a trial left trigeminal stimulator. The patient reports attempting medications, gamma knife treatments, microvascular surgery with imaging showing compression on trigeminal nerve and Botox injections that have all failed and made her pain worse, as well as side effects from the Botox that resulted in not being able to close her left eye. She currently takes 2,400 milligrams (mg) of gabapentin and 30 mg of amitriptyline with side effects of sleepiness, hunger and lethargy with minimal pain relief as well as Xanax .25-.5 mg for anxiety. She reports that the trial provided 60-80% improvement in pain and was able to function each day more than the next. magnetic resonance imaging (MRI) and computed tomography (CT) brain reviewed. Her pain is rated 8/10. The subject under review is the permanent placement of the nerve stimulator, whether this will be of greater benefit to the patient than standard treatment.

The stimulator is more likely to be beneficial than any other standard treatment. The patient has tried multiple medications, gamma knife treatments, microvascular surgery and Botox injections with resultant side effects from medication and Botox. It appears she has exhausted all possible clinical treatments without much relief.

Treatment of TN (trigeminal neuralgia) is still challenging, as individual responses to different therapeutic options may vary considerably. Only a few available therapy options have confirmed efficacy fulfilling current standards for evidence-based medicine. However, novel therapeutic options are on the rise; for the first time, substances are in clinical testing on larger patient populations specifically for this very disabling but rare disease. Outcome predictors and risk factors for treatment failure are being systematically assessed more and more so that an individual patient-guided treatment decision can be made. The continual effort by clinicians, researchers, and the pharmaceutical industry may soon provide therapeutic options that are more tolerable, more specific, and more efficient for patients with TN. (3)