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

Diagnosis: Hip Pain
Treatment: Hip Replacement
The health plan denied the requested Hip Replacement as not medically necessary. 
The health plan's determination is overturned.

This is a male who was diagnosed with severe bilateral hip osteoarthritis. The appeal request states that the patient has severe bilateral hip osteoarthritis, right greater than left. The prior treatment has included cortisone injections and oral medications with no relief. The surgery was previously denied due to the patient being a smoker. The provider notes that the patient has not smoked in preparation for the surgery. There is a clinical note documenting evaluation of the right hip. The hip pain has been ongoing for years. The prior treatment has included steroid injections, Ibuprofen, Tylenol, physical therapy, and activity modification. Objectively, there is pain with logrolling of the hip, pain with flexion and rotation with limitations, and groin and buttock pain on examination. The x-rays of the right hip are noted to show severe osteoarthritis with complete loss of joint space and marginal osteophytes. The plan was for surgery. There is a clinical note documenting a visit regarding right hip pain. The note states that the patient quit smoking in preparation for the surgery. The medication list includes Meloxicam. The comorbidities include chronic obstructive pulmonary disease (COPD), cerebrovascular accident, depression, hyperlipidemia. The treatment plan includes the hip arthroplasty.
This is a request for review of ambulatory surgery-hip replacement.

The recommendation is to overturn the health plan's determination of medical necessity.

Yes. The request was previously recommended for noncertification, as the initial documentation had suggested that the patient was a current smoker which is associated with a known risk of perioperative complications. The updated documentation clarified that the patient has not smoked in preparation for the surgery.
The article from Lancet states that a hip arthroplasty is a frequently done, highly successful surgical intervention undertaken for those who have advanced osteoarthritis of the hip. The article from Statpearls states that a total hip arthroplasty for hip osteoarthritis shows specifically pain relief, functional restoration, and improved quality of life. In this case, the patient has well-documented severe osteoarthritis of the right hip that has been insufficiently managed with steroid injections, Ibuprofen, Tylenol, physical therapy, and activity modification. Further nonoperative treatment in the setting of advanced osteoarthritis would not be expected to provide meaningful benefit and could result in progression of the derangement and a worse prognosis. The recommendation is for certification of the ambulatory surgery-hip replacement.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems- Class I occlusion on right and left.
Treatment: Dental/Orthodontic Procedure- Comprehensive orthodontic treatment.
The insurer denied Comprehensive orthodontic treatment.
The denial is upheld. 

The patient is a female who presented with Class I posterior occlusion on right and left, mild rotations and spacing on upper and lower, with estimated overjet of 1-millimeter (mm), estimated overbite of 1mm at maxillary central incisors, estimated overbite of 0.5mm at maxillary right lateral incisor, and estimated overbite of negative (-)1mm at maxillary left lateral incisor.
At issue is the medical necessity of Comprehensive orthodontic treatment.

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

The requested health service/treatment of Comprehensive orthodontic treatment is not medically necessary for this patient.
Orthodontic treatment in this patient is not medically necessary in order to address eating, speech, breathing difficulties, or to prevent permanent damage to the teeth and/or supporting oral structures (temporomandibular joint(s), bones, soft tissues, intra and/or extra oral muscles). There is not a severe handicapping malocclusion as a result of the existing relationship between the maxillary (upper) and mandibular (lower) dental arches and/or teeth. Under these generally accepted standards, the orthodontic treatment is not medically necessary.
Therefore, the requested health service/treatment of Comprehensive orthodontic treatment is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Upheld

The patient is a male with a complex past medical and surgical history who presented to the emergency department (ED). He has a history of acute traumatic pancreatitis and had been discharged 2 weeks earlier to a nursing facility after a long hospital course complicated by adult respiratory distress syndrome (ARDS), multiple intubations, cardiac arrest, tracheostomy, colostomy, intra-abdominal drain placements. His complaint was that of abdominal/flank pain. He had come to the hospital for outpatient follow up appointments but was waiting on a stretcher for several hours and this acutely worsened his pain. The patient reported an improvement in his pain level. The heart rate had normalized to 78/minute. The white blood cell (WBC) count was down to 7.13 thousand (K). Pain management, surgery, and pulmonary consultations were obtained. The patient was described as not being in acute distress. The tracheostomy was removed. An abdominal computed tomography (CT) scan showed resolution of a prior small bowel obstruction and a midline enterocutaneous fistula. He was receiving the ongoing pain regimen. He was tolerating a regular diet. Physical therapy assessed the patient. He was stable post removal of the tracheostomy. He was receiving local wound care and pain management. Discharge planning was in process. Progress notes state that the patient was clinically stable and was medically cleared for discharge. The subject under review is the medical necessity for the inpatient stay.

The inpatient stay was not medically necessary for this patient. The submitted records support that this the patient presented to the hospital ED with a complex past medical history. However, he had no acute medical issues than mandated admission to inpatient status. He was assessed in the ED and by medical, surgical, pulmonary, and interventional radiology consultants and was determined to be clinically stable for return to a skilled nursing facility. He did not require acute surgical or interventional treatment and remained stable throughout the period of monitoring. Although this patient had a complex past medical history and ongoing chronic medical issues, the care and treatment provided could have been rendered with a lower level of care than inpatient status. Based on the submitted medical records, the medical necessity of inpatient stay is not established. A lower level of care would have satisfied the clinical needs of this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems-Maxillofacial Deformity.
Treatment: Dental/Orthodontic Procedure.
The insurer denied Periodic Orthodontic Treatment Visit services.
The denial is overturned. 

The patient is a male who has treatment planned for orthodontics and orthognathic surgery. Orthognathic surgery to correct a maxillofacial deformity and orthodontic care are recommended.
At issue is the medical necessity of Periodic Orthodontic Treatment Visit.

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

Yes, the requested health service/treatment of Periodic Orthodontic Treatment Visit services is medically necessary for this patient.
This patient presented with an anterior crossbite and a skeletal jaw imbalance. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. 
The patient has significant spacing with all maxillary teeth in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. He is already damaging his lower central incisors. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons orthodontic treatment is medically necessary.
Therefore, the requested health service/treatment of Periodic Orthodontic Treatment Visit services is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: plantar fasciitis
Treatment: Custom shoe inserts
The insurer denied Custom shoe inserts
The denial is overturned.

The patient is a male with a past history of bilateral congenital metatarsus adductus, bilateral acquired flat feet, and current plantar fasciitis. According to the appeal form submitted by the provider, he has been wearing previously covered L3000 orthotics for both feet, which he has now outgrown and are causing him pain. The provider has submitted an authorization request for new, proper sized L3000's. In the past, per the provider, the patient has tried exercises and other conservative measures. The health plan's initial denial stated the medical records do not show the patient had recently tried and failed all other treatments including stretching, change in activity, certain medications for pain/swelling, and over the counter shoe inserts. The subject under review is the medical necessity for custom shoe inserts.

The requested custom shoe inserts are medically necessary for this patient. There are medical records demonstrating that the patient has a prior history of congenital bilateral metatarsus adductus and then bilateral flat feet. A progress note references treatments and custom orthotics going back several years. A progress note references the prior note and states the patient had not used orthotics for 1.5 years, and at that time, exercises and another prescription for custom orthotics was provided. At one point he required a cam-walker. At the follow up, it was noted the custom orthotics for flat feet had become too small, and he was having pain with walking and standing for a few weeks. Another prescription for orthotics was provided to replace the pair that was too small. Although prior requests, according to the provider and parent, had been authorized by the same insurance company, this request was denied. The health plan denial does not provide an explanation for why a patient already successfully using custom orthotics to treat a covered condition would have to go back to "failing" over-the-counter orthotics prior to receiving proper sized replacement custom orthotics. There is sufficient information in the medical record and appeal documentation to support the medical necessity of replacing the previously approved custom orthotics with new, proper sized orthotics.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Outpatient procedures (64628 x 1, 64629 x 1), Radiofrequency ablation (RFA) of basivertebral nerves at L (lumbar) 4, L5 and S (sacral) 1.
The insurer denied coverage for Radiofrequency ablation (RFA) of basivertebral nerves at L4, L5 and S1.

The denial is overturned.

This is a male with a history of lower back pain. He presented to the Pain Management physician's office for a follow-up visit for lower back pain. Radiofrequency ablation was previously performed. The patient reported that he experienced pain relief. The pain was rated at a level of 6 out of 10. The patient takes Percocet and cyclobenzaprine. The physician recommended the Intracept procedure to treat back pain.  

There are RCT (randomized controlled trials) that show its effectiveness at two years. 

Intracept is medically indicated/FDA (food and drug administration) approved for use in patients who have the following: a history of low back pain of at least 6 months duration; and failed to respond to at least 6 months of non-surgical management;  magnetic resonance imaging (MRI) demonstrated Modic Type 1 or Type 2 changes at one or more vertebrae from L(lumbar)3 to S(sacral)1; activities of daily living that are limited by persistent low back pain; and all other reasonable sources of pain have been ruled out.

This patient meets all criteria above with axial low back pain of more than 24 months duration that has been refractory to conservative approaches including but not limited to PT (physical therapy) home exercises, non-steroidal anti-inflammatory drugs (NSAID), opiate analgesics, radiofrequency ablation (RFA) and spinal injections. He has documented MRI findings consistent with Modic changes at L4-L5 and L5-S1. His ADLs (activities of daily living) are limited by low back pain, with the inability to stand or walk for extended periods due to pain. All other reasonable sources of pain have been ruled out.

This is a young male patient with chronic low back pain, which has failed conservative treatments - physical therapy (PT), home exercises, NSAIDs, opiate analgesics, RFA, and spinal injections. His pain is affecting his ability to function and perform activities of daily living (ADLs) and has been of a long-term duration greater than 24 months. His back pain is associated with Modic Type 1 and Modic Type 2 changes at L4-L5 and L5-S1 as documented on MRI. He would like to avoid invasive surgical procedures as well as repeated RFA and epidural injections.  

Based on peer-reviewed literature and the medical information provided, the requested service Intracept procedure would be more beneficial than continued standard treatments/procedure for this particular patient without increased risk.

The carrier's denial of outpatient procedures (64628 x 1, 64629 x 1), intraosseous nerve ablation, should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Outpatient procedures (64628 x 1, 64629 x 1), Radiofrequency ablation (RFA) of basivertebral nerves at L (lumbar) 4, L5 and S (sacral) 1.
The insurer denied coverage for Radiofrequency ablation (RFA) of basivertebral nerves at L4, L5 and S1.
The denial is upheld.

This is a male with a history of lower back pain. He presented to the Pain Management physician's office for a follow-up visit for lower back pain. Radiofrequency ablation was previously performed. The patient reported that he experienced pain relief. The pain was rated at a level of 6 out of 10. The patient takes Percocet and cyclobenzaprine. The physician recommended the Intracept procedure to treat back pain.  

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 in patients who no longer require narcotics. For one level of disc disease, each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeons or spine surgeons. There are no National Organizations that provide guidelines or indications. 

A search was performed using PubMed. The key word was Intracept Lumbar. There were references. The articles submitted by the appeal were also reviewed. There were small numbers of people evaluated for a short duration. The references submitted showed studies of 50-150 patients with adverse effects. This patient has several other conditions that more than likely could be causative of his pain. i.e., he has herniations at every level and associated stenosis. 

The procedure is currently being performed by an investigative group and likely an IRB. (Investigational Review Board). The procedure is not a mainstay nor currently accepted treatment by the practicing medical community. 

The requested service is not likely to be more beneficial than any of the standard treatments for this patient. 

There are several level 1 studies showing the benefit of this procedure up to 2 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. As such, at this time the Intracept procedure is experimental/investigational and therefore not medically necessary.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes. FDA (food and drug administration) approval has been granted but no statement about efficacy or outcomes. 

This patient is not a good candidate for outpatient procedures (64628 x 1, 64629 x 1), or intraosseous nerve ablation and this is not the best available treatment for this patient at this time. The adverse risks are increased over standard treatment/services.

The carrier's denial of outpatient procedures (64628 x 1, 64629 x 1), and intraosseous nerve ablation should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ankle Sprain.
Treatment: Durable Medical Equipment (CAM walker boot).

The insurer denied the Durable Medical Equipment (CAM walker boot).
The denial is overturned.

The patient is a female who injured her right ankle. She was evaluated by a PA (physician assistant). The patient was running and stepped in a pothole. She heard a pop.

The patient's physical examination was significant for the following: antalgic gait, swelling and global tenderness. Her BMI (body mass index) was 33. Motion was decreased.

X-rays showed no fracture. The patient was diagnosed with a sprain. She was advised to use a walking boot.

Yes, the requested health service is medically necessary.

The records show a traumatic event occurred with resultant right ankle problems. There was consistency of subjective complaint, physical finding and diagnosis. The treatment would be protection against asymmetrical ankle forces. A pneumatic walking boot would hold the ankle in position and assist in healing/protection.

Therefore, given the above, the requested health service was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission

The denial is overturned

This is a male with a history of a previous hospitalization for a respiratory illness. He was exposed to a dog 4 days prior to the hospitalization and had acute allergy symptoms. He then had 3 days of a dry cough and chest congestion. On the day of admission, it was noted it took increased work to breathe and he had retractions when he woke up coughing at 3 AM (morning). He improved after receiving a dose of albuterol. Three hours later he woke up coughing and with worsening respiratory symptoms. His mother brought him to the emergency room (ER) for further treatment.

In the ER, he was noted to be in respiratory distress with nasal flaring, suprasternal, abdominal and subcostal retractions and wheezing. His pulse oximeter reading was 92%. He was started on supplemental oxygen, and he received 3 doses of Combivent and prednisone. On physical examination he continued to have increased work of breathing and wheezing. He was treated with intravenous (IV) magnesium sulfate and an IV bolus of normal saline. He then was continued on albuterol every 2 hours. His pulse oximeter continued to be low at 93% and his HCO3 (bicarbonate) was 18. Since he continued to have an increased work of breathing and bilateral wheezing, the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus for continued treatment with albuterol every 2 hours

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment.

The patient was treated appropriately in the ER for an acute episode of wheezing, hypoxemia and difficulty breathing. The child has a history of a previous hospitalization for a respiratory illness. When he did not respond to treatment in the ER and he was noted to have hypoxemia and acidosis despite oxygen supplementation and IV fluids, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing oxygen supplementation and albuterol every two hours. He was not stable enough to be safely discharged. 

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 an inpatient is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Cardiac
Pharmacy/prescription drugs

Diagnosis: atrial fibrillation
Treatment: Eliquis (apixaban)
The insurer denied Eliquis (apixaban). The health plan's determination is upheld.

The patient is a woman with a history of nonobstructive coronary artery disease, hypertension, hyperlipidemia and paroxysmal atrial fibrillation. Coverage for apixaban (Eliquis) for thromboprophylaxis is at issue.

A formulary exception is not indicated in this case. The formulary alternatives include warfarin, a vitamin K antagonist, and rivaroxaban (Xarelto) which, like apixaban (Eliquis), is a direct oral anticoagulant (DOAC).
Warfarin would be expected to be less safe and less effective in this instance as compared to apixaban. Data from multiple randomized controlled trials have shown that use of DOACs, as compared to warfarin, for thromboprophylaxis in atrial fibrillation has been associated with fewer ischemic events and fewer severe bleeding episodes. While retrospective studies have suggested that apixaban is superior to rivaroxaban when used for thromboprophylaxis in patients with atrial fibrillation, there have been no randomized controlled trials addressing this issue and direct comparison is confounded by differences in enrollment criteria in the different studies. Thus, to date, it is not clear that rivaroxaban would be less safe or less effective in this particular case. Current guidelines do not specify the use of one DOAC over another in this situation. The patient can try Xarelto. A formulary exception is not indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD
Treatment: LINX procedure
The insurer denied the LINX procedure. The health plan's determination is overturned. 

The patient is a female status/post (s/p) sleeve gastrectomy with persistent reflux, hiatal hernia and esophagitis. Her body mass index (BMI) is 23.6. She is being treated with omeprazole. She has been on daily acid suppression without relief. An esophagogastroduodenoscopy (EGD) shows hiatal hernia and esophagitis. 

The LINX Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This patient does not have other good options for treatment. Medications have not worked, and conversion to Roux en Y bypass carries significant risk and morbidity. The development of Barrett's and a premalignant condition is a real risk.
The LINX system is the least invasive and most beneficial option compared to current other options. Someone who has had a sleeve gastrectomy will not be able to have a Nissen fundoplication as the stomach is not large enough to perform a wrap (her upper gastrointestinal (UGI) series provided with the medical records confirm this).