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

Diagnosis: Prep for dental implants
Treatment: CT Scan (total of three)
The health plan denied CT Scan (total of three). The denial is overturned.

The patient is an adult female who is going to have dental implants.

The health plan denied coverage of CT (computed tomography) scans, because the Dental Director said that these were only needed for "facial abnormalities, implants or skull fractures." The denial is being appealed.

The patient is to have dental implants. On the claim form submitted, Section 35 under remarks, the provider has written, "Before placing dental implants in bone, we need to check the health of the bone to see if the bone is healthy and can hold a dental implant. CBCT [cone beam computed tomography] is needed to check the health of the bone." The literature referenced below reinforces the use of CT (computed tomography) scans when placing dental implants.

There are many reasons that a CT (computed tomography) may be needed besides "facial abnormalities, implants and skull fractures." CT scans are routinely used to determine the position of tooth roots in relation to vital structures, to diagnose fractures of the mandible, maxilla, nasal and orbital bones. They are used in the planning stages of implant placements. They are also used to determine the extent of cysts of the maxilla and mandible and the extent of bone infections.

Therefore, given the above, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Atypical Teratoid Rhabdoid Teratoma (AT/RT).
treatment:  Tazverik (tazemetostat).

The insurer denied Tazverik (tazemetostat).  The health plan's determination is overturned.

The patient is a male who presented for care with a 5 centimeter (cm) cystic/solid minimally enhancing mass in the 4th ventricle/left foramen of Luschka with heterogeneous restricted diffusion, and multifocal leptomeningeal dissemination. He had a stereotactic guided subtotal resection and the pathology was consistent with atypical teratoid rhabdoid tumor (ATRT). He was started on treatment as per the Children's Oncology Group (COG) protocol. Stem collection happened and she started the second induction. A lumbar puncture was performed that showed continued rare tumor cells, and the magnetic resonance imaging (MRI) of the brain and spine showed increased ventriculomegaly with diffuse leptomeningeal spread but no definite tumor progression at the primary site. The auto-transplantation was completed. The provider is now recommending treatment with Tazverik (Tazemetostat).

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment, and in the best interest of the patient.

Yes, the requested health service/treatment of Tazemetostat is medically necessary for this patient. This patient has a likely terminal brain tumor with her ATRT with leptomeningeal spread. There are currently no clear Food and Drug Administration (FDA) approved treatments for this type of cancer, and historically, this disease has almost been uniformly fatal. The provider has recommended treatment with Tazemetostat, a selective enhancer of zeste homolog 2 (EZH2) inhibitor, noting that it has previously shown at least some antitumor activity in ATRT cases. As per a recent review of this topic, epigenetic altering drugs such as Histone Deacetylase (HDAC) inhibitors, Panobinostat and Tazemetostat and Ribavirin may restore epigenetic balance to ATRT. There is in vivo mouse data to support this therapy, and the dosing of this product has previously been determined in pediatric patients.

Given the rarity of this likely terminal disease using the current therapies, and no FDA approved medications for this type of cancer, the use of Tazemetostat is clinically appropriate and has a possibility of being at least somewhat effective. There are no other standard treatment options at this time. Therefore, this request should be approved as medically necessary at this time.

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

Diagnosis: Kidney disease, hypertension and peripheral vascular disease

Treatment: Personal care aide (PCA) level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week

The insurer denied coverage for PCA level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week

The denial is overturned.

This is an elderly male with chronic medical problems including kidney disease, hypertension and peripheral vascular disease.  According to his treating physician, the patient is terminally ill, enrolled in a Visiting Nurse Service (VNS) hospice program (nursing facility) and reportedly has less than 6 months to live.    Upon his return home, the insurer indicated it will approve PCA level 2: 10.5 hours/day - 7 days per week for a total of 73.5 hours per week.   The request is for personal care aide (PCA) level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week.

The recent Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as severely impaired.  He is totally dependent for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  He is also totally dependent for bathing, personal hygiene, dressing, bed mobility, locomotion and toilet transfer/use.  He is incontinent of bladder and bowel.  The patient is essentially bed bound and non-ambulatory.  

The patient's functional ability has decreased when compared to the previous UAS report. He is currently a resident in a skilled nursing facility.  According to the notes from the nursing facility, the patient "is totally dependent on the staff for all aspects of Activities of Daily Living (ADL) care."  The patient's medical condition, severe cognitive deficits and physical limitations are at the level or unpredictable as to require the requested PCA level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week.

Based on the records reviewed, a live-in PCA is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep.  The patient's functional needs would be more appropriately provided and maintained with the requested PCA level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week.

From a physical medicine and rehabilitation perspective, personal care aide (PCA) level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week is medically necessary.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care aide (PCA) level 2, 12 hours/day - 7 days per week; 12 hours/day - 7 days per week - for a total of 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myasthenia Gravis
Treatment: Eculizumab, 10 milligrams
The insurer denied Eculizumab, 10 milligrams.
The determination is overturned.

This is a female patient who has a listed diagnosis of myasthenia gravis. The records indicate that the patient has previously failed prednisone, mycophenolate, thymectomy and intravenous immunoglobulin and persists with intermittent dysphagia and dyspnea. Eculizumab is requested and under review for medical necessity.

Yes. Eculizumab, 10 milligrams (mg) is medically necessary for this patient.

The patient remains disabled due to myasthenia gravis, despite multiple treatment failures. Eculizumab is proven, Food and Drug Administration (FDA) approved, and may be lifesaving. There is insufficient evidence from high-quality peer-reviewed literature, large, well-designed, blinded, randomized trials to support the long-term superiority of the remaining alternatives, over Eculizumab. It should be noted that the criteria requires high scores of Myasthenia Gravis-Activities of Daily Living (MG-ADL); however, such scores are neither required by the manufacturer or by the FDA.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: breast cancer status post-surgery and chemotherapy, chronic fatigue.

Treatment: Personal Care Aide 40 hours/week, Consumer Direct, 1 Client.

The insurer denied coverage for Personal Care Aide 40 hours/week, Consumer Direct, 1 Client.

The denial is overturned.

 
This is a female patient who has been diagnosed with a history of multiple medical problems, including breast cancer status post-surgery and chemotherapy, chronic fatigue, and pain in both axillae. The patient is limited and needs assistance in all her activities of daily living (ADLs), including cooking, personal hygiene, transfers, and housekeeping chores. The request is for Personal Care Aide 40 hours/week, Consumer Direct, 1 Client, which is under review.

The patient is limited and needs assistance in most of her activities of daily living (ADLs), thus 40 hours a week is reasonable request for the safety of the patient. Personal Care Aide 40 hours/week, Consumer Direct, 1 Client is medically necessary for this patient.

"This includes assessment systems for adults in inpatient psychiatry, community mental health, emergency departments, mobile crisis teams, and long-term care settings, as well as a screening system for police officers. A similar set of instruments is available for child/youth mental health. The instruments form an integrated mental health information system because they share a common assessment language, conceptual basis, clinical emphasis, data collection approach, data elements, and care planning protocols. The key applications of these instruments include care planning, outcome measurement, quality improvement, and resource allocation. The composition of these instruments and psychometric properties are reviewed, and examples related to homeless are used to illustrate the various applications of these assessment systems." (Hirdes, J. P. et al. 2022).

Per Landers, S., et al., (2016), "Medicare skilled home health" care or "home health care" refers to services offered by Medicare-certified home health agencies under the Medicare home health benefit. By contrast, "home-based care" refers to a wide array of different types of care provided in the home by a wide range of parties. The continuum of different types of home-based care delivered in the home varies in terms of different dimensions, including acuity, type of care provided, and degree of physician involvement. Home-based care includes both formal and informal personal care services, Medicare skilled home health, physician house calls, and even "hospital-at-home" services."                                                         

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 Personal Care Aide 40 hours/week, Consumer Direct, 1 Client is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is upheld.

This is a female patient with low back pain. The pain began over one year ago. Prior treatment has included chiropractic care, medications, as well as therapy. The patient's activities of daily living (ADLs) s are impacted secondary to the symptomatology. The pain is rated 10 out of 10. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated multiple levels of degenerative changes. At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment, Intracept procedure, is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 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 a lack of data to recommend this procedure as a 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 health service or treatment, Intracept procedure, is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is overturned.

This is a female patient with low back pain. She has had low back pain for many years, and her pain was exacerbated by a boat ride. She describes her pain as constant dull and throbbing. The pain level is 10/10. Her activities of daily living (ADLs) are limited due to pain. She had tried chiropractic manipulation and Advil with minimal relief. The physical exam (PE) was unremarkable with a negative straight leg raise (SLR) and facet loading tests. Magnetic resonance imaging (MRI) showed Modic type 2 changes at lumbar (L) 3, L5, sacral (S) 1 without significant central or foraminal stenosis, grade 1 anterolisthesis with broad disc bulge, facet hypertrophy at L3/4, Broad disc bulge and facet arthropathy at L4/5.
At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Yes. The Intraosseous nerve ablation procedure, Intracept, is designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple well-designed clinical trials demonstrated the effectiveness of Intracept in alleviating vertebrogenic pain. This patient's persistent low back pain is consistent with vertebrogenic pain. She had tried conservative treatments without success. Her pain level is 10/10 with limitation on her activities of daily living (ADLs). Further interventions are medically necessary to improve her pain and function. Other potential treatment options are long-term use of medications (opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Given this clinical scenario, the Intracept procedure is the next step intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stab wound
Treatment: Inpatient admission.
The health plan denied inpatient admission. The denial is upheld.

The patient is an adult male. He presented to the hospital with history of stab wound to the abdomen. The stab wound was initially reported as self-inflicted, but the injured patient states it was accidental when he tripped while holding a knife. He had reportedly been arguing with his girlfriend while drinking alcoholic beverages.

The patient's vital signs were significant for hypertension and tachycardia. Physical examination showed a 2 cm (centimeter) wound in the lower abdomen. Focused abdominal ultrasound for trauma (FAST) showed no intraperitoneal fluid. The wound was explored in the Emergency Department and found to not penetrate the fascia. The wound was closed in the ED (emergency department). The patient was admitted to acute inpatient level of care. The patient was ordered for antibiotics and psychiatric evaluation. Psychiatry noted the patient suffered from an adjustment disorder with mixed disturbance of emotions and conduct as well as acute alcohol intoxication. Psychiatry recommended 1:1 observation (suicide precautions) while admitted to trauma and monitoring for alcohol withdrawal. Toxicology screen was positive for alcohol, cocaine, and THC (tetrahydrocannabinol).

The patient was seen by Psychiatry and Trauma Surgery and cleared for discharge. The patient denied the stabbing was a suicide attempt. He was discharged in the morning with recommendation for outpatient therapy following suicide attempt and follow-up in trauma surgery clinic.

A stab wound without violation of the peritoneum does not require admission to the hospital from a trauma surgery viewpoint. The patient also had psychiatric evaluation for suicide attempt and monitoring for alcohol withdrawal. Psychiatry evaluated the patient and noted the patient suffered from an adjustment disorder with mixed disturbance of emotions and conduct as well as acute alcohol intoxication. Psychiatry recommended 1:1 observation (suicide precautions) while admitted to trauma and monitoring for alcohol withdrawal.

The care rendered did not require acute inpatient level of care. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periodontal disease. 
Treatment: bone replacement graft for ridge preservation - per site (D7953), guided tissue regeneration, natural teeth - resorbable barrier, per site (D4266), and surgical placement of implant body: endosteal implant (D6010). 
The insurer denied coverage for bone replacement graft for ridge preservation - per site (D7953), guided tissue regeneration, natural teeth - resorbable barrier, per site (D4266), and surgical placement of implant body: endosteal implant (D6010). 
The denial is upheld. 

Based on review of the submitted documentation which includes copy of pretreatment panoramic radiograph, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla number 12 area. The periodontist reports that number 12 was nonmaintainable and extracted due to severe periodontal disease. He is recommending bone replacement graft guided tissue regeneration and surgical placement of implant at the number 12 site to restore function. The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant and related services are only covered when documented and meeting medical necessity criteria. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in the maxilla. As regards to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces with or without sinus augmentation surgeries, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. Further, the documentation provided does not support, justify, or substantiate the requested treatment, particularly as the only objective documentation provided for review is the radiographic examination which is outdated being approximately 2-3 years old. There are no dental treatment records or periodontal records provided. Therefore, as the documentation is inadequate, and as removable partial dentures remain a standard of care in general dental practice, and further the medical documentation does not indicate a specific limitation precluding use of dentures, the graft surgery, resorbable barrier and endosteal implant is considered elective and not medically necessary. 

Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary. 

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 bone replacement graft for ridge preservation - per site (D7953), guided tissue regeneration, natural teeth - resorbable barrier, per site (D4266), and surgical placement of implant body: endosteal implant (D6010) is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Refractory obsessive-compulsive disorder
Treatment: CPT 61735: creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus and associated inpatient hospital stay
The insurer denied: CPT 61735: creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus and associated inpatient hospital stay
The denial is overturned.

The patient is an adult male with a longstanding history of obsessive-compulsive disorder. He is status post previous anterior capsulotomy performed last year. The patient experienced good relief with surgery but incomplete lesioning by MRI (magnetic resonance imaging). 

The health plan should cover the proposed treatment, CPT 61735: creation of lesion by stereotactic method, including burr hole(s) and localizing and recording techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus and associated inpatient hospital stay. 

The health plan should cover the proposed treatment. The patient has had excellent relief with initial surgery and incomplete lesioning by MRI (magnetic resonance imaging). The treatment has been proven effective, therefore it should be covered. The requested health service is more beneficial than any standard treatment for the patient's condition or disease. This is the best treatment regimen available for this patient. 
The patient had undergone treatments in the past and it was successful. However, the treatment was incomplete. Revision with the completion of the same treatment is likely to more beneficial than any standard treatment for the insured's condition or disease.