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

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Humatrope. 
The denial is overturned.

This is a male diagnosed with short stature. This request is for Humatrope. As reported; he started on growth hormone (GH) therapy (currently getting 0.277 milligrams per kilogram per week [mg/kg/wk.]). His initial magnetic resonance imaging (MRI) of brain showed Chiari malformation. His Insulin-like Growth Factor 1 (IGF1) was 141 (187-599); Z-score was -2.4; Insulin-like growth factor binding protein 3 (IGFBP3) was 4.4 (3.3-10). 

The health plan's determination is overturned.

GH is indicated for the treatment of growth hormone deficiency (GHD) in certain patients who do not fail GH stimulation tests based on the Lawson Wilkins Pediatric Endocrine Society (LWPES) alternate criteria [2] which state, "No gold standard exists for the diagnosis of growth hormone deficiency (GHD). Although children severely affected by GHD fail GH stimulation tests, there is no doubt that some children with GHD achieve stimulated GH concentrations above the arbitrary cutoffs that have been applied. A trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests, but who meet most of the following criteria: (1) height greater than 2.25 standard deviation (SD) below the mean for age or greater than 2 SD below the mid parental height percentile; (2) growth velocity less than 25th percentile for bone age;(3) bone age greater than 2 SD below the mean for age; (4) low serum insulin-like growth factor 1 (IGF-I) and/or insulin-like growth factor binding protein 3 (IGFBP3); and/or (5) other clinical features suggestive of GHD."
This patient met criterion 1 as pretreatment height was -2.77 SD. IGF1 was low. bone age was delayed. Height velocity is less than the 25th percentile. The patient therefore met 4 of the above criteria. The patient is growth hormone deficient. The patient has benefited from growth hormone. Treatment with growth hormone is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain. 

Treatment: 22899 Unlisted procedure, spine (INTRACEPT) C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance (fluoroscopy), lumbar/sacrum. 

The insurer denied coverage for 22899 Unlisted procedure, spine (INTRACEPT) C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance (fluoroscopy), lumbar/sacrum. 

The denial is upheld. 

The Intercept procedure is "intraosseous ablation of the basivertebral nerve". It has been proposed to address low back pain identified by Mobic changes. 

The procedure is performed within the vertebral body. It has been proposed that pain relief is manifested by patients who no longer require their narcotics. For one level of disc disease each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeons nor spine surgeon. There are no National Organizations which provide guidelines nor indications. 

The facts are no specific pain generator has been defined for this patient as well. The physician has recommended the procedure to L(lumbar) 5-S (sacral)1 yet there are significant changes to L4-5. He has also recommended ESI (epidural steroid injection) which does not support discogenic pain as a pathologic site. 

The findings were this procedure is currently I/E (investigational/experimental). There were small numbers of people evaluated for a short duration. The procedure is currently being performed by an investigative group and likely an IRB (Investigational Review Board). The procedure is not mainstay nor current accepted treatment by the practicing medical community. 

The procedure is essentially a thermoablation performed within the vertebral body. 
There are several level 1 studies showing the benefit of this procedure 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 carrier's denial of 22899 Unlisted procedure, spine (INTRACEPT) C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance (fluoroscopy), lumbar/sacrum should be upheld. It is not more beneficial than any other standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain. 

Treatment: 22899 Unlisted procedure, spine (INTRACEPT) C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance (fluoroscopy), lumbar/sacrum. 

The insurer denied coverage for 22899 Unlisted procedure, spine (INTRACEPT) C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance (fluoroscopy), lumbar/sacrum. 

The denial is overturned. 

This case involves a female who presented with a history of low back pain and degenerative disc disease. Records indicated she tried and failed multiple conservative modalities to include chiropractic care, physical therapy, and NSAIDs (non-steroidal anti-inflammatory drugs). A reference was made to an unofficial MRI (magnetic resonance imaging) showing diffuse degenerative disc bulging with mild stenosis from L (lumbar) 5-S (sacral) 1. She had spondylolisthesis with diffuse degenerative disc bulging at L4-L5 and mild to moderate stenosis at the same level. The requesting physician was recommending intracept interosseous nerve ablation to treat L5-S1 vertebra for the relief of vertebra genic chronic low back pain. The requested services were denied for coverage with reports that the proposed treatment has not been shown to be effective for the patient's condition. An appeal letter was submitted from the treating physician stating that all available treatment options have been considered and that the Food and Drug Administration has approved the intercept treatment. This review pertains to the denial of coverage for 22899 Unlisted procedure, spine (INTRACEPT) C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance (fluoroscopy), lumbar/sacrum. 

CLBP (chronic low back pain) patients treated with BVN (basivertebral nerve) ablation exhibit sustained clinical improvements in function and pain with high responder rates at a mean of 6.4 years following treatment. BVN ablation is a durable, minimally invasive treatment for vertebrogenic CLBP. In this case the patient has failed nonoperative management to include physical therapy, chiropractic management and Mobic. She has type 1 (bone marrow oedema and inflammation) and type 2 (marrow ischemia) Modic changes on MRI. Per the attached literature she is a good candidate for Intracept procedure as outcomes have been good in this patient population. It is the opinion of this reviewer that the original denial be overturned in this case. 

The carrier's denial of 22899 Unlisted procedure, spine (INTRACEPT) C9752 destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance (fluoroscopy), lumbar/sacrum should be overturned. It is more beneficial than any other standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Cancer
Chemotherapy

Diagnosis; gastric cancer
Treatment: Balversa
The insurer denied Balversa. The health plan's determination is upheld.

This is a female with stage IV gastric cancer. The patient's disease has been progressive on nivlumab+FLOT (Fluorouracil, Leucovorin, Oxaliplatin and Docetaxel) and on ramucirumab+FOLFIRI (Folinic acid, fluorouracil and irinotecan). A next generation sequencing panel was obtained and revealed an FGFR2 (fibroblast growth factor receptor 2) mutation.

There is a paucity of data demonstrating the efficacy of Balversa in this clinical scenario. This approach to therapy is being evaluated in the MATCH trial (NCT02465060) but results have not been published yet. The use of Balversa is not recommended by the National Comprehensive Cancer Network (NCCN) nor by the authors of UpToDate nor in the peer-reviewed literature. Lacking evidence of efficacy, it cannot be stated this approach is as affective as standard options that are Food and Drug Administration (FDA) -approved for this indication and recommended in national guidelines.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Severe Scalp Psoriasis

Treatment: medication Cosentyx

The insurer denied coverage for medication Cosentyx

The denial is overturned

The patient is a male with a history of severe scalp psoriasis and androgenic alopecia.  The patient has failed prior therapy with Taltz and Xeljanz.  According to the submitted documentation, the patient has been successfully treated with Cosentyx for his psoriasis.  The requested medication is continuation of Cosentyx.  

The patient has failed therapy with Xeljanz (used for his alopecia) as well as Taltz.  He has been successfully treated and maintained on Cosentyx for his psoriasis since without any reported adverse effects and excellent clinical results.  In a Cochrane review of treatment of psoriasis, it is apparent the no agent is successful at a level that one can assume a lack of need of successive trials of different agents. This is supported in this patient who has already being tried on 2 different biologic agents that were not effective. In contrast, Cosentyx, has been effective since starting.  It is thus not clinically appropriate to now try another agent simply because it is available. In sum, based on the documentation provided and the standard of care, the decision is overturned and the use of Cosentyx is supported.   

The insurer's denial of coverage for Formulary Exception for the medication Cosentyx is overturned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Asthma. 
Treatment: Formulary exception for Asmanex. 

The insurer denied the Formulary exception for Asmanex. 
The denial is overturned. 

The patient is a female. She has diagnoses of mild persistent asthma and Churg Strauss syndrome. Denial of Asmanex is being appealed. 

The request was denied coverage by the health plan due to lack of trial and failure of formulary alternatives. The patient has an autoimmune response to inhalers with Fluticasone. She has been taking Asmanex for many years. Clinical records notes she has been stable on medication regimen, which included Asmanex. 

Yes, the health plan should cover the Formulary exception for Asmanex. 
Asmanex is FDA (United States Food and Drug Administration)-approved for maintenance treatment of asthma as prophylactic therapy. The requested medication was denied due to lack of trial and failure of formulary alternatives that include Arnuity Ellipta, Flovent Diskus, Flovent HFA (Hydrofluoroalkane), Pulmicort Flexhaler, and Qvar Redihaler. 

The provider notes the patient has a contraindication to fluticasone, but there is no evidence of trial and failure of the non-flucatisone alternatives, which include Pulmicort Flexhaler and Qvar Redihaler. Medical literature does not support Asmanex as being superior to Pulmicort Flexhaler or Qvar Redihaler. However, records support that the patient has successfully been managed with Asmanex for several years. Based on the patient's years of stability with Asmanex, the medication is medically necessity because it is consistent with generally accepted medical standards for continuity of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer and Self Directed Personal Assistance Services To 70 Hours Per Week (The health plan is reducing hours to 42 hours/week)
The insurer denied the Consumer and Self Directed Personal Assistance Services To 70 Hours Per Week (The health plan is reducing hours to 42 hours/week)
The denial is overturned

This female has chronic conditions including dementia. She lives alone.  She is appealing denial of consumer and self directed personal assistance services (CDPAS) to 70 hours per week. The health plan is reducing hours to 42 hours per week.  The hours were decreased based on the UAS (Uniform Assessment System) evaluation.  UAS (Uniform Assessment System) evaluation performed  showed the member needs assistance with preparing meals, housekeeping, laundry, shopping, bathing, dressing, personal hygiene (combing her hair, brushing your teeth) and toileting.  

A letter from the provider notes the member lives alone and needs additional hours due to progression of medical conditions, including dementia, diabetes and osteoarthritis.  She requires physical assistance and frequent  reminding and verbal cuing.

Yes. The proposed treatment is medically necessary.

No. The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
This member has multiple chronic medical conditions, including dementia.  She is appealing denial of consumer and self CDPAS (Consumer Directed Personal Assistance Services) to 70 hours per week. The health plan is reducing hours to 42 hours per week.  UAS (Uniform Assessment System) evaluation performed showed the member needs assistance with preparing meals, housekeeping, laundry, shopping, bathing, dressing, personal hygiene (combing her hair, brushing your teeth) and toileting.  An appeal letter states the member needs additional hours due to progression of conditions and need for reminding/cuing.  Based on this information provided, the reduction to CDPAS (Consumer Directed Personal Assistance Services) 42 hours per week is is not supported.  The member requires physical assistance as well as reminding with ADLs (activities of daily living) and personal care.  The proposed increase in CDPAS(Consumer Directed Personal Assistance Services) 70 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder/Anemia.
Treatment: Pharmacy/Prescription Drugs.
The health plan denied the requested intravenous iron therapy as not medically necessary.
The health plan's determination is upheld.

The case involves a patient who was recommended to receive Injectafer, a high potency intravenous iron product, for the management of iron deficiency in the setting of chronic renal disease.
At issue is the medical necessity for intravenous iron therapy.

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

The documentation provided does not include documentation of serum Ferritin or Transferrin saturation to assist in solidifying the diagnosis of iron deficiency. Furthermore, a trial of oral iron is generally considered before parenteral iron therapy with parenteral iron therapy being reserved for those who can not tolerate or who do not respond appropriately to oral supplementation.[1] Therefore, I would recommend to uphold the initial denial rendered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Angina
Treatment: Surgical Services (All)
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a woman with a past medical history of hypertension, hyperlipidemia, diabetes, obesity, osteoarthritis and worsening spinal stenosis. For the evaluation of exertional dyspnea, she had a coronary angiography which demonstrated occlusive lesions in the proximal left anterior descending (LAD) and distal right coronary artery (RCA). She was offered a coronary artery bypass graft (CABG) but instead opted for multivessel percutaneous coronary intervention (PCI). Consequently, she presented for a staged PCI. This was performed and she had placement of drug eluting stents to her LAD and left circumflex artery and medical management of her RCA lesion was recommended. She was started on dual antiplatelet therapy with aspirin and Plavix and was admitted to the telemetry unit overnight. She did not have any events overnight and was discharged home the next day.
At issue is the medical necessity of the inpatient stay.

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

This patient presented for an elective outpatient PCI. Her proximal LAD and left circumflex artery were treated with drug eluting stents. There were no intraprocedural complications such as significant bleeding, coronary dissection, or perforation. There was also no evidence of access/vascular complications. She was hemodynamically and electrically stable during the procedure and post-procedurally. She did not have evidence of acute coronary syndrome, there was no heart failure, no renal failure, no need for therapeutic anticoagulation and no antiplatelet or contrast allergy. She did not have any chest pain post-procedurally. Consequently, based on the provided documentation, there is insufficient clinical data to support the medical necessity for an inpatient level of care. Observation level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain. 
Treatment: Pain management services/spinal cord stimulator trial. 

The insurer denied pain management services/spinal cord stimulator trial. 
The determination is overturned. 

The patient has severe low back pain with radiation to the right lower extremity (RLE). Her pain is sharp, stabbing with tingling and numbness. The pain level is 8/10. She underwent right lumbar (L) 5 and sacral (S) 1 transforaminal injections with improvement of the low back pain. However, she continues to have radiating RLE pain. She had failed conservative treatments including physical therapy (PT) and pain medications. The patient is not interested in any surgical intervention. A neuropsychological evaluation was conducted that revealed no significant predictors to show a poor response for spinal cord stimulator. Magnetic resonance imaging (MRI) revealed dextrocurvature of thoracolumbar spine, mild retrolisthesis L1 over L2, L2 over L3 and L3 over L4. Foraminal stenosis at L3-4 L4-5 and L5-S1 levels with mild central canal stenosis. 

The issue is whether a spinal cord stimulator (SCS) trial is medically necessary for this patient's condition. 

Yes, this patient has severe pain from foraminal stenosis and lumbar radiculopathy. She had failed treatments including physical therapy (PT), pain, and injections. Further treatments are medically necessary to improve her pain and functionality. She is not interested in surgery, which is understandable due to significant risks and complications associated with multilevel lumbar decompression and fusion. It is understandable this patient is not interested in surgery. There is adequate clinical evidence to show that SCS is effective in treating low back pain, especially radicular pain in the lower extremities. SCS trial is the best treatment option for this patient's condition. 
Given this clinical scenario, a SCS trial is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a female who underwent prior left total hip replacement surgery. She fell the year prior and sustained a peri-prosthetic femur fracture for which she underwent open reception and internal fixation surgery. The surgery was successful, and the patient was walking when she felt a crack in the same one thigh. Radiographs confirmed a non-union of the femur fracture and failure of the previously placed hardware. The patient was admitted to the hospital for repeat surgery on her left femur. The surgery was successful with no documented complications. She progressed well with therapy after the operation and was deemed stable for discharge to home. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld. 

The requested health service/treatment of an inpatient stay was not medically necessary for this patient. This patient underwent hardware removal and revision open reduction and internal fixation of a peri-prosthetic femur fracture. The care rendered was consistent with the current standard of care based upon the current literature as documented by Vemulapalli and associates in the Orthopedics Journal and by Patel and colleagues in the Journal of Arthroplasty. The provided records document that the surgery was successful with no documented complications. The records do not document that the patient suffered any post-operative infection, significant blood loss requiring transfusion, or any other significant peri-operative complication that would necessitate a two-night inpatient hospital admission. Thus, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer. 
Treatment: Breast MRI (77046). 

The insurer denied the Breast MRI (77046). 
The denial is upheld. 

The patient in this case, a female, was diagnosed with right breast cancer several years ago.  She was treated with neoadjuvant chemotherapy followed by right partial mastectomy and sentinel node biopsy.  She had residual human epidermal growth factor receptor two (HER2) positive breast cancer and was treated with radiation and additional chemotherapy.  The patient was seen in the emergency department and diagnosed with right breast mastitis.  She presented with pain and swelling in the right breast and also had chills, fatigue and fever.  Ultrasound revealed multiple new hypo echoic lesions in the breast.  She was treated with oral and intravenous (IV) antibiotics and has had persistent skin erythema. Skin punch biopsy was negative. Physical exam was notable for mild pink discoloration of the right breast with mild dependent right breast subcutaneous edema.  Magnetic resonance image (MRI) was ordered to rule out recurrence of her right breast cancer. 

No, the proposed magnetic resonance image is not medically necessary. 

This patient had mastitis based on signs and symptoms.  Ultrasound was done and revealed newly evident hypo echoic areas with inflammatory change.  She has improved with antibiotics but has some residual mild pink discoloration of the skin of the breast and some dependent edema of the breast.  Notably, she has not had a repeat ultrasound to assess for interval change. Magnetic resonance image (MRI) of the breast is not clearly indicated in this case.  Standard of care would call for repeat ultrasound to look for any suspicious findings before considering a mammogram. The likelihood of recurrence is low given the clinical improvement with antibiotic treatment and the lack of progressive symptoms in the breast.  If she had an inflammatory recurrence it is expected that her breast would have worsened in the three months following her initial presentation. 

Yes, the health plan did act reasonably.