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

Diagnosis: autism spectrum disorder, blindness, diabetes, and seizure disorder
Treatment: Personal Care Aide (PCA) services for 49 hours
The insurer denied coverage for Personal Care Aide (PCA) services for 49 hours.
The denial is upheld. 

This is a young child with autism spectrum disorder, blindness, diabetes, and seizure disorder.  The insurer decreased the patient's previously approved 49 personal care aide (PCA) hours/week to 10.5 PCA hours/week.  The patient's mother is seeking reinstatement of the 49 PCA hours/week.  

The Uniform Assessment System (UAS) report was reviewed. He was noted to be alert and responsive.  Many of his activities of living tasks required maximal assistance given his age and developmental delay. However, he was independent with mobility including bed mobility, general transfers, toilet transfer, and ambulation.  His mobility had significantly improved when compared to the prior UAS report.  Only limited assistance was needed for feeding.  The patient continues to require nasal oxygen at night due to underlying lung disease.  

The clinical records do not support the medical necessity of continuing 49 PCA (Personal Care Aide) hours/week.  The medical records from the child's treating physician were also reviewed.  The patient was having asthma exacerbations and his doctor "advised asthma plan." As noted by the insurer, the patient "has not gone to the hospital, or gone to the Emergency room in the last 3 months" and there was "No letter of medical necessity was submitted by your Doctor as to why you would need additional aide hours each day."  The patient has a supportive mother and family "Supervision is considered a normal parental responsibility. Consumer Directed Personal Care Aide Services are not to be used as supervision, childcare or to replace normal parental duties. While the aide may go with you to medical appointments, that does not qualify you for more hours. If you choose to have an aide accompany you to an appointment, they may not have enough time to complete other tasks.  Your needs were reassessed, and it shows that (his) need for help with daily activities can be reasonably met with the hours that (he) is already approved to receive."

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 Personal Care Aide (PCA) services for 49 hours services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peri-Nasal Abscess
Treatment: Inpatient Emergency Admission
The insurer denied the inpatient emergency admission.
The health plan's determination is overturned.

The patient is a female who presented to the Emergency Department for a painless lesion on the left side of her nose with associated headache. Her symptoms occurred after initial treatment for tonsilitis with Clarithromycin and Prednisone, and the patient was transitioned to Clindamycin due to concern for drug reaction. On admission, her examination was consistent with an abscess on her nose, and laboratory studies revealed significant leukocytosis.

A computed tomography (CT) was performed which showed a 1 centimeter (cm) facial abscess, and subsequently the patient became febrile with tachycardia. The emergency department admitted the patient due to concerns regarding sepsis, bacteremia, secondary to an abscess that required intravenous antibiotics (Vancomycin, Ceftriaxone), that seemed to not be responding to recently given oral antibiotics. She subsequently left the hospital against medical advice.

The requested health service/treatment of an inpatient admission was medically necessary for this patient. The patient required an inpatient admission to treat a serious, potentially life-threatening condition, with intravenous antibiotics since there was concern about sepsis, bacteremia, with progression of a facial abscess despite prior treatment with oral antibiotics. The patient had a facial abscess that progressed even while patient had recently taken 2 different classes of oral antibiotics. She was febrile, had significant leukocytosis, and was deemed to require intravenous antibiotics for stabilization. The patient was evaluated daily to determine continued need for hospital admission.

The health plan's determination is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

The patient is a male with complaints of low back pain. The pain began over 7 years ago. The pain impacts activities of daily living (ADL). Pain can be as high as 5 out of 10. Prior treatment has included lower back injections, exercises, as well as physical therapy. Magnetic resonance imaging (MRI) lumbar spine demonstrated degenerative changes.

The proposed Intraosseous Basivertebral Nerve Ablation 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.
This procedure is not recommended in this case. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. An 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 Intraosseous Basivertebral Nerve Ablation 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: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

This is a male with Vertebrogenic Low Back Pain; Lumbar Spondylosis, Cervical Radiculitis; and Thoracic Spondylosis. Records indicate that the patient was recommended to undergo the Intracept procedure to address the chronic low back pain.
The provider states that the Intracept procedure (intraosseous basivertebral nerve ablation) is to address chronic back pain identified by Modic changes. The provider states that the patient's chronic low back pain began over seven years ago. The patient has tried multiple treatments including facet injections, home exercises, lumbar epidural injections, medial branch blocks, and medication management as well as physical therapy. 

Intraosseous Basivertebral Nerve Ablation 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 is noted to have a history of chronic back pain that has not responded to conventional conservative treatment or injections. 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, the MRI does not mention any degenerative endplate changes or Modic changes. 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 its safety and efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Orthopedic 
Pain management

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied Intraosseous Basivertebral Nerve Ablation Procedure. The health plan's determination is upheld. 

This is a female who has chronic neck and low back pain. Her back pain is constant, sharp, and burning with radiating pain to the bilateral lower extremities. Her pain level ranges from 5/10 to 7/10. Range of motion (ROM) of the lumbar spine, exercising, lifting and bending can aggravate her pain. She underwent lumbar epidural injections and facet injection with temporary pain relief. Lumbar spine had decreased ROM, pain with flexion extension and facet loading. Magnetic resonance imaging (MRI) revealed minimal disc bulge at L (lumbar) 4/5 with facet arthrosis at L3/4 L4/5 and L5/S (sacral)1.

Intraosseous Basivertebral Nerve Ablation 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 Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient responded to the prior lumbar facet injections. Physical exam (PE) showed positive facet loading test. Magnetic resonance imaging (MRI) revealed minimal disc bulge at L4/5 with facet arthrosis at L3/4 L4/5 and L5/S1 but no Modic changes. Modic changes on MRI is the most important diagnostic criteria for vertebrogenic pain. Truumees's study supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the primary inclusion criteria is Type 1 or Type 2 Modic changes on an MRI at one or more vertebral bodies from L3 through S1. In addition, the patients with radicular pain and radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were in the exclusion criteria.
Given this patient's clinical presentation, MRI findings of facet arthropathy, and the current clinical evidence, it is unlikely that the proposed Intracept Procedure will be more beneficial than any standard treatment.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Acne

Treatment: Azelex 

The insurer denied coverage for Azelex

The denial is overturned

This is a patient with acne involving the face.  The patient has failed therapy with topical tretinoin, aczone, isotretinoin, doxycycline, spironolactone.  The patient could not tolerate topical tretinoin due to skin sensitivity.  The request is for formulary exception for Azelex cream.  

Based on the provided medical information, the use of Azelex for the treatment of the patient's acne is medically necessary and a formulary exception is warranted.  The patient has failed numerous systemic therapies, including isotretinoin and spironolactone.  The patient is currently being treated with spironolactone and has had sensitivity from use of topical tretinoin.  The patient would likely experience skin sensitivity from other formulary alternatives, including the over-the-counter (OTC) formulary alternatives such as benzoyl peroxide and adapalene containing retinoid products.  Azelex is a reasonable alternative in this clinical scenario to improve the patient's acne and can be used in conjunction with topical aczone.  

The formulary drugs are expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Azelex to treat acne is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Grade 1 Meningioma
Treatment: Temozolomide
The insurer denied Temozolomide.
The determination is upheld.

This is a female patient with a cavernous meningioma (grade 1). The patient has undergone multiple resections and proton therapy but has had progression resulting in left optic nerve compression resulting in left eye blinding. The patient also has right eye visual loss, exophthalmos, and proptosis. Due to ongoing progression, the medical record indicates treatment with everolimus+sandostatin has been recommended. Temozolomide is under review for medical necessity.

The role of temozolomide in this clinical scenario is not established. This agent is not recommended for the treatment of grade 1 meningiomas in national guidelines nor in the peer-reviewed literature. Further, a search of clinicaltrials.gov does not demonstrate any ongoing or completed trials of temozolomide in this setting. A recently published retrospective analysis of patients with meningioma treated at the University of Colorado with temozolomide chemoradiation failed to demonstrate a significant difference in progression free survival (PFS) and overall survival (OS) in the treatment of meningiomas compared to historic controls. Lacking an outcomes benefit, medical necessity cannot be established for this service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease

Treatment: Skyrizi J2327

The insurer denied coverage for Skyrizi J2327

The denial is upheld.

 
The patient has Crohn's ileocolitis and has had a fistula. She had been treated with prednisone, Humira, and infliximab. She remains with active disease and a partial small bowel obstruction. She has maintained good infliximab levels, but it is not controlling her disease. She is in the second trimester of pregnancy. 

The American Gastroenterological Association has published a clinical practice guideline on the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn's Disease. The guideline states that vedolizumab is a recommended treatment both for the induction and maintenance of remission for moderate to severe Crohn's disease. 

Therapeutic Advances Gastroenterology 2020 Volume 13 has an article titled 
"Safety of vedolizumab in the treatment of pregnant women with inflammatory bowel disease: a targeted literature review." The conclusion was that there was no evidence for safety concerns regarding pregnancy outcomes associated with vedolizumab therapy as of this publication. 
The Journal of Crohn's and Colitis Volume 16 Issue 12, December 2022 pages 1808-1815 has an article titled "Safety of Ustekinumab and Vedolizumab During Pregnancy-Pregnancy, Neonatal, and Infant Outcome: A Prospective Multicentre Study." The conclusion was that both ustekinumab and vedolizumab were safe in pregnancy and had favorable postnatal infant outcomes. 

This patient has active Crohn's disease and has failed treatment with an anti-TNF agent. A different biologic agent is required at this time. The insurance company has offered Entyvio. Treatment with Entyvio is recommended for use in moderate to severe Crohn's disease as per the American Gastroenterological Association guidelines for Crohn's disease. Skyrizi is also an appropriate treatment. However, since Entyvio is formulary, the insurance company has acted reasonably and with sound medical judgment. Skyrizi is not medically necessary. 
The denial is upheld.

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 Skyrizi J2327 services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces
The insurer denied: Braces
The denial is overturned.

The patient is a teenage male requesting orthodontic treatment. Patient has a Class I malocclusion. Prior denial was due to handicapping score of 8.

The requested health service is medically necessary. 

The patient has 2 anterior teeth in cross bite with clinical attachment loss and gingival recession. These are automatic qualifiers according to the handicapping index scale. Orthodontic treatment is needed to correct these issues and the case is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.
 

The patient has a history of chronic obstructive pulmonary disease (COPD) and essential thrombocytopenia who presented to the emergency department (ED) with complaints of cough for three weeks. The patient had gone to urgent care earlier where a chest x-ray (CXR) was performed. The patient was told they had pneumonia and was referred to the ED.

In the ED, the patients vitals were: Temperature 98.6 Fahrenheit (F), respiratory rate (RR) 20, pulse 99, blood pressure (BP) 106/72, oxygen saturations 95% on room air.  The patient was in no acute distress. The patient had wheezing and rales heard on exam.  The patient's white blood cell count (WBC) was 24, blood urea nitrogen (BUN) and creatinine were within normal limits, hemoglobin 10.9, and platelets were in the 800's at baseline.  A CXR and computed tomography (CT) revealed a right sided pneumonia (PNA). The patient was admitted to the hospital for treatment of community acquired pneumonia (CAP).  The patient was started on Rocephin and Azithromycin.

The patient remained stable after admission. As per the history and physical, the attending physician noted that the patient's oxygen saturations were 100% on room air.  The patient was in no acute distress.  The patient denied chest pain and shortness of breath.  Vital signs were: Temperature 98.1 degrees F, pulse 99, BP 97/64, and oxygen saturations were 94% on room air. The patient's lungs were clear.  The patient was ambulatory.  The WBC was trending lower to 20.  The patient was tolerating oral intake.  

This patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. Observation could have been for up to 48 hours. This patient remained stable after admission. The patient was afebrile and hemodynamically stable. The patient was not hypoxic, and BUN and creatinine were normal.  The patient was ambulatory and tolerating oral intake and had a CURB-65 (Confusion, BUN, Respiratory Rate, Blood Pressure, Age greater than 65) score was zero.  The patient could have been discharged home on oral antibiotics after a period in observation. The patient could have been followed up in the outpatient setting after discharge.

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pneumonia
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with a medical history of asthma was admitted for an asthma exacerbation secondary to pneumonia with symptoms of cough with sputum production, fever and mild headache for three days prior to admission. His chest x-ray demonstrated pneumonia in the right lower lobe but did not demonstrate evidence of an empyema/abscess/necrotizing pneumonia. 

Inpatient hospital stay was not medically necessary for this patient.
This patient with a medical history of asthma was admitted for an asthma exacerbation secondary to pneumonia with symptoms of cough with sputum production, fever and mild headache for three days prior to admission. As per the clinical documentation, on admission, the patient was afebrile, hemodynamically stable, with a respiratory rate of 20 breaths per minute, oxygen saturation 93% on room air, had a normal pulmonary effort but had bilateral wheezing on auscultation of the chest. His chest x-ray demonstrated a pneumonia in the right lower lobe, but did not demonstrate evidence of an empyema/abscess/necrotizing pneumonia. He was treated with antibiotics (Ceftriaxone & Doxycycline), Solumedrol and albuterol/ipratropium nebulizers.

He was alert, awake and oriented throughout his stay, he did not have documented hypercapnia or documented hypoxemia, he did not require any ventilatory support, he did not have a documented immunosuppressed state, bacteremia, and he was able to take oral medications and feeds. The CURB-65 score was 1 and Pneumonia Severity Index score was a risk class 2. A lower level of care would be considered reasonable. In addition, although he had acute renal injury, it was secondary to dehydration which improved with intravenous fluid hydration and his asthma symptoms improved with observation. Therefore, the Inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertical Coronal Fractures

Treatment: D2644, onlay porcelain - four or more surfaces, tooth #14; D0220, intraoral periapical first radiograph, tooth #1

The insurer denied coverage for D2644, onlay porcelain - four or more surfaces, tooth #14; D0220, intraoral periapical first radiograph, tooth #1

The denial is upheld 

Upon review of the documentation provided which includes copies of one undated periapical radiograph, 1 undated intraoral clinical image, patient notes, narrative letter from Dr. Darryl Smith, and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended onlay for tooth #14. The insurer has denied these services stating there is no clinical/radiographic evidence, such as traumatic injury or decay, provided to support the necessity of this services and therefore the services do not meet medical necessity criteria. The patient is appealing. 

The objective documentation provided for review is undated periapical radiograph in addition to a solitary undated intraoral clinical photograph. It appears that there is no evidence of fracture or other pathology specifically affecting #14 based on the images provided for review. There does not appear to be any radiographic evidence of caries. There does not appear to be any structural or pathologic issue associated with the existing crown on #14. The clinical photo and radiograph do not substantiate the requested dental services as enumerated above and therefore they are deemed not medically necessary. 

Uphold denial of coverage for D2644, Onlay porcelain-4 or more surfaces, tooth/quadrant #14; D0220, intraoral periapical first radiograph, tooth/quadrant #1 as not medically necessary as the documentation is insufficient to justify or substantiate the treatment.

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 D2644, onlay porcelain - four or more surfaces, tooth/quadrant #14; D0220, intraoral periapical first radiograph, tooth/quadrant #1 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient Hospital

Diagnosis: Small Bowel Obstruction
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male with a history of colon cancer status/post (s/p) partial resection and multiple abdominal procedures who presented with nausea and vomiting.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of an inpatient hospital admission was not medically necessary. The computed tomography (CT) CT was with findings of a small bowel obstruction (SBO). The patient was admitted for bowel rest, intravenous fluids (IVF) IVF and he was treated with conservative management with bowel decompression with a nasogastric (NGT). The patient began to pass flatus and was transitioned to a clear liquid and regular diet. The patient was able to be managed at an alternate level of care with supportive care and resolution of his small bowel obstruction.

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