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

Diagnosis: Low Back Pain
Treatment: Thermal Destruction of Intraosseous Basivertebral 
Nerve (Radiofrequency Ablation)
The insurer denied: Thermal Destruction of Intraosseous Basivertebral Nerve (Radiofrequency Ablation)

The denial is upheld.


The patient is an adult male with chronic low back pain status post L5-S1 (lumbar five to sacral one) laminectomy several years ago. The patient has tried bilateral L3-S1 (lumbar three to sacral one) medial branch blocks and per note "multiple medications and multiple injection procedures." Magnetic resonance image (MRI) of the lumbar spine shows an L4-L5 (lumbar four to lumbar five) moderate left paracentral disc extrusion with compression of the left L5 (lumbar five) nerve root and moderate left foraminal stenosis, a L3-4 (lumbar three to lumbar four) right paracentral disc protrusion with abutment of the right L4 (lumbar four) nerve root and mild/moderate foraminal stenosis, and L5-S1 (lumbar five to sacral one) abutment of the left S1 (sacral one) nerve root. An addendum added states type II Modic endplate changes are present at L4-S1 (lumbar four to sacral one) and type I/II Modic changes at L3-4 (lumbar three to lumbar four). 
Request for Intracept was denied as not medically necessary.

The proposed treatment is not medically necessary.

Review of the literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. 
At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the 
procedure. As such the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain. 
Treatment: Ablative Nerve Treatment in the Spine. 

The insurer denied Ablative Nerve Treatment in the Spine. The health plan's determination is overturned. 

This patient is a female who has a 6-year history of chronic back pain. Her pain is localized at the lumbosacral junction region. Sitting for longer than 5 min. increases her pain. Pain level is 10/10 with significant effect on her activities of daily living (ADL). She had previously tried physical therapy (PT), chiropractic manipulation, and pain medications without improvement. 

The Ablative Nerve Treatment in the Spine is medically necessary for this patient.
This patient has severe persistent back pain. Her pain is severe enough to have a negative impact on her activities of daily living (ADL) and quality of life. She had tried pain medications, physical therapy (PT) and chiropractic manipulation without success. Further interventions are medically necessary to improve her pain and function. Other potential treatment options are long-term use of medications including opioids and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the Intracept procedure is medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Alzheimer's disease, heart disease, hyperlipidemia, arthritis, and gait abnormality.
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week (split shift).

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week (split shift).  The denial is modified.
 
This is an elderly patient with heart disease, arthritis and Alzheimer's disease. She lives with relatives, including a grandniece, who directs her care. The insurer approved Consumer Directed Personal Assistance Services (CDPAS) 63 hours/week, and the request is for CDPAS, 24 hours/day, 7 days/week, (split shift).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as "severely impaired." She is totally dependent for most of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing, dressing and toilet use. Extensive assistance is needed for eating and toilet transfer. She is frequently incontinent of bowel and bladder. Only limited assistance is needed for mobility (bed mobility, locomotion and ambulation). The patient's condition and functional needs are not at a level or unpredictable as to require the requested CDPAS 24 hours/day, 7 days/week (split shift). Based on the records reviewed, the patient's health and safety can be more appropriately provided and maintained at home with an increase CDPAS 12 hours/day, 7 days/week (84 hours/week). This physician does note the patient's condition had deteriorated over the prior 90 days, "due to further cognitive decline, worsened agitation and wandering." This physician would also agree that the patient may require additional monitoring for safety and companionship; particularly due to her agitation, wandering and attempts to leave the residence. However, safety monitoring under PCS (personal care services) does not include monitoring an individual (with dementia) when no other Level I or Level II personal care services task is being provided.  

Based on the above, the insurer's denial must be modified. 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 consumer directed personal assistance services (CDPAS) 24 hours a day, 7 days a week (split shift) services is not substantiated. However, increasing CDPAS to 12 hours/day, 7 days/week (84 hours total) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cognitive impairment
Treatment: Home health care
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week. 
The health plan's determination is overturned. 

The patient is a male with past medical history of cognitive impairment, cerebellar degeneration, and cerebral ataxia who had been signed CDPAP (Consumer Directed Personal Assistance Program) services.

Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week are medically necessary for this patient.
The patient's medical provider documented medical necessity for increased CDPAP services, specifically stating the patient needed assistance with toileting. The video assessment underestimated the patient's care needs when compared to the assessment from the patient's medical provider. The assessment also incorrectly stated that the patient had informal help from his ex spouse outside of the hours of currently assigned CDPAP services when she was only available at times. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: metastatic non-small cell lung cancer
Treatment: Foundation One Liquid CDx
The insurer denied: Foundation One CDx
The denial is: Overturned

The patient is a male with metastatic non-small cell lung cancer (adenocarcinoma). The patient recurred while receiving adjuvant cisplatin+pemetrexed. The Foundation One Liquid CDx was obtained and is under review for medical necessity.

The targeted genomic sequence analysis panel is medically necessary. The use of next generation sequencing gene panels to guide the treatment of patients with metastatic non-small cell lung cancer is recommended by the National Comprehensive Cancer Network (NCCN) Guidelines, which state "...t is recommended at this time that when feasible, testing be performed via a broad, panel-based approach, most typically performed by next generation sequencing (NGS).... The assay in question is Food and Drug Administration (FDA) approved and evaluates the cancer for the recommended biomarkers - epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), ROS1, met proto-oncogene (MET), rearranged during transfection (RET), human epidermal growth factor receptor 2 (HER2), v-raf murine sarcoma viral oncogene homolog B1 (BRAF), Kirsten rat sarcoma (KRAS), and Tropomyosin receptor kinase (TRK).
The authors of UpToDate state "...ext generation sequencing (NGS) overcomes many of the shortcomings of direct sequencing and allele-specific testing...It retains sensitivity even in specimens with low tumor cellularity, which is an improvement over direct sequencing, and can identify new abnormalities, which would not be detected by allele-specific testing. Moreover, NGS can often detect abnormalities that would historically be tested by fluorescence in situ hybridization (FISH)...". Finally, NGS panel testing has been demonstrated in multiple trials, to be less expensive than single gene testing for the recommended biomarkers. The service under review is not the subject of ongoing investigation for these purposes.
For these reasons, the use of this assay in this scenario meets criteria for medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Central Nervous System/Neuromuscular Disorder/Other/Dementia.
Treatment:  Home Health Care/home delivered meals: 3 meals per day x 7 days per week.

The health plan denied the requested home delivered meals: 3 meals per day x 7 days per week. The health plan's determination is upheld.

The patient is a female with a past medical history of age-related cognitive decline, hypertension, incontinence of urine, incontinence of feces, obesity, diabetes mellitus type 2, and hyperlipidemia who has been assigned personal care aide (PCA) services. The patient's friend and healthcare proxy noted the patient's PCA service aides were not providing meals low in sodium and diabetic friendly. There was a request to approve home delivered meals 3 meals per day x7 days/week. The patient was approved for PCA services 9 hours/day, 7 days/week to total 63 hours/week. There was documentation that the patient's personal care service aides were reinstructed on healthy meals. Aides attested to providing healthy balanced meals at the request of the patient. It was noted the patient's healthcare proxy and friend did the shopping for the patient and was responsible for the type of food in the patient's home. The patient's healthcare advocate provided a letter requesting an external appeal of the denial decision. The patient and healthcare proxy appealed the denial decision to cover home delivered meals 3 meals per day x7 days/week.

At issue is the medical necessity for the requested health service/treatment of home delivered meals: 3 meals per day x 7 days per week.

I uphold, in whole, the health plan's determination of medical necessity.

No. There is documentation from the plan that it provided additional education to PCA service aides regarding preparation of nutritional meals. The plan documented that although there was no wrongdoing, the supervisors of these aides did provide this additional training. It was also noted that nutritional training was provided to all PCAs within their training manual. The plan also recommended that if the patient was not satisfied with the food or the PCA's cooking was not to the patient's liking, they could request a change in an aide services. In addition, it was noted the patient's healthcare proxy and friend did the shopping for the patient and, therefore, could have chosen foods to be prepared that were low-sodium and appropriate with her diabetic diet.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Erectile dysfunction (ED)
Treatment: Penile Prosthesis Implantation 
The insurer denied the penile prosthesis implantation.
The health plan's determination is overturned. 

The patient is a diabetic man with erectile dysfunction (ED). He did not adequately respond to PDE5 (phosphodiesterase type 5 inhibitor) agents. He has neuropathy and is maintained on Neurontin. He is also hyperlipidemic. 

Penile prosthesis implantation is medically necessary for this patient.

The patient has documented ED of organic etiology. The patient has hyperlipidemia, and neuropathy as etiologies of ED. Oral therapy has not proven successful. The Current guidelines of the AUA (American Urological Association) endorse the use of penile prostheses in patients with ED who are willing to undergo surgery without the need for step therapy.

The AUA notes, "Men with ED should be informed regarding the treatment option of penile prosthesis implantation, including discussion of benefits and risks/burdens. The benefits of prostheses include the ability to generate an erection sufficient for intercourse on-demand, for as long as is desired, and as frequently as is desired." 

The AUA states, "Although many men may choose to begin with the least invasive option, the Panel notes that it is valid for men to begin with any type of treatment, regardless of invasiveness or reversibility."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Abdomen and pelvis CT (Computed Tomography - pictures of inside the belly area)

The insurer denied coverage for abdomen and pelvis CT 

The denial is upheld

The patient has a history of gastric bypass, diabetes, atrial fibrillation, and morbid obesity. The patient was having Right Upper Quadrant (RUQ) abdominal pain. The patient developed new onset ascites. The patient had a Computerized Axial Tomography (CAT) scan which showed a heterogeneous liver consistent with a fatty liver and cirrhosis. On a follow up visit, the patient had an Interventional Radiology (IR) paracentesis, and 5.7 liters of fluid were removed. The physician is requesting to do another CAT scan to evaluate the patient. 

Milliman Care Guidelines (MCG) has listed indications for Abdominal/Pelvic CT scan. Liver disease is an indication for the procedure if one of the following indications are met. These include elevated alpha-fetoprotein level, significant worsening of jaundice or encephalopathy, a nodule on a screening ultrasound, palpable RUQ mass, portal vein thrombosis, or a fatty liver when an ultrasound or Magnetic Resonance Imaging (MRI) is not available. The patient did not have these conditions. 

This patient has ascites and evidence of liver disease based on both a previous CAT scan and abdominal ultrasound. If it is necessary to reimage the liver at this time or to repeat the paracentesis, an abdominal ultrasound can be obtained. It is not indicated to repeat the CAT scan as one was done several months prior. A CAT scan of the abdomen and pelvis is 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 abdomen and pelvis CT (Computed Tomography - pictures of inside the belly area) is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Deep vein thrombosis
Treatment:  Eliquis
The insurer denied Eliquis
The denial is overturned

The patient in this case is an adult male who has multiple myeloma and is on treatment with maintenance Revlimid. He has a history of bilateral deep vein thrombosis (DVT). He has been on long-term anticoagulation. Initially he was treated with Eliquis. He was changed to Xarelto for insurance reasons and while on that medication he suffered recurrent deep vein thrombosis. He had missed two to three doses right before that and the new deep vein thrombosis was felt to be due to his missed doses. He was changed back to Eliquis.

The health plan should cover the proposed formulary exception for Eliquis.

Eliquis has been shown to be safer and more effective than both warfarin and Xarelto for treatment of deep vein thrombosis. This patient had been previously managed with Eliquis without any significant complications and without recurrent venous thrombosis. Based on this and based on published data showing it is safer and more effective than the formulary alternatives, Eliquis should be covered.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional Impairment

Treatment:  Personal Care Assistance

The insurer denied coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week 

The denial is overturned

This is the case of an adult patient with history of arthritis, recurrent falls, hypertension, knee replacement, hyperlipidemia, congestive heart failure (CHF), gastroesophageal reflux disease (GERD), hypothyroidism, and chronic obstructive pulmonary disease (COPD). The patient is requesting an increase in home health aide services. The patient was dependent on all activities of daily living such as walking, toileting, incontinence care, nursing, bathing, and taking medications. Using her walker often made her dizzy and she was unsteady using the device. She required physical help from an aide, had frequent bladder incontinence and needed to be changed, when necessary, otherwise she was at risk of skin breakdown. She also required repositioning every 2 hours while sleeping. Her treating physician indicated that the patient required 24-hour care with 12-hour split shifts. The patient lives alone and her son only visits once a week for one or two hours.  Her daughter calls daily but because of her own health concerns, is unable to care for the patient.  

The assessment conducted noted that the patient required anywhere from maximal assistance up to being totally dependent on functioning. Her condition had deteriorated significantly as compared to 90 days prior. The patient reported being in moderate intermittent pain chronically. 

Personal aide care is an available service that allows patients with needs to receive their care within their own home rather than receiving treatments and services in a skilled nursing facility or assisted living. The patient previously received authorization for 84 hours of personal aide services but had a decline in her health within the 90 days prior to her most recent assessment. Her treating physician noted that she was dependent on all activities of daily living such as walking, toileting, incontinence care, dressing, bathing, and taking medications. She also required care throughout the night to prevent skin breakdown to include repositioning every 2 hours and changing soiled undergarments.

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 per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week services is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Psoriasis.
Treatment:  Sotyktu.

The insurer denied coverage for Sotyktu.  The denial is upheld.

The patient has a history of psoriasis. The patient has failed therapy with Otezla. The requested medication is Sotyktu tablets.  

Based on the submitted documentation and the standard of care Sotyku is not medically necessary. The patient has no true contraindications to numerous appropriate available formulary treatment modalities, which would make the use of Sotyktu medically necessary.  There are no definitive, comparative, controlled head-to-head studies showing that Sotyktu has a superior efficacy or safety profile to reasonable alternatives such as Humira, Enbrel, Cosentyx, Skyrizi, Tremfya, or phototherapy, all of which are formulary treatment options.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient.  

There is no documentation to suggest that Sotyktu would be more effective than available formulary alternatives or that the patient has an absolute contraindication to a preferred medication, which would specifically necessitate Sotyktu. The appeal is upheld in whole.  

The formulary drugs are not 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 not expected to be ineffective.

The non-formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of request for formulary exception for Sotyktu to treat psoriasis is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Primary Immunodeficiency
Treatment: Genetic Testing (81479)
The insurer denied: Genetic Testing (81479)
The denial is upheld

This patient is a male child. He has a history of fever and recurrent infections. There is concern for immune deficiency versus periodic fever syndrome. The patient has required several courses of antibiotics. The request is for genetic testing (81479) for primary immunodeficiency (PID).

The proposed genetic testing is not medically necessary.

This is a patient with hypogammagobulinemia.
Per Rohan Ameratunga et al (1), while they advocate that all patients with common variable immunodeficiency disorders (CVID) should be routinely offered diagnostic genetic testing, this has not yet similarly been advocated by the practice guidelines by Bonilla et al (3) for the diagnosis of common variable immunodeficiency. Additionally, the authors do admit limitations in testing including presence of variants of unknown significance (VUS), de novo pathogenic mutations in databases, etc.
While the patient has hypogammaglobulinemia, it is unclear how additional testing would specifically change his treatment course. Therefore, this would not be medically necessary.