Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Basivertebral Nerve Ablation (64628 and 64629).
The insurer denied: Basivertebral Nerve Ablation (64628 and 64629).
The denial is upheld.

The patient is an adult male. Per the appeal letter: The patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of vertebrogenic pain 
identified by degenerative endplate changes on magnetic resonance image. The patient had pain for greater than six months and failed treatments for greater than six months. Magnetic resonance image showed Modic changes at L3-S1. The patient has tried multiple treatments including activity modification, chiropractic care, home exercise, injections, physical therapy and medication management.
This patient presented with a history of low back pain. The patient had prior epidural steroid injections with relief for about a month. The patient has tried physical therapy, and chiropractic therapy. His pain is in the lower back and is seven out of ten (7/10), intermittent and radiates to the buttocks and legs. The patient's exam showed positive facet loading bilaterally. Diagnoses included lumbar spondylosis, lumbar disc degeneration and vertebrogenic low back pain. The patient continues with a home exercise program. The patient had reported 100% relief from the medial branch block. The patient 
wishes to proceed with the lumbar radiofrequency ablation.

The health plan should not cover the proposed treatment.

Based on the documentation provided, the requested basivertebral nerve ablation is not considered medically necessary in this case. Though the patient has a history of low back pain, it was noted that the patient had 100% relief with the prior diagnostic blocks. The patient wishes to proceed with radiofrequency ablation of the lumbar medial branches. There is no indication as to the medical appropriateness for the basivertebral nerve ablation since the patient had significant improvement with the medial branch blocks.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Basivertebral Nerve Ablation (64628 and 64629).
The insurer denied: Basivertebral Nerve Ablation (64628 and 64629).
The denial is upheld.

The patient is an adult male who with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, home exercises, and facet injections, but no 
radiofrequency ablation. The patient has failed non-steroidal anti-inflammatory drugs (NSAIDs) and over the counter (OTC) medications. The patient's magnetic resonance image (MRI) shows Modic changes. His physical exam does not reveal any neurological injury.

The health plan should not cover the proposed treatment.

The requested Intracept procedure is not medically appropriate. 

The requested health service or procedure is no likely to be more beneficial than standard treatments. The patient is an adult male with chronic low back pain in whom an Intracept procedure has  been requested. The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, home 
exercises, and facet injections, but no radiofrequency ablation. The patient has failed non-steroidal anti-inflammatory drugs (NSAIDs) and over the counter (OTC) medications. The patient's magnetic resonance image (MRI) shows Modic changes. His physical exam does not reveal any neurological injury.
The procedure is Food and Drug Administration (FDA) approved procedure for axial low back pain. It has been shown effective in randomized controlled trials (RCT) with five-year results.
The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve 
ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type I or type II  vertebral endplate changes, typically in situations where conventional and typical options have been exhausted.
However, this patient has not failed or attempted sacroiliac joint injections or radiofrequency ablation of medial branches, which are common causes of axial low back pain. The patient has had two successful medial branch blocks (MBBs) but still has not had the radiofrequency ablation (RFA), which is used to treat low back pain. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives, sacroiliac injections, medial branch radiofrequency ablation, do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.

Treatment: Nerve ablation (procedure code 64628).

The insurer denied coverage for nerve ablation (procedure code 64628).

The denial is upheld.

This patient has chronic low back pain. He has tried heat/ice, Physical therapy and transcutaneous electrical nerve stimulation (TENS). He has had a laminectomy. His medications trials have included Ibuprofen and Tylenol. A magnetic resonance imaging study (MRI) showed Modic changes at lumbar (L) 3, L4,L5 and sacral (S) 1.	

The publications to date have been company sponsored and had methodology flaws.  There is no published data on long term complication rates. There are other evidence- based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al (3) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (4) while favorable pointed out the limitations of the current literature:

1)	Industry funding is a potential source of study bias for the available data reviewed.
2)	Limited number of studies.
3)	Short-term follow up for the majority of studied patients.
4)	Unknown effect on the primary degenerative process

Urits et al (5) also commented on the need for more research on this promising technique:  "reproducible large randomized controlled studies (RCTs) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of radiofrequency (RF) ablation in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

In sum, this procedure is NOT likely to be more beneficial than the standard of care.

The denial of  nerve ablation (procedure code 64628) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Low Back Pain.
Treatment:  Nerve Treatment in the Spine.

The insurer denied the nerve treatment in the spine.  The health plan's determination is upheld.

The patient is a female with a history of chronic low back pain. She was seen by her doctor, who documented that the patient was treated with conservative care, and her magnetic resonance imaging (MRI) revealed a disc displacement. Her treating provider recommended the Intracept procedure.

The proposed health service or treatment nerve treatment in the spine is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.

Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. While a recent study has shown promising results, the limitation of most of the studies performed include unavailable long-term comparative data, lack of sham controls and short duration of follow-up.

In this case the proposed treatment of the Intracept procedure is not supported by the literature to offer long term relief and the treating provider does not offer any specific rationale on how this intervention would offer any long-term relief for this patient.

The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, nausea and vomiting. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This patient is an adult male with a history of alcohol abuse who presented with sharp upper abdominal pain the radiated from the epigastrium to the back associated with vomiting. The patient's vital signs were stable, and he was afebrile. His blood pressure 157/119. Oxygenation was 100%. The patient's abdominal exam was remarkable for tenderness in the umbilical area. His complete blood count (CBC) was normal and basic metabolic panel (BMP) was unremarkable. The patient's creatinine was 0.63, alanine aminotransferase (ALT) was 62, and lipase was 1266. The patient's electrocardiogram (EKG) was normal. His chest x-ray showed no acute disease. His Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was three. 

The patient was admitted with acute pancreatitis. Plan of care included intravenous fluids, advance diet in the morning, and ultrasound. On the next day, the patient's vital signs were stable. His blood pressure was 155/95. He was on a clear liquid diet. The abdominal ultrasound showed hepatic steatosis. On the second day, the patient's vital signs were stable. He was tolerating oral intake (PO). There were no signs of alcohol withdrawal. The patient was discharged. 

The proposed treatment was not medically necessary. 

This patient was admitted with acute pancreatitis. The patient was hemodynamically stable and had normal oxygenation. The patient did not have electrolyte abnormalities or renal failure. Labs were remarkable for elevated lipase. Imaging did not 
confirm pancreatitis. The patient was able to tolerate oral intake and did not have uncontrolled pain. He received intravenous fluids during his hospital stay and remained stable. The patient had not failed an observation level of care. Acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission
The denial is upheld

The member was admitted for a urinary tract infection (UTI). During this hospital stay, the patient remained hemodynamically stable, responded appropriately to antibiotic therapy, and was discharged within 48 hours. Patients with an uncomplicated UTI (such as no fever, no flank pain) are treated as outpatients (if no other indication for admission is present). Some patients with an uncomplicated upper UTI (hemodynamically stable, able to maintain hydration orally) do not require an inpatient admission. Database analysis including 572,479 adult visits to an emergency department for UTI found an inpatient admission rate of 17% (percent). Another analysis of a national database found that out of more than 1.5 million visits to the emergency department for pyelonephritis, 27% were admitted to inpatient care. Therefore, per standard of care and evidence-based literature, an inpatient admission was not medically necessary and a lower level of care was more appropriate. 

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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive heart failure, osteoarthritis, and Alzheimer's disease
Treatment: Personal care aide (PCA) services 7 days per week, 10 hours per day, 70 hours per week
The insurer denied coverage for PCA services 7 days per week, 10 hours per day, 70 hours per week
The denial is overturned

This is an elderly patient with congestive heart failure, osteoarthritis and Alzheimer's disease.  The patient was hospitalized for a urinary tract infection, Coronavirus (COVID) and stroke. The patient lives with daughter in a private residence. The insurer approved PCA 9 hours per day, 7 days per week and the request is for 10 hours per day - 7 days per week (total 70 hours per week).

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "minimally impaired." The patient is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient also requires maximal assistance for bathing, dressing and toilet transfer and use. The patient is frequently incontinent of bladder and continent of bowel. Extensive assistance is needed for bed mobility and personal hygiene. The patient is totally dependent for locomotion and is unable to ambulate. The patient's cognition and functional ability have significantly declined compared to the previous UAS report. The patient may require additional monitoring. The patient's condition and functional ability continue to decline, are at a level and unpredictable as to require the requested PCA services 70 hours per week. Given the patient's continued decline and based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing PCA services to 10 hours per day, 7 days per week, totaling 70 hours per week.  

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) services 7 days per week, 10 hours per day, 70 hours per week is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease. 
Treatment: Surgery (transoral fundoplication using the EsophyX - procedure code 43210).

The insurer denied: Surgery (transoral fundoplication using the EsophyX - procedure code 43210). 
The denial is overturned. 

This patient is an adult female with history of gastroesophageal reflux disease (GERD) refractory to medical management. The patient has a complex past surgical history with Nissen fundoplication. The patient had recurrent symptoms and underwent a repeat hiatal hernia a year later. The patient then underwent a repeat Nissen, Collis procedure and recurrent hiatal hernia repair. Esophagogastroduodenoscopy (EGD) revealed a small hiatal hernia. Repeat 24-hour testing revealed an elevated Demeester score of 30 consistent with severe gastroesophageal reflux disease. The patient remains symptomatic despite maximal proton pump inhibitor (PPI) intake. The patient had a normal gastric emptying study. The patient does not document morbid obesity and or other lifestyle issues that are considered contributing factors. 

The health plan should cover the proposed treatment. 

This patient has severe refractory gastroesophageal reflux disease despite prior surgical treatment. Transoral incisionless fundoplication (TIF) is considered a standard endoscopic treatment for gastroesophageal reflux disease. It is supported by published guidelines and literature to be better than medical management. This patient already had two revisions of a prior anti-reflux procedure and would be at very high risk of surgical complications related to scarring. Conversion to gastric bypass would require takedown of the prior Nissen fundoplication and would also be very complex and high risk of complications. Both as a published standard procedure, but also because this patient has unique clinical concerns that would support an endoscopic treatment as a safer and less morbid treatment option and should be covered to treat this patient's refractory gastroesophageal reflux disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease. 
Treatment: Surgery (transoral fundoplication using the EsophyX - procedure code 43210). 

The insurer denied: Surgery (transoral fundoplication using the EsophyX - procedure code 43210). 
The denial is overturned. 

The patient is an adult female with prior history of three fundoplications for GERD (gastroesophageal reflux disease) and reflux disease. They have both failed and the patient has persistent symptoms of reflux disease. DeMeester is still high. Motility is noted to be dysfunctional. She has persistent symptoms. Denial prior due to the transoral incisionless fundoplication procedure being experimental and investigational per the policy. 

The health plan should cover the proposed treatment. 

Per the documentation, the patient has failed three prior surgeries for reflux disease that are standard of care procedures for this type of problem. This patient continues to fail these procedures and still have refractory symptoms of gastroesophageal reflux disease. Transoral incisionless fundoplication is a technique that is well described in the literature for treating patients that have undergone prior fundoplication or are not willing to undergo fundoplications. Consensus statements from the American Foregut Society and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) have provided recommendations that this procedure is safe and effective for the treatment of gastroesophageal reflux disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Patient is an adult with a past medical history significant for stroke, Parkinson's disease, atrial fibrillation, diabetes mellitus, and hypertension (HTN) who presented to the emergency department with complaints of confusion and diarrhea. 

Vitals on presentation included: Temperature 37.6 degrees Centigrade, Blood Pressure 139/82, Pulse 90, Respiratory Rate 16, oxygen (O2) saturation 94%. Laboratory results included the following: white blood cell count (WBC) 10.3, Hemoglobin 9.5, Hematocrit 30.6, creatinine-0.81, glucose-172, lactate 2.5, potassium 3.1, urinalysis showed moderate leukocyte esterase and negative nitrite. Chest x-ray was negative. Head computed tomography (CT) scan was negative.

Patient was given intravenous fluid boluses for possible dehydration and empirically started on intravenous antibiotics (ceftriaxone) for possible urinary tract infection. Urine culture grew Escherichia coli, antibiotics was switched to oral cephalexin. Patient underwent physical therapy. He remained afebrile, hemodynamically stable, and was transferred to short-term rehabilitation.  

According to documentation, patient presented with vague complaints, and according to family member- "something was off." Otherwise, he was afebrile, hemodynamically stable, with no acute findings on laboratory results including a normal WBC. Patient was treated for an incidental finding of a urinary tract infection requiring oral antibiotic. He was described as "non-toxic, non-diaphoretic, chronically-ill appearing." Their clinical impression was "near syncopal episode due to orthostasis, likely in the setting of underlying autonomic dysfunction with Parkinson's disease. Based on above findings, patient did not meet criteria for acute hospital admission.   

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

Diagnosis: Heart failure, chronic obstructive pulmonary disease (COPD), and alcohol dependence.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with a past medical history of heart failure, chronic obstructive pulmonary disease (COPD), and alcohol dependence who presented to the emergency department for evaluation of exertional shortness of breath and urinary retention.  On arrival to the emergency department, the patient was afebrile, heart rate was 69 beats per minute (bpm), blood pressure was 109/66, respiratory rate was 16, and oxygen saturation (SPO2) was 100% on room air.  On exam, the patient had bilateral lower extremity edema, decreased breath sounds with minimal wheezing, and diffuse skeletal tenderness.  Initial labs showed a white blood cell (WBC) count of 7.0, hemoglobin of 10.8, platelet count of 170, sodium of 127, potassium of 4.1, blood urea nitrogen (BUN) of 26, and creatinine of 1.36.  Chest x-ray demonstrated no acute cardiopulmonary abnormalities.  Electrocardiogram (EKG) showed sinus bradycardia without acute ST changes.  She was given intravenous Lasix and was admitted to the inpatient unit for further care.

The proposed inpatient hospital admission was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. The patient's chest x-ray did not demonstrate evidence of pulmonary edema or pleural effusions. There was no acute ischemia or pleural effusions. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diganosis: Alopecia areata.
Treatment: Olumiant.
The insurer denied: Olumiant.
The denial is: Upheld.

The patient is a male with alopecia areata. His beard is also affected. He has failed intralesional triamcinolone injections, mometasone, Opzelura, and minoxidil. The subject under review is the medical necessity for Olumiant.

The health plan's determination is upheld.

The requested health service/treatment of Olumiant is not medically necessary for this patient.
The Olumiant was denied by the plan because there was no SALT score of greater than 50%. The Severity of Alopecia Tool (SALT) score assesses the degree of hair loss, with 0 being no hair loss, and 100 being complete hair loss. Given that the hair loss in this patient is less than 50, it would not be considered severe enough to warrant a systemic therapy such as Olumiant, especially without exhausting all the topical therapies first.