Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Paroxysmal Atrial Fibrillation (AF)

Treatment: Eliquis (apixaban)

The insurer denied coverage for Eliquis

The denial is overturned.

According to the review, this case of a female with a history of paroxysmal atrial fibrillation (AF) and status post tachy-brady syndrome and permanent pacemaker implantation.  Relevant past medical history includes hypertension, diabetes mellitus, obstructive sleep apnea and obesity, status post bariatric surgery. The patient was previously treated with Xarelto therapy. Echocardiographic imaging revealed an intracardiac thrombus on her right atrial pacemaker lead. She was switched to Pradaxa but developed gastrointestinal symptoms.  She was ultimately treated with Eliquis therapy which she has tolerated. Formulary alternatives are Xarelto and warfarin.

The American Heart Association, American College of Cardiology and Heart Rhythm Society Guidelines list a Class I (level of evidence A) recommendation for treatment with novel oral anticoagulant regimen instead of warfarin. This recommendation was based on several randomized clinical trials that enrolled thousands of patients. The direct thrombin inhibitor medications and the Factor Xa [protein that reverse the effects of anticoagulant) inhibitor medications (including Xarelto/Rivaroxaban) were at least non inferior and in some cases superior to warfarin therapy. When Xarelto was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated non-inferiority to warfarin in preventing stroke or systemic embolism (Reference 2). This patient had clear evidence of intracardiac thrombosis while treated with Xarelto necessitating the use of an alternative such as apixaban (Eliquis). In fact, when Eliquis was utilized to treat patients with atrial fibrillation in a large randomized controlled study, results demonstrated superiority to warfarin in preventing stroke or systemic embolism. In addition, patients treated with Eliquis had less bleeding and a lower mortality than those treated with warfarin (Reference 3).

Based on the above, the formulary drugs are likely to cause the patient an adverse reaction and/or have been ineffective based on the patient's clinical history. The formulary drug Xarelto, was ineffective. This was clearly documented when an intracardiac thrombus was noted while the patient was taking Xarelto in the past. The formulary drug warfarin would also cause an adverse reaction given its narrow therapeutic window and propensity for either bleeding or thrombosis in a patient with AF and previous intracardiac thrombus. The requested drug, apixaban, would therefore be more effective than the formulary drugs.

The insurer's denial of coverage for Eliquis is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Blood Disorder. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Eliquis. 
The denial is upheld. 

The patient is a female stated to have an acute deep venous thrombosis of a lower extremity. The patient is taking Eliquis; this is under review. 

Based on the available information, this patient does not have a contraindication to either warfarin or Xarelto. There is a paucity of evidence to indicate that Xarelto is inferior to Eliquis. Neither the authors of UpToDate nor the peer-reviewed literature nor guidelines recommend one direct factor Xa inhibitor over another. With regard to warfarin, studies to suggest the potential for a greater risk of bleeding relative to Xarelto, there is no evidence in the included documentation that this patient is at particular risk of bleeding and this agent is still widely used and considered an appropriate option in this clinical scenario. For these reasons, either of the formulary options are appropriate and effective in this setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Perirectal Abscess.
Treatment: Inpatient Hospital.

The health plan denied the requested inpatient stay.  The health plan's determination is upheld.

The patient is a female who presented to the emergency room (ER) with a worsening peri rectal abscess, at the direction of her colorectal surgeon. The patient had been seen 2 days previously in the ER for this and underwent drainage. Her pain had reached 9/10. Vitals were as expected. Examination demonstrated purulent drainage on external examination of the anus. The white blood cell count (WBC) was 6.6.  A repeat computed tomography (CT) scan demonstrated a marked decrease in the abscess. The patient was hospitalized overnight on intravenous (IV) antibiotics. The next day the patient was rounded on and was found to be doing well.  The patient was discharged that evening.
At issue is the medical necessity of the inpatient stay.

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

The inpatient stay was not medically necessary. While the patient appears to have had a rectal abscess with increased pain, the patient does not appear to have utilized hospital services at the inpatient level of care. The patient was identified to have a rectal abscess which had already been drained surgically with concerns, as the patient had increased pain. The patient's vitals and labs were normal. The patient did well while in the hospital and was discharged the day after admission. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Premature atherosclerotic cardiovascular disease (ASCVD)

Treatment: Current procedural terminology (CPT) code 83695, lipoprotein A and CPT code 83704, lipoprotein, blood; quantitation of lipoprotein particle numbers, includes lipoprotein particle subclasses when performed to assess for cardiac risk factors
The insurer denied coverage for (CPT) code 83695, lipoprotein A and CPT code 83704, lipoprotein, blood; quantitation of lipoprotein particle numbers, includes lipoprotein particle subclasses when performed to assess for cardiac risk factors
The denial is upheld

This case involves a patient with a history of a prior myocardial in addition to hypertension as well as hyperlipidemia and overactive bladder.  He was seen for a follow up after an inferior wall myocardial infarction.  He presented with crescendo angina followed by sudden onset of persistent chest discomfort.  Ruptured plaque with TIMI II (thrombolysis in myocardial infarction) flow was noted in the RCA (right coronary artery) as well as severe stenosis in the RPL (right posterolateral) branch.  He was previously noted to have elevated lipids and a very strong family history of early onset coronary artery disease.  He continues to have issues regarding anxiety as well as urinary retention and overactive bladder.  He did have a decreasing lipoprotein a, however, it remained elevated.  His LDL (low density lipoprotein) had significantly decreased on the Repatha.  There were no significant physical examination findings.  The recommendation was made to continue with medication and strongly consider inclusion in a clinical trial.  The request was received for CPT code 83695 and 83704.

This test does not support a result of improvement. The patient is not a good candidate. The risks are not increased over other standard testing.

A lipoprotein (a) test is used to check for risk of stroke, heart attack, or other heart diseases. It is not a routine test. It is usually only given to people who have certain risk factors, such as a family history of heart disease.

Elevated lipoprotein (a) is causally implicated in atherosclerotic cardiovascular disease (ASCVD) and testing in specific patients may help to tailor the appropriate intensity of preventive measures. However, because of the lack of standardization and heterogeneity of the available data, optimal cut-offs remain a source of intense debate. The current focus of clinical care is on traditional risk factor control in patients with high lipoprotein (a) as targeted treatment options are limited (1).  

This testing is not likely to be more beneficial than any other standard testing.

The carrier's denial of current procedural terminology (CPT) code 83695, lipoprotein A and CPT code 83704, lipoprotein, blood; quantitation of lipoprotein particle numbers, includes lipoprotein particle subclasses when performed, should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Premature atherosclerotic cardiovascular disease (ASCVD)

Treatment:  Current procedural terminology (CPT) code 83695, lipoprotein (Lp) A and CPT code 83704, lipoprotein, blood; quantitation of lipoprotein particle numbers, includes lipoprotein particle subclasses when performed to assess for cardiac risk factors
The insurer denied coverage for (CPT) code 83695, lipoprotein A and CPT code 83704, lipoprotein, blood; quantitation of lipoprotein particle numbers, includes lipoprotein particle subclasses when performed to assess for cardiac risk factors
The denial is overturned

The patient has a history of inferior wall myocardial infarction, hypertension, and hyperlipidemia. He has a family history of premature atherosclerotic cardiovascular disease (ASCVD).  Following treatment with high dose statin therapy his low-density lipoprotein (LDL) remained above goal and he was successfully treated with Repatha. His physician ordered testing of lipoprotein A (CPT 83695) and lipoprotein particle quantitation (CPT 83704). 

The scientific evidence in peer reviewed literature supports a result of improvement in health outcome. Lipoprotein A (Lp (a)) has been shown to have atherogenic potential (Reference1,2). The American Heart Association cholesterol clinical practice guidelines consider elevation of Lp (a) a risk enhancing factor (Reference 3).  

Current procedural terminology (CPT 83695, 83704) has approval from the appropriate regulatory bodies for diagnosis. Indications for measurement include a family history of premature coronary artery disease and ASCVD not explained by major risk factors. (Reference 3). The US (United States) National Lipid Association and the European Society of Cardiology guidelines recommend testing for Lp (a) in patients with premature coronary artery disease and or a strong family history of ASCVD (Reference 4,5). Based on guidelines, this patient is a good candidate for these tests on date of service.

Multiple clinical trials have reported an elevated level of major adverse cardiac events in patients with good reduction in LDL cholesterol and elevated Lp(a) (Reference 6,7). Assessment of Lp(a) is the best procedural treatment for the patient at this time.  There are no apparent adverse risks to these tests. In fact, testing will be useful for guiding therapy.

In conclusion, testing of lipoprotein a (CPT 83695) and lipoprotein particle quantitation (CPT 83704) is likely to be more beneficial than any standard therapy in this patient with premature ASCVD, family history of ASCVD and few cardiac risk factors to explain an inferior wall myocardial infarction.

The carrier's denial of current procedural terminology (CPT) code 83695, lipoprotein A and CPT code 83704, lipoprotein, blood; quantitation of lipoprotein particle numbers, includes lipoprotein particle subclasses when performed, should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Degenerative Disc Disease (DJD).
Treatment: procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation.
The insurer denied coverage for procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation.

The denial is upheld

This patient has had chronic low back pain for a year. She has had Epidural Steroid injections, Facet injections and radiofrequency ablation (RFA). Medication trials have included Mobic, Prednisone, Robaxin and tramadol. The patient has left paracentral protruding disc abutting sacral (S)1 and multi-level disc bulges. She has Modic changes at lumbar (L)5-S1.  The request is for RFA of the basivertebral nerves.

There are RCT (randomized controlled trials) that show its effectiveness at two years. In fact, there is another follow-up study where it was recommended  that  patients  cross  over to the treatment arm due to effectiveness early on.

lntracept is indicated in patients who have a history of low back pain of at least 6 months duration; and - Failed to respond to at least 6 months of non-surgical management; and MRI (magnetic resonance image) demonstrated Modic Type 1 or Type 2 changes* at one or more vertebrae from L3 to S1; and activities of daily living that are limited by persistent low back pain; and all other reasonable
sources of pain have been ruled out.

Despite a history of chronic low back pain of more than six months, the magnetic resonance imaging (MRI) findings did not point to any evidence of Modic type 1 or type 2 changes at any vertebra, which is a recommended requirement by RELIEVANT, the lntracept medical device manufacturer (source: https://www.relievant.com/wp content/uploads/2019/05/MKT  0066-RevD - Re...)

Based on the lack of MRI findings of Modic changes, the lntracept procedure is unlikely to be more beneficial than standard treatments/procedures for this patient 

The carrier's denial of procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Degenerative Disc Disease (DJD).
Treatment: procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation.
The insurer denied coverage for procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation.

The denial is upheld

This patient has had chronic low back pain for a year. She has had Epidural Steroid injections, Facet injections and radiofrequency ablation (RFA) and has done a home exercise program. Medication trials have included Mobic, Prednisone, Robaxin and tramadol. On MRI (magnetic resonance image) she has Left paracentral protruding disc abutting S (sacral)1 and multi-level disc bulges. She has Modic changes at L (lumbar) 5-S1.  The request is for RFA of the basivertebral nerves.

Fischgrund and colleagues (1) published a double-blind, sham controlled RCT [randomized control trial] evaluating the Intracept system and RF [radiofrequency] ablation of the Basivertebral nerve for the treatment of chronic low back pain. A total of 225 participants with chronic (>= 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n=78) or treatment (n=147) intervention. In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85C (Celsius) for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Owestry disability index (ODI) of 30 points (on 100-point scale) and a minimum VAS [visual analog scale] of 4 cm (centimeters) (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13% [percent]) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance.

The publications to date have been company sponsored and had methodology flaws.  There is no published data on long term complication rates.  UpToDate has evaluated this procedure and concluded that it is unproven.  There is other evidence - based interventions available to this patient.  This procedure is unlikely to be more beneficial than any other standard services or treatments.

The carrier's denial of procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Degenerative Disc Disease (DJD).
Treatment: procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation.
The insurer denied coverage for procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation.

The denial is upheld

This patient has a history of hypertension, hyperlipidemia, arthritis, bowel perforation, diverticulitis, and degenerative disc disease (DJD). She presented to the Pain Management physician's office for a follow up visit for lower back pain. Imaging revealed mild disc bulging at lumbar (L) 1-sacral (S) 5. There was left paracentral protrusion and facet hypertrophy at L1-S5. The patient has failed more than 6 months of conservative treatment. The physician recommended procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation to treat back pain. 

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 no longer require their narcotics. For one level of disc disease each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeon nor spine surgeon. There are no National Organizations which provide guideline nor indication. 

A search was performed using PubMed. The key word was Intracept Lumbar. There were two references. The articles submitted by appeal were also reviewed. There were small numbers of people evaluated for a short duration. The procedure is currently being performed by an investigative group and likely 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 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. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.  It had approval for marketing but no statement about efficacy for diagnosis. This patient is not a good candidate for procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation.

This is not the best available treatment for this patient currently. There are no adverse risks reported. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of procedure codes C9752 and 22899, Intracept procedure, intraosseous basivertebral nerve ablation should be denied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oligodontia

Treatment dental implants, procedure code D6010 to tooth # 4, 6, 19, and 21

The insurer denied coverage for dental implants, procedure code D6010 to tooth #s 4, 6, 19, and 21.

The denial is overturned.

Upon review of the submitted documentation including copy of panoramic radiographs, narrative letter of medical necessity letter and insurer correspondence including Excellus Medical Policy on Dental Implants, it appears that this patient presented for dental evaluation. Oligodontia and functional defect was identified and therefore, the dentist, recommended the aforementioned endosteal implants. The insurer has denied these services as not medically necessary as the services recommended do not meet their medical necessity criteria.  

Based on review of the documentation it appears that this patient is exhibiting significant functional deficits. In this case, a standard of care in dental practice would be the aforementioned recommended treatment.  Peer reviewed literature supports implants in this clinical circumstance to restore function. Further, as per the insurers policy guidebook, implants are covered services and this patient clinical circumstance fulfills their medical necessity criteria. As this is the case and these are covered services, the implants and associated services are deemed medically necessary.

Dental implants, procedure code D6010 to teeth #4, 6, 19 and 21 provided 
is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for dental implants, procedure code D6010 to tooth # 4, 6, 19, and 21 is overturned. Medical Necessity is substantiated.