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

Diagnosis: Febrile Seizure. 
Treatment: Inpatient Admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

This case involves a male child who presented to the emergency room with indications of a febrile seizure. The patient was positive for influenza and reportedly had a first-time seizure at home on that date. He reported nasal congestion prior to admission along with nausea and vomiting for 2 weeks. Fever and headache were noted before the incident and the seizure-like activity included whole body shaking, eyes rolling back, and urinary incontinence. The seizure lasted approximately 10-15 seconds with the patient not able to be aroused for around 15 minutes after the event. He was transported via ambulance to the emergency department whereupon vital signs obtained showed an elevated temperature at 103 degrees F (Fahrenheit), heart rate of 143 bpm (beats per minute), and with laboratory values: hyperglycemia with glucose at 112; hyponatremia with sodium 134; elevated procalcitonin at 0.73; and leukocytosis with white blood cell count at 15.1. Computed tomography (CT) of the brain was obtained and was negative for any abnormalities. The patient was admitted for further evaluation and monitoring given his age and concerns for febrile seizure. An electroencephalography (EEG) demonstrated right occipital slowing and excessive beta frequencies in the frontal area. While hospitalized, the patient underwent additional testing, received treatment with anti-pruritic, intravenous fluids, Tamiflu, and monitoring. An MRI (magnetic resonance imaging) of the brain was obtained prior to discharge, showing a left hippocampal inversion. 

Literature states that children with first complex febrile seizures are often admitted for observation. Evidence has shown that child with first complex febrile seizures is at low risk for seizure recurrence during admission. Multiple seizures at presentation are associated with risk of early recurrence and may warrant an admission. In the case of this patient, records stated that he presented after having a febrile seizure at home related to influenza, which was confirmed on initial testing. In taking the patient's age into consideration, the Milliman Care Guidelines state that when a child over the age of 5 years has a febrile seizure, they may be considered for inpatient admission. However, the guidelines also state that some patients may be appropriate for observation care. In the case of this patient, he could have been placed on observation status to undergo additional testing and receive 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 the hospital admission services is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Knee Pain.
Treatment: Pain injection- genicular nerve block.
The insurer denied pain injection- genicular nerve block.
The determination is upheld.

This is a patient who has a diagnosis of knee pain. The patient was seen with complaints of chronic bilateral knee pain right greater than left and rated at 9/10. It was noted the patient had bilateral knee x-rays showing moderate to severe osteoarthritis most in the right and left medial joint spaces with genu varus noted. The patellofemoral joint spaces were also narrowed bilaterally. It was noted that the patient has received bilateral knee joint steroid injections which helped initially but the pain came back after a few days. The patient has participated in activity restriction, a home exercise program, and physical therapy for the past 4 to 6 weeks with some benefits. The patient has been taking acetaminophen and oral nonsteroidal anti-inflammatory drugs (NSAIDs). The current medications were listed as Abilify, albuterol, duloxetine, and Spiriva. The physical examination of the right knee revealed genu varus deformity, moderate tenderness over the medial joint space, decreased range of motion with flexion; strength 5/5; positive varus stress and instability; normal sensation. The left knee revealed genu varus deformity, crepitus, moderate tenderness over the patella, decreased flexion, positive varus stress, and instability. The patient was recommended for a right knee genicular nerve block. At issue is whether this is likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease.

The proposed health service or treatment pain injection-genicular nerve block is not likely to be more beneficial than any standard treatment or treatments for the insured's life-threatening or disabling condition or disease. Per the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended for diagnostic evaluation or treatment of osteoarthritis of the knee." Records indicate that the patient has a history of chronic bilateral knee pain with moderate to severe osteoarthritis. Evidence-based guidelines and peer-reviewed medical literature do not recommend either genicular nerve blocks or radiofrequency ablation, as this treatment has not been proven to be either safe or effective, and there are no high-quality long-term studies with long follow-up periods available. There is no evidence to suggest that this procedure would be more likely to be beneficial than other standard treatments for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Knee Pain.
Treatment: Pain injection- genicular nerve block.
The insurer denied pain injection- genicular nerve block.
The determination is overturned.

This is a patient with a history of chronic knee pain secondary to osteoarthritis confirmed by imaging. They have been treated with therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), steroid injections, viscosupplementation, and activity modification. Her provided recommended genicular nerve blocks and if a diagnosis is successful then ablation will be planned. At issue is whether the proposed health service or treatment pain injection-genicular nerve block is likely to be more beneficial than any standard treatment or treatments for the insured's a life-threatening or disabling condition or disease.

Yes. Genicular nerve blocks and genicular nerve ablation are safe and effective therapeutic procedures for chronic knee pain. The genicular nerve block should be performed no more than twice, and if the patient receives greater than 50 percent (%) temporary relief, then the patient would be a candidate for genicular nerve ablation. Considering the patient's medical history and failure with other conservative options, the treatment appears appropriate. Genicular nerve blocks and ablation are commonly used and are a widely accepted treatment standard among pain management physicians for patients with chronic knee pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease. 
Treatment: Stelara. 

The insurer denied Stelara.  The denial is upheld. 

The patient is a male with a history of Crohn's disease. He has tried and failed corticosteroids. The treating provider is requesting Stelara for induction, then at 90 milligrams (mg) every four weeks. The subject under review is the medical necessity for Stelara in this patient. 

The health plan's determination is upheld. 

Stelara is not medically necessary in this case. Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease. 

Chavannes M et al., reported a multi-centered cohort study supporting the safety and efficacy of Stelara in pediatric patients with Crohn's disease. 

The clinical practice guidelines support the use of Stelara in pediatric Crohn's patients who failed tumor necrosis factor (TNF)-alpha inhibitors. (van Rheenen, Patrick F., et al).
Therefore, the use of Stelara in refractory cases of Crohn's disease is appropriate.
However, this patient was recently diagnosed and has not yet tried and failed the standard and FDA approved therapies for his age and condition. There is no evidence that Stelara is superior to the FDA approved alternatives in terms of safety or efficacy. There is no clinical reason for this patient to avoid using the standard approved therapies. There is no literature supporting the use of Stelara in children as a first line biologic, before using and failing the standard and FDA approved therapies. 

Therefore, the request for Stelara in this patient is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: GIST (Gastrointestinal Stromal Tumor of Small Intestine)
Treatment: Stivarga
The insurer denied Stivarga. The health plan's determination is upheld.

This is a female with recurrent, metastatic GIST (Gastrointestinal Stromal Tumor of Small Intestine). The patient has previously undergone multiple resections. The patient has been managed on Sutent. Stivarga has been requested as an additional component of therapy; this is under review.

Stivarga is not medically necessary for this patient.
The use of Stivarga in combination with Sutent has not been demonstrated to improve outcomes. This approach remains the subject of ongoing investigation in a number of trials including, but not limited to, NCT05366816 and NCT02164240. The proposed Stivarga is not recommended by the peer-reviewed literature, by the National Comprehensive Cancer Network (NCCN) Guidelines, nor by the authors of UpToDate.
Currently, based on phase II and III data, Stivarga is indicated in patients with imatinib- and Sutent-refractory GIST. In the GRID trial, 199 patients with metastatic or unresectable GIST refractory to or intolerant of Sutent were randomly assigned to best supportive care plus either Stivarga (160 milligrams (mg) once daily for three of every four weeks) or placebo. Compared with placebo, Stivarga improved progression-free survival (PFS; 4.8 versus 0.9 months). Based on these data, the US (United States) Food and Drug Administration (FDA) approved regorafenib for treatment of metastatic or unresectable GIST no longer responsive to imatinib and Sutent. Based on the included documentation, however, it is not clear that 1) this patient has failed imatinib and 2) that Stivarga is being given as a single agent. For these reasons, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory failure
Treatment: Long Term Acute Care Hospital (LTACH) Admission 
The insurer denied Long term acute care hospital admission. 
The health plan's determination is upheld. 

The patient is a male with a medical history of Alexander disease, hypertension, hyperlipidemia, type 2 diabetes mellitus and acute hypoxic respiratory failure due to COVID-19 (coronavirus disease 2019) pneumonia with a previous hospital course complicated by a failure to wean from mechanical ventilation requiring the placement of a tracheostomy and feeding tube. Most recently, he was treated for aspiration pneumonia, undergoing wound care and physical therapy. 

The Long-Term Acute Care Hospital (LTACH) Admission is not medically necessary for this patient.
As per the clinical documentation, this patient has a medical history of Alexander disease, hypertension, hyperlipidemia, type 2 diabetes mellitus and acute hypoxic respiratory failure due to COVID-19 pneumonia with a previous hospital course complicated by a failure to wean from mechanical ventilation requiring the placement of a tracheostomy and feeding tube. Most recently he was treated for aspiration pneumonia, undergoing wound care and physical therapy. Per the clinical documentation, he is alert/awake, hemodynamically stable, tolerating tube feedings, no longer requires ventilator support, does not have any severe electrolyte abnormalities, has stable renal and liver function testing, and does not have severe anemia or bleeding diathesis. Per the physical therapy notes, he is a total assist for all activities, has 0/5 muscle strength on all extremities and can only participate in physical activity 2 - 3 times per week. There is no indication he can tolerate or benefit from acute physical therapy to improve his functional status or has the potential to recover to his previous baseline. In addition, his wounds do not require complex care. He does not require frequent diagnostic services, nursing care > (greater than) 6.5 hours per day or daily physician assessments. Therefore, the requested Long-Term Acute Care Hospital (LTACH) Admission is not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Irritable Bowel Syndrome with Constipation.
Treatment:  Formulary exception for Trulance (plecanatide).
The insurer denied the  Formulary exception for Trulance (plecanatide).  The denial is overturned.

The patient is a female with irritable bowel syndrome - constipation (IBS-C). She has failed Miralax, Senna, Metamucil, Colace, Dulcolax, Mg citrate, lactulose, Linzess and Amitiza. She has been doing well on Trulance for several years. The attending physician (A{P) is requesting to continue Trulance.

Yes, the health plan should cover the proposed Trulance.

The patient has irritable bowel syndrome - constipation (IBS-C). Trulance is safe and effective, Food and Drug Administration (FDA) approved and medically necessary for the treatment of IBS-c (irritable bowel syndrome - constipation). As the patient has failed formulary alternatives Lactulose, Linzess and Amitiza, the health plan should cover Trulance.  The three formulary drugs have been ineffective for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.  The denial is upheld.

The patient has a history of gastric sleeve surgery and an abdominoplasty and presented with abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. An abdominal computed tomography (CT) scan was negative for acute disease. The surgical consult advised that no surgical interventions were needed. She was felt to have poor motility. An enema and bowel regimen were given. She had bowel movements and felt better. 

Milliman Care Guidelines (MCG) criteria for inpatient admission with Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had abdominal pain and was felt to have poor motility. She responded well to a laxative regimen. Intravenous (IV) hydration and the bowel regimen could have been given with observation care. She did not require an inpatient hospitalization to treat the gastroparesis or the constipation. She did not meet MCG criteria for Undiagnosed Abdominal Pain. 

The insurer's denial is 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 the inpatient admission is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: lumbar radiculitis, left hip pain, cervical spondylosis, and failed back syndrome of the lumbar spine

Treatment: 22899, unlisted procedure, spine, Intracept, C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum and C9753 destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g. fluoroscopy, lumbar/sacrum

The insurer denied coverage for 22899, unlisted procedure, spine, Intracept, C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum and C9753 destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum

The denial is upheld.

This case involves an adult female who has complaints of ongoing low back pain that started after being involved in a motorcycle accident. The documentation indicated the patient has undergone multiple treatments to include a laminectomy with partial discectomy as well as lumbar epidural steroid injection, medication management and physical therapy. According to the physician the patient continues to complain of ongoing pain with a negative impact upon completing activities of daily living. Medications do include anti-inflammatories as well as oxycodone, lidocaine gel, and methocarbamol. The physician indicated the most recent magnetic resonance imaging (MRI) was performed demonstrating Modic type I changes at the L (lumbar) 3-L4 and L4-L5 disc space. Given the patient's disabling pain affects her quality of life on a daily basis, it has been recommended that she undergo the requested treatment. The official MRI reveals a prior laminectomy at the L3-4 level with partial discectomy and resultant significantly decreased/resolved spinal canal stenosis with evidence of moderate extension of posterior disc likely representing a disc bulge. At the L4-5 level there is evidence of a laminectomy with a moderate disc bulge causing minimal ventral thecal sac effacement.

There is literature supporting a result of improvement in health outcome.

The treatment does have final approval.

While there is documented pain despite conservative care, the provided imaging report does not note Modic changes. Therefore, this patient is not a good candidate.

While there is documented pain despite conservative care, the provided imaging report does not note Modic changes. Therefore, this is not the most appropriate treatment at this time for this patient.

The requested service in this case is not likely to be more beneficial.

The adverse risks are not increased.

The carrier's denial of 22899, unlisted procedure, spine, Intracept, C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum and C9753 destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: lumbar radiculitis, left hip pain, cervical spondylosis, and failed back syndrome of the lumbar spine

Treatment: 22899, unlisted procedure, spine, Intracept, C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum and C9753 destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum

The insurer denied coverage for 22899, unlisted procedure, spine, Intracept, C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum and C9753 destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum.

The denial is overturned.

This case involves an adult female with a history of hypertension, hypercholesterolemia, hypothyroidism, coronary artery disease, sleep apnea, anemia, hip fracture, thalamic hemorrhage, vertebrogenic pain, cervical radiculitis, lumbar spondylosis, and degenerative disc disease. A decompressive laminectomy L [lumbar] 4-L5, hemilaminectomy with partial facetectomy and discectomy at left L3-L4 and hemilaminectomy with partial facetectomy and discectomy at right L3-L4 was performed. A magnetic resonance imaging (MRI) scan of the lumbar spine revealed evidence of L3-L4 laminectomy with partial discectomy with decompression of prior severe central spinal canal stenosis. On clinic visit note, the day of physical examination revealed decreased and painful range of motion of the lumbar spine and positive lumbar facet loading. The patient was diagnosed with lumbar radiculitis, left hip pain, cervical spondylosis, and failed back syndrome of the lumbar spine. A request was submitted for an unlisted procedure, spine, Intracept, C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum and C9753 destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum. 

This patient could be a good candidate for the requested procedure, however there is no noted Modic changes reported on MRI which is a requirement.

Scientific evidence in peer-reviewed literature supports result of improvement in health outcome.

The requested procedure has final approval from the appropriate regulatory bodies for the noted diagnosis. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The adverse risks are not increased over standard treatment/services.

The carrier's denial of 22899, unlisted procedure, spine, Intracept, C9752, destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum and C9753 destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g. fluoroscopy), lumbar/sacrum should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease.
Treatment: Stelara.

The insurer denied the Stelara.  The determination is overturned.

The patient has moderate to severe ileocolonic Crohn's disease status post right hemicolectomy. He has failed Inflectra with 6-mercaptopurine after a long period of clinical remission (secondary loss of response and anti-infliximab antibodies). A colonoscopy confirmed worsening of his disease, with finding of rectal inflammation and inflammatory polyps. He has had abdominal pain and diarrhea for over 3 months. Stelara is under review for the treatment of Crohn's disease. The request was not approved because Entyvio has not been attempted.

The request for Stelara is medically necessary.

Stelara and Entyvio are recommended by American College of Gastroenterology guidelines for the treatment of Crohn's disease [1]. American Gastroenterological Association (AGA) guidelines for the treatment of Crohn's disease specifically do support the use of Entyvio in patients with Crohn's disease [2]. However, the guidelines recommend Stelara over Entyvio in Crohn's disease patients who have a secondary non-response to an anti-tumor necrosis factor (such as Inflectra, attempted by the enrollee), stating "In adult outpatients with moderate to severe Crohn's disease who previously responded to infliximab (secondary nonresponse), the AGA recommends the use of adalimumab or ustekinumab and suggests the use of vedolizumab over no treatment for the induction of remission" [2]. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-tumor necrosis factor (TNF) medications, which the enrollee has failed [3]. A recent study demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara [4]. Two studies showed that Stelara appears more effective than Entyvio in the treatment of Crohn's disease, with one finding odds ratio of remission of 2.01 and the other 2.58 [5,6]. For these reasons, the request is supported as medically necessary.