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

Diagnosis: Back pain

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This male patient has a medical history of aortic and mitral mechanical valves, hypertension, hypertrophic cardiomyopathy, chronic obstructive pulmonary disease (COPD), asthma, obstructive sleep apnea (OSA), gastroesophageal reflux disease (GERD), left shoulder melanoma, osteomyelitis of L5-S1 and infective endocarditis who presented to the Emergency Department (ED) with complaints of severe right-sided lower back pain that started five days before.  The patient was found to have a hematoma on imaging. The patient was treated with gabapentin and intravenous (IV) Morphine for pain control.

As per literature review, the use of intravenous Morphine and gabapentin in a patient with COPD and OSA mandates close monitoring and inpatient admission. Cozowicz, et al. (2018)'s systematic review states that the "initial 24 hours after opioid administration appear to be most critical with regard to life-threatening opioid induced respiratory depression (OIRD).  Further, obstructive sleep apnea (OSA)-related increased pain perception and enhanced opioid sensitivity could predispose patients with OSA to a higher risk for OIRD without overdosing.   While high-quality evidence is needed, retrospective analyses indicate that critical, life-threatening OIRD may be preventable with a more cautious approach to opioid use, including adequate monitoring." Lam et al. (2016) also states that "Epidemiologic evidence suggests that OSA together with other serious renal and heart disease, is among those conditions predisposing patients for opioid-induced ventilatory impairment (OIVI)...

In this case, this patient has COPD, OSA and cardiac conditions including hypertrophic cardiomyopathy and aortic/mitral mechanical valves on anticoagulation. The patient presented with symptomatic hematoma on anticoagulation that required intravenous opiates. Due to this patient's high-risk for opioid induced respiratory depression and risk of worsening hematoma on anticoagulation, inpatient admission was medically necessary for close monitoring and treatment management. 

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

The carrier's denial of coverage for the inpatient hospital admission should be overturned.  The medical necessity is substantiated.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis:  Migraine headaches.
Treatment:  Emgality.

The insurer denied Emgality.  The determination is upheld.

The patient was prescribed Emgality.  At that time, she was experiencing 10 or more headaches per month with six on average and with each headache lasting for 2 to 3 days.  Medications at that time were Alyacen, calcium, coenzyme Q10, magnesium, riboflavin, Soolantra cream and rizatriptan.

An office note indicated that she had headaches that would vary between 2 to 7 per month and would not typically qualify for prevention or preventive medication.  At that time, she continued on rizatriptan and Cambia.  Medications were Alyacen, calcium, Cambia, Coenzyme Q10, rizatriptan, Soolantra cream and Riboflavin.

Another office note indicated that she previously utilized medications including Zoloft, oral contraceptives, multiple triptans, magnesium, coenzyme Q10 in Riboflavin and nonsteroidal anti-inflammatory medications, and she was experiencing 8 migraine headaches per days per month.  Her neurological examination was normal, and at that time Emgality was recommended.  There is no documented contraindication to any oral migraine prophylactic medication.

A letter of medical necessity from her provider noted that Emgality has been Food and Drug Administration (FDA) -approved for the requested indication, but it did not indicate why the patient cannot utilize an oral migraine prophylactic medication.

A prior authorization form indicates prior trials and failures of naratriptan, rizatriptan and Cambia.

Emgality was denied by the health plan as noting that there must be eight or more migraine days per month for at least 12 months prior to requesting calcitonin gene-related peptide (CGRP) therapy, and there must be a trial and failure of three evidence-based prophylactic medications (Divalproex, topiramate, a tricyclic antidepressant, venlafaxine and a beta blocker).  At issue is the medical necessity of Emgality.

The Emgality is not medically necessary.  This is a patient with a history of episodic migraine.  She has had eight or more migraines per month.  There is no documentation that she has had a trial and failure of any oral evidence-based oral migraine prophylactic medications.  There is no evidence in the peer-reviewed medical literature that Emgality is superior with regard to patient outcomes compared with evidence-based oral migraine prophylactic medications, which include antiepileptics, such as topiramate and Divalproex, antidepressants, such as amitriptyline and venlafaxine, and beta blockers including propranolol and others.  The patient has no contraindication to any or all of these medications.  There is no rationale why the patient cannot utilize an oral migraine prophylactic therapy, as there is no expectation of inferiority to Emgality.  The Emgality is, therefore, not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory, Palpitations.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female who was referred by her cardiologist to the emergency department (ED) after she underwent Holter monitor in his office and found to have 200 pauses, the longest was 3.5 seconds. The patient was previously complaining of palpitations and lightheadedness. The patient has a history of hypertension (HTN) and hypothyroidism.
The patient was evaluated in the ED. Her vital signs were stable, blood pressure (BP) 156/86, heart rate (HR) 51 beats per minute (BPM), Her physical examination was unremarkable. Her electrocardiogram (ECG) revealed sinus rhythm, left ventricular hypertrophy (LVH), ST-T abnormality in lateral leads. A chest x-ray (CXR) was normal. Her creatinine was 1.34. Troponin was normal. her thyroid stimulating hormone (TSH) was 5.7. The patient was admitted. She was placed on cardiac monitor. The patient underwent an echocardiogram. It revealed normal left ventricular (LV) size and function, Mild LVH.

The Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with lightheadedness, which by history seemed to be upon getting up. There was no syncope, presyncope, chest pain or dyspnea. The reason for admission was the results of Holter monitor which revealed pauses. However, when electrophysiologic (EP) consult was done, these pauses were at night and EP did not feel that patient has indications for pacemaker. However, the next day, EP recommended pacemaker because she will "develop symptoms at some point soon".
The patient did not have indications for hospital admission. The patient could have undergone EP evaluation as an outpatient. Or, alternatively, she could have been evaluated in ED and sent home.
The Inpatient stay was not medically necessary. The patient could have been evaluated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diabetic Left Foot Ulcer.
Treatment:  Pharmacy/Prescription Drugs (Regranex).

The health plan denied the requested prescription drug.  The health plan's determination is upheld.

The case reviewed is regarding a patient with a non-healing diabetic ulcer of the left foot.  The medical records reviewed state the treating provider has requested Regranex (Becaplermin) for the treatment of the diabetic ulcer.  The question in the review is regarding the medical necessity for the use of Regranex. 

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

No, based on the indication for the use of Regranex (package insert) the requested service is not medically necessary at this time.

The indications for the adjunctive treatment of Regranex for diabetic neuropathic ulcers is an ulcer that extends into the subcutaneous tissue or beyond and have an adequate blood supply.  The enclosed medical records reviewed have not established this information.  It mentions the ulcer is through the epidermis.  Therefore, the health plan's decision to deny the use of Regranex is supported currently. 

The initial treatment for diabetic foot ulcers includes debridement, moisture balance dressings, and advanced wound care management (The Diabetic Foot Disorders, Ulcer Management,  September/October 2006 Journal of Foot & Ankle Surgery). 
Regranex is an advanced wound care modality.  Regranex is a recombinant human platelet-derived growth factor.  This agent has been shown to stimulate chemotaxis and mitogenesis of neutrophils, fibroblasts, monocytes and other components that form the cellular basis of wound healing.  The package insert states, Regranex Gel, 0.01% contains Becaplermin, a human PDGF (platelet derived growth factor), "is indicated for the treatment of lower extremity diabetic neuropathic ulcers that extend into the subcutaneous tissue or beyond, and have an adequate blood supply".  Regranex Gel is indicated as an adjunct to and not a substitute for good ulcer care practices.

In the medical records reviewed of the objective finding exam has no information recorded indicating the staging of the diabetic ulcer.  The medical records have a check off type template.  There is a handwritten note that states there is a left foot ulcer with dimensions 10 x 10 mm.  However, there is no check off on the template of the depth of the wound:  partial thickness, full thickness, subcutaneous, muscle tendon, or bone.  There is no information provided regarding the characteristics of the wound.  I was unable to determine where the ulcer is  located on the left foot.  In the same template note, the assessment (diagnosis) checked off was an ulceration through the epidermis.  In the treatment section, the provider checked off the procedure performed.  The area checked off states the ulcer was debrided through the epidermis. 

An additional letter was provided by the treating doctor for the review.  The letter mentions the diabetic ulcer has been present for 5 months.  The treatments performed were discussed.  There is no mention of the depth of the wound.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Failing restoration on tooth number 3, Periodontal disease 

Treatment: crown for tooth number 3 and periodontal scaling and root planing for the upper right (UR), lower right (LR), upper left (UL) and lower left (LL) quadrants

The insurer denied coverage for crown for tooth number 3 and periodontal scaling and root planing for the upper right (UR), lower right (LR), upper left (UL) and lower left (LL) quadrants.

The denial is overturned. 

This is a male patient who is under the care of his dentist for moderate periodontal disease. The patient presented to the dentist for care, with identification of two areas of concern: failing restoration on tooth number 3; and periodontal disease in all four quadrants. Recommended treatment was a full coverage crown on tooth #3 and four quadrants of scaling and root planing given multiple areas of 6 millimeter pocketing. 

As regards to the documentation for this patient's tooth number 3, the existing restoration placed on this tooth appears to be failing and recurrent caries are identified radiographically. Given this clinical circumstance, placement of a full coverage crown is indicated and is a conservative restorative option which would represent a standard of care for this clinical circumstance in general dental practice. As such services which are covered services for this individual, and a standard of care are deemed medically necessary.

As regards to the documentation of this patient's periodontal status, in particular the periodontal charting and radiographs, it is evident that there is a level of periodontal disease where there is root surface exposure and alveolar bone loss. All four quadrants exhibit multiple areas of 6 millimeter pocket depths. The literature supports that the appropriate treatment would be the recommended scaling and root planing to address any ongoing periodontal issues. This would be the standard of care treatment given the alveolar bone loss and level of periodontal disease as documented on the clinical and radiographic findings. As such, these services are considered medically necessary.

Based on the review of the literature and the medical record, both the crown for tooth number 3 and periodontal scaling and root planing for the upper right (UR), lower right (LR), upper left (UL) and lower left (LL) quadrants are medically necessary for this patient. This determination is further supported by clinical and radiographic documentation.
 
Coverage for crown for tooth number 3 and periodontal scaling and root planing for the upper right (UR), lower right (LR), upper left (UL) and lower left (LL) quadrants is considered medically necessary for this patient.

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

The carrier's denial of coverage for crown for tooth number 3 and periodontal scaling and root planing for the upper right (UR), lower right (LR), upper left (UL) and lower left (LL) quadrants should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism spectrum disorder

Treatment: consumer directed personal care assistance services (CDPCAS), 40 hours per week

The insurer denied coverage for consumer directed personal care assistance services (CDPCAS), 40 hours per week.

The denial is upheld.

This patient is a male child with a history of autism as well as developmental delay and asthma. He does not communicate and is unable to express his needs. The child is rarely understood. The patient's mother reported that he has had pain issues such as screaming as well as hitting others and aggression. The patient's mother also indicated that he will wake up during the night, and had experienced repeated falls for his inability to stand still. He also requires assistance with activities of daily living and needs constant supervision. The patient continues to utilize diapers due to incontinence of urine and bowel movement. He was on a normal diet and participated in therapy services monthly. The patient also receives occupational therapy as well as speech therapy twice a week at school. The patient has been approved for 11 hours of consumer directed personal care assistance services (CDPCAS). The patient's mother is requesting an additional 29 hours of CDPCAS during the week; 40 hours per week.

The patient has a diagnosis of autism spectrum disorder. Documentation supported identifiable target behaviors having an impact on development, communication, and interaction with likely developing peers. The patient could not adequately participate in developmentally appropriate essential community activities. An individualized treatment plan that was child-centered and specific target behaviors were clearly defined. There were objective measurable goals and initial behaviors had been outlined. The central elements were met. There is no medical indication for CDPCAS. There is no literature to support improved evidence-based outcomes in children diagnosed with autism. The parent expresses some hardship with caring for her children and appears to seek respite services as an option for custodial care. However, as per Whitmore (2016), additional research is necessary to better understand the relationship between respite care and stress among caregivers of children with autism spectrum disorder. The patient currently receives 11 hours of CDPCAS services per week. There is no clinical support for increased hours of CDPCAS services for this patient. The requested service would therefore not be deemed medically necessary.

The health care plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for CDPCAS, 40 hours per week should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, Shortness of breath

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This is a male patient with a medical history of congestive heart failure, coronary artery disease, diabetes mellitus, hyperlipidemia, hypertension, hepatitis B and polysubstance abuse who presented to the Emergency Department (ED) with complaints of chest pain, shortness of breath and cough. The patient reported brown productive cough x 2 days.  The patient's troponin was unremarkable, and his electrocardiogram (EKG) showed T inversion. The patient's chest electromagnetic radiation (x-ray) imaging showed no acute cardiopulmonary findings. The patient was admitted for further evaluation and management of chest pain and shortness of breath. The patient was continued on cardiac monitoring with no cardiac events noted. The patient's stress test was done and it showed negative results. The patient denied chest pain or shortness of breath on reassessment. The patient was medically cleared for discharge home on day 5 of admission with instructions to follow-up with his primary medical doctor and cardiology clinic upon discharge.

The patient presented with a history of chest pain which was concerning for cardiac etiology. The patient underwent appropriate initial evaluation in the ED, which was unremarkable. This included normal vital signs, physical examination, a non-diagnostic EKG and negative cardiac troponins. There were no other high-risk symptoms present to suggest acute coronary syndrome. As medically essential as it was to evaluate the patient's symptoms, inpatient admission was not medically necessary in this instance.  The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing. During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting an acute inpatient level of care. For all of these reasons, the inpatient admission was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low back pain
Treatment: Intracept Procedure 
The insurer denied the Intracept Procedure.
The denial is overturned. 

The patient is a male. The patient has history of chronic lower back pain. The patient has tried ESI (epidural steroid injection), lumbar RFA (radiofrequency ablation), extensive PT (physical therapy), chiropractor therapy, NSAIDs (nonsteroidal antiinflammatory drugs) and analgesics. His pain affects his daily activities. The patient has had laminectomy.

MRI Lumbar spine showed spondylitic changes with degenerative endplate changes at L4-5 and b/l (bilateral) foraminal stenosis. L5-S1-spondylitic changes with bulging and mild bilateral foraminal stenosis. Broad based central disc herniation.

This is a request for Intracept basivertebral nerve ablation.

Yes, the health plan should cover the Intracept Procedure (22899, C9752).

Yes, the Intracept Procedure (22899, C9752) is likely to be beneficial.

The patient had tried and failed conservative therapy with analgesics, PT, injection therapy and back surgery.

The patient has chronic lower back pain. He has tried and failed surgery and conservative therapy. BVN (basivertebral nerve) Ablation is an upcoming novel procedure to treat lower back pain arising from the basivertebral nerves. Although there are very few studies, literature does show improved outcomes in terms of pain and use of opioid therapy. There is also FDA approval, which was based on results of Relievant's prospective, double-blind, randomized, sham-controlled clinical trial of 225 patients, which that showed the findings to be promising.

One of the studies also demonstrates that BVN ablation provides clinically meaningful improvements in pain and function to two years. This evidence supports BVN as a treatment option for a well-defined sub-population of chronic low back pain patients. Therefore, the health plan should cover the proposed treatment in this patient's case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low back pain
Treatment: Intracept Procedure 
The insurer denied the Intracept Procedure.
The denial is overturned. 

The patient is a male with a history of chronic low back pain. He has failed multiple alternatives, including facet injections, radiofrequency ablation, physical therapy, chiropractic care, NSAIDs (nonsteroidal antiinflammatory drugs), and pain medication.  He is trying to avoid surgery. Intracept procedure has been recommended.   

Yes, the health plan should cover the Intracept Procedure (22899, C9752).

Yes, the Intracept Procedure (22899, C9752) is likely to be beneficial

The requested Intracept procedure is medically appropriate. The requested health service or procedure is likely to be more beneficial than standard treatments.  The patient is a male with chronic low back pain who continues to have low back pain despite multiple interventions. He has failed medications, physical therapy, home exercise, epidural injections, facet joint injections, and RFA (radiofrequency ablation). The only options that remain are lumbar fusion, high dose opiates, or potentially spinal cord stimulation.   

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new 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 used in patients with significant Modic type 1 or type 2 vertebral endplate changes.  The patient is young, and the alternatives, such as spinal fusion, do not have good long-term results in the literature.  Spinal fusion in younger patients is typically not recommended and sought to be avoided.  It is a very invasive procedure with high morbidity and poor outcomes.  In fact, most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion.  Therefore, the options are limited.  

Spinal cord stimulation is an alternative; however, it has not been shown to have excellent results in primarily axial mechanical/discogenic type pain.  Chronic opiates are not without risk, especially in younger patients, and have not shown to increase function long-term.   Therefore, the intracept procedure is a reasonable option.  It is FDA approved.  Randomized studies are available with good outcomes, at up to two years.  It is not to be confused with an intradiscal procedure, which have not shown to have good results in the literature.  Since there is no Medicare approved code (CPT code) for this procedure, the health plan has chosen a code for an intradiscal procedure. However, this does not accurately describe the requested procedure. 

Given that the alternatives do not show favorable outcomes in the literature, have higher risk, and morbidity, the requested Intracept procedure is medically appropriate.