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

Diagnosis: Alcohol withdrawal symptoms; alcohol gastritis.  

Treatment: Inpatient Admission  

The insurer denied the inpatient admission.  The denial was reversed. 

This is a male patient, who presented to the Emergency Department (ED) for alcohol withdrawal.  He had complaints of epigastric pain, slurred speech and unsteady gait.  His withdrawal symptoms included nausea, tremors, agitation, sweats, anxiety, and headache, and there was concern for seizure withdrawal.  His initial Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 14.  He had a past history of multiple inpatient hospital detoxification treatments.  He received Intravenous (IV) fluids, thiamine, and folic acid.  His withdrawal symptoms were managed with multiple doses of Ativan.  He reportedly attempted to elope and was placed on a 1:1 observation; several days later he was discharged.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  In this case this patient had been drinking large amounts of alcohol daily and had active alcohol withdrawal symptoms, as he had a CIWA of 14, and it was documented that he may have had withdrawal seizures.  He also had co-morbid medical issues including alcohol gastritis with epigastric pain.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment, as he could not safely and effectively be treated in outpatient detoxification settings, as he continued to use large amounts of alcohol despite medical issues and past multiple inpatient detoxification treatments, and he needed detoxification medication including Ativan initially to modify withdrawal and prevent worsened complicated and life-threatening withdrawal.  He was at risk for worsened withdrawal symptoms if not in this 24-hour setting then including severe and life-threatening withdrawal symptoms.  It was unlikely that he would remain abstinent while having withdrawal symptoms so he required hospital treatment and he required the hospital detoxification treatment then as he was at high risk for complicated and life threatening withdrawal symptoms.  The risk of life complicated withdrawal, such as delirium tremens, can occur 3-4 days after alcohol use, so he required the time in this hospital for inpatient detoxification treatment.  

It did not appear that the health care plan acted reasonably or in the best interests of the patient.  

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Viral Gastroenteritis
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld. 

This patient is a female child who presented to the Emergency Room (ER) with diarrhea and a cough for several days.  It was reported that the patient had been in the ER one day prior with complaints of the same symptoms but was discharged home due to negative results on clinical work up.  It was noted that the patient had a decrease in oral intake and 5 episodes of diarrhea.  Her vital signs on presentation were stable with no acute distress noted.  Intravenous (IV) fluids were administered; however, the patient was able to tolerate oral feedings without vomiting.  The patient was medically stabilized and discharged home.

The standards of care in the management of viral gastroenteritis is oral hydration when possible and supportive care.  This child proved that she was able to tolerate adequate oral intake at the emergency room.  After the admission, parents refused intravenous fluids or laboratory studies.  The care included monitoring but no further intervention needed.  

Per Dennehy, P. H (2019) "The American Academy of Pediatrics (AAP), the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN), and the World Health Organization (WHO) all recommend oral rehydration solution (ORS) as the treatment of choice for children with mild-to-moderate gastroenteritis in both developed and developing countries".

Per Banyai, K., et al. (2018) "For treatment of dehydration caused by gastroenteritis viruses, the administration of reduced-osmolality oral-rehydration solutions (5060 mmol/L sodium) is the first line of therapy.  Profuse vomiting, worsening dehydration with altered consciousness, or severe acidosis, hypovolaemic shock, abdominal distension, and ileus are indications for intravenous rehydration".

Per Stuempfig, N.D. and Seroy, J. (2019), "Due to the lack of readily available viral testing capabilities in most clinics and emergency departments, acute viral gastroenteritis is a clinical diagnosis.  Therefore, patients who appear clinically well-hydrated and who lack risk factors for severe disease do not necessarily warrant further testing."

This patient had no signs of severe dehydration or acidosis.  Therefore, the admission was not medically necessary for this child.  Her care could have been performed safely at outpatient level of care.      

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

Diagnosis: Lower Back Pain
Treatment: Intracept Procedure (22899 and C9752)
The insurer denied the Intracept Procedure (22899 and C9752). 
The denial is overturned. 

The patient is a male with a history of low back pain with the history of being involved in a motor vehicle accident. He reportedly has been treated with therapies including lumbar epidural steroid injections, transforaminal epidural steroid injections, medial branch blocks, SI (sacroiliac) joint injections, chiropractic manipulation, acupuncture, physical therapy and medications. Previous treatment has included gabapentin, clonazepam, escitalopram, tizanidine and Flexeril. He reportedly had an MRI (magnetic resonance imaging) demonstrating Modic type-2 changes at lumbar vertebrae 4-5 (L4-5) disc space and was felt to have chronic low back pain. The treating provider has requested Intracept procedure. The patient reportedly has failed nonoperative treatment. Intracept procedure is an interosseous ablation treatment intended to ablate the basivertebral nerve which innervates the osseous vertebra.

Yes, the health plan should cover the Intracept Procedure.

Yes, the available medical records do support that the requested Intracept Procedure is likely to be more beneficial than other standard treatment or treatments for the insured's condition or disease.    

The available medical records do support that the patient has been evaluated for such treatment and has otherwise failed other conservative care for at least six months. The records reflect that the patient has Modic type changes in endplates of lumbar vertebrae with pain localized to axial spine. The treatment is supported by peer-reviewed publications showing large randomized controlled trials of the treatment with demonstrated outcome. There is no demonstrated alternative treatment that may provide better or equivalent pain relief.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lower Back Pain
Treatment: Intracept Procedure (22899 and C9752)
The insurer denied the Intracept Procedure (22899 and C9752). 
The denial is overturned. 

The patient is a male with a history of chronic low back pain. He has failed multiple alternatives and is trying to avoid surgery. An Intracept procedure has been recommended for him.  

Yes, the health plan should cover the Intracept Procedure.

Yes, the Intracept Procedure is likely to be more beneficial.

The requested Intercept 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 physical therapy, home exercise, epidural injections, facet joint injections, RFA (radiofrequency ablation), chiropractic treatment, SI (sacroiliac) joint injections, acupuncture, and multiple medications. He has previously undergone two microdiscectomies, and he is looking for an alternative to a fusion.  

The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new FDA (Food and Drug Administration)-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. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intercept procedure. 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 and can lead to addiction and overdose. 

Therefore, the Intracept procedure is a reasonable option. It is FDA (Food and Drug Administration)-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 [Current Procedural Terminology] 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 concerns, the requested Intercept procedure is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ulcerative Colitis
Treatment: Laboratory Services (80230 - infliximab antibody testing) 
The insurer denied the Laboratory Services (80230 - infliximab antibody testing).
The denial is overturned. 

The patient is a female with history of ulcerative colitis (pan-colitis). She is being treated with infliximab for the treatment of colitis, presented with rectal bleeding. The patient's provider ordered the infliximab levels and antibody testing to evaluate the drug levels and antibody assay to determine if the dose adjustment of infliximab would be required to optimize the treatment.

Yes, the health plan should cover the Laboratory Services (80230 - infliximab antibody testing) for the management of this patient's colitis.

Therapeutic drug monitoring (TDM), defined as the assessment of drug concentrations and anti-drug antibody (ADA), is an important tool for optimizing biologic therapy. On the basis of the literature review, it is appropriate to order drug/antibody concentration testing in responders at the end of induction for all anti-TNFs (tumor necrosis factor) (2). It is appropriate to order drug/antibody concentration testing at least once during maintenance for patients on all anti-TNFs (tumor necrosis factor) (3). It is appropriate to order drug/antibody concentration testing of anti-TNFs (tumor necrosis factor) at the end of induction in primary non-responders (4). It is appropriate to order drug/antibody concentration testing for all anti-TNFs (tumor necrosis factor) in patients with confirmed secondary loss of response.

In this case, the patient has been on maintenance therapy and presented with symptoms of rectal bleeding. The provider ordered the assay to determine if the patient had optimal levels of the drug, so that the decision could be made about the dose-escalation; or to make a decision to a different TNF (tumor necrosis factor) antagonist if the patient had developed anti-drug antibodies (ADA) to the drug. Reactive TDM (therapeutic drug monitoring) to guide infliximab dose adjustment compared with clinical decision-making alone is associated with higher post-adjustment clinical response, endoscopic remission and fewer hospitalizations.

Yes, the Laboratory Services (80230 - infliximab antibody testing) drug assay is likely to be more beneficial than the standard empiric adjustment of the biologic (infliximab) for the management of this patient's ulcerative colitis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ulcerative Colitis
Treatment: Laboratory Services (80230 - infliximab antibody testing) 
The insurer denied the Laboratory Services (80230 - infliximab antibody testing).
The denial is upheld. 

The patient is a female with ulcerative colitis treated with Infliximab every eight weeks. Her provider is requesting infliximab drug and antibody levels. 

No, the health plan should not cover the Laboratory Services (80230 - infliximab antibody testing).

No, the Laboratory Services (80230 - infliximab antibody testing) is not likely to be more beneficial.

The patient has ulcerative colitis and is being treated with Inflectra every eight weeks. While the literature is controversial as to if patients with active IBD (inflammatory bowel disease) have an improvement in health outcomes when therapeutic drug monitoring is used, in patients with quiescent IBD (inflammatory bowel disease) treated with anti-TNF (tumor necrosis factor) agents, national societies and guidelines make no recommendation regarding the use of routine proactive therapeutic drug monitoring. 

Therefore, as it has not been determined to have a positive effect on health outcomes, the requested infliximab drug and antibody levels would not reasonably be expected to be more health beneficial for the patient, than adjusting the dose or changing to another agent based on the patient's clinical course, and the health plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Sided Numbness And Parenthesis (ischemic stroke).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He presented to the emergency ward with the complaint of left hemibody numbness. CT (computerized tomography) brain and MRI (magnetic resonance image) brain were negative for acute intracranial pathology.  He underwent echocardiogram, telemetry monitoring, continued on aspirin and started on high dose statin. 

No, the Inpatient Admission was not medically necessary. 

The patient presented with possible stroke. He had no significant neurological examination deficits, and neuro-imaging was negative. Risk stratification for TIA (transient ischemic attack) does not require inpatient admission in this clinical context. The diagnostic studies, monitoring and treatment could have been safely and effectively completed at a lower level of care. 

Therefore, given the above, the Inpatient Admission was not medically necessary
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain

Treatment: Outpatient Procedures (64635 x2, 64636 x6)

The insurer denied coverage for Outpatient Procedures (64635 x2, 64636 x6).

The denial is overturned. 

This is a female patient with facet-mediated back pain and problems with walking. The patient has had 3 prior sets of radiofrequency neurotomy performed. This is a request for an additional set.

As per Starr et al. (2020) study on the frequency of repeat radiofrequency ablation (RFA) performed for low back pain, the study found that "Initial RFAs were identified in 44,936 patients. Staged RFAs were performed in 33.1% of patients. Repeat RFAs through 1, 3, and 7 years were performed for 14.6%, 33.5%, and 45.7% of patients, respectively. Within 3 years, 12.2% of patients underwent one repeat RFA, whereas 13.2% of patients underwent two or more. Post-RFA opioid use was examined in 128,310 patients, 32.2% of whom used opioids pre-RFA. By 180 days post-RFA, 8.1% of patients discontinued opioids and 6.7% started opioids (p<.001). Exclusively examining pre-RFA opioid users, 24.9% stopped filling opioid prescriptions 180 days after RFA. This study delineates utilization rates of repeat RFA in the commercially insured population, with one-third undergoing repeat RFA within 3 years. Additionally, the present data indicate that lumbosacral RFA is associated with reduced filling of opioid prescriptions through 180 days."

Cohen et al. (2019) formulated multi-specialty clinical practice guidelines which considered the evidence supporting repeat RFA. Cohen et al. (2019) states, "the committee recommends repeating lumbar medial branch RFA on recurrence of pain in patients who experience a minimum of 3 months of improvement (and preferably 6 months improvement for multiple procedures) following a previous RFA. Given the drop-off in success rates reported in some studies and the mean duration of benefit, [the study] recommend repeating the procedure no more than two times per year; grade B recommendation, moderate level of certainty."  However, there was no limitation or lifetime limiting number of RFA blocks.

Based on the review of the medical record, repeat radiofrequency neurotomy/ablation is considered medically necessary for this patient. There is no peer reviewed evidence supporting a life-time cap on the number of RFA performed. Clinical practice establishes that it is the patient's response to treatment that determines the indication for repeat injection. In this case, the patient had a positive response to RFA.

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

Based on the above, the medical necessity for Outpatient Procedures (64635 x2, 64636 x6) is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sacroiliitis
Treatment: Radiofrequency Ablation 
The insurer denied the Radiofrequency Ablation.
The denial is overturned. 

The patient is a male with low back and buttock pain, thought to be related to sacroiliitis. He had previously undergone a radiofrequency ablation (RFA) a couple years ago, and subsequently had a repeat sacroiliac (SI) joint injection earlier this year with greater than 75% relief. A sacroiliac (SI) joint radiofrequency ablation (RFA) has been recommended. 

Yes, the proposed treatment with radiofrequency ablation is medically necessary. 

The patient is a male with low back and buttock pain, thought to be related to the sacroiliac joints. He had previously undergone a radiofrequency ablation (RFA) with 80% relief for about two years. The pain eventually returned, and he subsequently had a repeat sacroiliac (SI) joint injection with greater than 75% relief. The relief was short lived, and a radiofrequency ablation (RFA) has been recommended.  

The patient has buttock pain and has physical exam findings consistent with sacroiliac (SI) joint pain. He has failed conservative treatment.  He previously had an excellent response to the sacroiliac (SI) joint radiofrequency ablation (RFA) with almost two years of relief. The diagnosis was confirmed with diagnostic sacroiliac (SI) joint injection.  

Sacroiliac (SI) joint radiofrequency (RFA) has been shown to be effective in the relief of low back/buttock pain related to chronic sacroiliac (SI) joint pain/sacroiliitis.  Given that this is a repeat procedure, and the patient did very well and for an extended period of time, and that other options are limited, the requested radiofrequency ablation (RFA) is medically necessary.  Alternatives such as sacroiliac (SI) joint fusion has not been shown to be effective in the literature and carries a significantly higher morbidity and mortality then radiofrequency ablation (RFA).
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Skin Disorders (psoriasis). 
Treatment:  Pharmacy/Prescription Drugs. 

The insurer denied Taltz.  The denial is upheld in whole.

The patient is a female with psoriasis and has tried and failed topical triamcinolone and oral Keflex.  The patient tried cyclosporine but discontinued it because of jittery/anxiety symptoms.  Prednisone was ineffective.  Alcohol consumption has precluded use of Methotrexate (the clinic records report less than one alcoholic beverage consumed per day).

Health plan coverage of Taltz is under review.

The health plan's determination is upheld in whole.

No, the formulary alternative drug would not be ineffective.  Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Taltz, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario.  The patient has not utilized long-term and adherent trials of first-line psoriasis systemic therapies.  Furthermore, the options of Humira, Skyrizi, Tremfya, Enbrel, Cosentyx, or Cimzia are all appropriate and likely to be effective for use in a patient with no past history of biologic therapy.  Therefore, Taltz would not be more effective than the formulary alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: plaque psoriasis.
Treatment: Otezla.

The insurer denied Otezla. The health plan's determination is upheld. 

The patient is a male with moderate to severe plaque psoriasis (36% body surface area involvement) of both elbows, knees, and bilateral anterior trunk, as well as pseudogout. The patient has tried and failed topical steroids and oral steroids. The patient has had a positive clinical response to Otezla samples.

Otezla is not medically necessary for this patient. First-line systemic oral and/or light therapies have not yet been exhausted for this patient and are of similar efficacy and side effect profile for this patient's particular clinical scenario as is the Otezla.
The patient has insufficient to no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate (if alcohol consumption can be reduced to three drinks per week or less), Acitretin (for moderately higher alcohol consumption), and/or Phototherapy.