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

Diagnosis: back pain
Treatment: pain management
The insurer denied Intraosseous Basivertebral Nerve Ablation. 
The health plan's determination is upheld. 

The patient is a female with a chronic history of low back pain. Prior treatments have included chiropractic care, home exercises, lumbar injections, as well as medications. The pain impacts activities of daily living (ADL). The pain can be as high as 6 out of 10. Magnetic resonance imaging (MRI) lumbar spine reported Modic changes at disc spaces L (lumbar) 3-4, L4-5, L5-S (sacral)1.

The proposed Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required for the Intraosseous Basivertebral Nerve Ablation. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: pain management
The insurer denied Intraosseous Basivertebral Nerve Ablation. 
The health plan's determination is upheld. 

This is a female patient who is diagnosed with Vertebrogenic Low Back Pain. According to the records, the patient was recommended to undergo the Intracept procedure, which was denied by her health plan.
It was noted the patient has a history of low back pain and tried multiple treatments including chiropractic care, heat, ice, home exercises, lumbar epidural steroid injections, medication management and transforaminal epidural steroid injections. Medication has included meloxicam. Pain is rated at/10 and interfering with activities of daily living. The provider noted the patient had an magnetic resonance imaging (MRI) that showed Modic changes at disc spaces L (lumbar)3 - L4, L4 - L5 and L5 - S (sacral)1 and the provider believes this is the source of the patient's chronic back pain. 

Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment or injections. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System. There is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish safety and efficacy. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: pain management
The insurer denied Intraosseous Basivertebral Nerve Ablation. 
The health plan's determination is upheld. 

This patient is a female who has a longstanding history of chronic back pain. She previously underwent lumbar epidural steroid injections with significant pain relief until 2 years ago. Her pain returned after doing yard work. The pain is described as constant dull sharp with radiation to bilateral buttocks, anterior thighs and tingling/numbness sensation in both feet. Her other prior treatments included chiropractic manipulation, home exercise and non-steroidal anti-inflammatory drugs (NSAIDs). 

The Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient has low back pain with radiating pain to the buttocks and bilateral thigh with tingling numbness in both feet. An MRI (magnetic resonance imaging) showed multilevel degenerative disc diseases with facet arthropathy and moderate to severe central canal stenosis at L (lumbar) 3-4. Truumees's study supported the efficacy of Intracept procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded.
Given this patient's medical history, MRI findings of degenerative disc disease facet arthropathy with lumbar spinal stenosis, and the current clinical studies, the Intracept is not likely to be more beneficial than any standard treatment or treatments.
Appeal type: Medical necessity
Decision: Upheld

Respiratory
Inpatient hospital

Diagnosis: chronic respiratory failure
Treatment: Continued Subacute Rehabilitation Stay 
The insurer denied Continued Subacute Rehabilitation Stay 
The health plan's determination is upheld. 

The patient is a male with a history of chronic respiratory failure. He was in a sub-acute rehab facility and was sent to the emergency room for shortness of breath. He was discharged back to the sub-acute rehab facility. He was able to walk 175 feet. He was able to negotiate 7 steps; however, progress in the past 2 weeks has been stagnant.

The requested Continued Subacute Rehabilitation Stay is not medically necessary for this patient.
Since the patient has reached a plateau in rehab they would be a candidate for a lower level of care, i.e a long term care facility. Patients require closer supervision with their daily activities (eg bathing, dressing, feeding, toileting) that they are not able to feasibly receive at home. Medication management and intermittent vital signs are performed by nurses, but these patients do not require intensive skilled care such as rehab services, intravenous (IV) antibiotics etc.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Small cell lung cancer. 
Treatment: Proton treatment delivery (procedure codes 77522, 77523, 77525). 
The insurer denied coverage for the proton treatment delivery (procedure codes 77522, 77523, 77525). 
The denial is upheld. 

The patient is an adult male with extensive small cell lung cancer. 

The patient was treated with chemotherapy and was referred for radiation therapy (RT) to the lung. He presented with a cough and radiographs revealed multiple nodules in the right lung.  

About one year prior to presentation, the patient underwent a right upper lobe lung biopsy that showed high grade neuroendocrine carcinoma with attributes of small cell lung carcinoma (SCLC). 

The patient's physician has requested treatment with Proton Beam Therapy (PBT); which is the topic of this review. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes. 

There is limited current published medical literature that supports the use of PBT in patients with a diagnosis of small cell lung carcinoma (SCLC). 

77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex has final approval from the Food and Drug Administration (FDA). 

The patient is not a good candidate for 77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex. 

As this is not a retreatment, the standard of care (SOC) for this patient and this clinical scenario would be Intensity-modulated radiation therapy (IMRT). 

77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex is not the best available treatment for this patient, at this time. 

The standard of care (SOC) for this patient would be Intensity-modulated radiation therapy (IMRT). 

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

The treating provider has compared dose-volume histogram (DVH) for Proton Beam Therapy (PBT) and Intensity-modulated radiation therapy (IMRT). The concern is for lung radiation which is not much different and is acceptable for IMRT. 

Proton Beam Therapy (PBT) is not more likely to be more beneficial than any of the standard treatments/procedures for this patient. 

In summary, the denial of 77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Small cell lung cancer. 
Treatment: Proton treatment delivery (procedure codes 77522, 77523, 77525). 
The insurer denied coverage for the proton treatment delivery (procedure codes 77522, 77523, 77525). 
The denial is upheld. 

The patient is a male who was treated with Proton Beam Therapy (PBT) for a diagnosis of extensive stage small cell lung carcinoma (SCLC). 

The patient has been treated with chemotherapy and was referred for radiation therapy (RT) to the lung after he presented with a cough; radiographs revealed multiple nodules in the right lung. 

The patient underwent a right upper lobe lung biopsy that revealed a high grade neuroendocrine carcinoma with characteristics of small cell lung cancer (SCLC). 

The request is for 77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex, which is under review. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes. 

Scientific evidence in peer-reviewed literature indicated this treatment has not been shown to be safe or beneficial to treat the patient's type of cancer.    

77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex does have final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is not a good candidate for 77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex as scientific evidence in peer-reviewed literature indicated this treatment has not been shown to be safe or beneficial to treat the patient's type of cancer and is not standard of care. 

77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex is not the best available treatment for this patient, at this time. 

The standard of care (SOC) for this patient would be Intensity-modulated radiation therapy (IMRT), as there is not sufficient published data to support the use of Proton Beam Therapy (PBT) for small cell lung cancer. 

The adverse risks are not increased over standard treatment/service, however, the requested treatment is not standard of care for the patient's diagnosis. 

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

In summary, the denial of 77522, proton treatment delivery; simple, with compensation; 77523, proton delivery; intermediate; and 77525, proton treatment delivery; complex and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered Mental Status. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

This patient presented to the emergency department (ED) with complaints of altered mental status (AMS). The patient had a computed tomography (CT) brain, angiography of brain and neck which showed no significant abnormalities. The patient was admitted with possible seizure and postictal states. An electroencephalogram (EEG) was negative and Neurology service states that this is new-onset seizure activity. The request is for inpatient admission which is under review. 

The patient was afebrile, had no growth in the blood cultures, and was hemodynamically stable. There was no documentation of a new onset seizure and/or greater than two or more seizures in a 24-hour period. 

Therefore, inpatient admission is not considered medically necessary and is denied. 

"New-onset seizures are frequently encountered in community and hospital settings. It is likely that seizures presenting in these distinct settings have different etiologies and prognoses, requiring different investigation and treatment approaches" (Foster, E., et al 2018).

"There was no difference in the likelihood of antiseizure medication initiation between participants who had multiple prior nonmotor seizures followed by a motor seizure (thereby fulfilling the criterion for an epilepsy diagnosis) versus those presenting with a single lifetime motor seizure (39% vs. 43%). There was no difference in recognition of seizures as the presenting complaint (85% vs. 87%) or whether the participant was admitted or referred to a neurologist (87% vs. 79%)" (Pellinen, J., et al 2021). 

"The real-world use of point-of-care EEG (pocEEG) in emergency medicine, found that rapid EEG acquisition in the ED was feasible in a community hospital and significantly affected the management of suspected non-convulsive seizures... 

Treatment escalation occurred more frequently in patients with epileptiform activity (seizures or highly epileptiform patterns, 52%) than patients with non-epileptiform activity (normal or slow, 25%, P < 0.001), and avoidance of treatment escalation occurred more frequently in patients with normal or slow activity (27%) than patients with seizures or highly epileptiform patterns (2%, P < 0.001)" (Kozak, R., et al 2023).   

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

Diagnosis: Cellulitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a recent history of a dental infection treated with Augmentin who was admitted with complaints of (c/o) right ear pain and erythema. The vital signs were notable for a pulse of 101. The physical exam was notable for no apparent distress (NAD), not ill/toxic-appearing, right ear with drainage, swelling, and tenderness without mastoid tenderness. Lab work showed leukocytosis with left shift. Imaging studies included a computed tomography (CT) scan that showed right ear cellulitis. The patient was diagnosed with cellulitis secondary to right otitis externa and treated with antibiotic ear drops, while the emergency department (ED) documentation states there was no need for emergent intervention or inpatient treatment, and the patient was discharged, then re-presented due to pain and admitted for intravenous (IV) antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care.
The patient presented to the emergency department (ED) with complaints of (c/o) right ear pain and erythema. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, necrotizing fasciitis, animal or human bite with extensive damage, high risk location (neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. This patient was treated with intravenous (IV) antibiotics, and this could have been safely provided at an observation level of care. In addition, the initial ED documentation states there was no need for emergent intervention or inpatient treatment, and the patient re-presented due to uncontrolled pain. A lower level of care is ideal for the management of cellulitis infections because it allows frequent reevaluation to assess response to therapy while avoiding inpatient admission. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
The patient presented with chest and abdominal pains. She had recently started on an increased dose of semaglutide. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The liver enzymes were elevated but then started to improve. The troponin was negative. An abdominal ultrasound showed a possible gallstone. However, the Magnetic resonance cholangiopancreatography (MRCP) was negative for cholelithiasis. The computed tomography (CT) scan showed mild periportal edema. She was diagnosed as having hepatocellular injury and was advised to stop the semaglutide. 

Milliman Care Guidelines (MCG) M-05 lists clinical indications for admission for Undiagnosed Abdominal Pain. These indications include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and bacteremia. The patient did not have these conditions. 

MCG guideline M-570 lists clinical indications for admission for Liver Disease. These indications include having acute liver failure, hepatic encephalopathy, acute respiratory failure, infected ascites, severe alcoholic hepatitis, hepatorenal syndrome, acute liver necrosis, and portal or splenic vein thrombosis. The patient did not have these conditions. 

This patient had abdominal pain possibly related to the increased dose of semaglutide. She had elevated liver enzymes but was not in acute liver failure. The international normalized ratio (INR) was 1.09. The liver enzymes could have been followed with observation status. Intravenous (IV) hydration and antiemetics could have been given in the emergency room (ER) as an outpatient. The MRCP did not show evidence of acute gallbladder or biliary tract disease. She did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Liver Disease. 

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


Diagnosis: back pain
Treatment: pain management
The insurer denied Pain injections 
The health plan's determination is overturned. 

This is a female who has chronic thoracic back pain. Her pain level ranges from 3/10 to 10/10. Her pain is improved by rest and pain medications. Any type of physical activity including household chores such as cooking cleaning and laundry worsens her pain. She had tried physical therapy/home exercise without improvement. The prior thoracic epidural steroid injection provided her with temporary pain relief. Physical exam is significant for bilateral thoracic paraspinal tenderness and pain with extension. Thoracic spine magnetic resonance imaging (MRI) revealed multilevel degenerative disc disease and facet arthropathy most prominent at T (thoracic)10/11 level. This patient underwent thoracic facet blocks with 50% (percent) pain relief immediately after the procedure.

The requested Pain injections are medically necessary for this patient.
This patient has severe thoracic back pain. She has positive thoracic medial branch nerve blocks. She has failed other conservative treatments including physical therapy (PT) and pain medications without adequate pain relief. Her magnetic resonance imaging (MRI) revealed findings of thoracic facet arthropathy. She had positive diagnostic facet blocks. Given this clinical scenario, the requested pain injections are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Intracept procedure. 
The insurer denied the Intracept procedure. 
The health plan's determination is upheld. 

This is a female who has chronic back pain for at least 5 years. Her pain is worse with sitting for long periods and bending forward. Pain level is 9/10. She completed a course of physical therapy (PT). Physical exam (PE) showed pain with forward bending and positive facet loading test. Magnetic resonance imaging (MRI) revealed multilevel degenerative disc disease and facet arthropathy with discogenic endplate osseous reaction at L (lumbar)4/5. The provider recommends bilateral L3, L4, L5 medial branch nerve blocks and the Intracept procedure at L3 and L4. 

The Intracept procedure is not medically necessary. 
The Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient has a positive facet loading test. Magnetic resonance imaging (MRI) revealed multilevel degenerative disc disease and facet arthropathy. The provider recommends bilateral L3, L4, L5 medial branch nerve blocks (MBB) in addition to Intracept at L3 and L4. Truumees's study supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the patients with radicular pain and radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded. 
This patient has chronic back pain. She has signs and symptoms consistent with facet arthropathy. The provider has scheduled this patient for lumbar medial branch nerve blocks in an attempt confirm facet arthropathy as the primary pain generator. Given the clinical scenario, the Intracept procedure is not medically necessary at this time.