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

Diagnosis: Alzheimer's disease, hypertension, neuropathy, and incontinence

Treatment: Increase in Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person: 168 hours per week

The insurer denied coverage for an increase in Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person: 168 hours per week

The denial is upheld 

This is a patient with multiple medical problems including Alzheimer's disease, hypertension, neuropathy, and incontinence.  The insurer approved a PCW increase from 5.5 hours/day (38.5 hours/week) to 6.5 hours/day (45.5 hours/week). Under review is the request for an increase in PCW services to 24 hours/day (168 hours/week).

According to the Uniform Assessment System (UAS) the patient's cognitive skills are described as "minimally impaired." She has appropriate short- and long-term memory that has not changed over the prior 90 days. She requires extensive assistance for bathing and lower body dressing. Limited assistance is required for personal hygiene, upper body dressing and toilet transfers. She is occasionally incontinent of bladder and infrequently incontinent of bowel. She is independent for bed mobility and requires only limited assistance for mobility. There are no unmet nighttime needs identified by the plan at this time. The patient has a functional Personal Emergency Response System (PERS) at her home, and she can activate it in case of an emergency. Her activities of daily living skills have not significantly declined. The PCW hours were increased to 7 days per week, 6.5 hours per day: 45.5 hours per week, which are appropriate in order to allow her to continue living safely at home.  

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

The insurer's denial of coverage for an increase in Personal Care Worker (PCW) services) from 7 days per week, 5.5 hours per day, 38.5 hours per week, to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Unspecified Temporomandibular Joint Disorder.
Treatment: Botox Injections, pre-service.
The insurer denied the Botox Injections, pre-service.
The denial is upheld.

The patient is a male. The request is for Botox injections (pre-service) for unspecified Temporomandibular Joint  (TMJ) Disorder. Patient presents with headache and muscle soreness and TMJ pain.
This pain has not been relieved by other therapies such as nightguard usage.

The health plan denied the claim because it considers the Botox therapy experimental / investigational.

The claim was appealed to use this therapy, since other therapies have not been effective.

No, the health plan should cover the proposed treatment.
Given the importance of the TMJ (Temporomandibular Joint) as it relates to the ability to chew food properly and  in the movement of the TMJ (Temporomandibular Joint) in speech, It is important to get the best and safest therapy possible to keep the joint functioning in optimal condition.

Studies show that Botox injections can reduce the pain associated with TMJ (Temporomandibular Joint) disorder by paralyzing the muscles connected to the joint and thereby reducing the stress and the pain on the joint.

No, the requested health service or treatment may not be more beneficial than any standard treatment for the insured's condition or disease.
In this particular case, this patient has not responded favorably to the standard treatments that were used to alleviate the pain associated with his TMJ (temporomandibular joint). However, if there are long term safety concerns re: Botox use as a TMJ (temporomandibular joint) therapy; then the possible damage to the joint does not outweigh whatever short term benefits of pain relief one may experience.
However, there have been limited studies to show conclusively that there are major benefits and more importantly there may be some long term safety concerns.

In larger doses such as used in TMJ (Temporomandibular Joint) therapy, studies suggest that there may be muscle atrophy and bone density loss.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Unspecified Temporomandibular Joint Disorder.
Treatment: Botox Injections, pre-service.
The insurer denied the Botox Injections, pre-service.
The denial is upheld.

The case is a New York State appeal request to review the medical necessity of proposed Botox injections to be utilized in the treatment of an adult male patient with TMJ (Temporomandibular Joint Disorder) arthralgia and myofascial pain dysfunction symptoms . The case was previously denied as experimental / investigational .

No, the health plan should not cover the proposed treatment.
The case is a New York State appeal request to review the appropriateness of proposed Botox injections to be utilized in the treatment of an adult male patient with TMJ (temporomandibular) arthralgia and myofascial pain dysfunction symptoms. The case was previously denied as experimental / investigational . Clinical notes show a patient with jaw pain / myalgia , and myofascial pain. The patient's provider is requesting authorization for Botox injections to treat his symptoms. The requested use in this case is not an approved use by the FDA (Food And Drug Administration). The use in this instance is considered experimental and investigational, and is proven for only specific proven  uses  which do not include the presenting diagnoses in this case request. Clinical notes show a patient with jaw pain/myalgia, and myofascial pain. Currently, Botox has yet to be proven equivalent or more effective than conventional accepted conservative therapies such as physical therapy, medications/muscle relaxants, and or oral orthotic appliances for the presenting diagnoses.   As such the request is denied on this basis. The injection of Botox into the muscles of mastication is an off-label, limited - evidence use of the drug, per the FDA (Food and Drug Administration).  The United States FDA (Food And Drug Administration) does consider the usage in this case request as off - label, and unapproved. Studies are limited, and do not demonstrate that Botox injections offer benefit comparable to, or superior than, orthotic use, or other conservative modalities . 
The patient's clinical and diagnostic findings do not substantiate the currently accepted parameters for this use of Botox as requested, for the treatment of myofascial pain / clenching, or TMJ (temporomandibular) arthralgia. Therefore, the health plan should not cover the requested service as it is not medically appropriate for this patient's diagnosis and clinical findings.

No
The requested treatment has not yet been demonstrated to be more beneficial than any standard treatment for the insured's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Unspecified Temporomandibular Joint Disorder
Treatment: Botox Injections, pre-service
The insurer denied the Botox Injections, pre-service
The denial is upheld

The patient has been under an Oral Health program care since for facial pain and headaches. The pain is aching, radiating, and sore pain localized to the temporalis, masseter, SCM (sternocleidomastoid), and occipitalis muscles. Barometric pressure and stress changes the pain levels, with the levels ranging from 3-9/10. The patient has undergone splint therapy and physical therapy with limited results. The results are similar with muscle relaxants also. The treatment plan for the limited opening and pain in the muscles now extends to Botox injections into these muscles. This is an appeal review.

The health plan should not cover the proposed treatment
No, the health plan should not cover the proposed treatment. Botox is considered investigational or experimental for this patient's condition.

At this time there is no evidence to support that the request is more beneficial than any other conservative treatment.
The records mention that splint therapy and physical therapy has some effect. There are many modalities to treat myofascial pain and TMD (temporomandibular disorders). Many have not been discussed with the patient per the history provided by the surgeon.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Feeding Problems
Treatment: Special Feeding Routine
The insurer denied the Special Feeding Routine
The denial is overturned

This is a female with feeding difficulty, GERD (Gastroesophageal reflux disease), severe refusal sensory issues, limited diet.  She refuses more and more foods.  Her BMI (body mass index) is 4% and has difficulty maintaining her current weight.  She is considered to have failure to thrive. In the documentation it is noted that "Mom has not tried any intervention in the past."
The request is for intensive feeding services.

Yes, the proposed treatment is "medically necessary".
This is a female with feeding difficulty, GERD (gastroesophageal reflux disease), severe refusal sensory issues, and limited diet. She refuses more and more foods. Her BMI (body mass index) is 4% and has difficulty maintaining her current weight. She is considered to have failure to thrive. Therefore, intensive out-patient-feeding services at the Center for Pediatric Feeding Disorders is medically necessary. This patient is at risk of growth retardation and malnutrition.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the
patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: M54.50 - Low back pain, unspecified
Treatment: Surgery (22899 spine intracept, C9752 destruction of intraosseous basivertebral nerve)
The insurer denied the Surgery (22899 spine intracept, C9752 destruction of intraosseous basivertebral nerve)
The denial is upheld

The patient is a female with a history of chronic low back pain. Her pain has not responded to medial branch blocks or epidural steroid injections. She has tried various medications. No physical exam was attached. An Intracept procedure has been recommended. The procedure was denied coverage by the health plan as experimental/investigational. This is being appealed.

No, the health plan should not cover the Intracept procedure.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (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 I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. 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 Intracept procedure. In fact most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion.

However, the patient has not failed sacroiliac (SI) joint interventions, which is a common cause of axial low back pain. Spinal cord stimulation is also an alternative, however 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, while the Intracept procedure is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed. In addition, no documentation of conservative treatment being failed such as PT (physical therapy) has been documented. Given the above, the requested Intracept procedure is not medically appropriate.

No, the Intracept procedure is not more beneficial.
Alternatives exist.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: M54.50 - Low back pain, unspecified
Treatment: Surgery (22899 spine intracept, C9752 destruction of intraosseous basivertebral nerve)
The insurer denied the Surgery (22899 spine intracept, C9752 destruction of intraosseous basivertebral nerve)
The denial is upheld

The patient is a female with low back pain radiating down the left leg. She tried a transforaminal epidural steroid injection with some improvement of leg pain, but she only experienced 15% relief of back pain. A bilateral L3-5 (third lumbar spine vertebra to fifth lumbar spine vertebra) medial branch block was performed without benefit.

The patient's past medical history is significant for of lung cancer status post right upper lobectomy. Surgical history is further significant for L4-5 (fourth lumbar spine vertebra  fifth lumbar spine vertebra) laminectomy and discectomy. Her current pain medication is gabapentin.

The patient's MRI (magnetic resonance imaging) is significant for history of left L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) hemilaminectomy, foraminal stenosis, facet hypertrophy, and disc desiccation.

The request for Intracept was denied coverage by the health plan as experimental/investigational. This is being appealed.

No, the health plan should not cover the Intracept procedure.
A service is considered medically appropriate when it meets the accepted standards of medicine and is needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms.  There must be peer-reviewed medical literature based on scientific data that shows a treatment is safe and effective for treating or diagnosing a medical condition.  It must be necessary to meet a patient's basic health needs and it must be correct for the diagnosis.

Review of literature shows moderate-quality evidence that suggests that the Intracept procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes, as well as other inclusion and exclusion criteria used in published literature to date.  However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

Additionally, the patient does not meet inclusion and exclusion criteria in the current published studies.  As such, the health plan should not cover the Intracept procedure for this patient.

No, the Intracept procedure is not more beneficial than any standard treatment for the insured's condition or disease.
Other treatment options may include non-opioid medications (e.g., NSAIDs [nonsteroidal anti-inflammatory drugs], membrane stabilizing agents, and/or muscle relaxants), modalities (e.g., physical therapy, home exercise program, chiropractor treatments), and interventions (e.g., epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: M54.50 - Low back pain, unspecified
Treatment: Surgery (22899 spine intracept, C9752 destruction of intraosseous basivertebral nerve)
The insurer denied the Surgery (22899 spine intracept, C9752 destruction of intraosseous basivertebral nerve)
The denial is overturned

The patient is a female with chronic low back pain secondary in part to L5/S1 (fifth lumbar spine vertebra/first sacral vertebra) degenerative endplate pathology confirmed by MRI (magnetic resonance imaging) findings in the L (lumbar)-spine. Her pain has not improved with conservative management, medication management, interventional procedures (lumbar medial branch blocks and lumbar epidural steroid injections), and surgical interventions.

After reviewing her clinical history, examining the patient, and reviewing her MRI (magnetic resonance imaging), her treating physician recommended the Intracept procedure; however it was denied coverage by the health plan due to their considering the procedure experimental/investigational. This denial is being appealed.

Yes, the health plan should cover the Intracept procedure.
The patient has chronic low back pain secondary in part to L5/S1 (fifth lumbar spine vertebra/first sacral vertebra) degenerative endplate pathology confirmed by MRI (magnetic resonance imaging) findings in the L-spine. Her pain has not improved with conservative management, medication management, interventional procedures (lumbar medial branch blocks and lumbar epidural steroid injections), and surgical interventions.

The patient's MRI (magnetic resonance imaging) of the L-spine showed near complete loss of the intervertebral disc height, endplate osteophytes, and facet hypertrophy at the L5/S1 (fifth lumbar spine vertebra/first sacral vertebra) level. The endplate and intervertebral disc abnormalities correlate with vertebrogenic low back pain. The Intracept procedure is indicated for chronic vertebrogenic low back pain refractory to conservative treatments confirmed by MRI (magnetic resonance imaging) findings of endplate pathology.

The patient's pain has not improved with conservative management, medication management, interventional procedures (lumbar medial branch blocks and lumbar epidural steroid injections), and surgical interventions. 

Therefore, given the above, the health plan should cover the Intracept procedure.

Yes, the Intracept procedure is more beneficial than any standard treatment for the insured's condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures

Treatment inpatient stay

The insurer denied coverage for inpatient stay

The denial is upheld 

This case involves a male with a prior history of global developmental delay, autism, and Prader-Willi syndrome.   The patient was taken to the emergency department via emergency medical services due to seizures.  The documentation indicated the patient was seizing upon emergency medical service arrival.  The seizure was aborted with 5 mg(milligrams) of Versed.  The physician indicated the patient did arrive extremely sedated and postictal with poor respiratory effort.  The documentation indicated upon reevaluation the patient's respiratory effort was improved.  The recommendation was made to admit the patient for further testing and evaluation.  The patient was initially loaded with Keppra.  He continued with treatment.  Overnight he remained afebrile with no acute events or seizures.  His vital signs remained stable and there were no significant findings on examination.  The physician indicated he was doing well, and the exact cause of seizures remains unclear.  He was recommended to remain admitted for a further work-up to determine the etiology.  He did undergo additional testing to include respiratory viral panel which was positive for endogenous retrovirus.  He continued to remain stable and therefore, given there was no further adverse events, he was discharged with instruction to follow-up.

The acuity of this case is considered to have required observation as the patient had an uncomplicated seizure. Upon arrival the patient received one dose of Versed and had no complications of ongoing status epilepticus or respiratory distress. No events concerning for seizures were noted during the stay. The patient was loaded with Keppra with no other interventions necessary. The patient was described to be interactive and was able to be discharged. The patient did not require an escalated level of care.

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. Within the documentation it was noted the patient presented with no neurological deficits. The documentation detailed the patient was back at his baseline and could have been discharged. The requested inpatient admission would not be the most appropriate level of care and therefore, the prior denial remains upheld.

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease

Treatment: evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)

The insurer denied coverage for evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)

The denial is overturned.

This case of a woman with a history of aortic stenosis, coronary artery disease, stroke, hypertension, psoriasis, gout and hypercholesterolemia. She was prescribed Repatha after LDL (low-density lipoprotein) cholesterol remained elevated despite high intensity statin (rosuvastatin 40mg (milligrams) daily) and ezetimibe 10 mg daily therapies.  Lipid panel revealed LDL cholesterol of 90mg/dl (milligrams per deciliter).  The patient has documented coronary artery disease with significant coronary artery stenosis that required stent placement.  The patient's physician submitted documentation demonstrating that the patient has been treated with high intensity statin and ezetimibe.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. This patient is already treated with high intensity statin therapy and ezetimibe.  She suffers from atherosclerotic coronary artery and has a history of stroke.  Addition of a non-statin agent such Evolocumab in this setting has been associated with significant event rate reduction regardless of serum LDL level. (Reference 1, 2). Current American Heart Association and American College of Cardiology guidelines recommend addition of PCSK-9 (Proprotein convertase subtilisin/kexin type 9_ inhibitor therapy to maximally tolerated statin therapy in patients at high risk for future ASCVD events including those with multivessel disease. (Reference 1,2,3).  Such patients are given a class I indication for treatment with non-statin therapy such as evolocumab when LDL-C levels are greater than 55mg/dl. (Reference 3) In conclusion, the proposed treatment (evolocumab) is medically necessary.

The insurer's denial of coverage for the evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: crowding
Treatment: braces/monthly visits
The insurer denied braces/monthly visits. The health plan's determination is upheld. 

The patient is a female with severe maxillary and mandibular crowding. Tooth #11 has erupted labial within the arch due to lack of space. Tooth 28 is in crossbite. The patient has a class II occlusion with 4 millimeter (mm) overjet and 4mm overbite. The patient is treatment planned for braces to align the teeth and correct the bite. 


Braces and monthly visits are not medically necessary. While the patient has crowded teeth, there is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. The patient has a 4mm overjet, but research shows overjet would not affect oral health related quality of life unless it was greater than 6mm. If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, braces are not medically necessary.