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

Back Pain
Surgical Services

This is a patient who has a history of low back pain. This patient developed low back pain after a motor vehicle accident (MVA). Pain is across the lower back with radiation into the right buttock. The pain is exacerbated with walking, sitting, standing for a prolonged period of time, and relieved by positional changes. Patient underwent multiple spinal injections with temporary relief. Patient had tried physical therapy (PT), chiropractic treatments, acupuncture, gabapentin, Zanaflex and Duexis. None of these treatments provided  significant improvement.  Pain level ranges from 3/10 to 5/10. A magnetic resonance imaging (MRI) revealed multi-level degenerative disc disease from Lumbar (L)2 to Sacral (S)1, most severe at L4-5 with a broad based disc protrusion (greater than 5 millimeter (mm) based on MRI images in the medical records), facet joint arthropathy and moderate to severe central canal stenosis. This patient was recommended to undergo this new medical intervention named INTRACEPT. Uphold, in whole, the health plan's determination regarding the proposed health service or treatment.  The INTRACEPT system was designed to treat back pain from vertebral body by ablating intraosseous nerves. Reviewing of the available medical records did not reveal enough evidence that this patient has pain from his vertebral bodies. In actual fact, the symptoms of increased pain with walking are consistent with symptomatic spinal stenosis. . Given the symptoms of spinal stenosis, MRI findings of greater than 5mm disc protrusion and moderate to severe spinal stenosis, and the current clinical evidence, this patient is not a candidate for this INTRACEPT procedure. The procedure is not likely to be more beneficial for this patient's medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Back Pain
Surgical Services
The patient has chronic low back pain. A Lumbar magnetic resonance imaging (MRI) by report, describes degenerative disc disease.
Intraosseous basivertebral nerve ablation (BVN, "Intracept Procedure") is proposed. Uphold, in whole, the health plan's determination regarding the proposed health service or treatment. Reliable evidence shows that the consensus among qualified objective experts regarding the inherent nature of BVN is that further clinical studies, clinical outcomes research, or clinical trials are necessary to determine its safety, efficacy and anticipated outcomes as compared with the standard means of treatment or diagnosis of the condition in question and is therefore not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. BVN is not recommended in guidelines for the management of low back pain issued by relevant medical organizations.
Appeal type: Experimental/Investigational
Decision: Upheld

Back Pain
Surgical Services

The patient has chronic low back pain. The pain is described as constant, aching, throbbing and sharp. Patient has had physical therapy, chiropractor, as well as acupuncture treatments. A magnetic resonance imaging (MRI) of the lumbar spine dated mid-2019 indicated multilevel degenerative changes. There is a request for Intracept procedure to the Lumbar (L)4, L5, Sacral (S)1 levels. The reviewer Upholds in whole the health plan's determination regarding the proposed health service of Intraosseous ablation of the basivertebral nerve. There are insufficient large-scale, randomized, controlled studies showing the efficacy of this procedure. This proposed treatment Intraosseous ablation of the basivertebral nerve 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: Medical necessity
Decision: Upheld

Diagnosis:  Cognitive impairment, depression, neck and low back pain
Treatment:  PCA, ten hours per day, seven days per week for a total of 70 hours per week

The proposed treatment of an increase in PCA hours to ten hours per day, seven days per week for a total of 70 hours per week is not deemed medically necessary. 

This is a female with a history of depression, anxiety, cognitive impairment, insomnia, neck pain, low back pain and hypertension.  Due to restrictions/limitations related to her multiple comorbid conditions, she requires assistance with completion of the majority of her activities of daily living (ADLs).  However, a recent in home assessment of the patient's functionality was completed and determined that the currently approved plan of 45.5 hours per week was sufficient to meet all of the beneficiary's needs.  No additional medical documentation has been provided which indicates that the patient has demonstrated additional functional decline.  For these reasons, the proposed treatment of an increase in PCA hours to ten hours per day, seven days per week for a total of 70 hours per week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Dermatitis
Pharmacy/Prescription Drugs

The patient has refractory biopsy proven moderate-severe atopic dermatitis and has failed topical steroids, topical calcineurin inhibitors and laser light therapy. The patient is status post one year of successful treatment with Dupixent and is seeking refill of her systemic medication.

The health plan's determination is overturned. Dupixent is medically necessary for this patient. Dupixent (also known as Dupilumab) has been documented in the medical literature to be a safe and efficacious systemic treatment for patients suffering from moderate-severe atopic dermatitis. It has an excellent safety profile and resulted in clinically relevant improvements in signs and symptoms of atopic dermatitis in many clinical trials and meta-analysis reviews. It also greatly impacts quality of life for patients. It would not be standard of care to discontinue a treatment that works for this patient and keeps the atopic dermatitis in remission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gluteal pain and abscess
Treatment: Inpatient admission

The proposed treatment -- admission at an acute inpatient level of care -- was not medically necessary. 

Guidelines from the Infectious Diseases Society of America (IDSA) are clear -- for patients with abscesses, treatment includes: incision and drainage with associated wound care, abscess culture, and a short-course of antibiotics [STEVENS ET AL.]. All of these interventions may be provided on an outpatient basis. According to the Infectious Diseases Society of America, "Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability". 

As this patient did not have systemic inflammatory response syndrome (SIRS), altered mental status, or hemodynamic instability, she did not require hospitalization.

In the absence of SIRS, altered mental status, or hemodynamic instability -- in accordance with guidelines from the Infectious Diseases Society of America --, the patient did not require admission at an inpatient level of care; she could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Caries extending to the buccal cusps

Treatment:  D2740 - porcelain crown, D2950 - core buildup for tooth #19

The insurer denied coverage D2740 - porcelain crown, D2950 - core buildup for tooth #19.  The denial was upheld.

This patient is a male who presented for routine comprehensive dental treatment and was recommended for core buildup and full coverage crown after removing an existing amalgam restoration.

The insurer has denied these services stating that there is no clinical/ radiographic evidence provided to support the necessity of these services.

The objective documentation provided for review is periapical radiographs and the dental chart clinical notes.  It appears that there is no evidence of fracture or other pathology specifically affecting #19.  There does not appear to be any radiographic evidence of caries.  There is no periapical pathology.  Neither the radiographs nor the clinical notes substantiate the requested dental services as enumerated above; therefore, they are deemed not medically necessary.

Uphold denial of coverage for D2740 - porcelain crown, D2950 - core buildup for tooth #19 as not medically necessary, as the documentation is insufficient to justify or substantiate the treatment.

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

Based on the above, the medical necessity for D2740- Porcelain crown, D2950- Core build-up for tooth #19 is not substantiated.  The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a female patient with a history of Gastroesophageal Reflux Disease (GERD), Hiatal Hernia (HH), positive pH study that has failed Proton Pump Inhibitor (PPI) therapy. She had an endoscopy with a Bravo pH probe placed. The study revealed a DeMeester score of 42.9. An esophageal manometry was performed which showed normal Lower Esophageal Sphincter (LES) pressure and esophageal motility. She was awaiting a LINX Reflux Management System.

Zadeh, J., et al. (2018) states, "The initial approach to gastroesophageal reflux disease (GERD) management typically involves lifestyle modification and medical therapy utilizing acid reducing agents such as histamine blockers and proton pump inhibitors.  In severe cases refractory to such treatments, surgical therapy may be indicated.  The gold standard for surgical treatment of GERD is the laparoscopic Nissen fundoplication.  In recent years, a new technique known as magnetic sphincter augmentation (MSA) has been developed using the Linx Reflux Management System.  This is an implantable ring of magnetic beads that is placed around the esophagus at the gastroesophageal junction to restore lower esophageal integrity".  They go on to conclude, "After several years of clinical application, the Linx device has been shown to not only be effective for the management of GERD but also be as effective as fundoplication.  With respect to safety, the most common complication of MSA is dysphagia".

According to Zhang, H., et al. (2016), the "MSA (or LINX) devices provide an alternative surgical option for the patients who had failed in medical therapy.  This review of the current literatures demonstrates that MSA is as effective as the medical and conventional surgical therapies.  In the future, MSA will play a more important role in the treatment of GERD because of its unique advantage".   The LIX is likely to be more beneficial for the patient than any of the standard treatments or procedures.                                                 

The carrier's denial of coverage for 43284 Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a female patient with (GERD). It was reported that the patient had failed proton pump inhibitor therapy. A LINX procedure was recommended. 

From UpToDate; "In 2013, the US Federal Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. The device is a ring made up of a series of rare earth magnets that have sufficient attraction to increase the LES [lower esophageal sphincter] closure pressure but allow for food passage with swallowing.  Results from early studies at four years are encouraging.  Based upon a prospective study that included 44 patients, the mean total percent time pH <4 was reduced from 11.9 percent at baseline to 3.8 percent at three years (p<0.001).  Most patients at 4 years of observation experienced improved quality of life and complete cessation of the use of PPIs." 

Position statement from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) noted the implementation of the LINX device requires minimal dissection and relatively few technical steps when compared to Nissen fundoplication and that the LINX device may provide an option currently lacking in clinical practice for patients with medically refractory GERD who have not yet progressed to end-stage reflux disease with associated complications. The conclusion was that "on the basis of the available evidence, the LINX device should be an option available to patients and providers for the management of medically refractory GERD

The carrier's denial of coverage for 43284 Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD) 
 
Treatment: 43284 Laparoscopy, Surgical, Esophageal Sphincter Augmentation Procedure, Placement of Sphincter Augmentation device (i.e., magnetic band), including Cruroplasty

The insurer denied the Laparoscopy, Surgical, Esophageal Sphincter Augmentation Procedure, Placement of Sphincter Augmentation device (i.e., magnetic band), including Cruroplasty. The denial was reversed.  

This is a female patient who presented to a gastroenterologist with complaints of regurgitation and heartburn. She had a history of morbid obesity, gastroesophageal reflux disease (GERD), and irritable bowel syndrome (IBS). It was reported that she had been taking proton pump inhibitors without relief.  She had an endoscopy (EGD) with Bravo capsule placement. The results of the procedure revealed no esophagitis and 2-3 centimeters sliding hiatal hernia; GERD. A LINX anti-reflux device was recommended for treatment of her symptoms/diagnosis.

In March 2017, the Society for American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the LINX Reflux Management System.  With regard to safety, the conclusion was that long-term follow-up studies support the FDA conclusion that the device is safe.  With regard to efficacy there were several conclusions.  The LINX implant results in pH normalization, improved quality of life, and cessation of regular PPI use on a consistent basis.  When compared to laparoscopic fundoplication, rates of success in alleviating gastroesophageal reflux disease (GERD) symptoms and dysphagia are similar following LINX.  The long term follow-up data demonstrates that the LINX Reflux Management System is effective in the management of GERD.

Based on the recommendation of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Gastrointestinal Endoscopy article it has been shown that LINX improves health outcomes.  LINX does have FDA approval.  Since the patient has had persistent reflux symptoms and an elevated DeMeester score she is a good candidate for the procedure.  There are several options for both surgical and endoscopic treatments for GERD, but LINX has been shown to be an effective treatment.  A minimally invasive treatment such as LINX is appropriate for patients who have continued symptoms on medical management and do not want to have more extensive surgery.  The requested surgery is likely to be more beneficial than any of the standard treatments or procedures.

The carrier's denial of coverage for 43284 Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance Abuse/Addiction
Treatment:  Substance Abuse: Inpatient

The patient, who has a history of opioid use disorder, cocaine use disorder, cannabis use disorder, alcohol use disorder, depression, and posttraumatic stress disorder, presented for treatment related to his addictions.  The patient reported using 9 to 10 bags of heroin intravenous (IV) daily, $20 worth of IV cocaine, and drinking 1 to 2 pints of liquor daily.  The inpatient substance-abuse rehabilitation level of care is under review.  The patient had already been through detoxification prior to step down to rehabilitation inpatient level of care.  Clinical history was significant for a period of sobriety for 10 months, ending in 2018.  The patient had been taking Lexapro for depression and anxiety at 10 milligrams (mg) daily.  The patient denied ever having any thoughts to kill himself.  The patient denied having anyone close ever die by suicide.  The patient denied any history of psychosis or trauma.  The patient had a history of prior episodes of substance use disorder treatment.  Documented were five prior episodes of inpatient substance use disorder treatment dating back to 2016.  The patient had a history of hepatitis C and tinea pedis.

The health plan's determination is upheld.  The Inpatient Substance Use Rehabilitation Treatment was not medically necessary for this patient.  Using the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool for initial level of care:
The patient did not require hospitalization for a life-threatening medical condition or severe psychiatric crisis.  Opioids have greatest potential to cause harm to self or others.  The patient clearly met criteria for multiple substance use disorders, including opioid use disorder.  The patient was not in full remission from a substance use disorder.  The patient was not using substances with risk of medical complications for withdraw, because the patient had already been through inpatient detoxification.  The patient did not have serious medical symptoms that needed to be managed in an inpatient rehabilitation setting for you substance use disorder treatment to be effective.  The patient did not have symptoms of a psychiatric nature that needed to be managed in inpatient rehabilitation.  The patient was not using in amounts or frequencies likely to be imminently dangerous.  Clinical documentation does not establish that the patient had significant interpersonal deficits.  The patient was having difficulty managing triggers in the environment.  The patient did have access to stable food and shelter.  Based on the LOCADTR Level of Care tool, the patient could have been treated at a lower level of care (Intensive Outpatient).
Appeal type: Medical necessity
Decision: Overturned

The patient is a female, who is requesting an increase in consumer directed personal assistance program care from the plan's approved 7.5 hours a day for seven days a week to a requested 9 hours a day for seven days a week.  She has a history of multiple medical problems, including hypertension, macular degeneration, dyslipidemia, anemia, spinal stenosis, and urinary incontinence.  The documentation includes a physician visit note that states that the patient was complaining of right hip pain when standing up from a sitting position.  The visit was in follow-up to a recent right hip fracture, gait instability, and spinal stenosis.  Her right hip fracture was treated non-operatively, and she was scheduled to follow up with orthopedic surgery.

An evaluation form of the patient's "Client task sheet" shows that the patient requires extensive or maximal assistance for dressing, personal hygiene, bathing, transfer to the toilet, toilet use, eating, meal preparation, and medication management.  The estimates of minutes per day per activity on this sheet total to 427 minutes, which is then rounded to 7.5 hours per day for seven days per week.  A letter from one of the patient's physician states that she needs 24 hour supervision to assist with care.
The subject under review is the medical necessity for the increase in consumer directed personal assistance program to 9 hours per day, 7 days per week.

The health plan's determination is overturned.

Yes, the requested service Consumer directed personal assistance program (CDPAP) 9 hrs. per day - 7 days a week is medically necessary.  The reason is that the patient has a documented need for extensive or maximal assistance with multiple activities of daily living (ADLs).  It is correct that the health plan provides justification for their recommendation of 7.5 hours daily for seven days per week.  However, the activities included in the "Client Task Sheet" span the entirety of a day, and the hours for which a patient will need to complete toileting needs, and other essential activities of daily living (ADLs) may fall within time periods outside of a 7.5 hour period.  The patient and her representatives have requested 9 hours daily for seven days per week, and this duration is approved based on the clear documentation of the patient's need for extensive or maximal existence with multiple ADLs.
The patient is alone at home until her daughter returns at approximately 5 PM or 6 PM. She has a home health aide from 8 AM until 2 PM currently.  The patient's daughter is her only other caregiver.  Nine hours per day would allow for coverage after the home health aide leaves and provide assistance to the patient's daughter with the patient's ADLs in the evening.
The patient has extensive documentation of a need for help with multiple ADLs, and a request for consumer directed personal assistance program for 9 hours per day for 7 days per week is consistent with these needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Headaches, dizziness, left facial and chest pain
Treatment:  Inpatient stay

This is a female with a history of Alzheimer's Dementia, Diabetes Mellitus, Hypertension and Osteoarthritis presented to the ER for further evaluation/management s/p unwitnessed fall and headaches, dizziness, left facial and chest pain.  Her intake vitals were notable for significantly hypertensive blood pressure readings, and examination was notable for left periorbital hematoma and tenderness to the left lateral chest wall.  Laboratory studies were remarkable for hyponatremia with serum sodium of 125 mEq/L, transaminitis with elevated AST (aspartate aminotransferase) of 105 U/L and thrombocytopenia with platelets of 170,000/L.  ECG was notable for 1st degree AV block.  Trauma workup with ordered, including CT Head.  This was negative for acute intracranial bleed, but it showed evidence of soft tissue swelling overlying the left forehead and left periorbital area, with extracranial soft tissue hematoma on the left forehead noted. 

The patient was admitted to the inpatient medical service, where she received treatment with IV fluids for electrolyte repletion, continuous cardiac monitoring and close surveillance of neurologic status.  She improved with the prescribed therapies and was subsequently discharged in stable condition.  Evidence of a patient of advanced age with history of head trauma, neurologic symptoms of headaches, dizziness, significant hyponatremia, transaminitis and thrombocytopenia in the setting of 1st degree heart block made this patient extremely high risk for the development of subacute intracranial bleed, altered mental status from worsening metabolic derangement and/or cardiac arrhythmia.  Hence, this patient's care could not have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.  For these reasons, the proposed treatment of Inpatient admission is deemed medically necessary.