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

Diagnosis: Autism Spectrum Disorder/Autistic Disorder
Treatment: Occupational therapy
The health plan denied the requested health service/treatment of occupational therapy as not medically necessary. The health plan's determination is overturned in whole. 

The patient is a female with Autism. The occupational sessions were not covered as the denial notes no medical records were provided by requesting therapist/provider. On a thorough review of the provided documentation for this external review, there is no clinical documentation provided on the patient, current functional level, goals of therapy or therapeutic plans.
At issue is the medical necessity for the requested health service, treatment for occupational therapy.

This is a patient with autism. The issue at question for review was whether denial of occupational therapy services were all appropriate, or whether these services were appropriate and medically necessary in which case they should be covered. On initial review, a large case file of the patient's records were not included. For this request additional records regarding this patient's previous and current functional level including areas of challenge were provided.  With this data which includes the time periods in question, it is clear this patient has multiple areas of challenge which are appropriate to treat with skilled occupational therapy. The literature regarding children with autism supports therapeutic occupational therapy interventions to achieve best outcomes. The previous report includes multiple references which discuss this at length.
In light of these newly reviewed documents, I do overturn my original decision to uphold the original denial. The services are medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The determination is overturned.

This is a female patient being prescribed Wegovy auto-injectors for the diagnosis of obesity. Coverage for this medication was denied by the health plan. The patient is not currently being treated with the requested medication. This medication is not being requested in conjunction with any other weight loss treatments. The patient's current body mass index (BMI) is 34.1. The patient's other medical treatments have included phentermine and topiramate. She has snoring but no official sleep apnea diagnosis on the chart. She has arthritis pain. The health plan denied coverage for the requested medication. Medications for weight reduction are among the general exclusions from coverage under the terms of the health plan. Therefore, there are no formulary alternatives available to the patient. At issue is whether the non-formulary drug being denied is clinically appropriate for the patient's condition.

Wegovy has Food and Drug Administration (FDA) approval for the treatment of obesity. It has been helpful when used in combination with lifestyle changes to promote weight loss in individuals with obesity. The requested medication, Wegovy, is an appropriate treatment for the patient's diagnosis of obesity. It is FDA approved as a pharmacologic agent to promote weight loss as part of a comprehensive weight loss plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease
Treatment: Stelara Solution Prefilled Syringe 90MG (milligrams)/ML (milliliter) dosed every 6 weeks
The insurer denied Stelara Solution Prefilled Syringe 90MG (milligrams)/ML (milliliter) dosed every 6 weeks.
The denial is upheld.

The patient is a teenage male with moderate to severe Crohn's disease. He has failed mesalamine and budesonide, and received an intravenous Stelara (ustekinumab) 390 milligrams induction infusion. At six weeks after the infusion, serum Stelara level was 20. The doctor is requesting Stelara 90 milligrams every six weeks.

The requested health service is not medically necessary.

Stelara is United States Food and Drug Administration (FDA) approved for the treatment of moderate to severe Crohn's at a one-time intravenous induction, followed by a 90-milligram injection every eight weeks. In patients who have not responded to the intravenous induction and one subcutaneous (SQ) injection, and who have a serum Stelara level of less than 4.5, Stelara can be increased to 90 milligrams every four to six weeks. This patient has a super therapeutic Stelara level at six weeks (20 ug/ml [micrograms per milliliter], normal over 4.5ug/ml [micrograms per milliliter). Additionally, the patient is not documented to have received a SQ (subcutaneous) Stelara injection. Therefore, the requested dose intensification of Stelara is not clinically appropriate, accepted standard of care, or medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: type II diabetes mellitus, Benign Prostatic Hypertrophy, bipolar disease, bilateral lower extremity venous insufficiency and  bilateral carpal tunnel disease

Treatment: consumer directed personal assistance services (CDPAS) 168 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 168 hours per week.

The denial is upheld.
 

This is an adult with chronic medical problems including type II diabetes, Benign Prostatic Hypertrophy, bipolar disease, bilateral lower extremity venous insufficiency and bilateral carpal tunnel disease.  
 
The NYS (New York State) Comprehensive Assessment forms were reviewed. The patient's cognitive skills are described as basically intact except for new situations. Memory is intact.  The patient is assessed as requiring assistance for some Instrumental Activities of Daily Living (IADL) and activities of daily living (ADL) tasks. Maximal assistance is needed with stair climbing, meals, shopping and transport. The patient needs extensive assistance with bathing, lower body dressing and toilet transfers. The patient eats independently. The patient is also able to walk with a walker and limited supervision. The patient is assessed as being able to walk 150-290 feet. There have been no falls or hospitalizations in the last 90 days. The two Uniform Assessment System (UAS) forms reviewed showed no significant change.  There is no documentation for the need for 12 hours of nighttime help to meet the patients overnight needs.
Personal assistance service (PAS) hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance. 
 
Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained with 84 PAS hours/week  The patient has the means for emergency assistance through the 911 system and can use it. The patient also has the option of restructuring and flexibly using the 84 PAS hours weekly to better maintain and meet his functional needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever and Cough (Pneumonia). 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This is an adult female with recent Cesarean delivery one week prior. She presented to the emergency room for cough and shortness of breath and was admitted to the hospital for further workup. The patient has a history of avascular necrosis of hips, thyroid disease, and ovarian cysts. The patient was found to have probable pneumonia on chest X-ray in the emergency room and underwent computed tomography (CT) scan of the chest, which showed pneumonia. The patient was started on intravenous antibiotics. The patient was ruled out for pulmonary embolism. The patient remained in the hospital for 6 days for the management of pneumonia. This hospitalization is denied due to lack of medical necessity. This denial is being appealed. 

The requested health service was not medically necessary. 

The patient was admitted to the hospital for 6 days for the management of pneumonia. On day number (#) 3, the patient was hemodynamically stable with improvement in shortness of breath and chest pain. The patient was not on supplemental oxygen. The patient was not in any distress. The patient was able to tolerate oral diet. The patient remained on intravenous antibiotics until day #5 and was discharged home on oral antibiotics on day #6. Since the patient's condition improved significantly within 24-48 hours after emergency room treatment and the patient did not receive any treatment that could not have been safely and effectively be provided at a lower level of care, the requested admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3:

Diagnosis: Low back pain

Treatment: 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral

The insurer denied coverage for 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral

The denial is upheld

This is a patient who suffers from lower back pain. The patient has tried and failed conservative treatment. The treating provider has requested treatment with 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral, and 64629, which is under review.

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

Medicare does not have an National Coverage Determination (NCD) specifically for the use of the Intracept procedure in the treatment of chronic low back pain. Local coverage determinations (LCDs) do not exist at this time. Intracept remains a procedure without established efficacy.

Therefore, the request for 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral is denied.

64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral does not have final approval from the appropriate regulatory bodies for this diagnosis.     

In summary, the denial of 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral 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 substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1:

Diagnosis: Low back pain

Treatment: 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral

The insurer denied coverage for 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral

The denial is upheld

In assessing whether intraosseous basivertebral nerve (BVN) ablation using the Intracept device is considered more beneficial for this patient than standard treatments or procedures, it is important to know that the publications in peer-reviewed literature to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. Furthermore, despite Food and Drug Administration (FDA) approval, there are many exclusion criteria.

There are other medications and treatments available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. Any invasive procedure has risk of bleeding, infection, nerve injury or retained foreign body compared to non-invasive treatments.

The supporting publications to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. Despite FDA approval, Centers for Medicare and Medicaid (CMS) guidelines limit the use of basivertebral nerve ablation to a very select group of patients, which includes those who do not have magnetic resonance imaging (MRI) evidence of Modic changes at levels other than L3-S1. The Intracept procedure is unlikely to be more beneficial than standard treatments/procedures for this patient. 

In summary, the denial of 64628; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629; thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral 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 risk are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain
treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male who presented to the emergency department (ED) with a headache and chest pain. His headache started over 24 hours prior to presentation and chest pressure with cough which began in the morning of presentation. The patient is a high school teacher and is exposed to sick contacts. He described his chest pressure as a balloon in his chest. This sensation in his chest was without radiation. He had associated nausea. His cough worsened into this afternoon.
The patient reported that his blood pressure (BP) usually is well controlled. He also said he had recent cardiac tests done and there were no significant abnormalities.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with chest pain, but it resolved and did not recur. His troponin was not elevated. He had ST elevation, which was transient and contributed to Brugada, because it resolved with resolution of fever. Cardiology consultation did not feel that the patient had acute coronary artery disease (CAD) or non-ST elevation myocardial infarction (NSTEMI).
The diagnosis of Brugada was established based on the electrocardiogram (ECG). The patient did not have history of arrhythmia, syncope or sudden cardiac death. The presence of Brugada on ECG without any symptoms was incidental and did not support inpatient admission.
The patient had COVID with fever, but it resolved. He did not have evidence of respiratory distress, and his chest x-ray (CXR) was unremarkable. An infectious disease (ID) consultant did not recommend intravenous (IV) therapy.
Based on the above, the inpatient admission was not medically necessary. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal stenosis with neurogenic claudication, lumbar region
Treatment: Spine surgery
The insurer denied Spine surgery.
The determination is upheld.

This is a female patient diagnosed with spinal stenosis with neurogenic claudication, lumbar region. Records indicate the patient was recommended to undergo the MILD procedure (minimally invasive lumbar discectomy).
The provider notes that the patient has had lumbar spinal stenosis for more than 15 years and has chosen to move forward with the MILD procedure at lumbar (L) 2-L3 and L3-L4. The patient has had ongoing low back pain described as dull or aching pain that radiates to the legs, difficulty standing and difficulty walking distances. The average pain level is 7/10 and the pain compromises the patient's ability to perform activities of daily living and self-care. 
Magnetic resonance imaging (MRI) of the lumbar spine was done. 
The patient was seen regarding chronic low back pain reporting no change in symptoms. She wanted to discuss the MILD procedure and read through the brochure that was provided. She has had multiple injections that have not provided significant relief. The average pain level over the last week was 3/10. Medication is oxycodone. Nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated by use of Xarelto. The physical exam revealed tenderness to palpation at L3 - sacral (S) 1 bilaterally with limited range of motion secondary to pain. Lower extremity motor strength was 5/5, reflexes were equal and symmetric. The plan was to request authorization for the MILD procedure and this is under review for medical necessity.
The requested health service/treatment of spine surgery is not medically necessary for this patient. Per the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Mild (minimally invasive lumbar decompression), from Vertos Medical, Inc., describes a percutaneous procedure for decompression of the central spinal canal in patients with lumbar spinal stenosis. In contrast to surgical decompression, the mild procedure is a percutaneous decompressive procedure performed solely under fluoroscopic guidance (eg, without endoscopic or microscopic visualization of the work area). This procedure is indicated for central stenosis only, without the capability of addressing nerve root compression or disc herniation, should it be required. Due to the unknown impact of these limitations on health outcomes, randomized controlled trial (RCTs) in appropriate patients are needed to compare this new procedure with established alternatives." The patient is noted to have a history of chronic back pain with failed conservative treatment and was recommended to undergo the MILD procedure. However, additional studies are needed to evaluate the long-term net health benefits and comparative benefits with standard means of treatment for this condition. There is currently insufficient evidence support this treatment. This treatment is not considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth Pain.

Treatment: White Glass with Gold Crown for teeth 2 & 3.

The insurer denied coverage for White Glass with Gold Crown for teeth 2 & 3.

The denial is overturned.

Based on the submitted documentation which includes copies of panoramic bitewing and periapical radiographs, clinical treatment notes, a narrative letter from the patient, and insurer correspondence, it appears that this patient presented to the dentist for comprehensive dental care.  

Endodontic therapy was recommended and completed on teeth #2 and #3 with the additional recommendation of full coverage crowns on these teeth. The insurer has denied the full coverage crowns stating that the service is not medically necessary as the documentation did not demonstrate medical need and what is provided does not meet their medical necessity criteria. The patient is appealing the decision.

Upon review of the clinical and radiographic documentation, these support the recommended treatment. A review of radiographs indicates successful endodontic therapy on teeth #2 and #3.  There is ample coronal structure remaining on these teeth after the endodontic therapy for support of crowns and adequate residual periodontal alveolar bone height.  The standard of care in general dental practice would be the placement of crowns on endodontically treated teeth which would have an excellent long-term prognosis with the recommended treatment.  As the clinical and radiographic findings support the recommended treatment the full coverage crowns on teeth #2 and #3 are considered medically necessary.

White glass with gold crowns for teeth 2 and 3 is considered medically necessary for this patient.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for White Glass with Gold Crown for teeth 2 & 3 is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back Pain.
Treatment: Intraosseous basivertebral nerve ablation.
The insurer denied Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a male patient with pain that radiates to the right buttock, posterior, thigh, shin, calf, toes, and toes. The mechanism of injury is as follows: the patient fell off a ladder, and the injury was sustained. The physical examination shows lumbar flexion 60, extension 20, left rotation 20, right rotation 20. Magnetic resonance imaging (MRI) of the lumbar (L)-spine shows normal lumbar spine, multilevel disc desiccation from lumbar (L) 2-sacral (S) 1 with disc bulge. The progress notes reflect that there were significant endplate Modic type 2 changes. Intraosseous basivertebral nerve ablation is under review.

According to guidelines and cited references, despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. There should be at least 6 months of chronic low back pain following a defined injury, refractory to conservative care, as well as Modic type I or II changes between L3 and S1 on magnetic resonance imaging.
According to Becker, et.al: "Seventeen patients with chronic, greater than 6 months, low back pain unresponsive to at least 3 months of conservative care were enrolled. Sixteen patients were treated successfully following screening using magnetic resonance imaging findings of Modic type I or II changes and positive confirmatory discography to determine the affected levels. The treated population consisted of eight male and eight female patients; the mean age was 48 years (34-66 years)."
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial.
As cited above, Becker. et.al trial indicated only a 17-patient observational study.
These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures.
Current evidence on the use of intraosseous radiofrequency ablation of the basivertebral nerve (Intracept) as a treatment of low back pain is limited to a single small observational study and one randomized controlled trial. These studies have not demonstrated long-term improvements in patient health outcomes, including pain and disability measures. In addition, no United States (U.S.) guidelines based on research recommend this treatment. As such, the proposed health service or treatment of 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.