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

Diagnosis: Low back pain. 
Treatment: 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, 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. 

The denial is upheld. 

The Intracept procedure is "intraosseous ablation of the basivertebral nerve (BVN)". It has been proposed to address low back pain identified by Modic changes.  The procedure is performed within the vertebral body. It has been proposed that pain relief is manifested by patients no longer requiring their narcotics. For one level of disc disease each vertebral body requires precise targeting. The operation is not recognized by practicing neurosurgeons or spine surgeons. 

There are several studies in peer reviewed literature but no conclusions can be made. No definite statement nor guidelines showing definitive efficacy have been reported. Additional studies have been recommended. 

Food and Drug Administration (FDA) approval had been granted for Pre-Market approval. The FDA does not provide statements regarding benefit. 

The records do not substantiate vertebrogenic etiology for the reported back pain. The facts are there is instability (listhesis), progressive spondylosis and objective evidence of radiculopathy. Multiple epidural steroid injections (ESI) to several body sites had been provided with reported benefit, i.e. Etiology is radicular. Providing an ablation to the basivertebral nerve is not likely to provide any benefit as there is direct evidence of underlying pathology. It would be more important to address the long-standing conditions of instability, degeneration and nerve compression. There was no documentation showing these factors being taken into consideration. 

64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar or sacral is not the best available treatment for this patient at this time. 

The procedure is invasive. There have been reported complications of infection, broken hardware, endplate fracture and retroperitoneal hematoma. 

The requested service is NOT likely to be more beneficial than any of the standard treatment/procedures. 

In summary, the denial of 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar or sacral and coverage for the requested service/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 increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, 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. 

The denial is upheld. 

This patient has chronic low back pain. He has tried acupuncture, Chiropractic therapy, Physical therapy, Home exercise, and Heat/Ice.  He has had Epidural steroid injections, facet injections as well as trigger point injections.  His medication trials have included Advil, cyclobenzaprine, Diclofenac, and Ibuprofen.  He is in recovery from opiates. His magnetic resonance imaging (MRI) shows Modic changes as well as a disc herniation at lumbar (L)3-L4 and spondylosis at L4-L5 and L5-sacral (S)1 with foraminal stenosis.  A surgical consultation is not documented in the chart. 

The publications to date have been company sponsored and had methodology flaws. 

There is no published data on long term complication rates. 

There are other evidence- based interventions available to this patient. 

This procedure is unlikely to be more beneficial than the standard approaches. 

In summary, the denial of 64628 thermal destruction of intraosseous basivertebral nerve, including all imaging guidance: first 2 vertebral bodies, lumbar or sacral and coverage for the requested service/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 increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain

Treatment: pain injections (64493 x 2, 64494 x 2)

The insurer denied coverage for pain injections (64493 x 2, 64494 x 2)

The denial is overturned

 
This patient has chronic low back pain. She had facet injections which provided her with 18 months of excellent pain relief. The pain has returned, and the request is to repeat the facet injections, bilaterally.

While the percentage of pain relief is not specified, 18 months of "excellent" pain relief is very significant.

Clinical guidelines have considered what degree of pain relief is significant (1) :

"Numerous studies have been devoted to determining the optimal cut-off for proceeding to radiofrequency ablation (RFA). Guidelines on lumbar facet denervation specify that complete relief in a distinct topographical area is necessary for a particular block to be positive (though some pain may persist from other sources),16 while the American Society of Interventional Pain Physicians (ASIPP) guidelines note that there is stronger evidence for a cut-off of 75% (percent) than 50%. Both guidelines recommend that these cut-offs be used for dual blocks. Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) guidelines propose that a 30% or greater reduction in pain be considered a moderately clinically important improvement and that reductions of 50% or greater can be considered a substantial improvement.193 Although this cut-off was intended to categorize the response to pain treatments, given the implicit (although imperfect) correlation between the block and definitive treatment, in certain circumstances these cut-offs may also provide a benchmark for prognostic information despite not being validated in this context. High cut-offs may also be difficult to achieve physiologically given that facet degeneration almost never occurs in isolation. For example, radiological studies indicate that disc degeneration almost always precedes and is greater in magnitude than facet degeneration, and that muscle pathology accompanies facet joint inflammation."

The ASIPP clinical practice guidelines (2) support the performance of facet blocks in this patient:
"The level of evidence is I to II with moderate to strong strength of recommendation for lumbar diagnostic facet joint nerve blocks. Ten relevant diagnostic accuracy studies with 4 of 10 studies utilizing controlled comparative local anesthetics with concordant pain relief criterion standard of >=80% (more or equal) were included.  The prevalence rates ranged from 27% to 40% with false-positive rates of 27% to 47%, with >=80% pain relief."

Based on the above, the insurer's denial must be overturned. 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 pain injections (64493 x 2, 64494 x 2) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: right upper quadrant pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This an adult female who presented to the emergency department (ED) with the complaint of right upper quadrant (RUQ) pain for 5 days. As per the triage note she was afebrile with stable vital signs. She denied fever, nausea or vomiting. Examination revealed right upper quadrant (RUQ) pain without guarding, equivocal Murphy sign. The plan was intravenous (IV) fluids and pain medications. The principal diagnosis was acute cholecystitis. The case was discussed with general surgery and the patient was started on Zosyn. The patient was admitted. 

White Blood Cell (WBC) count was 17.64, aspartate transaminase (AST) 43, alanine transaminase (ALT) 95 and Alkaline phosphate of 243.  Computerized tomography (CT) of the abdomen revealed dilated gallbladder with thickened wall and inflammatory changes and fluid in the adjacent fat consistent with acute cholecystitis. No radiopaque stones were seen. Ultrasound revealed moderately distended gall bladder with 2.4 millimeter stone in the gallbladder neck with gall bladder wall thickened. The plan was laparoscopic cholecystectomy with intraoperative cholangiogram (IOC), possible open.

The patient decided to sign out against medical advice on same day as she did not want to proceed with surgery. She stated she was no longer in pain.

To approve this service, the following InterQual 2022 acute adult cholecystitis criteria must be met: there must be a documentation of ascending cholangitis. Acute cholecystitis is usually treated in observation level of care for up to 48 hours with all the following: confirmed by imaging, pain not responding to at least 2 doses of pain medication, pain medication 3 times in 24 hours or continuous and on anti-infective medication. In addition, there must be a documentation showing the care the patient needed could not be received in the emergency department (ED) for up to 8 hours and then in an observation level of care up to 48 hours, and then an admission in the hospital was required. These criteria are not met because: the patient was admitted for right sided belly pain for 5 days and constipation. The patient was examined had blood tests and pictures of the belly were done. The vital signs were monitored and were stable. The imaging of the belly showed acute cholecystitis. The patient was given medications to help with the symptoms. The patient left against medical advice the same day. There was no documentation of worsening of symptoms with treatment or documentation of ascending cholangitis. 

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: Overturned

Diagnosis: Pseudogout

Treatment: Kineret 100 mg (milligrams)/0.67

The insurer denied coverage for Kineret 100 mg (milligrams)/0.67

The denial is overturned


According to the medical records, this is an adult female patient has a history of pseudo gout along with chronic arthritis. She has tried and failed treatment with non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, methotrexate, Arava, Otezla, Enbrel and Cosentyx. The patient complains of morning stiffness, lasting about an hour. 

The patient has a diagnosis of pseudo gout as well as chronic arthritis with recurrent and disabling flares. She has tried and failed multiple medications that include with non-steroidal anti-inflammatory drugs (NSAIDs), Arava, Otezla, Enbrel, Methotrexate, Colchicine and Cosentyx. Studies have shown that Kineret (Anakinra) has been helpful in these types of cases.

Kineret 100 mg (milligrams)/0.67 Syringe is considered medically necessary for this patient. 

Per American College of Rheumatology (2019),"Anakinra is FDA approved to treat rheumatoid arthritis and neonatal-onset multisystem inflammatory disease (NOMID). Although not an FDA (Food and Drug Administration)-approved indication, anakinra is sometimes used to treat systemic juvenile idiopathic arthritis (SJIA), Adult-Onset Still's Disease (AOSD), gout, calcium pyrophosphate deposition (CPPD)(formerly called Pseudogout), Behcet's Disease, ankylosing spondylitis, uveitis, and other auto-inflammatory syndromes."

"Efficacy of anakinra was shown to be non-inferior to treatment as usual for the treatment of acute gout flares, suggesting that anakinra is an effective treatment alternative for acute gout flares." (Janssen, C. A., et al., 2019).                                                         

Based on the above, the insurer's denial must be overturned. 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 Kineret 100 mg (milligrams)/0.67 Syringe services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Orthodontic Needs: Moderate Maxillary Crowding, Moderate Mandibular Crowding, Severely Excessive Overjet, Moderate Maxillary Constriction, Deep Impinging Overbite with Severe Soft Tissue Damage.
Treatment: Braces and Monthly Visit x 12.
The insurer denied the Braces and Monthly Visit x 12.
The health plan's determination is upheld.

The patient in question is a young male with a Class II occlusion. He has a 4 millimeter (mm) overjet and a 6 mm overbite. He has minor crowding in the maxillary and mandibular arches. He is in the middle-mixed dentition phase of development. He has treatment planned for 30-36 months of orthodontics to correct his malocclusion.

At issue is the medical necessity for Braces and Monthly Visit x 12.
I uphold, in whole, the health plan's determination of medical necessity.

The requested health service/treatment of Braces and Monthly Visit x 12 is not medically necessary for this patient.

The patient has minor crowding. His bite is deep, but there is no indication of damage to the incisors or the palate in the photographs, and his cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided there is severe soft tissue damage (or any soft tissue damage) on this patient. There is no medical reason to correct his malocclusion with braces. The patient has a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. [1] This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 4 mm overjet, but this amount of overjet does not affect oral health related quality of life. [2] If his teeth were aligned, it would provide a minor aesthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient has Crohn's disease and presented with abdominal pain and bloody stool. He was afebrile and the vital signs were stable. He had been on Remicade but had not had an infusion for 3 months. There was no abdominal rebound or guarding. There was no leukocytosis. The hemoglobin was 7 .0 but he had sickle cell trait. A computed tomography (CT) scan was consistent with Crohn's colitis. He was treated with steroids and antibiotics but then left the hospital against medical advice (AMA) the same day. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-565 for Inflammatory Bowel Disease. Clinical indications for admission include hemodynamic instability, fistulizing Crohn's disease, intestinal perforation, intestinal obstruction, peritoneal signs, severe electrolyte abnormalities, bacteremia, and anemia with signs of cardiac ischemia. The patient did not have these conditions. He had anemia but did not have chest pain, heart failure, or altered mental status. 

This patient has Crohn's disease and was not compliant with his treatment. He had a flare of his disease and required steroids and antibiotics. However, after being treated in the emergency room (ER) as an outpatient, he could have been discharged on oral steroids and oral antibiotics. He was then stable to have been referred back to the gastroenterologist to resume Remicade infusions. He did not meet MCG criteria for admission for Inflammatory Bowel Disease. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

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: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female. She presented to the emergency room with pain in the RLQ (right lower quadrant), chills, and nausea. In the ED (emergency department), the patient had RLQ (right lower quadrant) tenderness and guarding. U/S (ultrasound) pelvis showed fibroids, tubular shaped avascular cystic structure with fluid attenuation in the right adnexal / col-de-sac region. The patient was treated with Recephin, Flagyl, Tylenol, Benadryl, Toradol, and Morphine. The patient was admitted with a diagnosis of RLQ (right lower quadrant) pain. The patient was continued with IVF (intravenous fluids), Zofran, Flagyl, Rocephin, Tapazole, and Heparin. The patient was discharged the next day.

The inpatient admission was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular Disorder
Inpatient Hospital

Diagnosis: Seizures.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male with a history of brain abscesses who was treated with craniotomy one year before this presentation. He experienced a seizure at home and was brought into the emergency department for an assessment. Before the seizure, the patient experienced no fevers, chest pain, or shortness of breath.
His vital signs included a normal temperature, respirations of 18, heart rate of 81, and blood pressure of 119/77. Upon examination, the patient is described as alert with no distress, no jugular vein distention (JVD), positive tongue biting, and an unremarkable cardiopulmonary examination. Neurologically the patient was alert and oriented times 4.

The inpatient admission is not medically necessary. Laboratory data revealed normal glucose of 95, stable electrolytes, and renal function. The white blood cell count was normal at 8.4, with a hemoglobin of 16. The toxicology screen was negative for cocaine amphetamines or benzodiazepines. Imaging studies included a head computed tomography (CT) scan showing interval right parietal craniotomy with apparent encephalomalacia and no acute intracranial hemorrhage or infarct. The chest x-ray was unremarkable. The patient was admitted for intravenous (IV) fluids, brain magnetic resonance imaging (MRI), and neurology consultation.
The neurologist assessed the patient, documenting a normal neurologic examination. A review of the MRI showed prior craniotomy with encephalomalacia but no mass. The neurologist concluded the seizure was likely due to right occipital postsurgical changes and recommended Keppra 500 milligrams (mg) twice daily and outpatient follow-up with neurology. The patient was discharged 12 hours later, in stable condition at home, with no recurrence of seizure activity.
The patient was appropriately observed, for 12 hours, for the recurrence of seizures. He underwent appropriate imaging, which showed postsurgical craniotomy changes, deemed the culprit for the patient's single seizure activity. Typically, single seizure activity with a known cause can be managed under an alternate level of care, with subsequent outpatient follow-up. The patient remained hemodynamically stable and showed no evidence of intracranial abscess recurrence, no tumors, and no intracranial bleed to warrant further inpatient admission. The rapid evaluation and treatment were accomplished within 12 hours, and the patient was appropriately discharged. Alternate level of care criteria are satisfied for this presentation; inpatient admission is not indicated. 
 
The health plan's determination of medical necessity is upheld in a whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Increase Home/Personal Care Level 2 per 15 Minutes to 24 Hours per Day (Split Shift). 

The insurer denied: Increase Home/Personal Care Level 2 per 15 Minutes to 24 Hours per Day (Split Shift). 
The denial is overturned. 

This patient is an elderly female with medical conditions that include hypertension, depression, dementia, and arthritis. She lives alone. Denial of an increase in home/personal care to 24 hours per day (split shift) is being appealed. The health plan has approved live-in services. Uniform Assessment System evaluation completed 3 months ago shows severely impaired cognition and functional status: total dependence with meal preparation, shopping, housework, bathing, upper body dressing and toilet use; maximal assistance with managing medications and finances, phone use, personal hygiene, toilet transfer, bed mobility, and eating. She has bowel and bladder incontinence. 

A letter from the patient's physician notes the patient is homebound and at risk for falls. She is not safe without supervision. Her condition is deteriorating, and she need assistance with all activities of daily living (ADLs). Another letter notes the patient has advanced dementia and is bedbound. She needs assistance with repositioning. She is unable to use her right side as result of a fall. She needs diaper changes every two hours due to urinary incontinence. 

The proposed treatment is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual who needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions, including dementia. Denial of an increase in home/personal care to 24 hours per day (split shift) is being appealed. The health plan has approved live-in services. Uniform Assessment System (UAS) evaluation showed the patient requires maximal assistance to total dependence with all activities of daily living (ADLs). She is incontinent of bowel and bladder. The appeal statements support the patient is bedbound and dependent with all activities of daily living. She requires frequent assistance with toileting and turning/repositioning. She needs diaper changes every two hours due to urinary incontinence. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The proposed increase home/personal care to 24 hours per day (split shift) is medically necessary.