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

Diagnosis: Mental Health/Attention Deficit Hyperactivity Disorder/ADHD
Treatment: Mental Health/Residential
The health plan denied the requested residential mental health admission as experimental/investigational. 
The health plan's determination is overturned.

The patient is a male referred by his outpatient mental health providers for outdoor behavioral health/residential mental health treatment to address behavioral disturbances in the context of mood and attentional disorders associated with impaired functioning and problematic behavior. The patient was diagnosed with dysthymic disorder or persistent depressive disorder and attention deficit hyperactivity disorder (ADHD). There was no co-occurring substance use disorder or co-morbid general medical disorder in this case. No specific clinical information or case records were provided.
The patient has reportedly been in multiple treatment settings with continued symptoms of mood instability associated with ADHD and problematic behavior prompted his referral and admission to outdoor behavioral health/residential mental health treatment. Again, the patient was referred to residential level treatment in an outdoor/wilderness setting in order to address the core symptoms of depression and ADHD and problems with functioning socially, educationally and with daily activities.

The health plan's determination regarding the proposed health service or treatment is overturned, in whole.

The requested wilderness treatment is more beneficial that any other standard treatment, as the patient was showing improvement with the ongoing evidence-based treatment that is provided. Indeed, the programming  is considered a standard treatment as indicated by the documentation, and is not experimental or investigational as the health plan asserts.
 
The  programming includes evidence-based treatments provided together with an outdoor behavioral health model as noted in the clinical summary. The proposed health service is reasonable and provided with sound medical judgment in the best interest of the patient. Alternative levels of care and treatment services that are equally beneficial include traditional residential treatment or lower intensity inpatient treatment that offer comprehensive programming with or without the outdoor therapeutic activities provided by the wilderness facility.
The proposed health service and treatment provided  is not considered experimental or investigational or unproven. The treatment and services provided are reasonable, and in the patient's best interest, and, the services and treatment provided are evidence of empirical-based services known to be beneficial for the conditions and behavioral disturbances in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain.

Treatment: Destruction / nerve ablation of intraosseous basivertebral nerve.

The insurer denied coverage for destruction / nerve ablation of intraosseous basivertebral nerve.

The denial is overturned. 

This is a female patient with a history of chronic low back pain. After magnetic resonance imaging (MRI), she was diagnosed with lumbar intervertebral disc degeneration at lumbar(L)/sacral(S) level L5-S1. Treatment attempts have included medications, sacroiliac joint injections, home exercise program, medial branch blocks, ice and heat, transcutaneous electrical nerve stimulation (TENs) unit, physical therapy, and radiofrequency ablation. The patient's treating Pain Management physician has recommended the spinal procedure of destruction of intraosseous basivertebral nerve first two level vertebral bodies of the lumbar / sacrum.

The patient has been diagnosed with other intervertebral disc degeneration, lumbar region, and low back pain. The prior authorization form noted the patient had a history of low back pain that went back more than 4 years. She had multiple treatments including sacroiliac joint injections, home exercise program, medial branch blocks, ice/heat applications, transcutaneous electrical nerve stimulation (TENs) unit, physical therapy, radiofrequency ablations, and medication management. The pain was noted to have a significant impact on her activities of daily living. She had been treated with medications. Nothing had provided significant sustainable relief. She has a body mass index (BMI) of 39.5. The severity of pain ranged between 3/10 and 8/10 with a visual analog scale score of 3/10.  

Magnetic resonance imaging (MRI) revealed Modic changes at L5-S1 disc space. The provider noted as such, the patient's low back pain was coming from the vertebral genic changes at L5 and S1 vertebral bodies. Given the patient had failed non-operative treatment, the provider opined that the only solution was the Intracept procedure.
The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

The requested destruction / nerve ablation of intraosseous basivertebral nerve has final approval from the appropriate regulatory bodies for this diagnosis.

This patient is a good candidate for the requested destruction / nerve ablation of intraosseous basivertebral nerve.

The requested destruction / nerve ablation of intraosseous basivertebral nerve is the best available treatment for this patient at this time.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The patient has ongoing chronic low back pain which has failed conservative treatment. There are noted Modic changes on MRI. This procedure is used to treat chronic pain with Modic changes in the vertebral spine. It is likely to be more beneficial than any of the standard treatments/procedures for this patient as she has failed standard treatments/procedures.

The carrier's denial of coverage for destruction / nerve ablation of intraosseous basivertebral nerve should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain.

Treatment: Destruction / nerve ablation of intraosseous basivertebral nerve.

The insurer denied coverage for destruction / nerve ablation of intraosseous basivertebral nerve.

The denial is upheld. 

This is a female patient with a history of chronic low back pain. After magnetic resonance imaging (MRI), she was diagnosed with lumbar intervertebral disc degeneration at lumbar(L)/sacral(S) level L5-S1. Treatment attempts have included medications, sacroiliac joint injections, home exercise program, medial branch blocks, ice and heat, transcutaneous electrical nerve stimulation (TENs) unit, and radiofrequency ablation. The patient's treating Pain Management physician has recommended the spinal procedure of destruction of intraosseous basivertebral nerve first two level vertebral bodies of the lumbar / sacrum.

The patient presented with a history of back pain and bilateral leg pain. The patient is status post bilateral radiofrequency ablation (RFA) with mild relief. The pain is rated as 3/10 that is intermittent, sharp, and shooting. The patient continues with a home exercise program. The patient has not started physical therapy. Diagnoses includes lumbar facet arthropathy, lumbar degenerative disc disease (DDD), and myofascial muscle pain.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. While results may appear promising, additional studies are necessary to determine efficacy as compared to other conventional therapies. Furthermore, there have not been large enough volume studies to support the requested procedure.  

Though there have been some studies that provide evidence of benefit from the procedure, most of the studies state that larger quality studies are needed to support efficacy and safety. As such, it is still not considered to have final approval from the regulatory bodies.     

Though the patient continues to have chronic low back pain and previously had tried prior treatments, there are other treatments such as behavioral therapy, chiropractic therapy, massage therapy, non-opioid medications as well as possible intervention surgically. 

The requested destruction / nerve ablation of intraosseous basivertebral nerve is not the best available treatment for this patient at this time.     
  
The carrier's denial of coverage for destruction / nerve ablation of intraosseous basivertebral nerve should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain.

Treatment: Destruction / nerve ablation of intraosseous basivertebral nerve.

The insurer denied coverage for destruction / nerve ablation of intraosseous basivertebral nerve.

The denial is upheld. 

This is a female patient with a history of chronic low back pain. After magnetic resonance imaging (MRI), she was diagnosed with lumbar intervertebral disc degeneration at lumbar(L)/sacral(S) level L5-S1. Treatment attempts have included medications, sacroiliac joint injections, home exercise program, medial branch blocks, ice and heat, transcutaneous electrical nerve stimulation (TENs) unit, and radiofrequency ablation. The patient's treating Pain Management physician has recommended the spinal procedure of destruction of intraosseous basivertebral nerve first two level vertebral bodies of the lumbar / sacrum. 

This patient has chronic low back pain. She has a body mass index (BMI) of 39.5. She has tried home exercise program, ice, heat, TENs unit, and physical therapy. Her MRI shows Modic changes at L5-S1 vertebral bodies. The request is for radiofrequency ablation (RFA) of the interosseous basivertebral nerve.

The denial of the Intracept procedure is upheld. The publications to date have been company sponsored and had methodology flaws. UpToDate has evaluated this procedure and concluded that the literature is still not yet available to determine this as standard of care. There are other evidence- based interventions available to this patient. 

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

The carrier's denial of coverage for destruction / nerve ablation of intraosseous basivertebral nerve should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: rib fracture.
	
Treatment: inpatient admission.

The insurer is denied coverage for inpatient admission.

The denial is upheld. 

This male patient who presented to the emergency department with right shoulder pain following a bicycle accident. A neighboring bicyclist crashed into the patient, and he landed on his right shoulder. On exam, the patient had abrasions to his right shoulder, right metacarpophalangeal joint and right knee. The patient's right scapula was tender to palpation. A chest x-ray showed right scapular lucency. A pelvis x-ray was negative. Orthopedic Surgery was consulted due to a minimally displaced right scapular body fracture and right fourth rib fracture.  The patient was admitted under the Trauma Surgery service for the rib fracture and further monitoring. He received medication for pain management as needed and wore a sling to his right upper extremity. There was no acute Orthopedic Surgical intervention. The patient was deemed stable for discharge with outpatient instructions to follow up with Orthopedic Surgery.

The records demonstrate a low energy type of injury.  The man sustained a direct blow to his shoulder girdle. He was found to have a non-displaced comminuted fracture noted on computed tomography (CT).  The rib fracture was non-displaced.  At no time were there any associated respiratory complaints consistent with contusion or other pathology.  His respiratory rate was never elevated. His physical examination reported no chest abnormalities.  There was no clinical documentation of any pulmonary problem to require treatment i.e. Normal pulse oximetry on room air. There was no indication for additional imaging or surgery. The patients' pain level was reported to be 2.  There was no evidence of splinting or inability to tolerate oral pain medication.  He received 1 dosage of Morphine in the ED, 1 dosage of Toradol and subsequently refused additional intravenous (IV) medication. These findings do not substantiate necessity for the acute admission and length of stay. Monitoring could have been completed at a lower level of care. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.


The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Back pain and spasms
Treatment: physical therapy services (procedure code 97110)
The insurer denied coverage for physical therapy services (procedure code 97110).
The denial is overturned.  

This female patient who was seen (via video) by her treating physician for back pain, spasms and limited range of motion, secondary to moving a box a few days prior.  Currently under review is the medical necessity of physical therapy services.

Based on the clinical records reviewed, the physical therapy for the patient's back pain with associated spasms and decreased range of motion was clinically appropriate and medically necessary.  This physician would agree that physical therapy should have as a goal improving the patient's function.  However, the inability "to take care of her daily needs" is not a medically necessary or essential criterion.  The 3 physical therapy sessions provided resulted in improvement of the patient's back pain and functional ability.  The documented goals by the physical therapist included elimination of muscle spasms, attaining a lumbar function score (LFS) of 100% and returning to her previous level of function; all of which were accomplished.

The health plan did not act reasonably, with medical judgment or in the best interest of the patient in this particular case.  Considerations included the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations.  All decisions are evidence-based.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, physical therapy services were medically necessary.

The carrier's denial of coverage for physical therapy services (procedure code 97110) should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara 90 mg
The insurer denied Stelara 90 mg.
The determination is overturned.

The patient has Crohn's disease status post total colectomy with J-pouch (ileo-anal pouch) complicated by chronic pouchitis and cuffitis, colitis, and intra-abdominal adhesions. He started Stelara and has been on Stelara 90 milligrams (mg) every 4 weeks, reportedly in clinical remission. He presented with recurrent iron-deficiency anemia requiring intravenous iron; he had been on corticosteroids (budesonide and Cortifoam) complicated by osteoporosis with hip and rib fractures. He presented with ongoing chronic pouchitis and 6 bowel movements per day. At issue is the medical necessity of Stelara 90 mg every 4 weeks for the treatment of Crohn's disease.

The request to continue Stelara to 90 mg every 4 weeks is supported in this case by current medical literature. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease [1-3]. Guidelines for the treatment of Crohn's disease recommend the use of Stelara [4]. In this case, the patient has severe disease based on extensive disease requiring colectomy. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response [5-7]. One study showed that dose escalation was required in approximately half of patients, and successful in 61.1% of dose escalation attempts [5]. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted [7]. Additionally, American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy" [4]. Additionally, Stelara has proven effective for the treatment of pouchitis, which the patient has [8,9]. In this case, the patient has failed Stelara every 8 weeks, and has had some disease symptoms requiring corticosteroids even on Stelara 90 mg every 4 weeks; discontinuation of dosing every 4 weeks (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with severe disease. For all of these reasons, continuation of Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied the Braces.
The determination is overturned.

The patient has an anterior crossbite on teeth 7 and 10. He presented with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. He is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity. At issue is the medical necessity of braces.

This patient presented with an anterior crossbite on teeth 7 and 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, the treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System-Asthma
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has overturned in whole the health plan's determination.

The patient has a past medical history of hypertension, hyperlipidemia, and asthma who was admitted with complaints of shortness of breath (SOB) associated with wheezing. Vital signs were remarkable for an oxygen saturation of 87%. Physical exam was notable for bilateral wheezing. Lab work was notable for partial pressure of carbon dioxide (pCO2) 60, peak flow was 250 with predicted 500 liters per minute, positive troponins. Imaging studies: transthoracic echocardiogram (TTE) showed no significant findings. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with an asthma exacerbation and treated with pulmonary treatments, intravenous (IV) steroids, magnesium, and IV antibiotics. The patient was discharged in stable condition with discharge peak flow of 340. 

The hospital stay was medically necessary at an acute inpatient level of care. This patient presented with a one-week history of worsening shortness of breath (SOB) associated with wheezing. The patient was evaluated and found to have bilateral wheezing. The patient was treated aggressively in the emergency department (ED) with DuoNeb's, IV antibiotics, and IV steroids. In addition, the patient's peak flow was 250, which was 50% of the patient's predicted. This is compounded by the patient's tachypnea, positive troponins, elevated pCO2 and hypoxia requiring 2 liters of oxygen therapy, which is a significant change from the patient's baseline. Overall, this patient suffered a severe exacerbation of asthma and could not have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient in this case has a complex medical history including ovarian cancer, intravenous (IV) drug abuse, polysubstance abuse and recent hospital admission with staphylococcus aureus bacteremia and also lung infection with stenotrophomonas. The patient is noted to have had multiple bilateral retroperitoneal abscesses, drained by interventional radiology during a recent admission before the admission in this case. She is noted to have had "darkish" stool since her prior hospital admission continuing after that admission.  

The patient was residing in a nursing home and labs were done that revealed a hemoglobin of 6.3 grams per deciliter (g/dl).  She was seen in the emergency department due to that issue.  At the time of evaluation, vital signs were unremarkable and she had no signs of ongoing active bleeding.  She had brown stool on rectal exam.  She was transfused two units and admitted to the hospital. She was continued on cefazolin, which she had been getting before admission for her known infection.  During her hospital stay, the patient had dark stool but no hematochezia or melena.  She had a stable hemoglobin after transfusion and the discharge summary notes that she was kept at the hospital to complete her course of cefazolin as she refused return to the nursing home.  She finished that course and was discharged.

No, the proposed inpatient admission was not medically necessary.
This patient had no active bleeding and no hemodynamic instability. She required transfusion but that did not need to be done on an inpatient basis. She was continued on intravenous (IV) antibiotic treatment with cefazolin for her infection, but that also did not require acute care inpatient admission.  The patient did not have active or worsening infection and was receiving that antibiotic to complete a previously prescribed course of treatment.  There were no active acute medical issues identified during her hospital stay. Therefore, this admission was not medically necessary.