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

Diagnosis: Chronic active Epstein-Barr virus (EBV)
Treatment: Jakafi
The insurer denied Jakafi
The determination is overturned.

This is a female patient with chronic active Epstein-Barr virus (EBV). Jakafi has been recommended to address inflammation-related clinical manifestations while awaiting an allogeneic stem cell transplant and is under review.

Yes, the proposed health service or treatment Jakafi (ruxolitinib) 10 milligrams (mg) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Chronic active Epstein-Barr virus (CAEBV) infection is a rare, life-threatening lymphoproliferative disorder that may involve B lymphocytes, T lymphocytes, or natural killer (NK) cells. Because this disease is so rare, there are no formal guidelines for therapy and there is a paucity of large trials. The only intervention that has been curative is hematopoietic stem cell transplantation. Treatment bridging a patient to stem cell transplant is necessary, however, as the patient needs to be stabilized while a donor is found and cells are obtained.
A review of the literature found ruxolitinib to be a common and effective intervention in birding. As noted in Arai's review, "...Onozawa et al. found that inhibition of a tyrosine kinase, Janus kinase (JAK) 1/2, which phosphorylates signal transducer and activator of transcription 3 (STAT3) by its inhibitor ruxolitinib, inhibited STAT3 activation in EBV-positive T or NK cell lines. Furthermore, ruxolitinib suppressed proliferation and induced apoptosis of these cells. It was also determined that ruxolitinib suppressed the messenger ribonucleic acid (mRNA) expression of interferon gamma (IFN-), tumor necrosis factor-alpha (TNF-), and interleukin (IL)-6 in EBV-T/NK cells. These results indicated that the JAK1/2 STAT3 pathway contributed to the development of both the inflammatory and neoplastic aspects of CAEBV....the JAK inhibitor ruxolitinib suppresses the proliferation and cytokine production of EBV-positive T or NK cells. JAK inhibitors are clinically used and effective for cytokine-associated inflammatory diseases, such as rheumatoid arthritis (RA), ulcerative colitis (UC), and graft versus host disease (GVHD). Since CAEBV shows sustained inflammation accompanied by hypercytokinemia, the effects of JAK inhibitors on inflammatory symptoms and disease activity are highly anticipated....". This was echoed by others including, but not limited to, Uemora, et al and Jin, et al. This agent is not the subject ongoing investigation. No agent is known to be more beneficial in this setting. Ruxolitinib is a clear standard of care for this disease.
Appeal type: Experimental/Investigational
Decision: Overturned


Diagnosis: Digestive System/Gastrointestinal/Other/Achalasia.
Treatment: Surgical Services/lower esophageal transoral myotomy (POEM)
The health plan denied the requested surgical service lower esophageal transoral myotomy (POEM) as experimental/investigational. 
The health plan's determination is overturned.

The patient is a male with type 2 achalasia. He has had two years of dysphagia and regurgitation as well as occasional chest pain. An esophagogram showed marked delay in passage of contrast from the esophagus to the stomach with smooth narrowing at the gastroesophageal junction suspicious for stricture. The esophagogastroduodenoscopy showed a dilated esophagus with minimal resistance to scope passage suspicious for achalasia. A computed tomography scan of the abdomen and pelvis showed a thoracic esophagus diffusely distended with fluid and air with no definite focal wall thickening. An esophageal manometry showed type 2 achalasia; peroral endoscopic myotomy was recommended.
At issue is whether the requested procedure, peroral endoscopic myotomy (POEM), is likely to be more beneficial than any standard treatment for the treatment of achalasia.

The health plan's determination is overturned, in whole.

Yes, peroral endoscopic myotomy (POEM) is supported as likely to be more beneficial than any standard treatment or treatments for the treatment of the patient's achalasia.
The American Gastroenterological Association best-practice for peroral endoscopic myotomy states that "if the expertise is available, POEM should be considered guideline as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (Kahrilas, et al). [1] The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, recommending POEM for the treatment of achalasia (Khashab, et al). [2] Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available (Barbieri, et al; Schlottmann, et al). [3,4] Despite comparable efficacy, POEM is significantly less invasive than surgical intervention resulting in less postoperative pain and a more rapid recovery (Docimo S, et al). [5] In this patient with symptoms including dysphagia, the use of POEM is supported by current medical literature and guidelines. For these reasons, POEM should be considered likely to be more beneficial than any standard treatment or treatments for the patient's achalasia.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Other/Achalasia.
Treatment: Surgical Services/lower esophageal transoral myotomy (POEM)
The health plan denied the requested surgical service lower esophageal transoral myotomy (POEM) as experimental/investigational. 
The health plan's determination is overturned.

The patient is a male with a two-year history of progressive dysphagia. The patient underwent a barium esophagram and endoscopy as well as manometry and was diagnosed with Type 2 achalasia. The patient is very symptomatic with an Eckardt score equaling 7. The patient was referred for a peroral endoscopic myotomy (POEM) procedure as definitive treatment for achalasia.
At issue is whether the proposed treatment procedure (POEM) is likely to be more beneficial than any standard treatment.

I recommend overturning, in whole, the health plan's determination regarding the POEM procedure.

Yes, the proposed treatment (POEM) is likely to be more beneficial.
Achalasia results from progressive degeneration of ganglion cells in the myenteric plexus in the esophageal wall. It is characterized by the failure of relaxation of the lower esophageal sphincter (LES), often accompanied by a loss of peristalsis in the distal esophagus. Treatment of achalasia is aimed at decreasing the resting pressure in the LES to allow passage of ingested material. Peroral endoscopic myotomy (POEM) is the endoscopic equivalent of surgical myotomy and a newer technique for the management of achalasia. POEM has been endorsed as a primary treatment for type II achalasia (as an alternative to pneumatic dilation and surgical myotomy) by major society guidelines. [1] The durable success rate of POEM (usually defined as an Eckardt score of 3) is between 78 and 92 percent at between 24 and 79 months. Less than 4 percent of patients required retreatment for achalasia. [2] POEM performs very well compared to standard surgery for achalasia (Laparoscopic Heller Myotomy (LHM)). In a meta-analysis of over 7000 patients in over 70 cohort studies, POEM was more effective than LHM in relieving dysphagia. [3] POEM also compares very favorably to pneumatic dilation initially, and its durability is much greater.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The health plan denied: Intraosseous basivertebral nerve ablation
The determination is: Upheld

The patient is a female with history of low back pain for over 6 months who has tried home exercises, medical management, physical therapy (PT), spinal cord stimulator (SCS), epidural injections, and chiropractic therapy. She has had no significant pain relief with any of the above that is sustained. The patient has a history of 2 prior lumbar surgeries.
Magnetic resonance imaging (MRI) of the lumbar (L) spine was completed which showed degenerative changes along end plates of L3-5.
Based on the clinical note provided, the patient had right leg pain for which a transforaminal injection was tried, and it responded. There is a computed tomography (CT) report provided, but there is no MRI report given.
At issue is whether the proposed health service or treatment intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment for the patient's condition.
The health plan's determination regarding the proposed health service or treatment is upheld in whole.
The procedure intraosseous basivertebral nerve ablation can certainly be more beneficial for low back pain in the right selective patient population.
Modic changes 1 and 2 are good indicators of patients needing treatment. This patient has not undergone an MRI to suggest modic changes. There is incomplete imaging done to justify proper inclusion criteria; therefore, there is no indication that this treatment would be more beneficial for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The health plan denied: Intraosseous basivertebral nerve ablation
The determination is: Upheld

The patient is a female with low back pain. Magnetic resonance imaging (MRI) of the lumbar (L) spine shows multiple levels of degeneration with foraminal narrowing.
At issue is whether the proposed health service or treatment intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment for the patient's condition.
The health plan's determination regarding the proposed health service or treatment is upheld in whole.
No, intraosseous basivertebral nerve ablation is not likely to be more beneficial, as no long-term studies have shown clear safety and efficacy of this procedure in a patient such as this with ongoing multiple levels of foraminal stenosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Disk herniation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This case involves an adult female who presented to the hospital for a scheduled excision of disc herniation and micro laminotomy at the right lumbar (L)5 - sacral (S)1.  On the date of surgery, the patient was noted to have a past medical history significant for adrenal adenoma, adrenal mass, asthma, carpal tunnel syndrome, nicotine abuse, central retinal vein occlusion, hypertension, hyperplastic colon polyp, kidney stones, renal cyst, type 2 diabetes, obesity, hypercholesterolemia, sciatica, and tinea.  The patient's preoperative vital signs noted blood pressure 141/75, pulse of 74, respirations 17, and a temperature of 36.7 degrees C.  She had a body mass index of 33.7 with a Mallampati II airway.  The operative report stated that the procedure went well with no complications.  The treatment plan included 24 hours of prophylactic antibiotics along with physical therapy and pain-relieving medications.  Following surgery, the patient was voiding freely and passing flatus.  Her laboratory values and vital signs were stable.  

The Milliman Care Guidelines (MCG) have stated that for lumbar discectomy, foraminotomy, or laminotomy, these procedures are considered ambulatory and do not require inpatient admission.  Extended stay may be recommended for individuals over the age of 65, when the patient has a dural tear or cerebrospinal fluid leak, extraspinal hemorrhage, intraspinal hemorrhage, or nerve root injury.  

The documentation provided for the review stated that surgery was completed without complication.  The patient was transferred to the post-anesthesia care unit after surgery for neurovascular checks.  She was given medication and was seen by physical therapy.  However, the services could have all been rendered safely and effectively on a lower level of care and did not require acute inpatient stay. 

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 full hospital is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite.
Treatment:  D8080 Braces.

The insurer denied D8080 Braces.  The denial is overturned.

The patient is a teenaged female. The request is for orthodontic treatment. The patient has a skeletal Class I malocclusion with Class III canines. There is severe upper crowding with moderate lower crowding. There is a deep bite and right posterior crossbite. The prior denial was due to handicapping score of 23.

The proposed treatment is medically necessary.

The patient has an anterior crossbite between teeth # (number) 7 and #27 with gingival attachment loss. This is an automatic qualifier according to the handicapping index scale. Therefore, the proposed treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower back pain
Treatment: pain injections (64483 x 1, 64484 x 1)
The insurer denied coverage for pain injections (64483 x (times) 1, 64484 x 1).
The denial is overturned.
 
According to the documentation provided, this is an adult with intractable pain in the right side of her lower back that radiates to the right leg with numbness and tingling. She was treated in the past with lumbar transforaminal epidural steroid injections (TFESI) that resulted in better than 80% (percent) pain relief and lasted 9 months. Her pain returned in the same location and a repeat lumbar TFESI was performed more recently. The health plan has denied payment for this last injection stating that continuation of injections beyond 12 months or more than 4 therapeutic injections is considered not medically necessary because effectiveness and safety has not been established. 

According to Centers for Medicaid and Medicare Services (CMS) guidelines (Epidural Steroid Injections for Pain Management)- it is generally not considered medically reasonable and necessary for treatment with epidural steroid injection (ESI) to extend beyond 12 months. However, use beyond 12 months may be medically reasonable and necessary if the following criteria are met: Pain is severe enough to cause a significant degree of functional disability or vocational disability; The ESI (epidural steroid injection) provides at least 50% (percent) sustained improvement of pain and/or 50% objective improvement in function (using same scale as baseline); Rationale for the continuation of ESIs including, but not limited to, patient is high-risk surgical candidate, the patient does not desire surgery, recurrence of pain in the same location relieved with ESIs for at least three months; The primary care provider must be notified regarding continuation of procedures and prolonged repeat steroid use.

Based on the documentation provided, this patient meets the CMS recommended criteria for additional ESI (epidural steroid injection) beyond 12 months. She has documented severe disabling pain; she has documented 80% (percent) pain relief (well above the required 50%) from prior ESI in the same location that lasted 9 months (well beyond the recommended three months). Documents also state that patient does not desire surgery. 

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 (64483 x (times) 1, 64484 x 1) services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, Emesis, and Abdominal Cramping. 
Treatment: Inpatient Hospital Admission. 

The insurer denied inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male with cigarette and marijuana use who presented to the hospital with nausea and vomiting and was noted with elevated renal function. The patient reported recent increase in marijuana use and was admitted to the hospital and started on intravenous fluid and was noted with stabilizing renal function. The patient was seen by Nephrology and Cardiology and was subsequently discharged. 

The proposed treatment was not medically necessary. 

The proposed treatment would not be considered medically necessary as it would be for the convenience of the patient or the practitioner. The patient was admitted with nausea and vomiting and noted with elevated renal function. Renal function stabilized with intravenous fluid hydration. Based on the available data, there was no documentation that the patient had renal failure and could not be managed in a lower level of care as indicated by clinical status unstable, altered mental status that is severe or persistent, hemodynamic instability, severe hypertension, cardiac arrhythmias of immediate concern or clinically significant electrolyte abnormality or metabolic abnormality that is severe or persistent or other significant finding or manifestation needing inpatient level of care. Based on the available data, these criteria are not met therefore inpatient level of care is not recommended.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth fracture or decay
Treatment: Amalgam or Resin Based Composite Filling (Restoration) for Tooth Numbers 03 and 05
The insurer denied Amalgam or Resin Based Composite Filling (Restoration) for Tooth Numbers 03 and 05.
The denial is Upheld.

The patient is an adult female requesting benefits for composite restorations in teeth numbers 3 and 5. The prior denial was due to no evidence of decay and/or fracturing of the teeth.

The proposed treatment is not medically necessary.

Based upon the multiple x-rays presented, there is no evidence of any new or recurrent decay present in teeth numbers 3 and 5. There also is no evidence of any fracturing or missing tooth structure in either of these teeth. There is no medical necessity for restorations in these teeth based upon the documentation presented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Preterm labor

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

This is a pregnant adult patient with a history of a short cervix and cerclage placement. On a recent perinatal scan there was no measurable cervix. The patient was admitted for fetal monitoring, betamethasone and magnesium sulfate. The patient was not in preterm labor. The patient was discharged two days after admission.

Preterm labor is an indication for admission and tocolysis. Preterm labor is defined as uterine contractions with cervical changes. During this admission, there was no documentation of any cervical changes. Repeat cervical examination did not show any changes. The patient was not in preterm labor. 

Ideally, this patient would have been observed in labor and delivery, received intravenous (IV) fluids and then reevaluated a few hours later. If upon reevaluation, no cervical changes occurred then the patient would be sent home. If cervical changes did occur, then the patient would be admitted for tocolysis and further management. Please note that neither the patient nor the fetus were in any jeopardy. There was no bleeding, and vital signs were stable. Fetal heart rate was reassuring. There was no evidence of ruptured membranes. 

The management that this patient received during the admission could have been done in a less acute setting. Once the provider ascertained that there was no evidence of preterm labor, (no change in cervical status after a few hours of observation) the patient could have been sent home after being hydrated. 

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Pancreatitis.
Treatment:  Inpatient Hospital Admission.

The insurer denied the inpatient hospital admission.  The denial is partially overturned.

The patient is an adult male with history of alcohol abuse and chronic pancreatitis, who presented with abdominal pain, nausea and vomiting (NV) and was found to have a lipase of 183. The patient was admitted, hydrated and treated with pain medication. On day # (number) 2, computed tomography (CT) scan of the abdomen and pelvis revealed acute pancreatitis. The patient was hydrated and monitored for alcohol withdrawal. Triglycerides were elevated, and he was treated with oral agents to lower them. On day #3, the patient was tolerating a diet and only had a mild tremor. There was no further vomiting. On day #4, the patient continued to improve. He was discharged on day #5.

The proposed inpatient hospital admission was medically necessary for days #1 and #2. However, the inpatient hospital level of care for days #3, #4 and #5 were not medically necessary.

On days #1 and #2 the patient had abdominal pain, a lipase elevation of greater than three times the normal and computed tomography (CT) findings of pancreatitis, and had vomiting, with an inability to tolerate oral intake or oral pain medication; criteria for acute inpatient hospital stay was medically necessary. However, on the remainder of the days, as the patient had no further vomiting, was tolerating oral intake, and had no evidence of alcohol withdrawal; he could have been discharged on oral pain medication, oral anxiolytics, and oral medication to treat his elevated triglycerides. Therefore, acute inpatient admission was medically necessary for the first 2 days. The patient was medically stable for discharge on day #3, and acute inpatient hospital stay was not medically necessary for the remainder of the inpatient days.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate Cancer
Treatment: Stereotactic body radiation therapy
The insurer denied stereotactic body radiation therapy.
The determination is overturned.

This is a male patient with a history of a prostate adenocarcinoma Gleason 7 (seven) disease treated with radiation therapy as definitive treatment. He then had a rise in his prostate-specific antigen (PSA). He had restaging scans and was found to have disease at the bilateral internal iliac nodes, right common iliac and left acetabulum. Palliative radiation therapy is recommended for this oligometastatic disease and stereotactic body radiation therapy (SBRT) for 5 (five) fractions to each lesion is recommended. At issue is the medical necessity of the stereotactic body radiation therapy.
The requested treatment of SBRT (stereotactic body radiation therapy) is medically necessary for this patient.
The statement on the denial information that there are more than five treatments for the course of treatments is not correct. The primary site of disease has been treated and in control. Because the pelvis has had previous radiation is also another reason to treat these oligometastases with SBRT (stereotactic body radiation therapy) to protect critical vital structures adjacent to the target volumes that have received some radiation dosing from primary radiation to the prostate. The medical policy states only up to 3 (three) lesions can be treated with no clinical trials stating the exact number of oligometastases that can be treated successfully and safely. The SABR - COMET trials [Stereotactic Ablative Radiotherapy for the Comprehensive Treatment of Oligometastatic Cancers] have shown excellent improvement in survival with no stated limits of the number of oligometastases treated with SBRT. The requested 4 (four) lesion to be treated with 5 (five) fractions of SBRT (stereotactic body radiation therapy) per course of treatment is considered medically appropriate and necessary.