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

Diagnosis: Back Pain
Treatment: Intraosseous Basivertebral Nerve (BVN) Ablation
The insurer denied Intraosseous Basivertebral Nerve (BVN) Ablation
The determination is upheld.

This is a male patient with a past medical history (PMH) of hypertension (HTN), gastroesophageal reflux disease (GERD), coronary artery disease (CAD) status/post (s/p) quadruple bypass and low back pain over the past 2 years. His lower back pain began following a cardiac procedure. His pain is worsened by bending and lifting. His sleep is impacted and he sleeps on a recliner. He had magnetic resonance imaging (MRI) performed which demonstrated facet arthrosis at lumbar (L) 2-3, L3-4 disc bulge with bilateral neuroforaminal narrowing and minimal disc bulge at L4-5. His physical examination is notable for full lumbar flexion and extension without pain.
He has pursued chiropractic care. He has undergone interventions including transforaminal epidurals, medial branch blocks and trigger point injections. He has tried Lyrica and over the counter medications. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No. The requested 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. This reviewer could not find evidence for trials of other standard treatment such as physical therapy, home exercises, interlaminar epidurals and usual medications other than Lyrica. The lumbar MRI radiology report does not indicate modic type I or II changes at the proposed level. At this time, it is unlikely that the proposed service will be more beneficial than standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intraosseous Basivertebral Nerve (BVN) Ablation
The insurer denied Intraosseous Basivertebral Nerve (BVN) Ablation
The determination is upheld.

This is a male patient with low back pain. The pain began over 2 years ago. Prior treatment has included chiropractic care, home exercises, as well as injections. The pain impacts activities of daily living (ADLs). Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic type II changes at lumbar (L) 5-sacral (S)1.

The proposed health service or treatment Intraosseous Basivertebral nerve (BVN) 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.
The patient has complaints of low back pain and intraosseous basivertebral nerve ablation is requested. This procedure is not recommended Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is a lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Orthopedic/Musculoskeletal
Pain Management

Diagnosis: Back Pain
Treatment: Intraosseous Basivertebral Nerve (BVN) Ablation
The insurer denied Intraosseous Basivertebral Nerve (BVN) Ablation
The determination is upheld.

This is a male patient who was diagnosed with low back pain. The patient was recommended for the Intracept procedure.
The provider noted the patient has a history of low back pain that began 2 years ago. Multiple treatments were tried including chiropractic, heat, ice, home exercises, medial branch blocks, medications, transforaminal epidural steroid injections and trigger point injections. Medications included Lyrica and over-the-counter medications. The pain is impacting the patient's activities of daily living with bending, lifting and sleeping. Nothing has provided significant sustainable relief. The provider noted the patient had magnetic resonance imaging (MRI) on 1/13/23 demonstrating Modic type II changes at disc spaces lumbar (L)5 - sacral (S) 1 and the provider stated that the patient's back pain is coming from vertebrogenic changes at L5 and S1. The provider would like the procedure to be approved.
At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment Intraosseous Basivertebral Nerve (BVN) 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. The patient was noted to have complaints of chronic low back pain with failed conservative treatment and injections. The provider stated the patient had an MRI demonstrating Modic type II changes at disc spaces L5 - S1 and believes that this is because of the patient's back pain. However, the MRI submitted does not mention any degenerative endplate changes or Modic changes. There is a lack of high-quality studies evaluating the long-term risks and benefits of the requested procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.  This treatment is not currently considered standard of care in the general medical community. There is a lack of high-grade evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Entyvio
The health plan denied: Entyvio
The determination is: Overturned

The patient is a young female with a history of Crohn's disease. She has tried and failed infliximab. Her provider has now prescribed Entyvio for treatment. At issue is the medical necessity of Entyvio.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of Entyvio is medically necessary for this patient.
Entyvio is Food and Drug Administration (FDA) approved for the use in the treatment of inflammatory bowel disease in adults. There are many peer reviewed literature reports supporting the use of Entyvio in pediatric patients with inflammatory bowel disease (IBD). Despite the lack of FDA approval in pediatric patients, Entyvio is being widely used for the treatment of children with Crohn's disease and ulcerative colitis. The safety and efficacy of Entyvio are well established in pediatric patients with inflammatory bowel disease.
Per Ledder O et al, "Vedolizumab was safe and effective in this cohort of paediatric refractory IBD". Similar findings were reported by Singh N et al and Anna-Maria Schneider et al.
Therefore, Entyvio is requested for a medically appropriate indication. The patient has already tried and failed infliximab. Conventional therapies are not recommended in severe cases refractory to infliximab. Therefore, Entyvio is the most suitable treatment option and is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide 7 days x 12 hours (hrs) x 2 shifts
The insurer denied the Personal Care Aide 7 days x 12 hours (hrs) x 2 shifts.
The determination is overturned.

This is a female patient with a medical history notable for dementia. The patient is approved for 11 hours per day, 7 days per week (77 hours per week) of personal care aide services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shifts), 7 days per week (168 hours per week) and the request was denied by the health plan.
Social services notes were provided for review. The patient is bed bound and requires total assistance with all activities. She has some redness in her sacral area. The patient has been receiving 11 hours per day of care and the family has been paying for a private overnight care aide. She is oriented to person only with periods of confusion. She is able to make simple needs known but has frequent nonsensical speech.
A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted via teleconference. The patient has been under hospice care for one year. She was awake and responsive and her family and aide meet and anticipate her needs. Her cognition is moderately impaired. She requires total dependence for all instrumental activities of daily living. For her activities of daily living (ADLs), she requires total dependence for bathing, dressing, toilet use, and bed mobility. She requires maximal assistance for hygiene and eating. She is incontinent of stool and urine with no control present; the family reported redness on her buttocks at the time of the assessment. She uses diapers for incontinence care. At issue is the medical necessity of Personal Care Aide 7 days x 12 hours (hrs) x 2 shifts.

The requested health service of Personal Care Aide 7 days x 12 hrs x 2 shifts is medically necessary for this patient.
The patient requires total dependence for essentially all activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). She is bedbound and incontinent of urine and stool. She has evidence of early skin breakdown in the sacral area. Her care needs are expected to be continuous and unscheduled throughout the day and night. She will need frequent checking throughout the night for diaper changes as needed and turning/repositioning to help with pressure ulcer prevention/treatment. The requested increase in hours is reasonable and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite/overjet.
Treatment: Braces and monthly visits.

The health plan denied Braces and monthly visits.  The determination is Upheld.

The patient is a female with a Class I occlusion with a 3-milimeter (mm) overbite and 4-mm overjet. She has maxillary and mandibular crowding. Tooth 4 is in a crossbite. She is treatment planned for 30-36 months of orthodontics to correct her malocclusion, but her insurance company rejected the claim on the basis that treatment is not medically necessary.
At issue is the medical necessity of braces and monthly visits.
The health plan's determination of medical necessity is upheld in whole.
The requested health treatment of braces and monthly visits is not medically necessary for this patient. The patient's mouth is crowded, but no teeth are impacted. Her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior crossbites present. The insurance requires a handicapping labio-lingual deviation (HLD) score of 26 or above in the absence of an auto qualifying condition to qualify as medically necessary. This reviewer scores the patient at a 20 (4 overjet, 3 overbite, 10 maxillary and mandibular anterior crowding, 3 labio-lingual spread), and confirms the absence of an auto qualifying condition as described by the insurance plan and the provided HLD (handicapping labio-lingual deviation) index form.
Discounting the HLD score, there is still no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no anterior crossbite. There is a single tooth posterior crossbite, but there is no sign of damage to the tooth. There is no evidence of wear or periodontal recession. There are functional problems that may 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. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion.[2] The patient's overjet is more than ideal, but her overjet would not affect oral health related quality of life unless it was greater than 6-mm.[3] If her teeth were aligned, it would provide an esthetic 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: Failure to conceive

Treatment: in vitro fertilization (IVF), code S4011 and related laboratory code 89528

The insurer denied coverage for in vitro fertilization (IVF), code S4011 and related laboratory code 89528

The denial is upheld 


The patient is a female interested in conceiving with donor sperm. She underwent 2 in vitro fertilization (IVF) cycles in the past. 

The insurer has denied coverage for in vitro fertilization (IVF), code S4011 and related laboratory code 89528, on 2 dates of services, as not medically necessary. In a Final Adverse Determination letter stated that in vitro fertilization (IVF) can be standard treatment for patients with infertility who fail less invasive fertility treatments such as ovulation induction with insemination. There is no documentation that other treatments were tried before in vitro fertilization (IVF). 

This patient presented interested in conceiving with donor sperm. According to the submitted information, this patient was never diagnosed with infertility. The provider stated that the patient tried and failed to conceive in her 30's with a prior partner but there is no information about that partner.

In the absence of a diagnosis of infertility, in vitro fertilization (IVF) is not medically necessary. This patient should fail at least 3 cycles of insemination with donor sperm prior to being labeled as infertile and eligible for infertility services. While I agree with the provider that aging increase the odds of aneuploidy and decrease the odds of live birth, not every woman in her early 40's needs to undergo in vitro fertilization (IVF) as the majority conceive naturally when exposed to sperm. Note that the patient had good ovarian reserve based on the submitted anti-Mullerian hormone (AMH) level.

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 in vitro fertilization (IVF), code S4011 and related laboratory code 89528, requested dates of service is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatitis, coronary artery disease, and end stage renal disease on dialysis with tunneled dialysis catheter
Treatment: Acute Inpatient Admission
The insurer denied: Acute Inpatient Admission
The denial is upheld.

The patient is an adult female with hepatitis, coronary artery disease, and end stage renal disease on dialysis with tunneled dialysis catheter. The patient had catheter dysfunction and only completed one hour of dialysis treatment and was sent to the hospital. Alteplase was instilled during the hospital stay with successful improvement in flow and resumption of maintenance Monday/Wednesday/Friday dialysis. There was a denial of the requested inpatient level of care as not meeting Milliman Care Guideline (MCG) criteria. The physician is appealing the 
determination.

The proposed treatment was not medically necessary.

The request would be for the convenience of the patient or practitioner; inpatient admission is not considered standard of care. Based on the Milliman Care Guidelines (MCG) criteria for renal failure, inpatient level of care may be necessary in the setting of altered mental status that is severe or persistent, hemodynamic instability, severe hypertension, cardiac arrhythmias of immediate concern, and significant respiratory findings that are severe or persist despite observation care treatment. Also, clinically significant electrolyte abnormality or metabolic abnormality that is severe or persists despite outpatient or observation care treatment, acute treatment of renal failure (e.g., dialysis) not feasible or appropriate in observational care setting or uremic findings. Based on the available data, these criteria were not met. For date of service under review, the patient could have safely and effectively been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Other/Spondylosis.
Treatment: Surgical Services/Radiofrequency joint denervation and/or ablation.
The health plan denied the requested Radiofrequency joint denervation and/or ablation as not medically necessary. 
The health plan's determination is overturned.

The patient is a male with several years of chronic low back pain. Pain is axial in nature. No reports of radiculopathy. Physical exam is notable for tenderness to the paraspinals, sacroiliac (SI) joints and sciatic notches bilaterally. Painful lumbar range of motion. + facet challenge bilaterally. Neurovascularly is intact otherwise. A magnetic resonance imaging (MRI) of the lumbar spine demonstrated degenerative changes without significant neural compression. An electromyography (EMG) /nerve conduction study (NCS) demonstrated no abnormalities. Prior treatments include previous injections, ((lumbar) L3/4 interlaminar with 80% pain relief x 2 months, bilateral radiofrequency ablation (RFA) L3 L4 L5 with 50-60% pain relief x 24 months, bilateral L3/4 L4/5 L5/S1 medical branch bock (MBB) and with 80% pain relief x 3 weeks), 4 weeks of physical therapy (PT) which made his symptoms worse, a home exercise program (HEP), chiropractor, Lyrica, narcotics, and muscle relaxers. The patient was once again recommended bilateral L3, L4, L5 RFA for the treatment of his pain.

The health plan's determinations of medical necessity are overturned, in whole, as per above.

Yes. The patient has facetogenic low back pain that is chronic in nature. It has been treated well with MBB and RFA in the past with most recent RFA lasting 2 years. That is significant pain relief for a low-risk procedure. It would be in the best interest of the patient to repeat the RFA and perform the requested treatment as ordered. To deny it would leave the patient in pain and be more costly to the health plan and health care system in the long run.
Health plan criteria for facet RFA is provided. The policy states facet RFA is medically necessary when ALL are met:
A. Findings an imaging identifies no other cause-> MET.
B. Pain x at least 3 months-> MET.
C. Patient has tried and failed conservative treatment for at least 4 weeks in the past 3 months-> MET.
D. 2 positive diagnostic facet injections/MBB with 80% pain relief-> MET.
The health plan criteria met. Therefore, no, the health plan did not act reasonably or with sound medical judgment nor in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing Tooth/Teeth
Treatment: Surgical placement of implant body: endosteal implant
The insurer denied Surgical placement of implant body: endosteal implant.
The health plan's determination is overturned. 

This patient is a female being treated with chemotherapy for breast cancer, who had implants placed in the number (#)12 and #13 areas to replace a failed bridge. No sign of infection was noted. 
At issue is the medical necessity of Surgical placement of implant body: endosteal implant.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Surgical placement of implant body: endosteal implant is medically necessary for this patient.
The options to restore function in this case are a removable denture or implants. Implants are the best choice. A partial denture has been shown to lead to the loss of adjacent teeth and have less chewing efficiency than implants. Implants are the standard of care and more efficient than a partial. Implants are the closest thing to natural teeth, preserve the bone and are not susceptible to caries. Implants are the generally accepted standard of care.
Therefore, the requested health service/treatment of Surgical placement of implant body: endosteal implant, is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Eustachian tube dysfunction (ETD)
Treatment: Nasopharyngoscopy, Surgical, with Dilation of Eustachian Tube (i.e., Balloon Dilation)
The insurer denied Nasopharyngoscopy, Surgical, with Dilation of Eustachian Tube (i.e., Balloon Dilation). The health plan's determination is upheld. 

The patient is a female with complaints of right > (greater than) left ear popping. The first note provided reports that the patient was told she had fluid by an outside audiologist. Physical exam at that time showed normal-appearing tympanic membrane with no effusion.
Audiogram performed showed mild high-frequency sensorineural hearing loss with no conductive component. Tympanograms were normal bilaterally indicating normal Eustachian tube function.
A Follow-up note reports that the patient was complaining of popping in her ears which had not improved with nasal mometasone. In the provided documentation, there are no reports of prior episodes of otitis media.

Nasopharyngoscopy, Surgical, with Dilation of Eustachian Tube (i.e., Balloon Dilation) is not likely to be more beneficial than any standard treatment for this patient's disease.
In the documentation provided, there is no objective evidence supporting a diagnosis of eustachian tube dysfunction. The patient had a normal physical exam on both office visits. An audiogram showed type A tympanograms indicating normal eustachian tube dysfunction.
Balloon Dilation of the Eustachian tube is a procedure that has been proven to be effective for chronic, symptomatic Eustachian tube dysfunction (ETD) which has not improved with medical management or tympanostomy tubes. However, in this case there is no evidence that the patient has ETD.