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

Diagnosis: Low Back Pain
Treatment: Surgery (intraosseous basivertebral nerve ablation 22899 and C9752)
The insurer denied the Surgery (intraosseous basivertebral nerve ablation 22899 and C9752)
The denial is upheld

The patient is a female with low back pain for several years.

The patient's VAS (Visual Analogue Scale) score was 8/10. Per report "her symptoms are exacerbated by bending, lifting, straining, twisting, NSAIDs [nonsteroidal anti-inflammatory drugs], muscle relaxants, opioids, physical therapy, obtaining surgical opinion, back brace, epidurals, facets, RFAs [radiofrequency ablations], rest."  MRI (magnetic resonance imaging) of the lumbar spine is significant for a small left foraminal disc protrusion and annular bulge at L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) and small left foraminal disc protrusion at L3-4 (third lumbar spine vertebra-fourth lumbar spine vertebra). The provider notes that images were reviewed and show L4-5 (fourth lumbar spine vertebra-fifth lumbar spine vertebra) Modic Type 1 changes and recommends L4-5 (fourth lumbar spine vertebra-fifth lumbar spine) Intracept procedure.  Coverage for this was denied by the health plan as experimental/investigational.

No, the health plan should not cover the Intracept procedure.

A service is considered medically appropriate when it meets the accepted standards of medicine and is needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms. There must be peer-reviewed medical literature based on scientific data that shows a treatment is safe and effective for treating or diagnosing a medical condition. It must be necessary to meet patients basic health needs and it must be correct for the diagnosis.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable.

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Surgery (intraosseous basivertebral nerve ablation 22899 and C9752)
The insurer denied the Surgery (intraosseous basivertebral nerve ablation 22899 and C9752)
The denial is upheld

The patient is a female with a history of chronic low back pain. Her pain has not responded to facet joint injections, radiofrequency ablation (RFA), physical therapy (PT), acupuncture, chiropractics, bracing, and pain medication.  Physical exam shows decreased range of motion (ROM) and pain on facet loading maneuvers

An Intracept procedure has been recommended. The procedure was denied coverage by the health plan as experimental/investigational. This was appealed.

No, the health plan should not cover the Intracept procedure.
The requested Intracept procedure is not medically appropriate. The requested health service or procedure is not likely to be more beneficial than standard treatments.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted.  Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability.  Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure.  In fact most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion.

However, the patient has not failed sacroiliac (SI) joint interventions, which is common cause of axial low back pain.  Therefore, while the Intracept procedure is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed.   Given the above, the requested Intracept procedure is not medically appropriate.

No, the Intracept procedure is not more beneficial.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and nausea

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is the case of a male admitted for abdominal pain and nausea and was found to have elevated creatinine and lipase. He was treated with pain medication and intravenous (IV) fluid. He was also found to have low blood sugar which improved with oral intake.

During this admission, the patient was hemodynamically stable, with normal oxygenation and negative cultures, he did not have significant electrolytes disturbance or irreversible kidney failure. He did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting. There was no documentation of refractory pain and he was able to tolerate oral diet and did not need total parenteral nutrition and his condition responded to IV fluid hours.

A lower level of care is appropriate when oral replacement therapy is feasible for individuals with mild or moderate dehydration who can drink and have no significant dehydration-related cognitive or physical compromise.

A randomized study of 13,347 non-critically ill adults requiring IV fluid treatment in the emergency department randomized to treatment with isotonic crystalloid or normal saline found no difference in hospital-free days but found that patients treated with the isotonic crystalloids had a lower composite outcome of death, need for renal-replacement therapy, or persistent renal dysfunction than the saline-treated group.

There is no evidence-based literature to support that inpatient level of care was medically necessary and this patient's condition could be treated safely under lower level of care.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Throat Pain
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female who presented to the emergency room (ER)  with a history of throat pain and reported fever.  There was a history of recent tonsillectomy a few days prior.  Trismus and inability for oral (PO) intake was reported.  The patient was afebrile and vital signs were stable on presentation in the ER.  Medical therapy was started, including intravenous (IV) antibiotics and steroids.  IV fluids were also administered.  Ear, nose and throat (ENT) consult reported normal post operative changes.  The patient was started on a liquid diet and discharged home on day three.  The request for inpatient care was previously denied as not medically necessary and the provider is appealing the denial.

No, the proposed inpatient hospital admission was not medically necessary.

All records were reviewed.  The patient presented with a history of throat pain and reported fever.  There was a history of recent tonsillectomy. 

The patient's vital signs were stable in the emergency room and the patient was afebrile.  The patient was able to tolerate her secretions and there was no respiratory distress.  She improved with initial medical therapy in the ER.  ENT consult did not note any abscess or bleeding or infection.  

Therefore, based on the information provided, the medical necessity of the inpatient hospital admission is not confirmed as the patient's care could have been provided at a lower level of care, observation.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient as the patient's care could have been provided at a lower level of care, observation.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Asthma
Treatment: Asmanex
The insurer denied Asmanex.
The health plan's determination is overturned.

The patient is a male with mild to moderate persistent asthma. He has been trialed with 2 inhaled corticosteroids and he was started on Asmanex once a day. As per the physician report and the mother's report, since the patient has been trialed on Asmanex, the need for rescue medicines have decreased with improved quality of life.

A formulary exception is indicated for this patient. The nonformulary drug is more effective and can be safely tolerated.

On Flovent and QVAR, the patient was not responding and was having asthma symptoms. Moreover, these 2 inhaled corticosteroids get absorbed more systemically and impact growth in children who are Tanner 1 and not attained puberty. Asmanex, aka mometasone furoate, has been demonstrated to be superior in terms of controlling the asthma [less need for Beta 2 agonist inhalers, and increased quality of life (QOL), decreased interruption in life, less emergency department (ED)/hospitalizations]. Mometasone systemic absorption is not concerning and has less impact on the final height on growing children. 

Since the introduction of Asmanex, the patient has been having less asthma exacerbations and improved quality of life. Also, the patient is at the growing age period. The mometasone (Asmanex) has a favorable profile in terms of the systemic absorption and impact on the growth and final height.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Postherpetic neuralgia. 
Treatment: Outpatient Procedure  76000x 1, 64555 x 1, 95972 x 1  (occipital nerve stimulation). 

The insurer denied the Outpatient Procedure  76000x 1, 64555 x 1, 95972 x 1  (occipital nerve stimulation). 
The denial is overturned. 

The patient is a male. As noted the patient complains of persistent intractable post herpetic neuralgia. He reports having an 8/10 level of pain for the past week. The patient has failed best medical management to date. His pain is severe, intractable, and interfering with his quality of life and activities of daily living. Continued severe pain in the face as a result of post herpetic neuralgia can become debilitating and further reduce activities of daily living with associated depression. 

Yes, the Health Plan should cover the requested health service. 

The prior final adverse determination denial notice denied the request noting that it was requesting approval for occipital nerve stimulation. It stated that the role of this procedure remains uncertain and that the available evidence has not proven that it is useful to improve help outcomes. 

This reviewer disagrees with this determination. The request is for Peripheral nerve field stimulation in a patient with medically refractory trigeminal neuralgia. This treatment does involve a modified variant of stimulation. There is, additionally, peer-reviewed literature that supports this efficacy in the treatment of refractory trigeminal neuralgia. Specifically, the studies suggest a possibly beneficial long-term effect of PNFS (peripheral nerve field stimulation) on refractory trigeminal neuralgia. 

Yes, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease. 

As noted  the patient complains of persistent intractable post herpetic neuralgia. He reports having an 8/10 level of pain for the past week. The patient has failed best medical management to date. There are no other standard therapies to offer this patient at this point.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Postherpetic neuralgia. 
Treatment: Outpatient Procedure  76000x 1, 64555 x 1, 95972 x 1  (occipital nerve stimulation). 

The insurer denied the Outpatient Procedure  76000x 1, 64555 x 1, 95972 x 1  (occipital nerve stimulation). 
The denial is overturned. 

The patient is a male with post-herpetic neuralgia in distribution V1 (ophthalmic nerve) and V2 (maxillary nerve) of Trigeminal nerve.  This has been refractory to medical management. The request is for trial of PNS (peripheral nerve stimulation) for post-herpetic trigeminal neuralgia. 

Yes, the health plan should cover the requested health service. 

Current treatment includes medical (systemic tricyclic antidepressants, anticonvulsants and opioids, topical lidocaine and capsaicin) and interventional (subcutaneous Botox injections, nerve blocks and nerve stimulation) therapies. These therapies are not always effective, and each carries their own profile of side effects and risks. Moreover, up to 50% of patients with PHN (postherpetic neuralgia) are refractory to management. PNS (peripheral nerve stimulation) is an effective treatment for trigeminal herpetic neuralgia following acute or subacute HZ (Herpes Zoster). As a extend neuromodulation method, subcutaneous peripheral nerve-field stimulation might be a useful option to reduce the progression of neuropathic changes caused by persistent transmission of pain signals in the trigeminal nerve branches after the acute or subacute phase of HZ (Herpes Zoster). 

Yes, the requested health service is more beneficial. 

The literature reveals that PNS (peripheral nerve stimulation) is an effective treatment for trigeminal herpetic neuralgia following acute or subacute HZ (Herpes Zoster). As an extend neuromodulation method, subcutaneous peripheral nerve-field stimulation might be a useful option to reduce the progression of neuropathic changes caused by persistent transmission of pain signals in the trigeminal nerve branches after the acute or subacute phase of HZ (Herpes Zoster).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Postherpetic neuralgia. 
Treatment: Outpatient Procedure  76000x 1, 64555 x 1, 95972 x 1  (occipital nerve stimulation). 

The insurer denied the Outpatient Procedure  76000x 1, 64555 x 1, 95972 x 1  (occipital nerve stimulation). 

The denial is overturned. 

The patient is a male with post-herpetic neuralgia with significant intensity that has failed an adequate trial of nonsurgical management. The patient was recommended peripheral nerve stimulation of V1 (ophthalmic nerve) and V2 (maxillary nerve). 

Yes, the health plan should cover the requeted health service. 

On evaluation of the literature, there are multiple studies examining outcomes associated with this type of treatment. 

"This study revealed that PNS [peripheral nerve stimulation] is an effective treatment for trigeminal herpetic neuralgia following acute or subacute HZ [Herpes Zoster]. As a extend neuromodulation method, subcutaneous peripheral nerve-field stimulation might be a useful option to reduce the progression of neuropathic changes caused by persistent transmission of pain signals in the trigeminal nerve branches after the acute or subacute phase of HZ [Herpes Zoster]." (2) 

"SON [supraorbital nerve] and/or ION [infraorbital nerve] stimulation can be an effective treatment for intractable facial pain due to post-herpetic, traumatic or idiopathic etiology." (1) 

Yes, the requested health service is more beneficial. 

Yes, there are limited alternatives for this patient, and all are not very effective.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus

Treatment: Emergent admission 

The insurer denied coverage for emergent admission

The denial is overturned

This is a patient with a history of asthma. He presented to the emergency room (ER) as a transfer from another facility with complaints of a one-day history of shortness of breath (SOB). The patient was given duo-nebulizers and solumedrol at the prior facility. He was started on 15 liters of high flow nasal cannula (HFNC) at 25%. The chest x-ray (CXR) was unremarkable. One dose of Ceftriaxone was given for leukocytosis. The patient was continued on HFNC. Albuterol was spaced to every 4 hours. He was placed on a 5-day course of steroids. He was discharged after a period of hemodynamic stability.

Patient had severe status asthmaticus. This was evident from the fact that patient required Magnesium Sulfate, and HFNC and continuous positive airway pressure (CPAP). Patient had prior pediatric intensive care unit (PICU) admission. Due to tissue hypoxia from status asthmaticus patient even had lactate of almost 8. This is indication of severe respiratory acidosis and metabolic acidosis due to tissue hypoxia. The initial pH also showed respiratory acidosis. The patient also needed a bolus of steroids in the receiving hospital. Patient rapidly improved with escalation of therapy, every 2 hours nebulizers, second dose steroids, HFNC. However, the initial presentation which was consistent with severe acute status asthmaticus needs inpatient level care. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the emergent admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility.
Treatment: genetic testing.
The insurer denied Embryo Biopsy for Genetic Testing of Embryos for PGT-A. 
The health plan's determination is upheld.

The patient is a woman undergoing in vitro fertilization (IVF) for infertility. She has done one prior IVF cycle with an embryo that had complex aneuploidy. At issue is the medical necessity of Embryo Biopsy for Genetic Testing of Embryos for PGT (Preimplantation Genetic Testing)A in this upcoming IVF cycle. She has no known single gene defects.

Infertility Service(s): Embryo Biopsy for Genetic Testing of Embryos for PGT-A is not medically necessary for this patient.
According to American Society of Reproductive Medicine (ASRM), there is not clear evidence that the use of PGT-A as a universal screening test for all IVF patients is necessary and few randomized controlled trials (RCTs) in patients aged 38-41 demonstrated improved live-birth rates per cycle.
At this time, PGT-A is not medically necessary for this patient. According to American Society of Reproductive Medicine (ASRM), there is not clear evidence that the use of PGT-A as a universal screening test for IVF patients is necessary and there are few randomized controlled trials (RCT) in patients aged 38-41 that demonstrate improved live-birth rates per cycle. A number of studies question its efficacy beyond standard IVF.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins.
Treatment: Outpatient Procedure (37766LT x 1, 37765LT x1, 37785LT, 37799LT x1)
The insurer denied the Outpatient Procedure (37766LT x 1, 37765LT x1, 37785LT, 37799LT x1).
The denial is overturned.

The patient is a female. The patient presents with leg pain associated with standing. She has failed a compression stocking trial that she initiated. Exam shows enlarged varicose veins. Reflux testing shows no axial reflux but demonstrates varicose veins ranging in size from 2.6 to 3.7 millimeters. The provider has proposed phlebectomy and has included multiple alternative phlebectomy codes in the case request.

Coverage was denied by the health plan on the basis that (1) the patient does not have varicose veins larger than 3 millimeters, and (2) phlebectomy is only covered when the patient has axial reflux that has been treated in the past or will be treated concomitantly with phlebectomy.

Yes, the Outpatient Procedure (37766LT x 1, 37765LT x1, 37785LT, 37799LT x1) is medically necessary.

This patient presents with symptomatic varicose veins. Symptoms are severe enough to affect her job as a hair stylist, and she has failed a recent trial of compression stockings. The key issue, in this case, is the medical necessity for phlebectomy in the absence of axial reflux. Most patients with symptomatic varicose veins have both enlarged varicosities and axial reflux, in which case treatment of the axial reflux (with or without phlebectomy) is medically necessary. However, when patients present with isolated branch varicosities (i.e., varicose veins without axial reflux), phlebectomy is well accepted as the appropriate treatment strategy [1-2]. Clinical results of phlebectomy in this patient group are excellent [1-2].

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The health plan's denial rationale assumes that phlebectomy is only appropriate in the setting of axial reflux. However, phlebectomy is well accepted as the sole therapy for patients with isolated, symptomatic branch varicosities.

Also, the health plan's denial stated that the patient did not have varicose veins larger than 3 millimeters. However, the reflux study demonstrates otherwise, with veins ranging from 2.6 to 3.7 millimeters.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment:  Orthodontic treatment and monthly visits
The insurer denied Orthodontic treatment and monthly visits.
The determination is upheld.


The patient has a Class II occlusion with a 5-millimeter (mm) overjet and 7-mm overbite. The maxillary and mandibular arches have moderate crowding. He is treatment planned for 30-36 months of orthodontics to correct his malocclusion. At issue is the medical necessity of orthodontic treatment and monthly visits.

The orthodontic treatment and monthly visits are not medically necessary, 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 5 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 esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.