Persius/hicric huggingface dataset:
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Small Intestine Bacterial Overgrowth
Treatment: Xifaxan (550 mg or TABS)
The insurer denied the Xifaxan (550 mg or TABS)
The denial is overturned

The patient is a female with recurrent abdominal pain. She has small intestinal bacterial overgrowth. She has failed antispasmodics, H2 (histamine H2-receptor) blockers, and proton pump inhibitors. The request is for Xifaxan.

Yes, the requested Xifaxan is medically necessary.
Xifaxan (Rifaximin) is FDA (United States Food and Drug Administration)-approved for use in traveler's diarrhea, hepatic encephalopathy, and irritable bowel syndrome - with diarrhea. The drug is used off-label for small intestinal bacterial overgrowth (SIBO), with most studies reporting favorable results.

In a study by Chedid V et al, herbal therapy was equivalent to rifaximin for the treatment of small intestinal bacterial overgrowth (Chedid V, et al. Glob Adv Health Med.).

In an open-labeled prospective study, 19 patients with a positive lactulose-H2 (histamine H2-receptor) breath test received rifaximin 1200 mg (milligrams) daily for 10 days and repeated the breath test two weeks after treatment. The breath test normalized in 8/19 (42.1%) subjects (Boltin D, et al. Ann Clin Microbiol Antimicrob.).

In a meta-analysis of studies looking at the effect of antibiotic therapy on small intestinal bacterial overgrowth, rifaximin was the most commonly studied antibiotic (eight studies) with overall breath test normalization rate of 49.5% (Shah SC, et al. Aliment Pharmacol Ther.).

In a meta-analysis of thirty-two studies involving 1331 patients, when patients with SIBO (small intestinal bacterial overgrowth) were treated with Rifaximin, the overall eradication rate according to intention-to-treat analysis was 70.8% and to per protocol (PP) analysis 72.9%. A subset of studies in IBS (irritable bowel syndrome) patients showed the pooled SIBO small intestinal bacterial overgrowth) eradication rate was 71.6% based on ITT (intent-to-treat) analysis and 75.4% based on PP (per protocol) analysis (Gatta L, et al. Aliment Pharmacol Ther.).

Xifaxan is medically necessary over the health plan's preferred alternatives, as it is gut specific and associated with few systemic side effects.

Therefore, given the above, the requested Xifaxan is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Literature supports use of Xifaxan for small intestinal bacterial overgrowth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Stay. 
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female admitted to the hospital. The patient has had a gastric sleeve for morbid obesity. The patient presented with complaints of severe LLQ (left lower quadrant) pain confirmed by physical exam. She was afebrile and denied fever or chills. On labs, normal lactate was noted. White blood cell count (WBC) was low. A computed tomography (CT) scan showed trace fluid around the gallbladder of unclear significance. The patient was admitted to the surgical service and empirically placed on IV (intravenous) antibiotics. The overnight physical exam was mildly improved as initially there was evidence of rebound, but was now no longer present. 

The inpatient admission was not medically necessary. Based on objective data and descriptions from the providers, the patient could have been managed at a lower level of care. The patient had no evidence of a significant inflammatory or infectious process in the abdomen on cross-sectional imaging (CT). There was no perforated viscus or major vascular disorder. Based on the CT, she did not require urgent or emergent interventional radiology or surgery. It appears the patient was much more comfortable by the second hospital day and was able to tolerate a by mouth (PO) diet. With a normal appearing gallbladder without stones as confirmed on ultrasound and without significant LFT (liver function test) abnormalities, the yield from a HIDA (hepatobiliary iminodiacetic acid) was extremely low and should not have delayed discharge. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient presented with left lower quadrant (LLQ) pain with radiation to the left flank. The vital signs were within normal limits. The white blood cell count (WBC) was 6.9. The lactic acid was 1.6. A computed tomography (CT) scan demonstrated findings that likely reflected a mild or early acute appendicitis in the proper clinical setting. The patient was admitted and placed on intravenous (IV) antibiotics and IV fluids. The patient improved and the patient's diet was advanced. The white blood cell count (WBC) was 6.2. The patient was discharged home. At issue is the medical necessity of an inpatient stay.

An inpatient medical stay was not medically necessary. The patient could have been safely managed at a lower level of care. The patient met discharge status criteria the day after admission, did not experience complicated appendicitis, and did not have clinically active comorbidities. The patient  did not experience an ileus, did not experience complications or conditions such as anemia, arrhythmia, electrolyte disorder, fever, gastrointestinal (GI) bleed, hyperglycemia or complicated diabetes control, mental status change, psychiatric disorders, respiratory insufficiency, urinary complications, thrombotic complications or wound and skin care complications. There is no evidence that a complicating event occurred during the hospitalization that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic rhinitis. 
Treatment: Current procedural terminology (CPT) code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach]. 
The insurer denied coverage for CPT code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach]. 
The denial is overturned. 

The patient is a female with chronic symptomatic rhinitis in both sides of the nose. The patient had associated post-nasal drip, rhinorrhea, and throat clearing. Her rhinitis remained unchanged despite nasal surgery including balloon sinuplasty, septoplasty, sinus surgery, and the use of Flonase and antihistamines. Bilateral intranasal destruction of intranasal lesion via cryotherapy, CPT code 30117, was performed. 

CPT code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach] is considered more beneficial for this patient's diagnosis as scientific evidence in peer-reviewed literature support a result of improvement in chronic rhinitis in those patients who have failed medical management. 

Chang, M. T., Song, S., & Hwang, P. H. (2020) write that, "Cryoablation of the posterior nasal nerve (PNN) for chronic rhinitis is safe and can result in relief of nasal symptoms and improvements in quality of life." 

Lastly, per Hwang, P. H., Lin, B., Weiss, R., Atkins, J., & Johnson, J. (2017), "Officebased cryotherapy of the posterior nasal nerve (PNN) region is safe and well tolerated. Symptom scores were significantly decreased by 7 days postprocedure and remained lower at 30, 90, 180, and 365 days." 

CPT code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach] does have final approval from the appropriate regulatory bodies for this diagnosis as it was approved by the FDA in 2017. 

The patient is a good candidate as she has failed medical management. 

The procedure is the best available treatment for this patient at this time. 

Any invasive procedure has potential adverse risks; however, this patient has failed medical management. 

This treatment is likely to be more beneficial than any of the standard treatments/ procedures for this patient's condition. 

The carrier's denial of CPT code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach] be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic rhinitis.
Treatment: Current procedural terminology (CPT) code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach].
The insurer denied coverage for CPT code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach].
The denial is overturned.

This is a female with chronic rhinitis. The symptoms included runny nose, postnasal drainage, and throat clearing. The past surgical history includes sinus surgery, septoplasty, and balloon sinuplasty. Flonase and antihistamines were trialed without improvement. ClariFix was recommended for improvement of the patient's rhinitis complaints refractory to medical management. 

CPT code 30117 is considered more beneficial for this patient's diagnosis especially given the lack of improvement with medical management. Current peer-reviewed literature supports this technique for this patient. According to Del Signore et al (2021), "Cryotherapy is superior to a sham procedure for improving chronic rhinitis symptoms and patient quality of life." 

According to Hwang et al (2017), "Office based cryotherapy of the posterior nasal nerve (PNN) region is safe and well tolerated. Symptom scores were significantly decreased by 7 days postprocedure and remained lower at 30, 90, 180, and 365 days." 

According to Ow et al (2021), "Cryotherapy significantly and clinically improves rhinitis symptoms and quality of life with outcomes that are durable through 24 months after treatment." 

CPT code 30117 has final approval from the appropriate regulatory bodies for the diagnosis. It was approved by the Food and Drug Administration (FDA) in 2017 for this patient's purpose. 

The patient is a good candidate for the requested procedure. The patient has failed medical and surgical management. ClariFix is approved by the Food and Drug Administration (FDA) to treat chronic rhinitis by ablation of the posterior nasal cavity nerves responsible for the condition. The device in this patient's case was not used for swell body reduction for which it is not indicated medically. 

The requested procedure, 30117 / ClariFix, is the best available treatment for this patient at this time. There is documented failure of medical and prior surgical management. The FDA has approved this device to treat the patient's refractory condition. 

The adverse risks are not increased over standard treatment. 

Clarifix is the most beneficial treatment at this time. The patient has failed medical and surgical management. Clarifix is approved by the FDA as of 2017 to treat chronic rhinitis by ablation of the posterior nasal cavity nerves responsible for the condition. 

This treatment is likely to be more beneficial than any of the standard treatments/ procedures for this patient's condition. 

The carrier's denial of CPT code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach] should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic rhinitis.
Treatment: Current procedural terminology (CPT) code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach]. 
The insurer denied coverage for CPT code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach].
The denial is upheld. 

This is a case of an adult female who underwent ClariFix procedure for treatment of chronic rhinitis. The patient has a history of nasal surgery. She has used Flonase, Dymista, and oral antihistamines in the past without improvement of posterior rhinorrhea. The patient recently underwent an esophagogastroduodenoscopy (EGD). There is no documentation of whether or not the patient has gastroesophageal reflux disease (GERD). This review is for ClariFix procedure for treatment of chronic rhinitis.

Peer-review literature shows that cryoablation of the posterior nasal nerve (PNN) for chronic rhinitis is safe and can result in relief of nasal symptoms and improvements in quality of life. Most recent studies in 2018 consisted of a prospective single-arm trial of 98 adult patients at six United States centers with chronic allergic and nonallergic rhinitis. Another 2021 prospective study of ninety-one participants completed the study through the initial 12-month study period. Sixty-two participants consented to the long-term follow-up with 57 completing the 24-month follow-up. In these studies, cryotherapy significantly and clinically improved rhinitis symptoms and quality of life with outcomes that were durable through 24 months after treatment. Given the above, although cryotherapy appears safe and efficacious, heterogeneous past investigations with low-quality evidence make strong, evidence-based recommendations difficult to make. Further study with validated metrics and controlled populations is certainly warranted and should be encouraged. 

The requested procedure has final approval from the appropriate regulatory bodies for this diagnosis. This is a recognized treatment by the American Academy of Otolaryngology Head and Neck surgery. 

It is unclear if the patient is a good candidate for the procedure. The documentation does not show if the patient has had a full allergy workup. There is no documentation if the patient has treatment for GERD. There is no documentation of treatment with Ipratropium bromide nasal spray. 

The requested procedure is not the best available treatment for the patient at this time. She may need treatment for GERD and/or nasal anticholinergic nasal spray such as Ipratropium bromide. 

The adverse risks are not increased over standard treatment/services. 

This treatment is not likely to be more beneficial than any of the standard treatments/procedures for this patient's condition. 

The carrier's denial of CPT code 30117 [excision or destruction (e.g., laser), intranasal lesion; internal approach] should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Knee Pain.
Treatment: Genicular Nerve Injection.
The insurer denied the Genicular Nerve Injection.
The determination is upheld.

The patient is diagnosed with knee pain and bilateral primary osteoarthritis. Records show that a request for a genicular nerve block was denied by the health plan. An x-ray of the bilateral knees revealed moderate osteoarthritic changes, not significantly changed in the right knee from a prior x-ray.
A progress note shows the patient with complaints of bilateral knee pain described as aching, sharp, stabbing, numbness, cramping, and crushing and rated at 8/10. The pain has been present for more than one year. Treatment has included trigger point injections, physical therapy, occasions, and a home exercise program. The patient has difficulty with activities of daily living secondary to pain. Currently, the patient is on no medications. The physical examination was unremarkable. The provider performed a corticosteroid injection and the patient was recommended to undergo a genicular nerve block. At issue is whether the genicular nerve injection 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 genicular nerve injection is not likely to be more beneficial than any standard treatment or treatments for the insured's a life-threatening or disabling condition or disease. Per the Official Disability Guidelines (ODG) by MCG, "Not recommended for diagnostic evaluation or treatment of osteoarthritis of the knee." The ODG by Milliman Care Guidelines (MCG) regarding genicular radiofrequency ablation (RFA) states "Not recommended for treatment of osteoarthritis of the knee." Records indicate the patient has a history of chronic bilateral knee pain with osteoarthritis. Guidelines do not recommend either genicular nerve blocks or radiofrequency ablation as this treatment has not been proven to be either safe or effective and there are no high-quality long-term studies with long follow-up periods available. There is no evidence that it would be likely to be more beneficial than other standard treatment options for this patient's conditions.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Knee Pain.
Treatment: Genicular Nerve Injection.
The insurer denied the Genicular Nerve Injection.
The determination is upheld.

The patient was diagnosed with bilateral primary osteoarthritis and knee pain. A request for a genicular nerve block was denied by the health plan. X-rays of the bilateral knee showed moderate osteoarthritic changes, not significantly changed in the right knee from a prior x-ray.
The patient was seen for a follow-up visit with complaints of bilateral knee pain described as aching, sharp, stabbing, numbness, cramping, and crushing. The pain was rated at 8/10. Treatment included trigger point injections, physical therapy, medication, and a home exercise program. The patient had difficulty with activities of daily living secondary to pain. The patient was not currently using any medications. The physical examination was normal with no knee exam performed. The provider performed aspiration and a cortisone injection to the knee. The patient was recommended for a genicular nerve block. At issue is whether this 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 genicular nerve injection is not likely to be more beneficial than any standard treatment or treatments for the insured's a life-threatening or disabling condition or disease. Per the Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended for diagnostic evaluation or treatment of osteoarthritis of the knee." The patient has complaints of chronic knee pain present for more than one year with x-rays showing moderate osteoarthritic changes. The provider indicated the patient had failed conservative management including nonsteroidal anti-inflammatory drugs, physical therapy, home exercises, and trigger point injections. However, there were no abnormal findings on the exam related to the knee. There is a lack of evidence found in the peer-reviewed medical literature supporting genicular nerve blocks as either safe or effective as well as a lack of long-term studies. There is no evidence to suggest that this treatment would be likely to be more beneficial than other standard treatment options for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Knee Pain.
Treatment: Genicular Nerve Injection.
The insurer denied the Genicular Nerve Injection.
The determination is overturned.

The patient has a history of chronic bilateral knee pain secondary to osteoarthritis. She was treated with trigger point injections, therapy, Tylenol, nonsteroidal anti-inflammatory drugs (NSAIDS), steroid injections, and home exercises. The treating provider suggested a genicular nerve block with a plan for radiofrequency ablation if the patient has successful relief from the block. At issue is whether the genicular nerve injection 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 genicular nerve injection is likely to be more beneficial than any standard treatment or treatments for the insured's a life-threatening or disabling condition or disease.
Genicular nerve blocks and ablation are commonly used and are a widely accepted treatment standard among pain management physicians for patients with chronic knee pain. Knee osteoarthritis (OA) pain can be managed conservatively with physical therapy and medications while joint replacements are reserved for more severe joint disease with intractable pain symptoms. Modalities like genicular nerve block and radiofrequency ablation were introduced to alleviate knee pain in patients with chronic knee osteoarthritis. Interruption of nociceptive pathways via genicular nerve radiofrequency is a technique that can potentially provide long-term pain relief. In this case, the proposed treatment is a genicular nerve block and the plan would be to perform radiofrequency ablation of the genicular nerve if the patient were to receive more than 50% relief from the block. As described above this is a reasonable treatment plan considering the patient's diagnosis of knee osteoarthritis and her failed conservative treatments. Considering the patient's medical history and failure with other appropriate conservative options outlined, including trigger point injections, therapy, Tylenol, NSAIDS, steroid injections, and home exercises, the treatment is appropriate and likely to be more beneficial than any standard treatment or treatments for the insured's a life-threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis; psoriatic arthritis
Treatment: Taltz
The insurer denied Taltz.
The denial is overturned.

The member is an adult female with psoriasis affecting 5 percent body surface area (BSA) and psoriatic arthritis for whom Taltz is requested. She has tried and failed treatment with fluocinonide, triamcinolone, naproxen, Humira, Stelara, Otezla, Tremfya, Cosentyx, and phototherapy. She developed an injection site reaction with Cosentyx.
The health plan denied the request as they require documentation that the patient will not be taking Taltz in combination with Otezla, and that the patient cannot take Orencia, Xeljanz or Rinvoq.

The proposed Taltz is medically necessary.
Psoriasis is a chronic immune-medicated inflammatory condition that affects 2-3 percent of the population, which can lead to psoriatic arthritis. There are multiple regimens for the treatment of psoriasis including disease-modifying antirheumatic drugs (DMARDs) and biologic agents, phototherapy, and apremilast. While monotherapy with biologic agents is effective for many, some patients do not reach satisfactory outcomes and require combination therapy. Based on current literature, there is evidence that apremilast (Otezla) can be safely combined with all biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to biologics alone. 

The member is taking Otezla for psoriatic arthritis, but needs an additional agent to control her skin disease. Taltz is an appropriate choice in view of prior success with Cosentyx. Rinvoq, Xeljanz and Orencia are not used to treat psoriasis and are not indicated for the skin disease. Therefore, Taltz is medically necessary.