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

Diagnosis: Chronic Pain Syndrome.
Treatment:  Hydromorphone HCL 8 mg tab.
The insurer denied the Hydromorphone HCL 8 mg tab.
The determination is upheld.

The patient is diagnosed with chronic pain syndrome. A letter from the health plan notes that the request for hydromorphone for the patient's diagnosis of chronic pain syndrome was denied as this drug is only covered when the dose is not over the maximum safe dose and this request did not meet the criteria.

A letter from the treating provider states that the patient is under their care for management of her pain related to an autoimmune inflammatory disorder. It was stated she is a medically complex patient whose pain has been progressively worsening and challenging to manage. Currently, she requires use of hydromorphone 16 milligrams (mg) every 3 hours to manage her acute pain flares, which adds up to 16 pills of hydromorphone 8 mg daily. It was requested that she be approved for coverage of 480 pills per month. It was noted she is under close surveillance by multiple specialists. At issue is the medical necessity of the requested hydromorphone HCL 8 mg tab.

No, the requested health service/treatment of hydromorphone hydrochloride (HCL) 8 mg tab is not medically necessary for this patient. The records provided indicate the patient being prescribed extremely high-dose opioids at 512 mg Morphine Milligram Equivalents (MME)/day, significantly exceeding standard of care, as well as Centers for Disease Control and Prevention (CDC) recommendations which indicate extreme caution dosing above 90 mg MME/day. There is no evidence in the peer-reviewed medical literature supporting opioid dosing at this level, which places the patient has significant risk for adverse effects including central nervous system (CNS) depression, overdose and death. There were no exceptional circumstances provided that would warrant dosing at this level which would not be considered safe or effective. The requested service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal and Liver Cancer. 
Treatment: Home Health Care. 
The insurer denied the requested health service/treatment of Increase in Personal Care Worker hours. 

The health plan determination is overturned. 

The patient is with a past medical history of hypertension, memory impairment, tremor, metastatic gastrointestinal stromal tumor with multiple recent hospitalizations for complications, hepatocellular carcinoma, hepatitis C, cirrhosis and biliary stricture. 

The increase in personal care worker (PCW) service to 7 days per week, 12 hours per day, 84 hours per week is medically necessary for this patient. 

The patient has a complicated past medical history. The PCW is medically necessary for helping the patient to transport and attend the medical appointments and tests. The patient does not have an informal helper. The patient has had worsening memory as documented by MMSE assessment with increased weakness related to underlying medical issues with an increased need for assistance with ADL's and Instrumental Activities of Daily Living (IADLs) as documented in multiple provider letters and in the assessment tool as compared to previous assessment. The patient lives in an apartment on the 6th floor with no elevator and the bathroom is not in the apartment, making her assistance needs for tasks of stairs, walking, locomotion, and toilet use higher than assessed. PCW service hours are not solely for supervision and safety but for assisting the patient with ADL's and IADL's. Multiple providers who care for the patient documented medical necessity to increase PCW service hours. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in the home, which is the case for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: N/A
Treatment: Crown on Teeth #22, #23, #24 and #25 (Pre-Service)
The insurer denied the Crown on Teeth #22, #23, #24 and #25 (Pre-Service).
The denial is upheld. 

The patient is a female requesting dental benefit for crowns on teeth #'s 22-25.

No, the proposed crowns are not medically necessary. 

According to the documents provided (copied x-rays of questionable quality), there is no decay seen or any fractures seen on teeth #'s 22-25. Therefore, there is no reason to need crowns. High-quality x-rays and photos showing decay would be needed to show the need for crowns. The documentation provided at this time does not show any need.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Asthmaticus, Rhino/Enterovirus, Dehydration

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

The patient is a male with a history of asthma and eczema. The patient had a fever and a cough with wheezing for the past five days prior to hospital presentation. The patient's sibling was also sick. The patient was prescribed azithromycin by his pediatrician and his mother was also administering albuterol three times per day without improvement in his symptoms. When the patient's breathing became fast with persistent crying, agitation and a decrease in his oral intake and urine output, the patient's mother brought him to the Emergency Room (ER) for further treatment. In the ER, the patient was noted to have respiratory distress with retractions and evidence of increased work of breathing; his pulse oximeter reading was 92% on room air. On exam, the patient also appeared to be dehydrated and was noted to have wheezing. The patient was treated with two albuterol inhalation treatments, DuoNeb, Decadron and two intravenous (IV) boluses of normal saline. The patient's white blood cell (WBC) count was elevated at 18,000 and his serum bicarb was low at 18. The patient's respiratory viral panel was positive for an infection by a rhino/enterovirus. The patient's chest x-ray did not show pneumonia. When the patient's symptoms did not improve with treatment in the ER, the decision was made to admit the patient with a diagnosis of status asthmaticus and dehydration for ongoing treatment and management with IV fluids and frequent albuterol administration.

Based on the review of the medical record, the patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. When the patient presented with ongoing respiratory distress with persistent wheezing and increased work of breathing following ER treatment, it was appropriate and consistent with the standard of care to admit this patient to the hospital for ongoing treatment with albuterol. The patient also presented with clinical signs and symptoms of dehydration. The patient's serum bicarb was low and had reduced urine output. In the setting of his respiratory distress, the patient was unable to tolerate adequate oral intake and required intravenous fluid repletion and hydration. According to UpToDate review on acute asthma exacerbations in children under a certain age, inpatient management was medically necessary for this patient. This patient's admission was appropriate and consistent with the standard of care for status asthmaticus and dehydration. 

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

The carrier's denial of coverage for the inpatient hospital should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: infertility and bilateral hydrosalpinges.
Treatment: Storage 89346, cryopreservation 89337, culture 89250, and 89254 oocyte identification, follicular fluid.
The insurer denied the Storage 89346, cryopreservation 89337, culture 89250, and 89254 oocyte identification, follicular fluid.
The denial is upheld. 
The patient is a woman with a diagnosis of infertility and bilateral hydrosalpinges. She consulted a reproductive endocrinologist, who recommended bilateral removal of hydrosalpinges, and elective oocyte cryopreservation.

No, the proposed treatment is not medically necessary.

The medical records and medical literature were thoroughly reviewed. The patient has a diagnosis of infertility and bilateral hydrosalpinges. Oocyte cryopreservation has been recommended. The medical records document the indication for oocyte cryopreservation as due to "a significant result of increased female age to increase her chances of successful conception with IVF in the future." Therefore, the proposed procedure is considered elective oocyte cryopreservation. 

Elective oocyte cryopreservation is a means to promote a patient's future fertility when delaying childbearing.  The American Society for Reproductive Medicine, in its Practice Committee Opinion, states: "Since there is a progressive loss of oocyte quantity and quality that occurs with female aging, the prevalence of infertility and the incidence of pregnancy loss and chromosomal abnormalities increase steadily up to the age of middle 30s and more rapidly thereafter. Technologies such as oocyte cryopreservation may allow women to have an opportunity to have biological children later in life. While this technology may appear to be an attractive strategy for this purpose, there are no data on the efficacy of oocyte cryopreservation in this population and for this indication. Data on the safety, efficacy, cost-effectiveness, and emotional risks of elective oocyte cryopreservation are insufficient to recommend elective oocyte cryopreservation Marketing this technology for the purpose of deferring childbearing may give women false hope and encourage women to delay childbearing. In particular, there is concern regarding the success rates in women in the late reproductive years who may be the most interested in this application. There is not yet sufficient data to recommend oocyte cryopreservation for the sole purpose of circumventing reproductive aging in healthy women". 

Therefore, the proposed procedure does not meet the standard of care at this time. Thus, the treatment is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Osteoarthritis, Spondylosis, Chronic vertebrogenic pain

Treatment: Intracept procedure

The insurer denied coverage for the requested Intracept procedure.

The denial is overturned.

This is a female patient with a past medical history of transient ischemic attack, stroke, depression, osteoarthritis, spondylosis and chronic vertebrogenic pain. The patient's low back pain and left hip pain had been treated with physical therapy, chiropractic care, home exercise, transforaminal epidural steroid injections, epidural steroid injections, ice, and heat therapy and medication therapy which provided little relief of her pain. The patient's magnetic resonance imaging (MRI) of the lumbar spine revealed L3/4-5/S1 facet arthrosis, L3/4-L4/5 herniated nucleus pulposus, L5/S1 osteophytes, and endplate changes L3/4 and L5/S1, which affected the nerve roots at L4 and L5. On the second read of the MRI, there was also L5 and S1 Modic type I changes. The patient's pain was rated 6-9 out of 10 in pain severity, and was described as continuous. The patient wanted to know if she was a candidate for the Intracept procedure. The patient was willing to try any procedure for relief as she was having continued severe pain.

Based on the review of the literature, there is scientific evidence that supports a result of improvement in health outcome with this requested procedure, Intracept. As per the documentation submitted for review, this patient has failed conservative treatment with physical therapy and medications. The patient has exhausted all non-operative options. This patient is considered an appropriate candidate for this procedure.

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

The carrier's denial of the requested Intracept procedure should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Osteoarthritis, Spondylosis, Chronic vertebrogenic pain

Treatment: Intracept procedure

The insurer denied coverage for the requested Intracept procedure.

The denial is upheld.

This is a female patient with complaints of low back pain as well as left hip pain. The patient rated her pain at a severity of 5/10. She had treatment with chiropractic care with little to no pain relief as well as anti-inflammatory medications and physical therapy. The patient had a limited physical examination due to the nature of the visit being telehealth.  The physician documented that the patient should begin cyclobenzaprine and should undergo trigger point injections until a more advanced intervention could take place.  The patient's official magnetic resonance imaging (MRI) indicated that the L5-S1 level of the disc was greatly reduced in height and was associated with a subtle retrolisthesis of L5 posteriorly on S1 demonstrating advancement since the prior scan. The patient's MRI revealed subtle degenerative reaction in the adjacent endplates present at this level. The physician detailed that this MRI was reviewed and the physician was awaiting a discussion with the radiologist in regard to documentation and further clarification of whether or not the patient had Modic signs. The physician later added an addendum indicating that the patient had Modic type I changes at the L5 and S1 level. It was recommended that the patient should undergo an L5 and S1 intraseptal procedure. The physician further clarified with an additional addendum that the patient has failed multiple conservative treatments and wanted to avoid taking opioid medications.

The role of radiofrequency ablation for low back pain is summarized by Up to Date as follows: "We suggest not using radiofrequency denervation for the management of chronic low back pain. The available data are inconsistent and suggest that, compared with placebo, radiofrequency denervation may modestly reduce pain in the short-term; however, there does not appear to be clear long-term benefit. When added to a treatment regimen that includes a regular exercise program and psychologic support, radiofrequency denervation provides little additional benefit."

Based on the review of the medical record and literature, this patient is not a good candidate for the Intracept procedure. Currently, there is insufficient clinical evidence in the literature to support the use of Intracept for this patient's treatment. There is insufficient data to support that this procedure is more beneficial than other standard treatments such as physical therapy, therapeutic home exercise program, anti-inflammatory medications and spinal injection. 

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of the requested Intracept procedure should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Osteoarthritis, Spondylosis, Chronic vertebrogenic pain

Treatment: Intracept procedure

The insurer denied coverage for the requested Intracept procedure.

The denial is upheld.

This is a female patient with a history of transient ischemic attack, stroke, depression, osteoarthritis, spondylosis, chronic vertebrogenic pain. The patient was seeing the pain management doctor for a few years and she was recommended the Intracept procedure. The patient has received physical therapy, chiropractic care, home exercise, transforaminal epidural steroid injections, ice and heat therapy, and medication therapy, but these didn't help her with the pain. The patient's magnetic resonance imaging (MRI) of the lumbar spine revealed multilevel degenerative disease with progression over the sequence of scans including more disc space narrowing and lateral listhesis with dextroscoliosis.

Based on literature review, radiofrequency ablation (RFA) of the basivertebral nerve is a very new technology that is promising but needs to be repeated by independent researchers and without cross-over. At this point it is still experimental/ investigational. It is not the standard of care.

Studies such as Fischgrund et al (2018) and (2019) provide clinical evidence that patients with Type I or Type II Modic changes of the treated vertebral bodies show clinically meaningful improvement at 3 months with radiofrequency ablation (RFA) of the basivertebral nerve and is maintained through 2 years. Becker et al (2017)'s clinical trial, which was an industry-sponsored study, showed that the patient-reported outcomes measures noted by Visual Analogue Scale (VAS) and Osewestry Disability Index (ODI) significantly improvement after RFA treatment at 3-month follow-up and at 12-month follow-up. However, this study was limited by a small sample size (i.e. 17 patients), lack of randomization and control and short-term follow-up.

Despite these positive clinical studies, studies such as Khalil et al (2019) found that though patient-reported outcome such as low back pain significantly decreased with RFA procedure, it did not affect the patient's opiate consumption. This prospective randomized trial found that follow-up was very limited in the standard care patients in the final analysis because of limited results collected up to the point of cross-over or study exit. 

Based on literature review, radiofrequency ablation (RFA) of the basivertebral nerve is a very new technology that is promising but needs to be repeated by independent researchers and without cross-over. Thus, the requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of the requested Intracept procedure should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoporosis.
Treatment:  Forteo.
 
The insurer denied Forteo.  The health plan's determination is overturned. 

This is a female with eating disorder with oligomenorrhea and osteoporosis.  She has a history of bilateral pelvic fractures.  She was unable to tolerate alendronate due to reflux.  T-score was -2.6 in her spine.  The medical necessity of Forteo is under review.

Forteo is medically necessary in this clinical situation and is supported by the peer-reviewed literature.  

This patient has tried and is intolerant to bisphosphonate therapy.  She is at high risk of a fragility fracture given her low T-score of -2.6 along with her history of bilateral pelvic fractures.  In a randomized, placebo-controlled trial in women with six months of teriparatide resulted in marked increases in bone mineral density at the posteroanterior (6 versus 0.2 percent for placebo) and lateral (10.5 versus -0.6 percent for placebo) spine.  Without Forteo, this patient will be at ongoing high risk of a fragility fracture.  Therefore, the requested Forteo is medically necessary for the treatment of osteoporosis for this patient.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Nursing Services (including Private Duty Nursing)

Diagnosis: osteoporosis/gait instability
Treatment: Personal Care Services - 24 Hours a Day (Live-In), 7 Days a Week 
The insurer denied Personal Care Services - 24 Hours a Day (Live-In), 7 Days a Week. The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, transient ischemic attack (TIA) versus hypertensive encephalopathy, glaucoma, constipation, osteoporosis, depression, history of gastrointestinal (GI) bleed, urinary incontinence, dementia, hearing loss, gait instability, right above the knee amputation and left below the knee amputation who had been assigned Personal Care Services. The patient was at high risk of falls due to bilateral amputations and requires hands on assistance when transferring from all surfaces, requires toileting during the day and overnight hours (3-4 times) and is dependent on one person to assist her with toileting. The patient's son recently had a stroke and is unable to provided evening care due to his compromised health, physical and emotional limitations.

Personal Care Services - 24 Hours a Day (Live-In), 7 Days a Week are medically necessary for this patient.

The patient's son who was her informal helper could no longer provide informal help with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). The patient needs assistance with all of her ADLs and IADLs except for eating. The patient has unscheduled and unpredictable care needs over a particular span of time. The patient has Personal Care Assistant (PCA) service needs that span 24 hours. The patient's Primary Care Physician (PCP) provided notes documenting medical necessity of 24 hour care due to her medical conditions and documented the need for assistance in the night-time hours. The plan did not evaluate and document whether the patient's needed assistance can be scheduled or may occur at unpredictable times during the day and night. The patient requires assistance with transferring, bed mobility, toilet transfer, toilet use and incontinence cares at unscheduled times and PCA services are not solely for supervision and safety but to assist the patient with her ADLs. PCA services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home. The patient needs assistance to transfer to and from wheelchair as well as wheelchair to toilet which are unpredictable and unscheduled care needs over a continuum of 24 hours. She is high risk for fall due to her amputation status without assistance. The patient's unscheduled needs would still occur outside of 12 hours of PCA service time and the patient does not have an informal helper during the hours the aide is not there. Therefore, the requested services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stage III rectal cancer.
Treatment: Lupron Depot (1-Month) 3.75 intramuscular (IM) kit.
The insure denied the Lupron Depot (1-Month) 3.75 intramuscular (IM) kit.
The denial is overturned. 

The patient is a female with Stage III rectal cancer receiving chemotherapy, which has been recommended to receive Lupron as ovarian suppression in order to avoid going into medical menopause from her cancer treatment. 

Yes, the proposed Lupron Depot is medically necessary. 

Although the use of Lupron to preserve ovarian function is not a listed indication by the Food and Drug Administration (FDA), the use of Lupron in this setting is medically necessary as supported by peer-reviewed data, and it is consistent with the standard of care practice in cancer patients who are pre-menopausal when undergoing cancer treatment.  

In a Cochrane database review by Chen et al., which included 12 randomized trials and 1,369 women treated with chemotherapy across multiple solid and liquid cancers, the reported incidence of menstruation recovery or maintenance was 74.5% in the gonadotropin-releasing hormone (GnRH) agonist group and 50.0% in the control group during a follow-up period no longer than 12 months, with an overall effect favoring treatment with gonadotropin-releasing hormone (GnRH) agonist (P = 0.006). 

Rectal cancer in someone this age is very rare, so data specific to it is limited. The goal of this type of treatment is to keep the patient from losing ovarian function from her cancer treatment. Based on what information is available, the standard of care and the general consensus in the specialty field would be to use Lupron to manage this issue.  

As noted above, although the use of Lupron to preserve ovarian function is not a listed indication by the FDA, the use of Lupron in this setting is medically necessary as supported by peer-reviewed data and it is consistent with the standard of care practice in cancer patients who are pre-menopausal when undergoing cancer treatment.