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

Diagnosis: Low Back Pain.
Treatment: Pain Injections (623323 x 1).
The insurer denied: Pain Injections (623323 x 1).
The denial is overturned.

The patient is an adult female with low back and left lower extremity pain. The patient has tried meloxicam, cyclobenzaprine, and physical therapy. The pain was a seven out of ten (7/10).  Approximately a year and a half ago, the patient had a L4-S1 epidural steroid injection (ESI) with 50% improvement in pain. The patient has subsequently had a lumbar medical branch block facet injection, and most recently, a bilateral lumbar radiofrequency ablation (RFA) with 70% ongoing benefit. Magnetic resonance image (MRI) of the lumbar spine from over a year and a half ago a report shows disc bulge at L3-4 and L4-5 with foraminal stenosis and nerve root impingement. The request indicates prior epidural was L5-S1 and that the current request is for L4-5 epidural steroid injection (ESI). Records show L5-S1 from a year and a half ago was a L5-S1 intralaminar epidural steroid injection (ILESI).

The proposed treatment is medically necessary.

Records indicate the patient had one injection at L5-S1 and the current request is the second epidural steroid injection at a different level that corresponds to the current magnetic resonance imaging (MRI). As such the proposed treatment is medically necessary as per the guidelines provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: human immunodeficiency virus (HIV)
Treatment: Cabenuva
The insurer denied Cabenuva.
The health plan's determination is upheld.

The patient is a male diagnosed with human immunodeficiency virus (HIV) 20 years prior. There does not appear to be any history of opportunistic infections. Previously, he had been treated with Truvada, Sustiva, Atripla, Genvoya. Records from an office visit state that he was recently started on Cabenuva. Other medical problems listed include hypertension (HTN), HLD (hyperlipidemia), gastroesophageal reflux disease (GERD), Lumbar disc disease status/post (s/p) discectomy and fusion, iron (Fe) deficiency, Depression, treated Hepatitis C, Hypogonadism, and Chronic pain syndrome. Cabenuva was refilled at that visit and labs were ordered, including HIV viral load (VL) and Immunodeficiency panel.

Cabenuva is not medically necessary for this patient.

There are numerous options for HIV therapy. Cabenuva is indicated as a complete regimen for the treatment of HIV-1 infection in adults who are virologically suppressed (HIV-1 ribonucleic acid (RNA) less than 50 copies per milliliter [mL]) on a stable regimen, with no history of treatment failure, and with no known or suspected resistance to either cabotegravir or rilpivirine.

At this time, Cabenuva would not be indicated based on the lack of information provided. There is no documentation of the patient's current HIV viral load, whether he is virally suppressed on this drug, if it is known whether any resistance testing had been performed, and what was the reason for changing from oral ART (antiretroviral therapy) to Cabenuva.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left leg wound, paraplegia, heart failure, sarcoidosis, chronic pain and weaknesses. 
Treatment: Topical Oxygen Therapy (TOWT) 16 Units/month for 6 months. 

The insurer denied: Topical Oxygen Therapy (TOWT) 16 Units/month for 6 months. 
The denial is upheld. 

The patient is an adult male with a history of paraplegia, heart failure, sarcoidosis, chronic pain and weaknesses had undergone laminectomy due to cervical invasion by sarcoidosis. Last Spring, he sustained an injury to his left leg which resulted in a wound with subsequent laceration repair. An examination three months ago indicated his left leg wound measured 2x1x.3 centimeter (cm) with 5% slough and 95% granulation. The wound was debrided, and a 3-layer compression dressing was applied along with a silver gel. An examination the next month indicated he continued to have a left leg wound that measured 2x1.8x.3 cm with 5% slough and 95% granulation. A silver gel dressing 
was applied and he was instructed about protein intake for wound healing. 

A week later an assessment by the nurse indicated the patient's left leg wound measured .4x.4 cm and sacrum stage 2 measured 3.5x4 cm. Silver gel was continued to the left leg. Four days later the treating physician requested the use of topical oxygen therapy. An application of topical oxygen occurred the next week. 
Ten days later the physician recorded the wound dimensions to be .8x5x.3 and topical oxygen was being "explored." The health plan denied the original request for oxygen therapy. After an appeal for oxygen therapy, the request was again denied by the health plan. After one month, the leg wound measured .7x.5x.3 with 5% slough and 95% granulation. Santyl was discontinued and silver gel was continued along with a bandage. 

The proposed treatment is not medically necessary. 

There are some case reports but lack of evidence in large, randomized trials or retrospective studies that support the use of topical oxygen for chronic leg wounds. Greater evidence exists for the use of Topical Oxygen for diabetic foot and venous ulcers. Most study protocol durations have been for 12 weeks. According to the plans guidelines, topical oxygen may be used for nonhealing traumatic wounds with appropriate documentation for the acceleration of granulation tissue that cannot be achieved by other topical treatments. In this case, failure of other adjunct modalities such as collagen, negative pressure therapy, serial debridement along with continued compression, etc. was not noted. Furthermore, the wound improved slightly prior to initiating topical oxygen. Topical oxygen was provided prior to exhausting other modalities to improve granulation. In addition, there is no indication that 6 months of topical oxygen would be required. Therefore, the request for 6 months of topical oxygen therapy is not considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck pain.
Treatment: Pain management Injections in Spine.
The insurer denied Additional Pain Management Injections in Spine. 
The health plan's determination is overturned. 

This is a male with back and neck pain with significant radiating pain into shoulders and tinging/numbness sensation in the upper extremities. Pain level was 10/10. He had prior cervical epidural injections (CESI). The CESI provided 80% pain relief for 2 months. However, his pain has returned. 

Additional Pain Management Injections in Spine are medically necessary for this patient.
This patient has multilevel cervical disc herniations and foraminal stenosis with resultant severe radicular pain. He responded to the prior CESIs. His pain is severe. Surgery will most likely require multilevel decompression and fusion, which carried significant risks and complications. It is understandable he is seeking a second opinion of surgical interventions. In the meanwhile, further treatments are medically necessary to alleviate his pain.
This patient has severe pain secondary to cervical radiculopathy. He responded well to the prior cervical epidural injections. This patient is not ready for surgery. Additional Pain Management Injections are medically necessary to alleviate his pain.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: headaches.
Treatment: occipital nerve block.
The insurer denied an occipital nerve block. 
The health plan's determination is overturned.

The patient is a female with chronic intractable migraines. Treatment with occipital nerve injections is the subject of this review. She has previously tried and failed an exhaustive number of preventative medication's including venlafaxine, amitriptyline, topiramate, propranolol, gabapentin, pregabalin, indomethacin, and Emgality. She is currently treated with Ajovy and occipital nerve blocks. 

Occipital nerve blocks are likely to be more beneficial than any other standard treatment or treatments for the patient's condition. As noted above, the patient has tried and failed an exhaustive number of medication's for prevention of migraine including anticonvulsants, anti-depressants, nonsteroidal anti-inflammatory drugs, and CGRP (Calcitonin gene-related peptide) inhibitors. The patient has tried and failed nearly all classes and types medications used to treat or prevent migraine.
In select patients, the use of greater occipital nerve blocks are an appropriate treatment strategy for migraines. Various studies have shown that the use of occipital nerve blocks results in decrease severity and frequency of headaches compared to controls.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: headaches.
Treatment: occipital nerve block.
The insurer denied an occipital nerve block. 
The health plan's determination is upheld.

The patient is a female who has chronic migraines. She has been treated with occipital nerve blocks. This is the subject under review.

Occipital Nerve Block is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Per Kahriman et al (2018): "Greater occipital nerve blocks (GONB) with an anesthetic (typically 1-2% lidocaine, or 0.25% bupivacaine) with or without steroids (typically methylprednisolone 20-40 mg) are generally safe and frequently performed by physicians for acute treatment of migraine. However, there is a lack of standardization in exact techniques and injectate used, in addition to a lack of placebo-controlled and sufficiently powered studies to be able to formulate a level of recommendation for this treatment. Retrospective data show that it may reduce pain intensity and medication use but not pain duration."
Per Velasquez-Rimachi et al (2022): "The limited evidence available shows that GONB with local anaesthetics could reduce headache frequency and intensity compared to placebo, while adding corticosteroids did not show additional benefits. GONB was safe with a similar number of minor adverse events. However, our confidence in these estimates is very low since the evidence is based on a few trials, with a small sample size and a significant risk of bias. In addition, the exploratory TSA (trial sequential analysis) was inconclusive, so we need larger and specific trials."
Per Uygunoglu et al (2019): "There is a large number of published data on peripheral nerve blocks (PNBs) for headache but most are related to clinical experience rather than well-designed randomized placebo-controlled studies. Further studies are therefore needed in order to widen the use of PNBs in clinical practice when considering that PNBs are cheap and safe, and provide rapid improvement in some types of headache disorders."
At present, there is limited evidence about quality of life and impact of occipital nerve blocks on migraine headaches. Large, randomized clinical trials are required to demonstrate that occipital nerve blocks provide health benefits, to define the clinical role of occipital nerve blocks, and to establish patient selection criteria.
Occipital nerve blocks are not indicated for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: headaches.
Treatment: occipital nerve block.
The insurer denied an occipital nerve block. 
The health plan's determination is overturned.

This is a female patient who is requesting coverage for occipital nerve blocks for headaches/occipital neuralgia. The patient has been receiving occipital nerve blocks with benefit. Per the appeal notes, the patient has received significant benefit from occipital nerve blocks in the past. 

Occipital Nerve Block is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is being treated for of chronic headaches and occipital neuralgia. Occipital nerve blocks and indicated and standard of care for this patient. The patient has tried and failed multiple headaches medications. Occipital nerve blocks provide relief while other headache management is ongoing. This is a continuation of standard care for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever; abdominal pain.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult female without significant past medical history. She was hospitalized with fever and abdominal pain. The patient's initial vital signs were notable for normal temperature, blood pressure 108/69, pulse 74, normal respirations and saturation of 98%. Labs were notable for white blood cell count of 16.7, normal creatinine of 0.9, mildly elevated ALT (alanine aminotransferase) 114 and AST (aspartate aminotransferase) 128. Urinalysis showed greater than 50 white blood cells. CT (computed tomography) of the abdomen and pelvis revealed right-sided pyelonephritis. Right upper quadrant ultrasound revealed hepatic steatosis. The patient was treated with intravenous ceftriaxone for pyelonephritis. Urine culture revealed Escherichia coli. She had clinical improvement and was discharged three days later.
The inpatient hospitalization was initially denied coverage by the health plan as not medically necessary.
The facility appealed this decision in a letter noting that the inpatient hospitalization was medically necessary based on the diagnosis of pyelonephritis and need for close monitoring, antibiotics, and medical consultation.
A final adverse determination noted that the decision to deny the inpatient hospitalization was upheld, as care could have been provided in "observation under monitoring." 
The plan notes that there were no hemodynamic, pulmonary, neurologic, or metabolic reasons for acute level of care.
The facility has submitted another appeal letter again noting that the patient required acute inpatient level of care for pyelonephritis and arguing that inpatient care prevented potential complications and adverse events in this patient.

The Inpatient admission was not medically necessary.

The documentation does not reflect clinical findings that support the need for acute inpatient level of care per the medical literature and evidence-based guideline "Urinary Tract Infection (UTI) (M-300)" in MCG (Milliman Care Guidelines) 26th edition. Specifically, the patient had no evidence of severe or persistent altered mental status, no evidence of worsening clinical findings despite observation care, evidence of pregnancy, kidney transplant, significant uropathy (e.g., obstructive defects), indwelling prosthetic device, ureteral obstruction (e.g., stone), significant impairment in bladder emptying, evidence of renal abscess, acute kidney injury, or need for intravenous support despite observation care (e.g., due to inability to maintain oral hydration). This patient was hemodynamically stable, had no critical derangement in labs, had no evidence of complicated pyelonephritis on imaging, and responded appropriately to medical therapy. Treatment could have safely and effectively been provided at a lower level of care. Thus, the inpatient 
hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite with gingival attachment loss
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is upheld.

The patient is an adolescent male with a Class I skeletal facial profile and a slightly concave soft tissue profile. The patient has permanent dentition but is missing the maxillary left lateral incisor. The maxillary and mandibular arch forms are tapered and have generalized spacing. There is no overbite. The patient has negative/reverse overjet as the maxillary anterior teeth are in crossbite relationship with the mandibular anterior teeth. Additionally, the photos reveal the patient has poor oral hygiene with inflamed marginal gingiva in the mandibular anterior teeth and staining or possibly dental caries in them. There were no medical diagnoses given or any other dental concerns provided for this patient.

The requested braces and monthly visits are not medically necessary.

This patient does not have an orthodontic auto-qualifying condition. While the patient does have anterior cross bite, the patient's occlusion does have a crossbite of individual anterior teeth with clinical attachment loss and recession of the gingival margin of these teeth. The provided photographs did not show evidence of clinical attachment loss or gingival recession. This patient also does not meet the HLD (Handicapping Labio-Lingual Deviation) Index requirement. The HLD (Handicapping Labio-Lingual Deviation) score for this patient was calculated to be 10 out of a total of 26 points, which is not considered a severe physically handicapping occlusion.
Further, there was no medical evidence nor medical diagnoses nor other dental concerns given in the provided documentation to show a medical need for braces. There was no documentation to suggest the patient has any functional or psychological impairment or that the condition of his teeth make it difficult to eat, speak, or breathe.
For these reasons, this patient does not evidence that comprehensive orthodontic treatment of the adolescent dentition is medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Refractory Crohn's disease
Treatment: Jakafi 7.5 milligrams (mg) twice daily (BID)
The insurer denied coverage for Jakafi 7.5 mg BID
The denial is overturned

The patient has severe inflammatory bowel disease (IBD) that clinically resembles Crohn's disease (CD). He was diagnosed very young and had failed steroids, Humira, Entyvio, and Stelara. The treating provider noted that he has an underlying immune deficiency. He has stricturing disease. He was switched to Jakafi and has a dramatic response. The treating provider wants to continue this medication at 7.5 mg dosing.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

There are several articles showing that Jakafi improves patients with immune defects including those with Crohn's like characteristics.

According to Deya-Martinez, et al. (2022), "Our study supports the potentially beneficial use of Jak inhibitors (JAKinibs) in patients with signal transducer and activator of transcription (STAT) 1 gain of function (GOF), in line with previously published data. However, consensus regarding their indications and timing, dosing, treatment duration, and monitoring, as well as defining biomarkers to monitor clinical and immunological responses, remains to be determined, in form of international prospective multicenter studies using established inborn errors of immunity (IEI) registries." 

Jakafi tablet does not have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient a good candidate for Jakafi tablets. Patient has already been using it and it has been very effective.     

Jakafi 7.5 mg BID is the best available treatment for this patient at this time.

The patient has failed all other medications that would treat his IBD. In addition, Jakafi has already provided a dramatic improvement for this patient.     

Compared to the other medications that he has failed (steroids, Humira, Stelara, methotrexate), there are no increased adverse risks.     

Current peer reviewed literature supports the use of Jakafi in patients with Crohn's like characteristics. Furthermore, Jakafi has already provided a dramatic improvement for this patient, so it is likely to continue to be beneficial. 

In summary, the denial of Jakafi 5 mg tablet and coverage for the requested treatment of 7.5 mg BID should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Refractory Crohn's disease
Treatment: Jakafi 7.5 milligrams (mg) twice daily (BID)
The insurer denied coverage for Jakafi 7.5 mg BID
The denial is overturned

This case involves a child diagnosed with early onset inflammatory bowel disease and Crohn's disease with stricturing disease who was recommended for Jakafi. The patient's mother submitted a letter stating that the family was at a standstill, unable to make plans, unable to comfort the patient, unable to explain why he cannot have the medicine that makes him okay.  The patient's mother endorsed that Jakafi had improved the patient's life and explained that when he was younger, he had a severe stomach virus and went from being a healthy happy child to one who experienced aches, anxiety, and diarrhea 15 times a day. He lost weight rapidly and showed no interest in food. He stopped growing and experiencing humiliating accidents in public. Prior treatment measures included prednisone, Pentasa, Delzicol, budesonide, Humira, methotrexate, Entyvio, and enteral nutrition. Additionally, the family trialed therapeutic diets, supplements, probiotics, and relaxation as well as therapeutic techniques, each of which failed.  For years, she claimed that the patient gained only 3 pounds and was frail, depressed, and unable to keep up with physical activities. The patient's mother explained that when the patient was on Jakafi, he gained 20 pounds in 5 months, had gone from daily bouts of crying with no explanation (due to malnourishment) to being a happy child.

Scientific evidence in peer-reviewed literature supports a result of improvement and health outcome.

Jakafi tablets need to have final approval from the appropriate regulatory bodies for the patient's diagnosis.

This patient is a good candidate for Jakafi 7.5 mg BID tablets.

Jakafi tablet is the best available treatment for this patient at this time.

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

The requested service is likely to be more beneficial than any of the standard treatment/procedures for this patient given that he has attempted treatment with multiple modalities of care without significant benefit. The information provided for the review also noted that prior use of Jakafi reduced the patient's symptoms and thus, allowed for weight gain, a right interest in eating, and increase in the patient's activity level, and overall improvement in his quality of life.

In summary, the denial of Jakafi 5 mg tablet and coverage for the requested treatment of up to 7.5 mg BID should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.