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

Diagnosis: Back pain. 
Treatment: Intracept Procedure [Intraosseous Basivertebral Nerve Ablation]. 
The insurer denied the Intracept Procedure [Intraosseous Basivertebral Nerve Ablation]. 
The health plan's determination is overturned. 

The patient is a male, with a body mass index (BMI) of 33.9 kg/m2, who has a longstanding history of lower back pain attributed to the vertebrogenic changes at L4-L5 and S1 vertebral bodies. The magnetic resonance imaging (MRI) of the lumbar spine without intravenous (IV) contrast performed revealed chronic multilevel moderate to severe degenerative disc and facet disease, most prominent at L4-L5 and L5-S1 levels; there was a subacute Schmorl's node at the inferior endplate of L4; and Modic Type I and Type II degenerative endplate changes at L4-L5 and L5-S1 disc spaces. 

Based on peer-reviewed literature, the Intraosseous Basivertebral Nerve Ablation is likely to be more beneficial than any standard treatment for the insured's life-threatening or disabling condition or disease. The basivertebral nerve ablation appears to be a safe, durable, minimally invasive treatment for the relief of chronic low back pain in a patient population that typically has few effective treatment options. This patient failed non-operative treatment including physical therapy, home exercises, epidural injections, nerve blocks, facet radiofrequency ablation, SI joint injections, and medications with transient relief and is not a surgical candidate for any type of fusion or disc replacement surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

Orthopedic/Musculoskeletal. 
Surgical Services (All). 

Diagnosis: Back pain. 
Treatment: Intracept Procedure [Intraosseous Basivertebral Nerve Ablation]. 

The insurer denied the Intracept Procedure [Intraosseous Basivertebral Nerve Ablation]. 
The health plan's determination is upheld. 

The patient is a male with complaints of low back pain, which is described as constant, and the degree varies and severity. The patient has had epidural injections, nerve blocks, radiofrequency ablations and sacroiliac joint injections in the past. The diagnoses include vertebral genic pain, lumbago, spondylosis of lumbar region without myelopathy or radiculopathy. 

The proposed health service or treatment Surgical Services: Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has low back pain. The requested procedure does not have substantial clinical evidence outlining its superiority over traditional techniques to combat back pain. Furthermore, there is insufficient data indicating the requested treatment improves short and long-term health. Therefore, it is not indicated for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic migraine headaches.
Treatment: Pain Management (occipital nerve block,trigger point injections), Pre-service.
The insurer denied the Pain Management (occipital nerve block,trigger point injections), Pre-service. 
The denial is upheld. 

The patient is a female with chronic migraine headaches following a motor vehicle accident (MVA).

No, the occipital nerve block, trigger point injections are not medically necessary.

The patient is a female with migraine headaches, post-concussion syndrome, and depression who has undergone occipital nerve blocks (ONBs) and trigger point injections (TPIs). She previously underwent these injections in the past with reportedly "good results."  However, there is no objective description of its effectiveness. The patient has had numerous injections at the same time.  Based on the records, the patient underwent greater occipital nerve blocks (GONBs), auriculotemporal nerve blocks, and supraorbital nerve blocks at the same time.  There is some marginal literature that supports the use of GONB in migraine headaches; however, coupled with the other two nerve blocks at the same time, it is impossible to determine which of these blocks were effective. Along with this, the patient also underwent trigger point injections to the neck and shoulder areas that also may cause headaches and neck pain.  Given the fact that the literature is inconclusive for nerve blocks for migraine headaches, and that multiple nerve blocks and trigger point injections were performed at the time, without objective documentation of relief, the requested ONB and TPI (trigger point injections) are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Tooth Decay.
Treatment:  D2740 - crown-porcelain/ceramic, D2950- core buildup, including any pins when required, tooth #2.

The insurer denied the D2740 - crown-porcelain/ceramic, D2950- core buildup, including any pins when required, tooth #2.  The denial is upheld. 

The patient is a male requesting benefits for crown and build up for tooth #2.

No, the D2740 - crown-porcelain/ceramic, D2950 - core buildup, including any pins when required, tooth #2, was not medically necessary.

With the documentation provided (i.e., pre-op x-rays), tooth #2 has decay on the mesial surface and an existing shallow occlusal composite restoration.  The treatment needed, based upon the x-rays, is a two-surface (mesio-occlusal) restoration, not a crown.  The documentation does not support the need for a crown.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial was upheld.

This male presented to the emergency department complaining of six weeks of constant chest pain. He had recently undergone myocardial perfusion imaging which, by report, was abnormal. He was scheduled to have a cardiac catheterization the following week but presented to the emergency department when his pain worsened.

His blood pressure was 110/62 millimeters of mercury (mmHg) with a heart rate of 57 beats/minute. His room air oxygen saturation was 98%. His cardiac exam was unremarkable. An electrocardiogram showed sinus rhythm without acute ischemic changes. His serum troponin level was normal.

The patient was admitted to the hospital. He was treated with antacids and pantoprazole and his chest pain resolved. He was discharged.

The subject under review is the medical necessity for the inpatient stay.

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

The inpatient stay was not medically necessary.

This patient presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. Based on his history, electrocardiogram (EKG), age, risk factors and Troponin (HEART) score, he was at a low risk for major adverse cardiac events. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer-Breast Cancer
Treatment: Genetic Testing
The Health plan denied the service of Genetic Testing Services: Foundation One CDx  Testing as Experimental/Investigational. The reviewer has overturned the determination.

This is a patient with a past history of colon cancer who was subsequently diagnosed with early stage breast cancer who underwent surgery which was reported as stage Tumor (T)1c Node(N)0, Estrogen receptor (ER) Progesterone receptor (PR) positive and human epidermal growth factor receptor 2 (her 2) negative disease. The patient subsequently presented with bone metastasis. Biopsy confirmed metastatic breast cancer which was ER PR positive and Her2/neu negative. The patient was started on Antiestrogen therapy and had undergone FoundationOne genomic profiling. Patient has received various regimen of treatment including Faslodex, Palbociclib, Radiation, Abemaciclib and most recent therapy with Capecitabine (Xeloda). Foundation One genomic profiling has discovered that breast cancer is harboring molecular alterations in following genes: anaplastic lymphoma kinase(ALK), Insulin Like Growth Factor (IGFR), murine double minute 2 (MDM2) and GATA. Tumor was Microsatellite stable.

The health service of Genetic Testing Services: Foundation One CDx (companion diagnostic) Testing is likely to be more beneficial for the patient.

Genomic profiling has become a crucial part of management of metastatic cancer including breast cancer. Information provided by the next generation sequencing (NGS) tests such as FoundationOne would help tailor patient's future management when standard therapies fail (progression on disease). Such genomic profiling would allow the patient to receive additional Food and Drug Administration (FDA) approved therapies for breast cancer (for example: Alpelsib for PIC3K mutation, Olaparib for breast cancer antigen (BRCA) mutation, Check point inhibitor therapy for MSI high, Larotrecitinib for NKTR gene fusion). Additionally certain mutation positivity would allow patient to participate in clinical trial such as MATCH protocol and many other early phase studies. Thus checking genomic profiling has become a standard part of management of a patient with metastatic breast cancer.
In this particular patient, ALK abnormalities discovered by FoundationOne would allow the patient to receive therapy targeting ALK gene such as Crizotinib, Alectinib, Brigatinib, Ceritinib, Lorlatinib, Entrectinib.
In a recent publication from The American Cancer Society, about 75.6% of oncologists reported using next generation sequencing (NGS) tests to guide treatment decisions. Thus comprehensive molecular profiling is no longer considered experimental.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer-Breast Cancer
Treatment: Genetic Testing
The Health plan denied the service of Genetic Testing Services: Foundation One CDx  Testing as Experimental/Investigational. The reviewer has upheld the determination.

The case in question involves a patient with a diagnosis of stage IV hormone receptor positive,  human epidermal growth factor receptor 2 (Her-2/neu) negative breast cancer with bone metastases whose oncologist requested a next generation sequencing panel from Foundation Medicine.

The proposed procedure is not likely to be more beneficial than standard treatments for this patient's condition or disease.
There is no consensus recommendation to perform broad panel next generation sequencing in patients with metastatic breast cancer at this time. The National Comprehensive Cancer Network (NCCN) guidelines recommend the testing for specific abnormalities with therapeutic implications such as the PIK3A mutation where there is a specific Food and Drug Administration (FDA) approved treatment option. Inclusion for such testing in such situations may evolve in the near future. However, at this time, such diagnostic testing cannot be endorsed as standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cancer-Breast Cancer
Treatment: Genetic Testing
The Health plan denied the service of Genetic Testing Services: Foundation One CDx  Testing as Experimental/Investigational. The reviewer has upheld the determination.

This is a patient with right breast cancer. The Foundation Medicine CDx assay was obtained and is under review.
The proposed health service is not likely to be more beneficial for this patient. 
The use of next generation sequencing gene panels to guide the treatment of patients with breast cancer has not been demonstrated to be of benefit. The assay in question is Food and Drug Administration approved. Several ongoing trials (e.g., the National Cancer Institute [NCI] Molecular Analysis for Therapy Choice [MATCH] and the American Society of Clinical Oncology (ASCO) Targeted Agent and Profiling Utilization Registry [TAPUR] trails) are using next-generation sequencing of multiple genes (gene panel tests) to identify molecular abnormalities in the tumors of patients with refractory cancers that may potentially match molecularly targeted therapies that are either in clinical trials or approved for treatment of other cancer types (National Clinical Trial (NCT)02465060 and NCT02693535).
To date, the SHIVA trial is the only large, randomized trial to off-label use of molecularly targeted agents on the basis of identified molecular alterations for which results have been published in the peer-reviewed literature. The conclusion of the authors was "...he use of molecularly targeted agents outside their indications does not improve progression-free survival compared with treatment at physician's choice in heavily pretreated patients with cancer. Off-label use of molecularly targeted agents should be discouraged, but enrollment in clinical trials should be encouraged to assess predictive biomarkers of efficacy....
Another important point is that simply having a potentially targetable mutation does not guarantee that the patient will benefit from a therapy that presumably targets that mutation. Another potential pitfall is if targeted testing identifies a potentially actionable genetic abnormality for which a molecularly targeted treatment is available but not yet approved.
Based on the paucity of supporting data, neither the National Comprehensive Cancer Network nor the authors of UpToDate recommend the use of the Foundation Medicine next generation sequencing assay in this clinical scenario. Treatment based on published literature and guideline recommendations has been encouraged.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis. 
Treatment: Inpatient Hospital. 

The health plan denied the acute inpatient stay. 
The health plan's determination is upheld. 

This is a review for the medical necessity for acute inpatient level of care. This is a female patient with a past medical history of ulcerative colitis who presented to the emergency room with abdominal pain and bloody diarrhea. She had completed a course of antibiotics a month prior. She was hemodynamically stable and afebrile. Her abdominal examination was benign without rebound, guarding or rigidity. She did have anemia which was chronic but did not have leukocytosis and had an elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). A computed tomography (CT) scan showed wall thickening in the sigmoid colon suggestive of colitis. She was started on intravenous (IV) fluids and broad-spectrum antibiotics. Gastroenterology was consulted and recommended sending stool studies for infections pathogens and C difficile which were negative. She was hence started on intravenous (IV) steroids and iron supplementation. Her diarrhea and abdominal pain resolved, her diet was advanced, and she was switched to oral steroids and her home medications. She was discharged to home with outpatient follow up. At issue is the medical necessity of the inpatient stay. 

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

No, the requested health service/treatment of Inpatient Hospital Admission (Full Admission) was not medically necessary for this patient. This patient could have been managed at a lower level of care. This patient had no evidence of hemodynamic instability and had benign abdominal examination without peritoneal signs. She did not have evidence of fulminant C Difficile infection or toxic megacolon. She did not have evidence of dehydration. Therefore, she could have been managed at a lower level of care rather than acute inpatient level of care and discharged to home once she was able to tolerate oral nutrition and medications. 

Ulcerative colitis is a chronic inflammatory disease of the colon as many as 25% of patients with this disease may require hospitalization. The goals of hospitalization are to assess disease severity, exclude infection, administer rapidly acting and highly effective medication regimens, and determine response. During hospitalization, patients should be given venous thromboembolism prophylaxis and monitored for the development of toxic megacolon. Patients who do not respond to intravenous corticosteroids should be considered for rescue therapy with Infliximab or Cyclosporine. Patients who are refractory to medical therapies or who develop toxic megacolon should be evaluated promptly for colectomy. Patients who do respond to medical therapies should be discharged on an appropriate maintenance regimen when they meet discharge criteria.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cataracts
Treatment: Viscocanalostomy CPT 66174
The insurer denied Viscocanalostomy CPT 66174.
The health plan's determination is upheld. 

The patient is a female with glaucoma for whom coverage of viscocanalostomy/canaloplasty is the subject of review. An exam documents the patient as using latanoprost drops for glaucoma. Vision was best corrected to 20/40 right eye (oculus dexter/OD) and 20/50 left eye (oculus sinister/OS). Intraocular pressures were 22 mm Hg OD and 21 mm Hg OS. Cup/disc ratios were 0.3 OD and 0.5 OS. Final diagnoses included bilateral cataracts, mild non-proliferative diabetic retinopathy without macular edema of both eyes, and primary open-angle glaucoma, moderate stage both eyes (oculus uterque/OU). Intraocular pressures were considered borderline. 

The Viscocanalostomy/Canoplasty is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The OMNI System (Sight Science, Menlo Park, California) allows a surgeon to perform viscodilation, after which a microcatheter is again introduced into Schlemm's canal and a trabeculotomy is performed to achieve both viscodilation and trabeculotomy in one procedure. Reportedly, the Visco 360/OMNI System is indicated for the treatment of open angle glaucoma and ocular hypertension. It can be performed as a stand-alone procedure or in combination with cataract surgery. It can be performed in patients who are phakic, pseudophakic or aphakic. There is limited peer reviewed medical literature to support the safety and efficacy of this procedure. A review of the peer reviewed medical literature fails to identify that Viscocanalostomy/Canoplasty is likely to be more beneficial than any standard treatment or treatments for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cataracts
Treatment: Viscocanalostomy CPT 66174
The insurer denied Viscocanalostomy CPT 66174.
The health plan's determination is upheld. 

The patient is a woman with posterior subcapsular cataract, diabetes mellitus and open angle glaucoma who underwent cataract surgery and canaloplasty in her left eye. Prior to the procedure, her intraocular pressure (IOP) was 21/20 in the right and left eyes respectively. The patient was on latanoprost. Her cup to disc ratios were 0.3 and 0.5 per the notes. No visual fields were available. Postoperatively, the IOP was 17 in the left eye on latanoprost. The visual acuity improved from count fingers to 20/20 due to the cataract surgery.

The Viscocanalostomy/Canoplasty is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Medical therapy is presently the most common initial intervention to lower IOP. This patient was on latanoprost, but there is no included documentation indicating that other medical therapies had been tried and failed either alone or in combination prior to the surgery. There is no description of a failure of compliance with medication or an inability or intolerance to topical medications. Laser trabeculoplasty can be considered as initial therapy in selected patients or an alternative for patients at high risk for non-adherence to medical therapy who cannot or will not use medications reliably due to cost, memory problems, difficulty with instillation, or intolerance to medication. There is no indication that the patient had tried and failed laser trabeculoplasty. Trabeculectomy is effective in lowering IOP; but it is generally indicated when medications and appropriate laser therapy are insufficient to control disease. It can be considered as initial therapy in patients who require significant lowering of IOP or an inability to use topical medications. There is no indication that these therapies were considered or trialed despite the fact that they may have been equally or more beneficial to the patient's glaucoma. There are other more standard therapies that are not documented as having been tried in this patient such as IOP control with topical medications or laser trabeculoplasty.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cataracts
Treatment: Viscocanalostomy CPT 66174
The insurer denied Viscocanalostomy CPT 66174.
The health plan's determination is overturned. 

The patient is a female with history of visually significant cataracts, diabetic retinopathy, and primary open angle glaucoma currently on medical treatment. She underwent cataract surgery as well as glaucoma treatment (viscocanalostomy CPT 66174) for visual improvement and intraocular pressure lowering. This is under review.

The Viscocanalostomy/Canoplasty is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Viscocanalostomy is a safe and proven procedure for the treatment of various forms of glaucoma as well as primary open angle glaucoma which was seen in this case. The risks and side effects of the procedure are less than that seen in traditional trabeculectomy surgery. The trend for microsurgical techniques (such as viscocanalostomy) for treatment of glaucoma have been increasing over the past decade due to the safety and efficacy of the procedure. This patient also has diabetes with diabetic retinopathy which may increase her short term and long term risk of failure of traditional trabeculectomy surgery due to bleeding, scarring, and infection. 

Viscocanalostomy (CPT 66174) is a proven treatment option for those patients with primary open angle glaucoma. Postoperative complication rate is less than that of traditional trabeculectomy surgery. Viscocanalostomy would be indicated in this patient based on her diagnosis.