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

Diagnosis: Back pain. 
Treatment: Procedure Code 64628 (intraosseous basivertebral nerve ablation). 
The insurer denied Procedure Code 64628 (intraosseous basivertebral nerve ablation). 
The health plan's determination is upheld. 

This is a male patient with low back pain. The provider states the patient has a history of low back pain that began 5 years ago. It was noted multiple treatments have been tried including activity modification, chiropractic, home exercise, lumbar epidural injections, medial branch blocks, medication management, physical therapy, radiofrequency ablation's, sacroiliac joint injections and trigger point injections. Medications have included baclofen, gabapentin, ibuprofen, lidocaine patches, Medrol Dosepak, meloxicam, and tizanidine. Pain is impacting patient's ability to perform activities of daily living and nothing has provided significant relief. It was noted the patient had a magnetic resonance imaging (MRI) performed and the provider states this demonstrated Modic changes at disc spaces L (lumbar)4 - L5 and thus this is the source of the patient's chronic back pain. 

Intraosseous Basivertebral Nerve Ablation Procedure 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 International Society for the Advancement of Spine Surgery's guideline on "Intraosseous ablation of the basivertebral nerve for the relief of chronic low back pain" (Lorio et al, 2020) stated that intraosseous ablation of the BVN (basivertebral) is a new procedure; its limitations included industry funding is a potential source of study bias for the available data reviewed, limited number of studies, short-term follow-up for the majority of studied patients, and unknown effect on the primary degenerative process." 
Per Becker et al," Ablation of the BVN for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period." However, this is noted to be an industry sponsored study and does not demonstrate long term effects of the procedure beyond one year. This treatment is not currently considered standard of care in the general medical community. There is a lack of high-grade evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Procedure Code 64628 (intraosseous basivertebral nerve ablation). 
The insurer denied Procedure Code 64628 (intraosseous basivertebral nerve ablation). 
The health plan's determination is upheld. 

The patient is a male with complaints of low back pain which is chronic. Pain began 5 years ago. Prior treatments have included chiropractic care, physical therapy, as well as multiple injections and medications. The pain severely impacts activities of daily living (ADL). A recent Oswestry Disability Index (ODI) score was 13. Magnetic resonance imaging (MRI) of the lumbar spine reported Modic changes in the L (lumbar) 4, L5 vertebral bodies. 

The proposed Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
This procedure is not recommended Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Procedure Code 64628 (intraosseous basivertebral nerve ablation). 
The insurer denied Procedure Code 64628 (intraosseous basivertebral nerve ablation). 
The health plan's determination is upheld. 

This patient is a male who has chronic low back pain with radiation into the hips. The pain is worse with prolonged walking and standing. Pain level is 2/10. This patient previously underwent Radiofrequency ablation of the lumbar facet joint with 100% pain relief, bilateral sacroiliac (SI) injections with 100% pain relief for one month, and an epidural injection with 65% pain relief. Physical exam (PE) showed decreased lumbar spine range of motion (ROM), positive SI joint tests including Faber, Yeomans's and Fortin finger. The magnetic resonance imaging (MRI) revealed findings of disc bulge and facet arthropathy from L (lumbar)2 to S (sacral)1 with high T (thoracic) 2 signals in the posterior annulus at L4/5 and L5/S1 levels. 

Intraosseous Basivertebral Nerve Ablation Procedure 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 Intraosseous Basivertebral Nerve Ablation Procedure was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient responded to the prior lumbar epidural steroid injections, SI injections and facet injections. His magnetic resonance imaging (MRI) showed diffused degenerative disc disease and facet arthropathy from L2 to S1 with posterior annular tears L4/5 and L5/S1 levels. Truumees's study supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the primary inclusion criteria is Type 1 or Type 2 Modic changes on an MRI at one or more vertebral bodies from L3 through S1. In addition, the patients with radicular pain and radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were in the exclusion criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg pain and shortness of breath

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This is an adult female with past medical history significant for hypertension, anemia, hyperlipidemia, venous insufficiency, and gastroesophageal reflux disease (GERD) who presented to the emergency department with complaints of bilateral leg pain and shortness of breath.

Vital sign on presentation included: Temperature 98.1 degrees Fahrenheit, Blood Pressure 150/72, Pulse 100, Respirations 16, Oxygen saturation 98% on room air. Laboratory results included the following: white blood cells (WBC) 7.7, hemoglobin (Hgb) 14.5, hematocrit (Hct) 46.9, creatinine 0.72 glucose 94. 

The patient was started empirically on intravenous (IV) antibiotics (Ancef and vancomycin) for lower extremity cellulitis. Chest X-ray (CXR) was negative. Chest computerized tomography (CT) scan was negative for pulmonary embolism. The patient remained afebrile, hemodynamically stable, and was clinically improved at discharge to continue outpatient management.

According to the documentation, the patient presented with lower extremity swelling (right worse than left). Otherwise, they were afebrile, hemodynamically stable, with unremarkable laboratory results including a normal white blood cell (WBC) count. The patient had no evidence of a disseminated infection, and no surgical intervention was required. The patient was described as "comfortable and in no distress." 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Loss of consciousness/altered mental status (LOC/AMS). 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient is an adult male who was admitted following an episode of loss of consciousness/altered mental status (LOC/AMS). The patient required persistent stimulation to arouse and stay awake. He was seen by neurology who recommended video electroencephalogram (VEEG) and magnetic resonance imaging (MRI). The patient's neurologic examination was normal. His vital signs showed elevated blood pressure and bradycardia, while lab results indicated elevated glucose and low cortisol levels. Further evaluation included a normal neuro exam, and endocrinology attributed the low cortisol to his circadian rhythm. Treatment for late latent syphilis was initiated. The patient improved, with normal cortisol levels upon retesting. He was discharged for follow-up on penicillin treatment and a sleep study for possible narcolepsy. The request for inpatient admission was denied as it did not meet level of care. 

The requested health service was medically necessary. 

The patient was seen by neurology who recommended video electroencephalogram (VEEG) and magnetic resonance imaging (MRI). The patient's neurologic examination was normal. This patient was recommended to have video electroencephalogram (VEEG) which is a continuous electroencephalogram that cannot be provided in the outpatient or observation level due to prolonged nature. For this reason, inpatient admission is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dizziness/atrial fibrillation
treatment: inpatient stay
the insurer denied the inpatient stay
The health plan's determination is upheld. 

This case involves a man with hypertension who was admitted to the hospital with lightheadedness, nausea, and vomiting. Examination revealed an alert person with no acute distress, obese, with a normal cardiopulmonary exam except for bradycardia. The abdomen was soft and nontender without guarding. There was no evidence of costovertebral angle (CVA) tenderness documented. Laboratory work-up showed a creatine kinase (CK) level of 81, glucose 143, and creatinine of 0.9, with normal electrolytes. The white blood cell count was 8.1, with hemoglobin of 15.3. The liver function tests were also normal. Imaging included a head computed tomography (CT) scan, showing no evidence of mass bleed or edema. Chest x-ray showed clear lungs without evidence of pneumonia. The electrocardiogram (EKG) showed atrial fibrillation, with a heart rate of 65 beats per minute (bpm). 

The inpatient hospitalization was not medically necessary. The patient was admitted with a new onset A-fib (atrial fibrillation), with a heart rate of 65. There is no documentation of unstable tachycardia, hemodynamic collapse, or evidence of acute ischemia causing the atrial fibrillation, decompensated heart failure, or thyrotoxicosis as part of the syndrome. The patient's atrial fibrillation was discovered relatively unintentionally by EKG. There were no complaints of chest pain or dyspnea. Therefore, inpatient criteria are not met. Anticoagulation for A-fib was started in the form of direct oral anticoagulation. The dizziness was evaluated with head computed tomography (CT) and brain magnetic resonance imaging (MRI), showing no evidence of acute stroke, bleeding, or tumors. The entire work-up could have been completed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and Monthly Visits
The insurer denied Braces and Monthly Visits.
The determination is overturned.

The patient is a male who presented with a skeletal Class I malocclusion and minor spacing. He has a 4-millimeter (mm) overjet and a 3-mm anterior open bite. He is treatment planned for orthodontic treatment to correct the spacing and open bite. At issue is the medical necessity of braces and monthly visits.

Orthodontic treatment is medically necessary for this patient due to the side effect described below and the fact that this is not something that will self-correct without orthodontic intervention.
Patients with an anterior open bite are among the most difficult patients to treat. (1) One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2) Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. (3) The requested orthodontic treatment is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion and severe crowding
Treatment: braces
The insurer denied braces
The health plan's determination is overturned. 

The patient in question is a young male with impacted tooth #22. He presents with a skeletal Class I malocclusion and severe crowding. He has a bilateral posterior crossbite. He is treatment planned for braces to address the crowding and to create space to bring the impacted tooth into the arch.

Braces are medically necessary for this patient.
This patient presents with a bilateral posterior crossbite and severe spacing. He is an excellent candidate for rapid maxillary expansion to assist with orthodontic correction. If he is allowed to reach skeletal maturity before the expansion is initiated the only option to achieve orthopedic expansion will be to perform RPE (rapid palatal expander) in conjunction with a surgical procedure, which would greatly increase the morbidity to the patient.
Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. If left untreated the damage that can occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. Therefore, braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: prostate/lung cancer
Treatment: radiation therapy
The insurer denied radiation therapy
The health plan's determination is overturned. 

This is a male with history of stage IV prostate cancer and stage IV lung cancer. He was recently treated to his brain with SRS (stereotactic radiosurgery) for brain metastases. Repeat imaging shows a left adrenal gland lesion as the only remaining site of active disease.

Radiation therapy is standard of care and medically necessary for this patient. SBRT (Stereotactic body radiotherapy) for management of limited volume metastatic disease is supported by the National Comprehensive Cancer Network (NCCN) guidelines, ASTRO (American Society for Radiation Oncology) Model Policy, and numerous high quality prospective clinical outcomes reported in the peer reviewed medical literature. SBRT allows for optimal target coverage while limiting exposure to the patient's kidney and bowel. SBRT is expected to provide the patient a significant break from systemic therapy by rendering the patient free of active disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Humira Pen
The insurer denied: Humira Pen
The denial is overturned.

The patient is an adult female with psoriasis, 20% body surface area (BSA), treated with topical steroids. The provider is requesting Humira. The patient also has granuloma annulare. 
The health plan requires a trial and failure to methotrexate for at least 3 months as well as use of formulary agents Otezla, Cimzia, Stelara, Tremfya, and Skyrizi. The patient must also have 
previously tried an immunomodulator or be on adalimumab therapy.

The requested health service is medically necessary.

Humira is an approved and widely used therapy in psoriasis and has also shown benefit in granuloma annulare. The patient should avoid methotrexate as she is a female of childbearing potential. Humira is a more appropriate choice given its effectiveness in granuloma annulare compared to the formulary alternatives. Therefore, Humira is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident (CVA)
Treatment: Increase Personal Care Services 24 Hours Per Day, 7 Days a Week (split shift)
The insurer denied: Increase Personal Care Services 24 Hours Per Day, 7 Days a Week (split shift)
The denial is overturned.

The patient is an elderly female. The request is an increase in personal care services to 24 hours per day, seven days a week (split shift). Previous information included a denial notice. This included a rationale as to why the patient was appropriate for six hours a day, seven days a week. At that point, therapy was upgraded to personal care services of eight hours a day, seven days a week. Clinical information included an appeals letter from family of patient. It was noted that the patient had an acute cerebrovascular accident (CVA) several months ago. It was noted that the patient had been hemiplegic and had worsening bed sores on the right heel of her foot. It was noted that she was totally dependent for meal preparation, housework, maximum assistance with medication management, stairs, transportation, bathing, upper and lower body dressing, transferring, toilet use, and bed mobility. It was also noted that she had frequent urinary and fecal incontinence.

The requested Increase Personal Care Services 24 Hours Per Day, 7 Days a Week (split shift) is medically necessary.

In this instance, this patient was receiving 56 hours of personal care services per week. However, it should be noted that she has multiple comorbidities, including advanced age, coronary artery disease, dizziness, essential hypertension, and hemiplegia following a recent acute cerebrovascular accident. She has frequent urinary and fecal incontinence, raising the risk of skin breakdown. It should also be noted that the patient has had worsening skin breakdown of her right lower extremity. She is at a significant risk for infectious decompensation with continued skin breakdown risk related to fecal and urinary continence and hemiplegia necessitating frequent repositioning throughout the day/night. The increase in the personal care assistant hours is appropriate for a split shift. Therefore, given the above, the requested Increase Personal Care Services 24 Hours Per Day, 7 Days a Week (split shift) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Ustekinumab (Stelara)
The insurer denied Ustekinumab (Stelara). 
The health plan's determination is overturned. 

The patient is a female with severe stricturing ileocecal Crohn's disease. Magnetic resonance enterography showed persistent transmural thickening, postcontrast enhancement and restricted diffusion involving a long segment of the terminal and distal ileum with possible skip lesion, prominence of the vasa recta and fibrofatty proliferation, luminal narrowing of the distal ileum with mild prestenotic dilation, and persistent active inflammatory changes related to known Crohn's disease. 

Stelara is medically necessary for this patient.
Stelara, Entyvio, and Humira are recommended by American College of Gastroenterology guidelines for the treatment of Crohn's disease. The American Gastroenterological Association (AGA) guidelines for the treatment of Crohn's disease also support the use of Entyvio and Humira in patients with Crohn's disease, but specifically recommend Stelara in patients who have failed anti-tumor necrosis factor (TNF) medications such as Inflectra and Renflexis. In this case, the patient has had objective evidence of ongoing inflammation and complications of Crohn's disease such as stricture while using anti-TNF medications, and there is no evidence that the patient ever had a complete response to anti-TNF therapy. The AGA guidelines recommend Stelara rather than Entyvio or Humira in Crohn's disease (CD) patients who have non-response to an anti-TNF medication, stating "In adult outpatients with moderate to severe CD who never responded to antiTNFa (primary nonresponse), the AGA recommends the use of ustekinumab and suggests the use of vedolizumab over no treatment for the induction of remission"; Humira is not recommended at all, and has the same mechanism of action as the medications which the patient failed. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications, which the patient has failed. A recent study demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara. Two studies showed that Stelara appears more effective than Entyvio in the treatment of Crohn's disease, with one finding odds ratio of remission of 2.01 and the other 2.58.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post cerebrovascular accident
Treatment: Increase Home Care/Personal Care Consumer 
Directed Personal Assistance Services (CDPAS) to 24 Hours Per Day (split shift)
The insurer denied: Increase Home Care/Personal Care Consumer Directed Personal Assistance Services (CDPAS) 
to 24 Hours Per Day (split shift)
The denial is overturned.

The patient is an elderly female. She is currently receiving home care/personal care consumer directed personal assistant services, for which there is a request for increasing hours to 
24 hours/day (split shift). The patient is presently receiving 56 hours/week. It was noted that the patient had an acute hospitalization, inpatient, for an acute CVA (cerebrovascular accident). Her current level of functioning is as follows: Bedbound/wheelchair-bound, requiring total assistance with transfers, nonverbal, PEG (percutaneous endoscopic 
gastrostomy) tube in place, fecal/urinary incontinence.

The requested Increase Home Care/Personal Care Consumer Directed Personal Assistance Services (CDPAS) to 24 Hours Per Day (split shift) is medically necessary.

In this instance, it is noted that the patient now requires total care following a recent inpatient hospitalization for an acute CVA (cerebrovascular accident). The patient is bedbound, fecal/urinary incontinence is prevalent, and with her requiring total assistance, she is at a significant risk for skin breakdown, subsequent infection, and subsequent increased risk in mortality. She requires total assistance with all activities and function. Previously, the patient was receiving 56 hours, however, this was prior to her recent acute stroke hospitalization, which has significantly impacted her current level of function as compared to her prior level of function. The patient now requires 24 hours/day (split shift).