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

Diagnosis: Back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied intraosseous basivertebral nerve ablation procedure.
The health plan's determination is upheld.

The patient is a female who is diagnosed with low back pain. According to the records, the patient was recommended to undergo the Intracept procedure.

Letters of appeal submitted by the provider note that the patient has a history of low back pain. It was noted she has tried multiple treatments including activity modification, acupuncture, back brace, home exercises, lumbar (L) epidural steroid injections, medial branch blocks, medications, physical therapy, sacroiliac joint injections, and trigger point injections. Medications have included methocarbamol, naproxen, and Tylenol. Pain is impacting activities of daily living and nothing has provided significant relief. The provider noted the patient had a magnetic resonance imaging (MRI) that demonstrated Modic changes that disk space is L3 - L4 and L4 - L5 and the provider believes 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. This procedure is not standard of care as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required." 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 nerve) 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."

This treatment is not currently considered standard of care in the general medical community. There is insufficient 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. Additional studies are needed to evaluate long-term risks and benefits of this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied intraosseous basivertebral nerve ablation procedure.
The health plan's determination is upheld.

The patient is a female with complaints of low back pain. She has a chronic history of low back pain which began years ago. Prior treatment has included acupuncture, physical therapy, home exercises, as well as multiple injections. The pain continues to impact activities of daily living (ADLs). The magnetic resonance imaging (MRI) of the lumbar (L) spine demonstrated L3, L4, L5, and Modic changes.

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.

There is a request for intraosseous basivertebral nerve ablation. 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: Intraosseous Basivertebral Nerve Ablation Procedure
The insurer denied intraosseous basivertebral nerve ablation procedure.
The health plan's determination is overturned. 

The patient is a female who has chronic low back pain. She has constant aching sharp pain across her waistline. Her pain is aggravated by prolonged sitting, lumbar (L) flexion, and improved with rest and walking. She is a registered nurse. This persistent pain impedes on her daily activities and her occupation as registered nurse. Her prior treatments include physical therapy (PT), L epidural injections and a sacroiliac joint injection. Her physical exam (PE) was unremarkable. Magnetic resonance imaging (MRI) showed combination of Modic type 1 and type 2 changes at L4/5 and Modic type 1 changes at L3/4 with multilevel disc bulges.

Intraosseous basivertebral nerve ablation procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The Intracept system was designed to treat low back pain from vertebral body by ablating basivertebral nerves. There are multiple clinical trials demonstrating the sustained improvements in pain and function from this intervention for patients with vertebrogenic pain. This patient had failed extensive treatments including PT, L epidural injections and a sacroiliac joint injection. Her pain is severe enough with negative impact on her activities of daily living (ADLs) and ability to work as a nurse. Further interventions are indicated to improve her pain and function. Other potential treatment options are long-term use of medications [non-steroidal anti-inflammatory drugs (NSAIDs), opioids] and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Given this clinical scenario, the Intracept procedure is likely to be more beneficial than any standard treatments for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
Treatment: Inpatient hospital admission
The insurer denied inpatient hospital admission.
The health plan's determination is upheld. 

The patient is a female with a past medical history (PMHx) significant for coronary artery disease (CAD) status/post (s/p) left anterior descending (LAD) drug-eluting stent (DES), hypertension (HTN), hyperlipidemia (HLD), and chronic obstructive pulmonary disease (COPD) who had a right coronary artery (RCA) chronic total occlusion (CTO) stented. Echocardiogram showed no significant valvular disease, no evidence of pericardial effusion and ejection fraction (EF) of 65%.
At issue is the medical necessity of the inpatient hospital admission.

The requested health service/treatment of inpatient hospital admission was not medically necessary for this patient.
This patient had an uneventful hospital procedure and short stay.  The patient did not have any complications.  The patient was hemodynamically stable the entire time.  Most stable percutaneous intervention (stenting) is done as an outpatient procedure.  There was no medical reason for an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental issues
Treatment: Dental treatment
The insurer denied White Glass with High Gold Content Crown Tooth 18 and Deep Gum and Root Cleaning Upper Right Quadrant 
The health plan's determination is upheld. 

The patient is a female Provided for review are letters of appeal and denial, a narrative from the patient, clinical notes, periodontal indices, radiographic images, and a single page of American Dental Association claim forms. In question is the medical necessity of White Glass with High Gold Content Crown Tooth 18 and Deep Gum and Root Cleaning Upper Right Quadrant.

White Glass with High Gold Content Crown Tooth 18 and Deep Gum and Root Cleaning Upper Right Quadrant is not medically necessary. 
There is no diagnosis and no evaluation offered of the tooth in question for the treatment of #18 crown and no diagnosis or evaluation of the quadrants for necessity of scaling and root planing. Based on the documentation provided, the requested White Glass with High Gold Content Crown Tooth 18 and Deep Gum and Root Cleaning Upper Right Quadrant are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult female. She was hospitalized for chest pain. Her past medical history is remarkable for bradycardia, urinary retention, and hernia. She presented to the emergency department for evaluation of chest discomfort, dyspnea, orthopnea, and constipation with no bowel movement for 15 days. Treatment included intravenous fluids and oral lactulose every eight hours. On exam, the patient was noted to be uncomfortable, but vitals were stable. Initially, she was put on a non-rebreather mask, but quickly improved and was off oxygen and asymptomatic by the next day and had a voluminous bowel movement. Lower extremities showed edema and she was worked up for peripheral arterial disease (PAD) and venous insufficiency without significant findings. Electrocardiogram (EKG) showed sinus bradycardia and no acute changes. Troponin panel was negative. There were no cardiac arrhythmias documented of immediate concern. Transthoracic echocardiogram (TTE) reported possible patent foramen ovale, atrial septal aneurysm and ejection fraction 75%. The requested coverage for Inpatient Admission was denied as not medically necessary. The denial is being appealed.

The Inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, criteria for inpatient hospital admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with 
acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom, or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care she received for severe constipation without a bowel movement for 15 days and no small bowel obstruction or other acute abdominal condition like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a medical history of acute calculus cholecystitis status post cholecystectomy, pancreatitis, alcohol abuse, gallstones including history of choledocholithiasis, gastric ulcer complicated by perforation requiring surgery, Roux-en-Y gastric bypass, hyperlipidemia, anxiety, major depression, panic disorder, and polycystic ovarian syndrome. She presented to the emergency department with abdominal pain and vomiting since the prior day, with chills, and dark bowel movements. She had been consuming alcohol.
A computed tomography scan of the abdomen and pelvis showed prior Roux-en-Y gastric bypass, focal short segment dilated small bowel at the jejunojejunal anastomosis without surrounding inflammatory changes likely normal postsurgical anatomy and less likely enteritis, lack of bowel obstruction, and hypoattenuating liver which can be seen with hepatic steatosis or acute liver injury. She was treated with morphine, Toradol, ondansetron, and famotidine. She was placed on a Clinical Institute Withdrawal Assessment (CIWA) protocol.
She had significant nausea and vomiting, with inability to tolerate sips of water.  A gastroenterology consultation noted right upper quadrant abdominal pain, epigastric pain, and diarrhea, with elevated transaminases likely related to alcohol use; the recommendation was to check hepatitis serologies, labs for autoimmune hepatitis, alcohol cessation, follow transaminases, start proton pump inhibitor twice daily, diet as tolerated, follow hemoglobin, and check stool pathogen studies if diarrhea persists. She still had some withdrawal symptoms, requiring Ativan; her abdominal pain was improving, but she still had nausea and vomiting, with limited oral intake. She was discharged with a plan for Primary Care follow-up. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care is not medically necessary by the provided information. The patient presented with abdominal pain and vomiting after alcohol intake, consistent with possible alcoholic gastritis; she did not have labs or imaging consistent with acute pancreatitis [1]. She was appropriately treated, with intravenous fluid administration, and gradual advancement of diet. However, there was no hemodynamic instability or other complications such as pseudocyst, pancreatic necrosis, thrombosis, ascending cholangitis, abscess, active gastrointestinal bleeding, peritonitis, or sepsis, which would require a higher level of care. There was concern for alcohol withdrawal, but no complicated or severe acute alcohol withdrawal was documented; she was appropriately maintained on a CIWA protocol. Her liver enzymes were elevated, but there was no acute liver failure or alcoholic hepatitis. She had resolved abdominal pain, mild nausea, and was tolerating liquids. All of the measures that were undertaken, including labs, imaging, intravenous fluids, monitoring, and CIWA protocol, could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental issues.
Treatment:  Cleaning Inside Roots of a Front Tooth (Root Canal), Post and Hard Material Under Cap, and Tooth-Colored Cap (Crown) for Tooth #21.

The insurer denied Cleaning Inside Roots of a Front Tooth (Root Canal), Post and Hard Material Under Cap, and Tooth-Colored Cap (Crown) for Tooth #21.  The health plan's determination is overturned. 

The requested Cleaning Inside Roots of a Front Tooth (Root Canal), Post and Hard Material Under Cap, and Tooth-Colored Cap (Crown) for Tooth #21 is medically necessary for this patient. Based on the provided documentation, the tooth has extensive decay that has reached the pulp in addition to periapical periodontitis. This means that the pulp of the tooth is infected, giving it the diagnosis of irreversible pulpitis in addition to significant tooth loss. In any situation where the patient has the diagnosis of irreversible pulpits, as long as the tooth is restorable, there is the requirement to treat the pulpitis through removal of the infected nerve, artery, vein, as well as the canal tooth structure, irrigate with sodium hypochlorite, and fill with gutta percha medicament, as this is the only therapy that will treat the diagnosed pathology. This is a root canal. If the therapy is not done, the pulpal infection can spread to the surrounding bone, which can lead to the presence of abscess, with an array of sequential systemic sequela. With the extensive loss of tooth structure there can no longer be a direct restoration, as the cusps have been involved, this requires a buildup to support the crown, which will restore the cuspal function and structure. Hence, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is an adult female with a submitted diagnosis of hyperglycemia. She was hospitalized for 3 days. She presented to the emergency department for evaluation of lightheadedness and elevated home blood glucose greater than 500 over the last 
few days. Her past medical history was pertinent for insulin-dependent diabetes, hypertension, hyperlipidemia, anemia, and current smoking. On examination, the patient appeared uncomfortable and fatigued with variable blood pressure readings ranging from 92/57 to 183/84. Laboratory studies were remarkable for glucose of 334, hemoglobin of 10.9, blood urea nitrogen (BUN) 43, creatine 1.8, and magnesium 1.6. 
Electrocardiogram (ECG) demonstrated normal sinus rhythm at 65 beats per minute and QTc (corrected QT interval) of 492 milliseconds. Chest radiograph demonstrated bibasilar platelike atelectasis. Treatment included intravenous regular insulin, intravenous sodium chloride bolus, and two grams of intravenous magnesium. The requested coverage for Inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization, diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar syndrome (HHS), worsening heart failure and progression to dehydration, hypovolemic, or cardiogenic shock, sepsis, cerebrovascular accident (CVA), acute renal failure (ARF), or any other medical condition, symptom, or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment for the patient's hyperglycemia that required inpatient hospital stay. The care she received for uncomplicated hyperglycemia without diabetic ketoacidosis is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Admission
The insurer denied Inpatient Admission.
The determination is upheld.

The patient is an adult male who was admitted to inpatient rehabilitation substance use disorder treatment of stimulant (cocaine), alcohol, and nicotine (tobacco) use disorders. The patient was using up to 7 bags of crack cocaine daily together with beers. The patient was also tobacco dependent with use of one-half pack per day. He had a longstanding substance use disorder with past substance use disorder treatment episodes with the last occurring in the month prior to presentation with detoxification treatment and relapse.
The patient has no acute general medical issues that were a focus of treatment. There was a report of co-occurring psychiatric disorders in this case best characterized as mild to moderate unspecified depressive disorder, as well as insomnia.
Mental status examination revealed a cooperative male with clear speech and linear thought processing that was goal directed. 
The inpatient level substance-related rehabilitation treatment included the opportunity to participate in groups, individual counseling, educational sessions, and recovery groups with peer support. The patient easily engaged in rehabilitation treatment. He actively participated in individual, group, and educational sessions. 
Discharge planning occurred that included recommendations for continued aftercare with recommendations for sober living upon completion of the program. The patient was cooperative and engaged throughout his inpatient stay with reasonable motivation and participation in therapeutic activities. There were no psychiatric or biomedical complications during his stay with discharge with referral for outpatient services.
At issue is the medical necessity of inpatient admission.
The requested health service/treatment of inpatient admission is not medically necessary for this patient.
The structure and intensity of services necessary for the rehabilitation/substance use disorder treatment could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober support. There is no evidence that the inpatient level structure and 24-hour nursing monitoring is medically necessary for a successful outcome in this case. There were no biomedical, psychiatric, or general medical issues that warranted the requested inpatient level services.
Thus, the patient's alcohol, stimulant (cocaine), and nicotine use disorders were amenable to treatment at a lower level of care in this case scenario, and the health plan's determination of medical necessity was consistent with the application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: intraosseous basivertebral nerve ablation, procedure codes 64628 and 64629

The insurer denied coverage for intraosseous basivertebral nerve ablation, procedure codes 64628 and 64629.

The denial is upheld. 

The patient has a history of low back pain. Of note, the patient had undergone prior lumbar spine surgery which was an exclusion for the Intracept procedure in the studies. The request is for the Intracept procedure, which is under medical necessity review.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. 

An industry-sponsored study by Becker, S., et al. (2017), "assessed the efficacy of intraosseous BVN (basivertebral nerve ablation) ablation, with the Intracept system, in 17 patients with chronic low back pain. Sixteen patients were treated successfully. Self-reported outcome measures were collected prospectively at each follow-up interval. There was a significant decrease in the average ODI (Oswestry disability index) at 3 months postoperatively, which was maintained at 12 months. Significant improvement in the VAS (visual analog scale) scores and quality of life were also reported at the 3-month follow-up. This study is limited by small sample size, lack of randomization and control and short-term follow-up."

Medicare does not have an National Coverage Determination (NCD) specifically for the use of the Intracept procedure in the treatment of chronic low back pain.

The intraosseous basivertebral nerve ablation, procedure codes 64628 and 64629 need final approval from the appropriate regulatory bodies for this diagnosis. 

Intraosseous basivertebral nerve ablation, procedure codes 64628 and 64629 does not have final approval from the appropriate regulatory bodies for this diagnosis. Therefore, it is not medically necessary for the treatment of the patient's condition.     

The patient is not a good candidate for intraosseous basivertebral nerve ablation, procedure codes 64628 and 64629.     

The intraosseous basivertebral nerve ablation, procedure codes 64628 and 64629 are not the best available treatment for this patient at this time.

The intraosseous basivertebral nerve ablation, procedure codes 64628 and 64629, is not the best available treatment for this patient at this time. 

In summary, the denial of intraosseous basivertebral nerve ablation, procedure codes 64628 and 64629 and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.