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

Diagnosis:  Multiple Myeloma.
Treatment:  Increase in personal care services from 28 hours to 32 hours per week.

The insurer denied increase in personal care services from 28 hours to 32 hours per week.  The determination is overturned.

This is a male patient with a medical history notable for cancer. The patient was approved for 24 hours per week of personal care services. The patient and his care team requested an increase to 32 hours per week, and this request was partially denied by the health plan; they did approve an increase to 28 hours per week. The denial of 32 hours per week is the subject under review. No medical records or letters of medical necessity were provided as part of this review.

A Uniform Assessment System (UAS) was completed. He was alert and oriented with periods of forgetfulness. He was able to call for help in the event of an emergency. For his instrumental activities of daily living, the patient requires total dependence for housework. He requires maximal assistance for shopping and meal preparation. He requires extensive assistance for transportation and stairs. He requires limited assistance for finances and medications. For his activities of daily living, the patient requires extensive assistance for bathing. He requires limited assistance for dressing. He was independent or required supervision only for all other activities. He is occasionally incontinent of urine and is continent of stool. He is able to manage incontinence care independently. He had one fall in the previous 90 days. The fall was in his apartment due to weakness and dizziness, and he was able to get up himself. A task tool associated with the assessment recommended 30.25 hours per week to address his personal care needs. Compared to a prior assessment, the patient showed a decline in activities of daily living functioning. At issue is the medical necessity of increase in personal care services from 28 hours to 32 hours per week.

The requested health service of increase in personal care services from 28 hours to 32 hours per week is medically necessary for this patient.

The patient's most recent UAS demonstrates that his level of functioning is declining. The task tool associated with the assessment recommended more than 30 hours per week to address his needs. The plan originally approved only 24 hours, and subsequently increased that to 28 hours per week. The plan should provide at minimum the number of hours recommended by the task tool. The patient's fall within the past 3 months could be viewed as evidence of unmet personal care needs. The task tool hours should be seen as a minimum, and personal care tasks may exceed that minimum to varying degrees, if needed to complete personal care activities. The requested increase is reasonable and in line with the task-based assessment tool. Therefore, the requested increase is medically necessary for the patient to address his personal care needs.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Diarrhea. 
Treatment: Gastrointestinal Pathogen Panel Testing (87507). 
The insurer denied: Gastrointestinal Pathogen Panel Testing (87507). 
The denial is overturned. 

This patient is an adult male who visited his physician with six weeks of unexplained left sided abdominal pain and watery diarrhea. A Gastrointestinal Pathogen Panel Testing (87507) was ordered and denied as not medically necessary. 

The health plan should cover the proposed treatment. 

The gastrointestinal pathogen panel is a new technology that efficiently screens for the genetic material that has been found to detect multiple pathogenic organisms. It leads to improved patient outcomes, especially in those with chronic diarrhea (greater than four weeks) as in the case of this patient. It should be covered by the health plan.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Diarrhea. 
Treatment: Gastrointestinal Pathogen Panel Testing (87507). 
The insurer denied: Gastrointestinal Pathogen Panel Testing (87507). 
The denial is upheld. 

This patient is an adult male with six to eight weeks of diarrhea, abdominal pain, and vomiting. The doctor ordered 12-25 target gastrointestinal pathogen panel. The plan denied it, as the plan only covers up to an 11-target gastrointestinal panel in patients with more than seven days of community acquired diarrhea when patients are not immunocompromised. 

The health plan should not cover the proposed treatment. 

Reliable evidence shows that the consensus of opinion among experts regarding the healthcare service is that further studies or clinical trials are necessary to determine efficacy as compared with the standard means of diagnosis, and that it does not improve net health outcome. Medical literature does not support that gastrointestinal pathogen panel via nucleic acid is more effective than standard stool cultures in the evaluation of diarrhea. Therefore, the use of more than an 11-target gastrointestinal panel was not clinically appropriate or accepted standard of care, and the health plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Duchenne Muscular Dystrophy	

Treatment: 39 Home Health Visits

The insurer denied coverage for 39 Home Health Visits

The denial is upheld 

This is a patient diagnosed with Duchenne Muscular Dystrophy (DMD). The patient is dependent for activities of daily living (ADL) and non-ambulatory. Under review is the medical necessity of occupational therapy (OT) 39 home health visits.

The clinical records submitted are insufficient to support the medical necessity for the requested OT services. The letter from the patient's treating physician describing the patient's underlying diagnosis (DMD), limited functional ability, and reported medical necessity of physical and occupational therapy was reviewed. Also reviewed were the office visit notes and "Video-Visit note". According to the notes, the patient "has been going for physical therapy (PT)/OT 3 times a week."  The provider also includes medical literature regarding the diagnosis, management and rehabilitation of DMD (1, 2). However, the actual PT/OT notes, which require evidence of continued and sustained functional improvement, were not included for review.   

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. Taken into consideration were including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies and boards. All decisions are evidenced based. 

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 occupational therapy 39 home health visits is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Ozempic Inj (injection) (semaglutide). 
The insurer denied coverage for Ozempic Inj (semaglutide). 
The denial is upheld. 

The health plan acted reasonably and with sound of medical judgment and in the best interest of the patient.

The policy criteria require the submission of medical records indicating a diagnosis of type II diabetes which is the approved indication of Ozempic. The patient does not have type II diabetes. The request does not meet the policy criteria.

Ozempic Inj (injection) (Semaglutide) is not considered medically necessary for this patient.

Semaglutide is a glucagon-like peptide-1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity (2-4). Recent studies published in major peer reviewed medical journals have shown safety and efficacy of Semaglutide for the treatment of obesity (5-7). There are no studies showing safety or efficacy of the requested medication for patients who do not have diabetes such as this patient. There are no extenuating circumstances in this case. 

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 Ozempic Inj (Semaglutide) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic neck and shoulder pain. 
Treatment: Hospital service for a cervical laminectomy spinal cord stimulator (SCS) trial: codes: 63655, 95972, 76000. 
The insurer denied coverage for Hospital service for a cervical laminectomy spinal cord stimulator (SCS) trial: codes: 63655, 95972, 76000. 
The denial is overturned. 

This adult patient has chronic neck and shoulder pain. The patient has had multiple cervical spine surgeries and has failed medication management.  A percutaneous trial was unsuccessful as the lead could not be passed high enough in the cervical spine.  A laminectomy is required by a neurosurgeon. The history and physical states that there is no indication for a Spinal Cord Stimulator (SCS) placement in the cervical spine in this case. 

Baeranidharan et al (1) conducted a systematic review and metanalysis and concluded:
Review identified 15 studies reporting efficacy and/or safety of cervical 10 kilohertz (kHz) SCS therapy. Meta-analysis of the data showed that 83% of the patients achieved response (greater than or equal to 50% reduction) and 39% reduced or eliminated their opioid use following 10 kHz SCS therapy. Implant site pain, lead migration, and infections were commonly reported adverse events. Current findings suggest that 10 kHz SCS therapy could be a promising, safe, minimally invasive alternative for the treatment of pain in the neck and upper extremities. This meta-analysis focuses on a new Stimulation pattern, but cervical SCS is well established therapy. 

Deer et al (2) similarly concluded in a study on cervical SCS: 

 "The results suggest that the use of SCS in the cervical spine is a medically effective method of pain management that satisfies and improves the quality of life (QoL) of most patients. The use of SCS can reduce the high cost of direct medical treatment of pain, as well as increasing the productivity of patients, and therefore should be reimbursed in appropriately selected patients." 

The request procedure is medically reasonable and necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for hospital service for a cervical laminectomy spinal cord stimulator (SCS) trial, codes 63655 laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural; 95972; electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex spinal cord or peripheral nerve (e.g., sacral nerve) neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional; and 76000; fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a patient with a past medical history remarkable for end stage renal disease (ESRD) status/post (s/p) renal transplant, diabetes, hypertension, gastroesophageal reflux disease (GERD), recurrent urinary tract infections (UTIs), who presented to the emergency department (ED) for fevers and right flank pain. Of note, the patient had a recent multidrug resistant (MDR) UTI. The review of systems was negative for additional clinical symptoms.
The physical examination was remarkable for right lumbar pain.
The patient was admitted for a MDR Escherichia (E coli) UTI, history of right lower quadrant transplant, ultrasound (US) with no hydronephrosis. The patient was treated with intravenous (IV) Zosyn. The patient was monitored, and medications were continued for transplant. The patient was also noted to have diabetes and her glycemia was treated. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was medically necessary. The patient was admitted for a urinary tract infection (UTI) in the setting of an immunocompromised state (s/p transplant), and recent MDR E. coli.
Complicated UTIs are associated with patient-level factors that compromise urodynamics or host defenses, such as indwelling or intermittent urinary catheterization. A prior history of urinary tract infection (UTI) is risk factor for complicated and recurrent UTI, multi-drug resistance and secondary bloodstream infections. Multidrug-resistant organisms (MDRO) are predominantly bacteria, that are resistant to one or more classes of antimicrobial agents. Patients with recurrent UTI requiring frequent antibiotics are at increased risk for MDRO and are likely to be hospitalized for IV antibiotics. It is well described in the literature that multi-drug resistant (MDR) bacteria are more prevalent the elderly patients with prior history if UTI and antibiotics resistance. It was, therefore, necessary to wait for a urine final urine culture and complete a minimum of five days of IV antibiotics. Overall, UTIs in the elderly have the potential for serious complications and mortality in the elderly patients and therefore must be treated with antibiotics tailored to the organism to avoid treatment failure and complications.
The patient's stay was medically necessary at the inpatient level of care due to high risk for complications and potential for resistant organisms.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient admission 
The insurer denied coverage for Inpatient admission.
The denial is Overturned.

This was a review of a young adult patient admitted to the hospital for right side abdominal pain, nausea, vomiting, and fever. The non-contrast computed tomography (CT) was unremarkable with borderline size appendix. In Emergency Room (ER), the patient had right lower quadrant (RLQ) abdominal pain and dysuria. CT with contrast was ordered in the ER. Urinalysis (U/A) was positive (+) for blood and LE (Leukocyte Esterase). The appendix was enlarged on 2nd CT scan, Surgical consult recommended conservative treatment with IV antibiotics, and the patient was initially admitted under observation. The patient continued with mild abdominal pain and nausea. A CT scan was done again and showed pyelonephritis of the kidney. The patient was admitted to inpatient and received (intravenous) IV Morphine and Zofran. The patient improved and was discharged home. The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health, Urinary Tract Infection (UTI) RRG, the patient does appear to meet guidelines for inpatient care - these include:

.	 Resistance or worsening of clinical findings (pain, vomiting) despite observation care.
.	Need for IV hydration support despite observation care.

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

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628 and 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (64628 and 64629)
The denial is upheld.

This is an adult female. The appeals letter states the patient has a history of chronic low back pain that resulted in vertebrogenic pain identified by degenerative endplate changes on magnetic resonance imaging (MRI). The patient has pain and failed treatment for greater than six months. Prior treatments include medication and physical therapy.

The health plan should not cover the Intraosseous Basivertebral Nerve Ablation (64628 and 64629).

Based on the documentation provided, the requested procedure is not recommended in this case. Though the patient has a history of chronic back pain, it was noted that the patient had tried medication and physical therapy. There was no documentation of the patient having tried and failed all other interventional treatments, considering the patient's imaging finding. Additionally, there was no documentation of any Modic type changes noted on magnetic resonance imaging.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628 and 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (64628 and 64629)
The denial is upheld.

The patient is an adult female with low back pain that began more than five years ago. Her past treatments include acupuncture, physical therapy, sacroiliac joint injection, Ibuprofen, oral steroids, and tramadol. Her pain is rated to be 9/10. Magnetic resonance imaging (MRI) of the lumbar spine shows Modic changes at T12-L1, L3-4, and L5-S1; grade 1 anterolisthesis L4 over L5; scoliosis; moderate to severe canal stenosis at L3-4; degenerative disc disease; and facet arthropathy. The request for Intracept at L3-S1 was denied coverage by the health plan, as experimental/investigational. This denial is being appealed.

The health plan should not cover the Intraosseous Basivertebral Nerve Ablation (64628 and 64629).

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes, as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.
At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure.
Furthermore, this patient has documentation of other causes of low back pain including lumbar spinal stenosis, scoliosis, facet arthropathy, and disc disease. As such, the health plan should not cover the requested health service. Other standard treatment options that exist in the medical literature may include non-opioid medications (i.e., non-steroidal anti-inflammatory drugs [NSAIDs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., physical therapy, home exercise program, chiropractor treatments), interventions (i.e., epidural steroid injections, medial branch blocks/radiofrequency 
ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628 and 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (64628 and 64629)
The denial is upheld.

The patient is an adult female with chronic low back pain for whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as 
experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, sacroiliac joint injections, and home exercises. The patient has failed multiple medications, including opiate medications. Magnetic resonance imaging (MRI) shows Modic changes. Physical exam does not reveal any neurological injury.

The health plan should not cover the requested Intraosseous Basivertebral Nerve Ablation (64628 and 64629).

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is no likely to be more beneficial than standard treatments. The patient is an adult female with chronic low back pain for whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, sacroiliac joint injections, and home exercises. The patient has failed multiple medications, including opiate medications. Magnetic resonance imaging (MRI) shows Modic changes. Physical exam does not reveal any neurological injury.
The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new United States Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or 
type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, the patient has not failed or attempted facet joint interventions/medial branch blocks, which are common causes of axial low back pain. In addition, there is no documentation of 
response to the sacroiliac joint injections. The Intracept procedure should be employed after all conventional and evidence-proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternative sacroiliac injections do show favorable outcomes in the literature and have lower risk and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma.

Treatment: Advair HFA (fluticasone-salmeterol).

The insurer denied coverage for Advair HFA (fluticasone-salmeterol).

The denial is upheld.

 
The patient is a teenager who can very well be taught to use diskus and the formulary alternative. She has only mild persistent asthma and hence Advair may not be needed. She has normal Pulmonary function tests, no excessive office visits/emergency department (ED) visits/hospitalizations/steroid bursts. 

There are no studies that show the superiority of Advair aerosol for inhalation (HFA) over diskus (powder for inhalation) or the formulary alternative documented above. Also, if we are treating mild persistent asthma, we may just treat with Singulair only without inhaled corticosteroids without much-expected change in outcome.  It is also questionable how the patient "failed" other inhaled corticosteroids, as there are no recent steroid bursts, ED visits, hospitalizations or continually missed school days. 

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug(s) is not expected to be ineffective.

The nonformulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Advair HFA (fluticasone-salmeterol) is upheld.