Persius/hicric huggingface dataset:
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 male with low back pain and throat pain secondary to stage II esophageal squamous cell cancer in remission. He does have a history of fungal infections after steroid injections. MRI (magnetic resonance imaging) of the lumbar spine shows diffuse disc bulges, degenerative changes, and facet arthropathy. The request for L(lumbar)2-5 Intracept procedure was denied coverage by the health plan as investigational. The denial is being appealed.

The requested Intraosseous Basivertebral Nerve Ablation (6468 and 64629) is not more beneficial than any standard treatment for the insured's condition or disease. 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 1 or type 2 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 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. The requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease.
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 overturned.

The patient is an adult male that presented with a history of continued back pain as well as bilateral knee pain. The pain is aggravated with walking, standing and stairs. The patient had participated in gel injections but back pain remains unchanged. The pain is aggravated with activity, bending over. Previous treatments also included medication as well as prior physical therapy. Pain is constant, aching, burning, sharp and shooting. Diagnosis includes vertebral genic low back pain, primary osteoarthritis bilateral knees and long-term prescription opiate use. It was noted that the patient had failed 6 months of physical therapy, injection therapy as well as pain medication. MRI (magnetic resonance imaging) shows Modic type I/II lumbar L2, L3, L4 and L5.

The health plan's prior denial of coverage noted, "Your doctor ordered a procedure interosseous basivertebral nerve ablation to treat your low back pain. His treatment is not approved under the plan clinical criteria because there is no proof or not enough proof it improves health. For this reason, the request is denied as investigational." The denial is being appealed.

The health plan should cover the Intraosseous Basivertebral Nerve Ablation (64628 and 64629).

Based on the documentation provided and per current studies, the requested basivertebral radiofrequency ablation is considered medically appropriate in this case. The patient has a history of stage III esophageal cancer that is in remission, low back pain with continued symptoms noted in the medical history as well as on exam. It was noted that the patient has Modic type changes on imaging. Despite prior treatments including physical therapy, medications as well as activity modification and injections, the patient continues to be symptomatic. Given that the patient has tried and failed prior other treatments, the requested treatment would be the next reasonable step in 
management.
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 male with chronic low back pain in 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 PT (physical therapy), epidural steroid injections, facet injections, and home exercises. The patient has failed multiple medications including potent opiate medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury.

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

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is not likely to be more beneficial than standard treatments. 
The patient is an adult male with chronic low back pain in 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 PT (physical therapy), epidural steroid injections, facet injections, and home exercises. The patient has failed multiple medications including potent opiate medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury.

The procedure is an FDA (United States Food and Drug Administration)-approved procedure for axial low back pain. It has been shown effective in RCT (randomized controlled trials) with 5-year results. The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal 
procedure. It is a new 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 in this case has not failed or attempted facet interventions, or sacroiliac joint injections, which are common causes of axial low back pain. 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 alternatives sacroiliac injections do show favorable outcomes in the literature, have lower 
risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent.
The health plan's determination is upheld.

The patient is a female with atopic dermatitis (AD). She is currently using Opzelura for her eyelids and face. The medication under review is Dupixent.

The requested Dupixent is not medically necessary for this patient.

There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the preferred treatments tacrolimus ointment and phototherapy, which have been shown to be effective for atopic dermatitis.

According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred treatments covered by the health plan, such as tacrolimus ointment and phototherapy, are effective treatments for the management of atopic dermatitis.

A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults". Phototherapy has also been well-documented as an efficacious, safe treatment for eczema, as in this patient.

Meduri, et al write in "Phototherapy in the management of atopic dermatitis (AD): a systematic review" that "narrowband ultraviolet B (NB-UVB), should be used for the management of chronic AD". Sidbury, et al write "NB-UVB is generally the most commonly recommended light treatment by providers when considering its low risk profile, relative efficacy, availability, and provider comfort level". Therefore, Dupixent prior to a trial of tacrolimus ointment or UVB phototherapy is not medically necessary. The formulary therapies should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient based on the evidence-based literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: utero vaginal prolapse
Treatment: inpatient hospital
The insurer denied the inpatient hospital admission. The health plan's determination is overturned. 

The patient is a female with abnormal uterine bleeding and utero vaginal prolapse. Her past medical history (PMH) is significant for hypertension and obesity. She underwent a complex robotic assisted pelvic surgery including robotic assisted Supra cervical hysterectomy, bilateral salpingectomy, oophorectomy, sacral Colpopexy with mesh and rectocele repair. During the dissection, some brisk bleeding was observed and there was concern for injury to iliac vessels specifically at the level of iliac bifurcation. Although bleeding stopped, a vascular surgery consult was obtained and their recommendation was to obtain post-operative computed tomography (CT) angiogram to rule out any injury to iliac vessels. For this reason, the patient was admitted to the hospital which is the subject of this review.

Inpatient Hospital Admission medically necessary for this patient.
This patient underwent a complex lengthy robotic surgery. During the surgery, there was concern for vascular injury and vascular surgery consult was obtained. Vascular surgery recommended computed tomography (CT) angiogram post-operatively to rule out potential damage to the iliac vessels at the level of bifurcation. Although at the time of the surgery there was no significant active bleeding and the patient had intact peripheral pulses, they could not rule out injury to the iliac vessels at the level of bifurcation. In light of this information, it was reasonable to admit patient and have close follow up as an inpatient, obtain a CT angiogram to rule out the injury prior to discharge. This patient's care required an inpatient hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

Acute cholecystitis and biliary complaints are common inpatient diagnoses. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible. A 50% increase in the liver function tests can be labelled as mild elevation and is considered negligible by many. 

Per clinical documentation, this patient presented to the emergency department (ED) with generalized abdominal pain that subsequently localized to the right lower quadrant. There was associated nausea and vomiting. Vital signs in the ED were within normal limits. The patient was afebrile. A computed tomography (CT) scan of the abdomen and pelvis demonstrated findings most consistent with cholecystitis. Liver function tests were within normal limits. The patient was admitted and underwent a laparoscopic cholecystectomy. There were no reported complications. There is no operative note provided and no clinical documentation of a need for inpatient admission. Per Milliman Clinical Guidelines (MCG) criteria, admission is indicated when common bile duct obstruction is indicated via imaging and there are signs of systemic inflammation. Peer-reviewed literature and MCG criteria indicate that an inpatient admission is not necessary in this circumstance. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: kidney stone.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male who presented with complaints of right flank pain. He was hemodynamically stable on presentation. White blood cell count (WBC) count was 14.6 and creatinine was 1.1. Prior history was significant for kidney stones. After initial evaluation, he was admitted to the inpatient service. Cystoscopy and ureteroscopy with retrograde pyelogram were performed.  He had an uneventful hospital stay and was discharged. 

The inpatient hospital stay was not medically necessary. The majority of patients who present with renal colic can be discharged within 24 hours of the presentation. This patient didn't present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. The procedure was not done on an emergent basis. The procedure performed is considered a minimally invasive outpatient procedure and as such in the absence of a "high risk surgical patient" does not warrant acute inpatient care. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. Observation for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with medical history of gastroesophageal reflux disease (GERD), candidal esophagitis, gastritis, hyperlipidemia, deep venous thrombosis/pulmonary embolism on warfarin, and human immunodeficiency virus on anti-retroviral therapy. He presented to the emergency department with chest pain, melena for four days, and one day of hematemesis with coffee ground emesis.

Vital signs were notable for elevated blood pressure of 140/79 millimeters of mercury (mmHg). Physical examination was notable for lack of tenderness, distention, and mass. Labs showed low hemoglobin of 13.4 grams per deciliter (g/dL) and hematocrit of 39.2%, low potassium of 3.4 moles, and elevated international normalized ratio of 2.49. Chest x-ray showed no acute chest disease. He was started on intravenous proton pump inhibitor twice daily. Warfarin was held. He was made nothing by mouth (NPO). Gastroenterology consultation noted a prior episode a year ago in the setting of supratherapeutic international normalized ratio and Grade D esophagitis, and recent esophagogastroduodenoscopy finding of Helicobacter pylori; the conclusion was hemodynamically stable upper gastrointestinal bleeding, and the recommendation was intravenous proton pump inhibitor, follow hemoglobin and transfuse as needed, NPO, infectious disease consultation for Helicobacter pylori treatment, clarify indication for anticoagulation, hold Warfarin, and plan for esophagogastroduodenoscopy the next morning. He was discharged on on amoxicillin, levofloxacin, omeprazole, and Lovenox (off Warfarin), with a plan for primary care gastroenterology, hematology, infectious disease, and vascular surgery follow-up. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay is not medically necessary. The patient presented with visible gastrointestinal bleeding characterized by hematemesis and melena, and reportedly had esophagogastroduodenoscopy in the past with finding of Helicobacter pylori; monitoring was warranted as bleeding can be severe and sudden in onset [1-6]. Additionally, the patient was on anticoagulation, which can increase the risk of adverse outcomes with bleeding [1-6]. However, there was no hypotension, hemodynamic instability, sharp drop in hemoglobin indicative of ongoing gastrointestinal bleeding, or visible ongoing gastrointestinal bleeding. Appropriate therapy was performed with a proton pump inhibitor, and esophagogastroduodenoscopy did not show any ongoing bleeding or high-risk stigmata. He was initiated on therapy for Helicobacter pylori, and anticoagulation was optimized by changing to Lovenox. All of the measures that were undertaken, including monitoring, proton pump inhibitor therapy, specialist consultations, change in anticoagulation, and esophagogastroduodenoscopy could have been performed without acute inpatient level of care, at a lower level of care [1-6].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Chest Pain.
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay. 
The health plan's determination is overturned.

This case involves a male with a past medical history significant for hypertension (HTN), hyperlipidemia, obstructive sleep apnea (OSA), coronary artery disease (CAD) a prior myocardial infarction (MI), prior coronary stents to the left anterior descending (LAD) and right coronary artery (RCA), and prior alcohol and cocaine abuse. He presented to the emergency department (ED) with complaints of worsening exertional chest pain. The patient was admitted under the inpatient level of care to rule out acute coronary syndrome (ACS) and treatment of community acquired pneumonia. A computed tomography (CT) of the chest showed a possible right upper lobe pneumonia and the patient was started on intravenous (IV) antibiotics. A stress test was performed that was positive for ischemia in the inferobasal wall. An echocardiogram revealed normal cardiac function. He was subsequently referred for coronary angiogram for further evaluation of occlusive CAD. Due to the abnormal stress test results and ongoing chest pain associated with new electrocardiogram (ECG) changes consistent with unstable angina, the patient was started on IV Heparin and was recommended to undergo urgent cardiac catheterization. The patient needed to be transferred to another hospital for further care and coronary angiogram.
At issue is the medical necessity for the inpatient stay.

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

The patient presented with chest pain concerning for unstable angina and subsequently clinically worsened during his hospitalization, experiencing ongoing chest pain and new ECG changes. Given his presentation of unstable angina, transfer for urgent coronary angiography was medically necessary and in the best interest for the well-being of the patient which is supported by peer reviewed medical literature and expert consensus guideline statements on non-ST segment myocardial infarction (NSTEMI) syndromes and chest pain. [1-3]
The inpatient level of care was medically necessary and appropriate and in the best interest for the safety of the patient for telemetry monitoring, IV Heparin infusion and urgent cardiovascular evaluation to determine the best next course of action which was ultimately to transfer to another medical center for a coronary angiogram. I recommend that the patient's health plan determination be overturned in order to grant coverage for an inpatient level of care for the evaluation and management of unstable angina in this case. Management of this patient under an alternate level of care would have been medically inappropriate and unsafe for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Skeletal Class I occlusion with Class II canines.
Treatment:  D8080 Braces, D8670 Monthly Visits x12.

The insurer denied: D8080 Braces, D8670 Monthly Visits x12. The denial is overturned.

The patient is a preteen male.  The request is for braces and monthly follow up visits. Has a skeletal Class I occlusion with Class II canines. He has moderate upper and lower crowding with a deep bite. The prior denial was due to a handicapping index score of eight.

The proposed treatment is medically necessary.

The patient has impacted anterior teeth (maxillary left and right permanent canines) where extractions are not indicated. These are automatic qualifiers for benefits according to the handicapping index scale. This case has medical necessity because of this. The monthly follow up visits are also medically necessary to make sure the treatment is progressing properly.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pseudopocketing due to superficial calculus accumulation and poor oral hygiene

Treatment: D4342 dental scaling on the lower left, lower right, and upper right and D4341 root planing on the upper left,

The insurer denied coverage for D4342 dental scaling on the lower left, lower right, and upper right and D4341 root planning on the upper left,

The denial is upheld.

Based on the submitted documentation which includes copies of periodontal charting, and full mouth series radiographs, narrative letter, member guidebook relevant portions and insurer correspondence, it appears that this patient presented for evaluation for dental services and periodontal therapy. The dentist reported periodontal chartings indicating 2-3 millimeters (mm) generalized periodontal pocketing with focal 4 mm depth readings. The recommended treatment was scaling and root planing in all four maxillary and mandibular quadrants. 

Upon review of the submitted documentation, both the radiographs and periodontal probing depths, there is minimal if any loss of alveolar bone height affecting these teeth. There is no evidence of radiographic calculus. The focal 4mm increased pocket depths likely represent pseudopocketing due to superficial calculus accumulation and poor oral hygiene. There is minimal significant periodontal probing with no periodontal probing over 4 mm depth. The insurer has correctly applied the clinical criteria in denying scaling and root planing services.

The clinical and radiographic documentation does not support or substantiate scaling and root planing services.

The health care plan did act reasonably, with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for D4342 dental scaling on the lower left, lower right, and upper right and D4341 root planing on the upper left is upheld. Medical Necessity is not substantiated.