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

Diagnosis: Gynecomastia.
Treatment: Breast reduction.
The insurer denied breast reduction. 
The health plan's determination is upheld. 

This male has a history of gynecomastia. He complains of pain. A Mammogram confirms the diagnosis of gynecomastia. Office notes from the plastic surgeon are not provided for review. Mastectomies are planned. This is under review.

Breast Reduction Surgery is not medically necessary for this patient.

According to the Milliman Care Guidelines (MCG), 26th Edition, Mastectomy for Gynecomastia:
Mastectomy for gynecomastia may be indicated for 1 or more of the following:
Postpubertal male and ALL of the following:
1) Functional impairment (eg, chronic skin irritation, pain, related psychological disorder requiring therapy) [MET, the patient reportedly has pain]
2) Gynecomastia did not regress after cessation of medications (eg, calcium channel blockers, cimetidine, phenothiazines, spironolactone, theophylline) known to cause condition, medications cannot be discontinued, or no medications that induce gynecomastia are being used. [NOT MET, there is no documentation of patient's medications]
3) No evidence of breast cancer [MET based on mammogram]
4) No evidence of other medical causes for gynecomastia, as indicated by normal results for ALL of the following: [NOT MET. A Medical workup for other causes of gynecomastia not documented.]
5) Hormone evaluation (ie, testosterone, lueinizing hormone, follicle-stimulating hormone, estradiol, prolactin, beta-human chorionic gonadotropin), Liver enzymes, Serum creatinine, and Thyroid function tests

The records do not include any notes from the plastic surgeon that document a health issue due to the enlarged breast tissue that has not responded to medical therapy. In addition, the records do not document a work-up for reversible causes of male breast enlargement.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a patient who presented to the emergency department complaining of one day of sharp left-sided nonexertional chest pain; he also reported exertional dyspnea and palpitations. His medical history was remarkable for hypertension, diabetes, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea and human immunodeficiency virus (HIV) infection. An electrocardiogram showed atrial fibrillation with a ventricular rate of 65 beats/minute without acute changes. His serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. A chest x-ray showed cardiomegaly without acute pathology. The patient was treated with aspirin and was admitted to the hospital to rule out acute coronary syndrome. Repeat troponin levels remained normal. Exercise stress testing was attempted but the patient stopped exercise within two minutes due to dyspnea. His oxygen saturation remained normal during a five-minute walk test. The patient was noted to be hostile and uncooperative. He indicated that he wished to go home and left the hospital without being discharged. At issue is the medical necessity of an inpatient admission.

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient, with known cardiac risk factors, presented with symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, a lower level of care until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation
Treatment: Cardiac Event Monitoring [heart monitor that is implanted under the skin]
The insurer denied Cardiac Event Monitoring [heart monitor that is implanted under the skin]
The determination is upheld.

The patient has hyperlipidemia, hypertension (HTN), atherosclerotic cardiovascular disease (ASCVD), mild carotid stenosis and adenocarcinoma of the right lung. He underwent thoracic surgery and was noted to have atrial fibrillation post-operatively. A Ziopatch was done showing a low atrial fibrillation (AF) burden. He was prescribed Eliquis.
He underwent stress testing and developed atrial fibrillation at the end of exercise. Most recently, he reports episodes of "brain scrambles" and near syncope, felt to possibly be arrhythmia-related. He reported heart rates in the 180s noted on his Apple watch, associated with brief palpitations during these episodes.
Insertion of a loop recorder (ILR) was recommended and is under review for medical necessity.

The requested service of ILR (implantable loop recorder ) monitoring is not medically necessary. This patient has known paroxysmal atrial fibrillation, diagnosed one year ago, and recently has symptoms of dizziness and difficulty focusing, which may be related to atrial fibrillation. While correlation of his symptoms with arrhythmia is important, insertion of a loop recorder is not indicated as the initial step in detection. External event monitoring has not been performed to assess his most recent symptoms.
ILR is indicated for suspected AF in the setting of cryptogenic stroke, and Holter monitor or other noninvasive cardiac monitor is contraindicated, or results unrevealing or indeterminate, and recurrent paroxysmal atrial fibrillation is suspected, and test results may impact patient management, per Milliman Guidelines for ILR.
The patient does not meet standard guidelines for ILR. He did not have at least 3 weeks of external event monitoring. While he did have event monitoring with a Ziopatch, this was prior to the current symptom onset.
Therefore, the requested service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lupus and rheumatoid arthritis.
Treatment: Olumiant.
 
The insurer denied the Olumiant.  The determination is upheld.

The patient has lupus and rheumatoid arthritis (RA) overlap. The patient is steroid dependent despite treatment with Plaquenil, methotrexate (MTX) and then Orencia and Rituxan. Olumiant was denied by the health plan and is under review. 

Olumiant is not medically necessary for this patient.

There are drugs on the health plan's formulary (Xeljanz and Rinvoq) that are not contraindicated.  Humira and Enbrel could potentially increase the risk of a lupus flare, as they are tumor necrosis factor (TNF) inhibitors which have been associated with drug induced lupus.  Xeljanz and Rinvoq are not expected to be ineffective based on the known clinical history and conditions of the patient and the patient's prescription drug regimen.  The patient has not tried the required prescription drug(s) (those on formulary) while under their current or previous plan or another prescription drug(s) in the same pharmacologic class or with the same mechanism of action and such prescription drug(s) were discontinued due to a lack of efficacy or effectiveness, diminished effect or an adverse event. The patient is not stable on prescription drug(s) selected by their health care provider for the medical condition under consideration. Enbrel and Humira are not in the best interest of the patient because they may exacerbate the patient's lupus. The patient is unable to tolerate Actemra due to headaches (HAs) and sinus infection. However, there is no medical reason the patient cannot try the other medications on the plan's formulary, such as Xeljanz or Rinvoq, which are both on the plan's formulary and are also JAK inhibitors, like Olumiant. As stated, Enbrel and Humira are not in the best interest of the patient because they may exacerbate the patient's lupus. Rinvoq or Xeljanz will not likely cause a significant barrier to the patient's adherence to or compliance with the patient's plan of care, will not likely worsen a condition of the patient, or will not likely decrease the patient's ability to achieve or maintain reasonable functional ability in performing daily activities. Of the formulary drugs available, there is no medical reason why the patient cannot try Xeljanz and Rinvoq, which are on the formulary.
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 in whom an Intracept procedure has been requested. The procedure was denied as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), and epidural steroid injections. The patient has failed multiple medications including NSAIDS (nonsteroidal anti-inflammatory drugs) and muscle relaxants. Of note, MRI (magnetic resonance imaging) report does not show Modic changes, though the office notes state there are Modic changes. Physical exam does not reveal any neurological injury.

The health plan should not cover the requested health service.

The patient is an adult female 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) and epidural steroid injections. The patient has failed multiple medications, including NSAIDS (nonsteroidal anti-inflammatory drugs) and muscle relaxants. Of note, the MRI (magnetic resonance imaging) report does not show Modic changes; however, the office notes state that there are 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 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. 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. 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, facet intervention and sacroiliac injections, do show favorable outcomes in the literature, have lower risk, and morbidity, coupled with the lack of definitive evidence of Modic changes, the requested Intracept procedure is not medically appropriate in this patient's case.
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 ex-gymnast with chronic low back pain. Her past treatments include physical therapy, epidural steroid injections, NSAIDs (nonsteroidal anti-inflammatory drugs), and Tylenol. MRI (magnetic resonance imaging) of the lumbar spine shows grade 1 anterolisthesis of L3 on L4, edema at the right L4 and L5 pedicle, spondylosis at L4-5, and severe bilateral neuroforaminal stenosis at L5-S1. The request for Intracept was denied coverage by the health plan with the contention that there is no proof or not enough proof that it improves health, and it is therefore investigational. The denial is being appealed.

The health plan should not cover the requested health service.

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 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. As such, there is not enough proof Intracept improves health, and it is considered investigational.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Asthma, macular degeneration, vertigo and early dementia

Treatment: Increase in PCA (personal care assistance) hours to live-in per diem, 24 hours per day, 7 days per week

The insurer denied coverage for Increase in PCA hours to live-in per diem, 24 hours per day, 7 days per week

The denial is modified 

This is a patient with chronic medical problems including asthma, macular degeneration, vertigo and early dementia. He lives alone in a 2-bedroom private home. The patient is currently receiving personal care assistance 5 hours/day, 7 days/week (35 hours/week total) and is requesting live-in per diem, 24 hours per day, 7 days per week, which is under review.  

The patient was admitted to the hospital, after a fall, transferred to a skilled nursing facility then eventually discharged home. According to the Uniform Assessment System (UAS) report, his cognitive status is "minimally impaired."  He is "able to identify emergency plan by calling/activating PERS (personal emergency response system)." The patient requires extensive assistance for activities of daily living including dressing, bathing, personal hygiene and toilet transfers/use. He is continent of bowel and (frequently) incontinent of bladder.   During the evaluation, he "was observed ambulating/transferring with use of walker and some weight bearing assistance provided by caregiver." According to the UAS report his functional ability has declined/deteriorated over the past 90 days. The clinical records do not substantiate a level of physical/cognitive impairment or debility to warrant an increase in PCA hours to the requested live-in per diem, 24 hours per day, 7 days per week as medically necessary. However, his recent falls history and functional decline support an increase in PCA services to 12 hours/day, 7 days/week in order to allow him the ability to live safely in his home.  

From a physical medicine and rehabilitation perspective, level 2, live-in per diem, 24 hours per day, 7 days per week is not medically necessary. However, an increase in PCA services to 12 hours/day, 7 days/week is medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for personal care aide level 2, live-in per diem, 24 hours per day, 7 days per week is modified. An increase in PCA services to 12 hours/day, 7 days/week is medically necessary. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Durable Medical Equipment (DME). 
The insurer denied Zoll Life Vest. 
The denial is upheld.

The patient is a male with a history of mixed ischemic/nonischemic cardiomyopathy, hemochromatosis, cirrhosis, type 2 diabetes and obesity. He presented with congestive heart failure and anasarca. An echocardiogram was performed and showed a left ventricular ejection fraction (LVEF) of 15-20%. Guideline directed medical therapy for congestive heart failure was prescribed with improvement in the patient's New York Heart Association functional class from Class IV to Class II. Cardiac catheterization was performed and showed total occlusion of the left anterior descending coronary artery, intermediate artery and a diagonal branch. There was an 80% stenosis of an obtuse marginal artery. There was severe global hypokinesis with an LVEF of 20-25%. The impression was that the patient's cardiomyopathy was primarily nonischemic. A multigated acquisition (MUGA) scan showed an LVEF of 35%. An echocardiogram performed showed an LVEF of 30-35%. The patient was encouraged to proceed with ICD implantation. Based on the information provided, coverage for the Zoll Life Vest is under review for medical necessity.

The health plan's determination is upheld.

Based on the documentation provided use of the Wearable Cardioverter Defibrillator (WCD) was not medically necessary.

This patient presented with congestive heart failure due to a primarily nonischemic cardiomyopathy; his left ventricular ejection fraction was 15-20%. Depressed left ventricular systolic function is a risk factor for, and powerful predictor of, sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients, such as this patient, with nonischemic cardiomyopathy and left ventricular ejection fractions (LVEFs) of 35% or less. However, due to the possibility that left ventricular function may improve with time and/or treatment, it is recommended that device implantation be delayed for at least 90 days following the initial diagnosis. If, after 90 days of optimal medical therapy, the LVEF remains less than or equal to 35%, ICD implantation is then recommended.  Thus, while use of the WCD for several months subsequent to the patient's diagnosis would have been appropriate, use of the device for the dates under review was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back Pain
Treatment: intraosseous basivertebral nerve ablation (Intracept)
The insurer denied: intraosseous basivertebral nerve ablation (Intracept)
The denial is: Upheld

The patient is a female with low back pain. The pain began over 30+ years ago. Prior treatment has included therapy, as well as low back injections along with multiple medications. Pain ranges from 5 out of 10 through 10 out of 10. Pain impacts activities of daily living (ADLs). Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic type II changes at lumbar (L)3-4, L4-L5 as well as L5-sacral (S)1. The patient's is noted to have vertebrogenic low back pain. The subject under review is the proposed Intracept procedure (intraosseous basivertebral nerve ablation), and whether it is likely to be of greater benefit to this patient than any standard treatment.

The proposed health service or treatment intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment for the patient's condition.
The patient has complaints of low back pain. 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.
Given the above, the proposed health service or treatment intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Back Pain
Treatment: intraosseous basivertebral nerve ablation (Intracept)
The insurer denied: intraosseous basivertebral nerve ablation (Intracept)
The denial is: Overturned.


The patient is a female with chronic back pain and radicular symptoms for over 39 years. Her pain started worsening after her left total hip arthroplasty (THA). She describes her pain as constant and dull. Her radicular pain to buttocks has improved since lumbar (L) 4/5 transforaminal epidural injection. However, her back pain continued. She has tried aquatic therapy, massage therapy and brace support with moderate relief in the past. She was evaluated by a surgeon who recommended the Intracept procedure. Physical exam (PE) was unremarkable except for lumbar pain with extension and rotation. Lumbar spine magnetic resonance imaging (MRI) showed mild multilevel degenerative disc disease with degenerative endplate changes most severe at L5/sacral (S)1 level.
The subject under review is whether the Intracept procedure (intraosseous basivertebral nerve ablation) is likely to be more beneficial for this patient than any standard therapy.

The proposed service is likely to be more beneficial for this patient than any standard therapy. The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. Multiple clinical trials demonstrated the efficacy of this intervention. This patient has persistent back pain consistent with vertebrogenic pain. She had failed extensive treatments in the past. Further interventions are required to improve her pain. 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 carries significant risks and complications. Given this clinical scenario, the Intracept procedure is the appropriate next step / intervention to alleviate her persistent pain.