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

Diagnosis: Chest Pain
Treatment: Inpatient Hospital
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

This female patient presented to the emergency department (ED) complaining of one week of intermittent chest pain and epigastric burning and nausea. She denied having chest pain at the time of presentation. Her medical history was remarkable for diabetes, hypertension, hyperlipidemia, chronic kidney disease, and an unspecified psychiatric disorder. In the ED her blood pressure was 137/85 millimeters of mercury (mmHg) with a heart rate of 77 beats per minute (bpm). Her room air oxygen saturation was 98 percent (%). Her electrocardiogram showed sinus rhythm and was a normal tracing. Her serum creatinine level was 1.45, which was her baseline. The patient was treated with aspirin and famotidine. She left the ED before all of her laboratory results were available. Subsequently, her high sensitivity troponin level was 59.4, which was above the upper limit of normal. The patient was called and asked to return to the hospital for admission to rule out acute coronary syndrome. When she returned, she denied having any pain. She was admitted to the hospital. Repeat troponin levels were 58 and 48. Myocardial perfusion imaging showed moderate fixed apical and inferior defects with minimal reversibility. Cardiac catheterization was recommended; however, the patient left the hospital against medical advice before the procedure could be performed.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is upheld in whole.
Based on the documentation provided an inpatient level of care was not medically necessary.
This woman presented with symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with a normal electrocardiogram (EKG). While her serum troponin level was mildly elevated, there was no significant delta troponin. She 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 under an alternate level of care. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the 2021 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: Overturned

Diagnosis: Chronic Migraine Headache Disorder
Treatment: Botox
The insurer denied the service and treatment of Botox.
The health plan's determination is overturned.

The patient is a female who is diagnosed with chronic migraine headaches. Treatment with Botox is the subject of this review. Botox was denied because there was not sufficient documentation to show that the patient had a positive response to treatment with Botox. The patient has provided diaries to demonstrate her response to Botox and also indicated that the plan did approve one injection cycle. The denial of further injection cycles was appealed by the provider.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The requested health service and treatment of Botox is medically necessary for the patient. Botox is prescribed for treatment of chronic migraine headaches. The patient has chronic migraine headaches. The patient was approved for one injection cycle of Botox and further injection cycles were denied as there was not sufficient documentation of a positive clinical response. Both the patient and provider have submitted documentation to show that the patient had a decreased frequency and severity of migraines secondary to treatment with Botox. As such, continuation is supported. Additionally, the provider has requested the Food and Drug Administration (FDA) approved dosing for Botox at a standard dosing frequency of every 12 weeks (3 months).

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbites.
Treatment: D8080 Braces, D8670 Monthly Visit.
The insurer denied: D8080 Braces, D8670 Monthly Visit.
The denial is overturned.

The patient is a young adult female requesting orthodontic benefits and monthly follow up visits. The patient has a Class III skeletal malocclusion with moderate upper and lower spacing. She has a posterior right crossbite and anterior crossbites of teeth #'s 26 and 27.

The proposed treatment is medically necessary.

The patient has a posterior crossbite on the right side. This means that her upper right teeth are inside of her lower teeth, which is backwards to what is normal. This will, over time, cause 
trauma to the teeth on that side because they will hit unevenly. Fractures and/or loosening of these teeth are possible. Also, with the teeth being "backwards', this will contribute to temporomandibular joint (TMJ) issues in the future, as the forces generated can degenerate the temporomandibular joints. The patient also has crossbites of two anterior teeth (#'s 26 and 27) with attachment (gum) loss. These are "automatic qualifiers" for orthodontic treatment according to the handicapping index scale. Orthodontic treatment and monthly follow up visits to monitor the treatment progress is definitely needed to correct this patient's malocclusion. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain. 
Treatment: Facet injections. 

The insurer denied Facet injections. 
The determination is upheld. 

This is a patient who was diagnosed with neck pain. The patient was recommended to undergo cervical facet joint injections, which were denied by the health plan as imaging studies show findings of other causes for the patient's pain such as severe spinal canal stenosis. 

There is a letter of appeal from the provider stating that the patient was seen with complaints of intractable axial neck pain rated at 8/10, present for years and not controlled with over three months of physical therapy, and  over-the-counter painkillers. The pain was interfering with activities of daily living. The physical exam findings included moderate to severe pain on palpation at cervical (C) 4 - C5, C5 - C6 and C6 - C7 facet joints. There was positive facet loading and pain with extremes of motion. The provider then referenced review of the patient's magnetic resonance imaging (MRI) showing C6 - C7 congenital fusion, C3 - C4 moderate central herniation with spinal cord deformity and mild/moderate spinal stenosis, C-4 - C-5 small central rightward herniation, spondylosis and mild spinal stenosis and C5 - C6 right paracentral herniation with mild spinal stenosis. The provider states they requested authorization for lumbar medial branch blocks which were denied. The provider states the disc changes shown on MRI study were likely in remission as there were no positive neurological findings orthopedic testing on examination. At issue is the medical necessity for facet joint injections. 

The requested health service/treatment of facet joint injections is not medically necessary for this patient. According to evidence-based Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG) guidelines, diagnostic medial branch blocks can be considered when there are objective examination findings consistent with facet mediated pain, absence of radicular pain, spinal stenosis, previous fusion (same level), infection, tumor, coagulopathy, or anticipation of a surgical procedure. There must be documentation at least 3 months of failed conservative treatment, including home exercise, physical therapy, and nonsteroidal anti-inflammatory drugs (unless poorly tolerated). One (single) set of diagnostic medial branch blocks (MBBs) is required, with documented pain reduction greater than or equal to (>=) 70 percent (%), lasting approximately 2 hours (lidocaine); confirmatory (repeat) blocks are not recommended prior to neurotomy if diagnostic criteria are confirmed. No more than 2 intervertebral disc/facet joint levels bilaterally should be injected during any one session." The MRI provided shows multiple other findings for the patient's pain including multilevel disc herniations and varying degrees of spinal stenosis. It is also noted the provider is requesting to perform 3 joint levels, which would exceed standard of care. The requested 3 level cervical medial branch blocks are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: bicuspid aortic valve and moderate aortic insufficiency.
treatment: inpatient admission.
The insurer denied the inpatient admission. 
The health plan's determination is overturned. 

The patient is a female for which an inpatient level hospitalization is under review. There was history of a bicuspid aortic valve and moderate aortic insufficiency. There was some intermittent shortness of breath walking long distances. Vital signs were essentially normal. The creatinine was normal. There was plan for a Ross procedure. She was extubated on postoperative day one. Postoperative echocardiogram demonstrated trivial regurgitation of the aortic valve. She ultimately remained stable and was discharged.

The inpatient hospital admission was medically necessary. This individual had an essentially bicuspid aortic valve with significant aortic regurgitation. This required an open surgical procedure for correction. This was accomplished successfully. Due to the invasive nature, there was also a requirement for post-operative intense monitoring. In this setting, the surgery cannot be accomplished at a level other than inpatient. An inpatient hospital admission is therefore considered medically necessary in this case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Mesenteric Artery Thrombosis.
Treatment:  Eliquis.

The insurer denied Eliquis.  The denial is upheld.

The patient is a male with history of a mesenteric artery thrombosis. Anticoagulation was required. The subject under review is whether Eliquis is preferable to the formulary alternatives warfarin or Xarelto.

The health plan's determination is upheld.

Individuals with mesenteric artery thrombosis generally require long-term anticoagulation. Among the available options include warfarin, Xarelto, and Eliquis. There is no definitive evidence in the setting of this case that one of these agents is established as standard of care, compared to the others, towards improved mesenteric artery thrombosis outcomes. In general, Eliquis and Xarelto are probably overall safer than warfarin, as far is risk of bleeding. However, in this case, there was no contraindication to Xarelto. Therefore, Eliquis would not be more effective than Xarelto.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept procedure
The insurer denied coverage for the Intracept procedure.
The denial is upheld.

This adult patient has chronic low back pain. She is status post lumbar discectomy and laminectomy. She is doing a Home Exercise Program. Her medication trials have included Aspirin, Duloxetine, Hydrocodone, Norco, as well as non-steroidal anti-inflammatory drugs (NSAIDs). Her magnetic resonance imaging (MRI) shows Modic changes at lumbar (L)5 and sacral (S)1.  Also of note are multi-level disc extrusions and foraminal stenosis. This request is for radiofrequency (RF) ablation of the basivertebral nerves at L5 and S1.

The publications to date have been company sponsored and had methodology flaws. There are no published data on long term complication rates. There are other evidence- based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al (3) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the basivertibular nerve (BVN). Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Urits et al (5) also commented on the need for more research on this promising technique: "reproducible large RCTs (randomized control trials) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of chronic low back pain (CLBP) and improve the quality of life of CLBP patients in the near future."

This procedure is not likely to be more beneficial than the standard of care.

In summary, the denial of an Intracept procedure: Thermal destruction of intraosseous basivertebral nerve, inclusive of imaging guidance, first two vertebral bodies, lumbar/sacral 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.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent 200 mg (milligram) /1.14 ml (millimeter) SC SOSY (subcutaneous solution syringe)
The insurer denied coverage for Dupixent 200mg/1.14ml SC SOSY
The denial is overturned

This is a pediatric patient with a history of atopic dermatitis with lichenification. The patient has failed topical steroids as well as tacrolimus ointment. Photos from prior visits indicate that the lesions are lichenified and thick with significant scale on the extremities which appear to necessitate systemic therapy. The patient improved after being provided with samples of Dupixent. The requested medication is Dupixent 200mg/1.14mL (SC) (SOSY). 

Dupixent is medically necessary for the treatment of the patient's diagnosis, atopic dermatitis. The patient is a child with decreased systemic treatment options available which could safely be administered given the patient's age. The patient has failed topical steroids and non-steroidal therapies. The lesions are extensive and lichenified and thus require systemic therapy. Prednisone, cyclosporin, azathioprine, and methotrexate all have significant risks, especially for a child. Dupixent is Food and Drug Administration (FDA) approved for children and offers significantly less risk of toxicity. As such, Dupixent is approved for use in the treatment of the patient's atopic dermatitis under close medical supervision and at an appropriate dosing schedule at the discretion of the treating physician.  

Based on the above, the insurer's denial must be overturned. 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 Dupixent 200mg/1.14ml SC SOSY is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, heart disease and dementia

Treatment: Personal care assistance services, a total of 134 hours per week

The insurer denied coverage for personal care assistance services, a total of 134 hours per week

The denial is overturned.

This is an elderly patient with a history of stroke, heart disease and dementia. The patient was living with the spouse in a private residence. The patient was a resident in a nursing facility at the time of the most recent assessment. The request is for Personal Care Assistance (PCA) services, a total of 134 hours per week.

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "Severely impaired." The patient is totally dependent for instrumental activities of daily living (IADL) including meal preparation, ordinary housework and managing finances. The patient requires maximal assistance for bathing, lower body dressing, ambulation and toilet transfer and use. The patient is incontinent of bowel and bladder. Extensive assistance is needed for upper body dressing, bed mobility and eating. The patient's severe cognitive status and limited functional ability are much the same as documented in the previous UAS report. However, after the more recent falls, hospitalization and current nursing facility length of stay, the patient's deconditioned status in addition to severe and progressive dementia, total dependence for IADL and extensive to maximal assistance for Activities of Daily Living (ADL) tasks, support the medical necessity of the requested 134 hours per week PCA services. Based on the enclosed documents reviewed, the patient's health and safety can be more appropriately provided and maintained by the requested PCA services, 134 hours per week; upon the patient's return home from the nursing facility. 

Based on the above, the insurer's denial must be overturned. 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 personal care assistance services, a total of 134 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female with asthma. The patient presented complaining of fever and right sided back pain. The patient was found to have pyelonephritis with a three-millimeter mid-ureteral stone on computed tomography (CT) of the abdomen. The patient was administered ceftriaxone and was given intravenous fluids. She continued to have back pain and nausea but denied fever, chills, chest pain, vomiting, or diarrhea. 

The proposed inpatient hospital admission was not medically necessary. 

The treatments the patient received (computed tomography, ceftriaxone, and intravenous fluids) did not require an inpatient level of care. It would have been safe and effective to treat the patient at a lower level of care. The patient was stable at the time of admission as evidence by stable blood pressure and respiratory status; there were no critical labs or other findings. Observation level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headaches. 
Treatment: Full Hospital Admission. 

The insurer denied: Full Hospital Admission. 
The denial is overturned. 

The patient is an adult female who presented to the Emergency Room with complaints of right-sided headaches for the prior four to five days associated with neck stiffness and unilateral arm weakness. There was also severe nausea and vomiting. Diplopia was also noted. Differential diagnoses included intracranial hypertension, optic neuritis, posterior reversible encephalopathy syndrome (PRES), transient ischemic attack (TIA) and stroke. The patient was admitted, and neurology was consulted. Permissive hypertension was allowed. Headache was also not controlled with oral medication including Tylenol. The inpatient stay was denied as it did not meet medical necessity for inpatient admission. 

The proposed full inpatient admission was medically necessary. 

Inpatient admission was medically necessary. The patient had severe headaches that were not controlled with oral medications. She had a severe headache and is over the age of 50 which warranted further workup and monitoring given potential for subarachnoid hemorrhage. Furthermore, stroke was in the differential and permissive hypertension was indicated. This cannot be done in the outpatient setting and requires telemetry monitoring and frequent neurological checks.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glioblastoma

Treatment: Riluzole 50 milligrams (mg) Tablet.

The insurer denied coverage for Riluzole 50 milligrams (mg) Tablet.

The denial is upheld.

This case involves an adult patient with a request for Riluzole 50 milligrams (mg) Tablet. The clinical note stated the patient had complaints of more memory problems as well as weakness in the lower extremities. Past medical history was significant for right occipital glioblastoma with resection. It was noted a magnetic resonance imaging (MRI) of the brain showed a new enhancing lesion in the right cerebellum suspicious for a tumor. The provider noted that it was unclear if findings were representative of disease progression versus postradiation therapy changes. The treatment plan was for ongoing therapy with addition of Riluzole and to rescan in 4 weeks. The appeal letter stated Riluzole has been shown to possess anticancer properties in multiple studies. The medication was being recommended for the patient given the diagnosis of glioblastoma status post resection followed by radiation and adjuvant therapy. It was noted that the patient's tumor originates from the cerebellum primarily where further growth will result in worsening symptoms.

The Riluzole 50mg Tablet is not considered medically necessary for this patient. In this case, there is a lack of high-quality scientific literature to support the use of Riluzole in the treatment of glioblastoma. The medication is being used off-label and not supported as safe and effective by the literature. The majority of the literature is on animals and there is a lack of long-term studies to demonstrate safety and efficacy in human patients. As discussed by Blyufer et al., "of note, Riluzole in combination with rapamycin (mTOR) or serine/threonine (AKT) inhibitors had promising results in vitro and in xenograft studies in melanoma with these mutations, and in glioblastoma. While the majority of these studies are limited and confined to animal experiments at the most, they may provide information on mechanisms of action of Riluzole or possibly lead to clinical trials in the future."

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 Riluzole 50mg Tablet is not substantiated.