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

Diagnosis: Malignant Neoplasm of Temporal Lobe.
Treatment: Xpovio.
The insurer denied: Xpovio.
The denial is upheld.

The patient is an adult female with GBM (glioblastoma multiforme) progressed on temodar + (plus) xrt (photon radiotherapy). Her provider has now requested Xpovio (Selinexor).

The requested Xpovio is not medically necessary.
The drug Selinexor is not currently approved or supported to treat GBM (glioblastoma multiforme). While there are some preliminary studies of Selinexor to treat GBM (glioblastoma multiform), these are not sufficient to support the routine use of this agent in the treatment of GBM (glioblastoma 
multiforme). The NCCN (National Comprehensive Cancer Network) does not recognize the use of Selinexor to treat GBM (glioblastoma multiforme) at this time. "Median selinexor concentrations in resected tumors from patients receiving presurgical selinexor was 105.4 nanomoles per liter (range 39.7291 nanomoles per liter). In Arms B, C, and D,  respectively, the PFS6 [6-month progression-free survival rate] was 10% [95% confidence interval (CI), 2.7935.9], 7.7% (95% confidence interval, 1.1750.6), and 17% (95% confidence interval, 7.7838.3). Measurable reduction in tumor size was observed in 19 (28%) and RANO [Response Assessment in Neuro-Oncology]-response rate overall was 8.8% [Arm B, 8.3% (95% confidence interval, 1.027.0); C: 7.7% (95% confidence interval, 0.236.0); D: 10% (95% confidence interval, 2.126.5)], with one complete and two durable partial responses in Arm D. Serious adverse events (AEs) occurred in 26 (34%) patients; 1 (1.3%) was fatal. The most common treatment-related AEs [adverse events] were fatigue (61%), nausea (59%), decreased appetite (43%), and thrombocytopenia (43%), and were manageable by supportive care and dose modification. 
Molecular studies identified a signature predictive of response (area under curve = 0.88)." (3)
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Nerve treatment in the spine 
The insurer denied Nerve treatment in the spine.
The determination is overturned.

This is a patient with a one-year history of low back pain. The pain is in the low back with occasional radiation to left buttock and both groins. The low back pain has been progressively worsening. His pain level is 8/10 with increased pain from prolonged sitting and flexion. He had tried chiropractic manipulation, trigger point injections with mild effect. The physical exam (PE) was unremarkable except for decreased range of motion (ROM) of the lumbar spine and pain with flexion. The lumbar spine magnetic resonance imaging (MRI) report indicated multilevel degenerative disc disease with mild bone marrow edema at lumbar (L) 4.
At issue is whether the nerve treatment in the spine likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The nerve treatment in the spine is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The intraosseous nerve ablation procedure ( INTRACEPT ) was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. He had tried chiropractic manipulation, Trigger point injections and non-steroidal anti-inflammatory drugs (NSAIDs) without adequate improvement. Further interventions are necessary to improve his pain and function. Other potential treatment options are long-term use of medications including 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Neck/back pain.
Treatment:   Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level.

The insurer denied Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level. The health plan's determination is upheld. 

This is a female patient diagnosed with lumbar radiculopathy, Vertebrogenic Pain, Intractable Chronic Migraine without Aura and without Status Migrainosus, Cervical Spinal Stenosis, Degenerative Disc Disease (Lumbar). Records show that requests for Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product was denied by the health plan as experimental and investigational. The provider notes that the patient has chronic back pain and has tried multiple conservative treatments including nonsteroidal anti-inflammatory drugs, analgesics, opioids, physical therapy, home exercise program, and epidural steroid injections. 

The Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Low back: Not recommended for low back conditions including fusion or low back pain. An systematic review (SR) / MA (meta-analysis) of platelet-rich plasma (PRP) efficacy for chronic low back pain identified 6 studies (196 patients) of intradiscal injection for disk degeneration, 5 studies (670 patients) of epidural injection, 3 studies (151 patients) of lumbar facet joint injection, and 3 studies (54 patients) of sacroiliac joint injection; all but one study was observational. Trending of improved pain scores were noted at 12-month follow-up in the MA of the epidural and lumbar disc injection groups, while MA could not be performed in the other categories. However, findings were limited by heterogeneity, small sample size, and lack of clinically meaningful results." While it appears the patient has had chronic back pain that has not significantly responded to prior conservative management and epidural steroid injections, there are alternative treatments as well as traditional surgical measures that can be utilized.

There is no evidence to suggest this treatment is superior to that of standard means of treatment for this condition and it would not be considered medically necessary or standard of care as a remains experimental and investigational. Further studies are needed to establish long-term safety and efficacy of this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Neck/back pain.
Treatment:   Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level.

The insurer denied Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level. The health plan's determination is upheld. 

This is a female patient with Lumbar Radiculopathy, Vertebrogenic Pain, Intractable Chronic Migraine without Aura and without Status Migrainosus, Cervical Spinal Stenosis, and Degenerative Disc Disease (Lumbar). The patient is noted to have a history of chronic low back pain and has previously undergone treatment including multiple medications, physical therapy, home exercise program, and epidural steroid injections. Lumbar spine magnetic resonance imaging (MRI) showed early to moderate disc degeneration at L (lumbar)4 - L5, disc bulge/protrusion L4 - L5, annular fissure L5 - S (sacral)1. It was noted that the patient underwent provocative discography identifying L4 - L5 with concordant pain. 

There is no evidence that the proposed Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Intradiscal procedures including Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product are not considered standard of care because their effectiveness has not been established. Per Beall et al., "This study is supported by data demonstrating that improved pain and function at 12 months can be attained with a supplemental viable disc matrix. Subjects receiving the VIA Disc Matrix achieved improvements that were durable at 12 months." However, this was a small study with only 24 patients. Further studies would be optimal to confirm efficacy. There is insufficient long-term data regarding long-term efficacy of this procedure. Therefore, the requested procedure is not likely to be more beneficial than standard treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Neck/back pain.
Treatment:   Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level.

The insurer denied Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level. The health plan's determination is upheld. 

The patient is a female with a history of chronic neck pain, low back pain and migraines. She has been treated with epidural injections and Botox injections. She has been treated with anti-inflammatories, muscle relaxers, antidepressants, gabapentin, and oxycodone. Magnetic resonance imaging (MRI) of the lumbar spine revealed disc displacement with degenerative changes at L (lumbar) 4-5 L5-S (sacral)1.

The proposed Percutaneous Injection of Allogenic Cellular and/or Tissue-Based Product, Intervertebral Disc, Unilateral or Bilateral Injection, with Fluoroscopic Guidance, Lumbar, First Level is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The function of the intervertebral disc is structural. Loss of tissue alters biomechanics, leads to subsequent disc degeneration, and is attributable to discogenic pain.

Various biological techniques have been developed and tested to treat the degenerative intervertebral disc. Common to each has been the aim to sustain delivery of biologically active factors to the disc that might guide regeneration or at least retain the status quo of the affected tissue and retard further regeneration.

Delivery of a growth factor, or other singular novel factor by intradiscal injection is one method that has been researched to restore degenerated discs.

Although this type of allograft technology can be administered in a controlled, safe, and regulated environment it is not fully understood whether the cells can differentiate and survive or produce signaling agents that cause the intervertebral disc to heal. The American Society of Interventional Pain Physicians (ASIPP) guidelines on "Responsible, safe, and effective use of biologics in the management of low back pain" (Navani et al., 2019) stated that there is Level III evidence for intradiscal injections of PRP and mesenchymal stem cells.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis suppurativa

Treatment: Cosentyx Pen (2 Pens) 15 milligram (mg)/milliliter (ml) pen injector

The insurer denied coverage for Cosentyx Pen (2 Pens) 15 mg/ml pen injector

The denial is overturned

The patient is an adult female with a diagnosis of severe hidradenitis suppurativa affecting the axilla and umbilicus. According to the submitted documentation, she has failed therapy with topical agents, oral antibiotics, light therapy, and Humira. The requested medication is Cosentyx.

Based on the submitted documentation, Cosentyx is medically necessary in the treatment of the patient's hidradenitis suppurativa. The patient has failed oral antibiotics as well as Food and Drug Administration (FDA) approved Humira for the treatment of her condition. It is noted that the patient had an adverse reaction to Humira, psoriasiform dermatitis which may preclude continued use of Humira. There is evidence to support a possible benefit of Cosentyx in this clinical scenario in which FDA approved therapies have been exhausted. As noted by Up to Date, clinical studies have shown benefit with no adverse events. The use of Cosentyx is medically necessary in this clinical scenario.  

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 Cosentyx Pen (2 Pens) 15 mg/ml pen injector services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dyspnea
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a male who was admitted to the hospital for fever and dyspnea. He has a history of renal cell carcinoma, diabetes, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), depression, anxiety, and hypogonadism. On presentation, vitals were stable. There was a history of renal cell carcinoma status post partial nephrectomy as well as laryngectomy from head and neck cancer. The patient was discharged recently for aspiration pneumonia. He had a recent diagnosis of aspergillus on bronchoscopy. Chest x-ray was noted to be unchanged on admission with improved opacities. Zosyn and Voriconazole was started. Pulmonary was consulted. 

Yes. The requested inpatient hospital admission was medically necessary for this patient. Per Milliman Care Guidelines (MCG) criteria, the patient was hypoxic which meets this requirement. The patient was on trach collar oxygen which was a new requirement. Additionally, according to Ware et al., (2005) and Clark et al., (2013), the patient had a new pulmonary embolism and this in the setting of the severe dysphagia, and persistent cough and dyspnea with persistent bradycardia made it most appropriate for inpatient management. Observation would not have been appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ruptured ectopic pregnancy

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient presented to the emergency room (ER) with complaints of abdominal pain. She was diagnosed with a ruptured ectopic pregnancy. She underwent an exploratory laparotomy and left salpingectomy and was discharged home.

This patient underwent a laparotomy. The standard of care is for patients who undergo an open procedure such as a laparotomy, is to stay in the hospital for up to 48 hours. Typically, on postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate and clear liquids are started. On postoperative day 2, if the patient is passing flatus, and tolerating regular diet she is discharged home.

This patient was discharged home a day earlier than standard (on postop day 1). The admission was medically necessary and should be approved based on Milliman Care Guidelines (MCG) Laparotomy criteria. 

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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness

Treatment: Inpatient evaluation

The insurer denied coverage for the inpatient admission 

The denial was upheld.

This case involves an elderly patient who came to the emergency department complaining of dizziness and a fall.  She claimed to have suffered multiple episodes of falls since that morning due to dizziness and claimed the room was spinning.  She denied weakness to any hemisphere and denied having any urinary complaints.  She did report left shoulder pain and left hip pain given her fall and reported history of diabetes mellitus and hypertension.  She was not taking blood thinners at the time of her assessment.  Triage assessment noted stable vital signs other than an elevated blood pressure at 167/55.  She had a history of other falls within the past 6 months described as a physiological fall.  She stated that dizziness worsened with head movements in all directions.  Her examination was relatively unremarkable.  The physician admitted the patient due to risk factors for cerebrovascular accident versus acute cardiovascular syndrome for further evaluation and management.  

The Milliman Care Guidelines state  that admission for inpatient care for those individuals who are suffering from dizziness is indicated by 1 or more of the following to include either acute bacterial otitis, cerebellar, brainstem, or cerebral ischemia or hemorrhage, suspected etiology requires admission for treatment (for example, vertebral artery dissection), hemodynamic instability, signs or symptoms that are severe and persistent, vomiting that is severe persistent, cardiac arrhythmias of immediate concern, severe neurologic findings requiring inpatient care as indicated by either papilledema, cerebral edema, mass-effect on CT scan, cerebral bleeding, ischemia, or vasospasm, or those who have increased intracranial pressure hydrocephalus.  Admission may also be indicated for the individual who requires intracranial pressure monitoring.  

The information provided for the review did not support that the patient met any of the above-stated criteria.  It was determined that her additional work-up and care could have been rendered on an outpatient or observational basis.  

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

Diagnosis: Sickle Cell Disease

Treatment: an inpatient admission 

The insurer denied coverage for an inpatient admission

The denial is upheld

According to the medical records, the patient is a young adult with sickle cell disease, who presented with abdominal pain. Vital signs were normal. The patient presented to the emergency room (ER) with complaints of a three-day history of abdominal pain. The patient was given a one-liter intravenous (IV) fluid bolus, Zofran, Acetaminophen, Toradol, and Ceftriaxone for a possible urinary tract infection (UTI), and IV morphine. 

The patient was admitted with a sickle cell crisis. A rising white blood cell (WBC) count was likely reactive. During the admission the patient was continued on IV fluids, pain medications, hydroxyurea, and folic acid. The patient was discharged with instructions to take 300 milligrams (mg) of oral (PO) Cefdinir every 12 hours (Q12H) for a day. 

The inpatient hospital admission is not considered medically necessary for this patient. There was no indication that this was a pain crisis of unusual severity or risk.

"The gold standard for pain assessment and diagnosis is patient self-report. There are no reliable diagnostic tests to confirm the presence of acute or chronic pain in individuals with Sickle Cell Disease (SCD) except when there are identifiable causes like avascular necrosis on imaging or leg ulcers on exam. The effects of pain on an individuals' function are assessed using patient-reported outcome measures (PROs) that determine to what extent pain interferes with an individuals' daily function. Tools shown to be valid, reliable and responsive can be used in clinical practice to track patients' pain-related function over time to determine additional treatment needs and to compare to population norms. There are currently no plasma pain biomarkers that improve assessment and management of SCD acute or chronic pain." (Brandow, A. M. et al. 2022).                                                         

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

Diagnosis: Psoriasis
Treatment: Cosentyx
The insurer denied coverage for Cosentyx.
The denial is upheld.

The patient is a young adult with a diagnosis of psoriasis predominately affecting the hands and elbows. The patient has failed topical steroid and limited light therapy excimer treatments. The patient recently completed a course of isotretinoin for acne, a category X (contraindicated) drug. The requested medication is Cosentyx.

Based on the submitted documentation and the standard of care, Cosentyx is not medically necessary. The patient has failed topical therapy and has no true contraindications to numerous appropriate available treatment modalities which would make the use of Cosentyx medically necessary. There are no definitive, comparative, controlled head-to-head studies showing that Cosentyx has a superior efficacy or safety profile to reasonable alternatives such as Humira or other formulary biologics. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient.

There is no documentation to suggest that Cosentyx would be more effective than available formulary alternatives or that the patient has an absolute contraindication to a preferred medication which would specifically necessitate Cosentyx.

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 patients. The medical necessity for Cosentyx is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Edentulism
Treatment: False tooth bridge for teeth # 5, 7, 8, 10, 20, 29, 27, 25, 24 and 12.
The insurer denied:  False tooth bridge for teeth # 5, 7, 8, 10, 20, 29, 27, 25, 24 and 12.
The denial is overturned.

The patient is a male who presented to the office of his dental provider for evaluation and treatment. Included for review are previous letters of appeal and denial, full mouth radiographic images, full mouth panoramic radiographic image, one page of American Dental Association (ADA) claim forms, and health plan language.

The subject under review is the medical necessity for the false tooth bridge.

The health plan's determination is overturned.

The previous denial of false teeth for fixed partial denture (bridge) according to the health plan was because the patient must be missing only one upper front tooth or only two lower front teeth. Further, to receive a pontic tooth the patient cannot be missing any posterior teeth. This rationale is not based on any medical or dental science. With the diagnosis of partial edentulism the only treatment is that of tooth replacement. Since the patient has multiple missing teeth being addressed with dental implants, those implants will support the fixed partial denture in order to also address the diagnosis of diminished posterior support. This is the standard in scientific and clinical treatment of missing teeth. Hence the requested treatment is medically necessary.