Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Vertebrogenic Low Back Pain. 
Treatment: Intracept Procedure (64628, 64629). 
The insurer denied: Intracept Procedure (64628, 64629). 
The denial is upheld. 

The patient is an adult male who has chronic low back pain. An Intracept procedure has been requested. The procedure was denied as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, and home exercises. The patient has failed multiple medications including potent opiate medications. 
Magnetic resonance imaging (MRI) shows no Modic changes. Physical exam does not reveal any neurological injury. 

The health plan should not cover the proposed treatment. 

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. An Intracept procedure has been requested. The procedure was denied as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, and home exercises. The patient has failed multiple medications including potent opiate medications. Magnetic resonance imaging (MRI) does not show Modic changes. Physical exam does not reveal any neurological injury. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new United States Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically use 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, this patient has not failed or attempted facet interventions or sacroiliac joint injections, which are common treatments of axial low back pain. The Intracept procedure should not be employed until after all conventional and evidence proven alternatives have failed. In addition, according to the magnetic resonance image report, no Modic changes are seen. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Vertebrogenic Low Back Pain
Treatment: Intracept Procedure (64628, 64629)
The insurer denied: Intracept Procedure (64628, 64629)
The denial is upheld.

The patient is an adult male with low back pain that began over five years ago. Past treatments include epidural steroid injections, trigger point injections, physical therapy, oxycodone, lidocaine patches, and tizanidine. Pain ranges from 4/10 to 6/10. Magnetic resonance imaging (MRI) of the lumbar spine shows multilevel disc bulges/protrusions most pronounced at right L (lumbar) 5-S (sacral) 1 with moderate foraminal stenosis and a large L3 hemangioma. Request for L4-S1 Intracept was denied as experimental/investigational.

The health plan should not cover the proposed treatment.

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

Diagnosis: Urinary frequency and fever
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult male with history of hemoglobinopathy, recurrent admissions for pyelonephritis and treatment non-compliance who presented to the hospital with urinary frequency and fever. The patient had abdominal computed tomography done and was given antibiotics and fluids. The patient was hemodynamically stable with stable electrolytes and cardiac status tolerating oral intake and with pain controlled. Based on available data and the health plan denial letter, the requested inpatient level of care did not meet Milliman Care Guidelines (MCG) criteria. The physician is appealing the determination.

The requested health service was not medically necessary.

Based on the available documentation and Milliman Care Guideline (MCG) criteria, there was no reported indication of hemodynamic instability, vomiting that was severe or persistent, altered mental status that is severe or persistent, persistence or worsening of clinical findings despite observation care treatment, parenteral antibiotics needed beyond observation care treatment, 
pregnancy with suspected pyelonephritis, renal transplant recipient with pyelonephritis, significant uropathy, bladder emptying impaired, or renal or perinephric abscess. Admission may be indicated for suspected infection of a prosthetic device, renal failure, acute kidney injury, or need for intravenous hydration support or other condition, treatment, or monitoring requiring inpatient admission. Based on the available data, these criteria are not met. Therefore, the requested dates of services are not recommended at an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headache and abdominal tenderness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This is an adult male patient who presented to the emergency room with his wife as he had worsening headache for four days. His wife stated he consumed alcohol daily and he had hit his head five days previously. On exam, there was diffuse abdominal tenderness. Labs showed elevated troponin, liver function tests (LFTs) (alanine aminotransferase [ALT] of 155, aspartate aminotransferase [AST] of 470), amylase, lipase (1025), and alcohol level at 324. Computed tomography (CT) of the abdomen/pelvis with contrast showed hepatosplenomegaly, fatty liver, and prominently distended gallbladder without obvious stones. Abdominal ultrasound limited to the right upper quadrant showed hepatomegaly and hepatic steatosis. The gallbladder contained a small amount of sludge, without evidence of 
cholelithiasis or cholecystitis. Initial treatment was nothing by mouth (NPO) and advance as tolerated, intravenous fluids, 
Dilaudid for pain control, and Zofran intravenous for nausea. Gastroenterology (GI) was consulted, and the patient's diet was advanced as tolerated. He was also put on an Ativan taper for alcohol withdrawal and daily Clinical Institute Withdrawal Assessment (CIWA) score and pertinent lab work was done. On discharge, the patient's liver function tests were down-trending to 106/197, alkaline phosphatase (ALP) 245, platelet count of 83, and there was normalization of lactate level.

The requested health service was medically necessary.

The patient had alcohol withdrawal requiring close monitoring with the Clinical Institute Withdrawal Assessment (CIWA) scale and treatment with intravenous Ativan. Additionally, the patient had elevated liver function tests that required work up with computed tomography of the abdomen / pelvis and ultrasound of the right upper quadrant. The patient required trending of liver function tests. The patient also had acute pancreatitis necessitating treatment with intravenous fluids and slow advancement of diet. Therefore, the requested health service was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This case involves an adult who presented to the emergency department (ED) from home via emergency medical systems (EMS) with complaints of nausea and vomiting. The patient reported that they went to Urgent Care 3 days prior for thrush and conjunctivitis, and mild nausea/vomiting. The patient reported worsening and persistent nausea/vomiting with multiple episodes of biliary vomiting. Zofran was given by EMS with no relief. In the ED, the patient's blood pressure was 136/84, temperature was 36.8, and oxygen saturation (O2) was 98% (percent) on room air. 

Laboratory results in the ED showed white blood cell (WBC) count of 15.6, neutrophils 77.0%, absolute neutrophil count (ANC) 12.0, potassium 3.4, lactate 2.56, alkaline phosphatase (ALP) 212, and total bilirubin 2.6. Ultrasound showed dependent cholelithiasis and/or sludge. The liver demonstrated heterogenous hyper echogenicity suggesting hepatic steatosis/hepatocellular disease. Computed tomography (CT) of the abdomen/pelvis showed stool throughout the ascending, transverse, descending and sigmoid colon compatible with constipation. The patient was admitted for intractable abdominal pain, nausea and vomiting. The patient was started with intravenous (IV) Zosyn, pantoprazole 40 milligram (mg) IV, bowel regimen and Tramadol. Hypokalemia was also supplemented with oral potassium. The patient reported continued epigastric abdominal pain with no further episodes of vomiting. The following day, the patient decided to elope from the hospital. 
The condition of the patient does not meet the criteria for admission per the Milliman Care Guidelines (MCG).
The care given for the patient is more appropriate in a lower level of care such as outpatient care in emergency department, observation care or a recovery facility.

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 stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Near Syncope.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

This is the case of a patient that presented to the hospital with lightheadedness and near syncope following treatment with lisinopril.  Past medical history was significant for hypertension, chronic obstructive pulmonary disease (COPD) and lung cancer. The patient noted that symptoms correlated with a low blood pressure (BP) at home (80/50). In addition, the patient reported a rash.  On arrival to the hospital vital signs were stable (BP 114/69, pulse 74). Physical exam revealed an erythematous skin rash over neck and arms. Serum blood tests revealed a creatinine of 2.1.  Cardiac enzymes were not elevated. Electrocardiogram (ECG) revealed normal sinus rhythm with normal intervals and no evidence of ST or T wave abnormality. The patient was admitted to the hospital for further testing.  Repeat BP was 77/62 and the patient was treated with intravenous (IV) fluids. Repeat serum creatinine was 1.35 and ultimately, telemetry monitoring revealed no sustained arrhythmia. The patient was discharged the following day. 

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. This patient presented with lightheadedness and near syncope. Physical examination revealed an erythematous rash.  Serum creatinine was elevated but recovered following treatment with intravenous fluids.  No rhythm abnormality was noted on ECG or telemetry. This patient falls into a low-risk group for syncope.  According to American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guidelines, such patients should be managed utilizing a structured emergency department (ED) observational protocol (Reference 1).  In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2).  In this case, the patient immediately responded to treatment with IV fluids. Acute inpatient admission was not medically necessary for this patient. 

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: Overturned

Diagnosis: Congestive heart failure
Treatment: Home health care
The insurer denied Personal Care Assistance Services: 8 Hours per Day, 5 Days per Week - Total of 40 Hours per Week 
The health plan's determination is overturned. 

The patient is a female with past medical history of bladder cancer, congestive heart failure (CHF), seizures, chronic pain, urinary incontinence, hypertension, hyperlipidemia, coronary artery disease, diabetes mellitus type 2, and hypothyroidism who had been assigned PCA (personal care assistant) services. 

Personal Care Assistance Services: 8 Hours per Day, 5 Days per Week - Total of 40 Hours per Week are medically necessary for this patient.
There is documentation the patient needs at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use which are unpredictable and unscheduled care needs and the insurer failed to document a plan to meet the patient's unpredictable and unscheduled care needs. The patient would need assistance with PCA outside of the hours that she has formal and informal support. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The tasking tool underestimated the patient's care needs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a patient with a history of hypertension and Chagas disease that presented to the emergency department (ED) complaining of chest pain and burning for 8 days that was relieved when placing a cold bottle of water over their sternum. Physical examination upon arrival was benign and no abnormalities were reported. 12 lead electrocardiogram (ECG) revealed normal sinus rhythm with a single premature ventricular contraction (PVC), left axis deviation, and poor R wave (interval on ECG) progression across the precordium. No acute ischemic changes were noted. Serum blood testing demonstrated no elevation in troponin (less than 0.1) and no elevation in B type natriuretic peptide. Echocardiogram demonstrated a depressed left ventricular ejection fraction (LVEF) with an LVEF of 35-40% (percent). Chest x-ray revealed clear lungs. Exercise perfusion stress testing demonstrated an LVEF of 47% with a small area of inferoseptal ischemia. Cardiac catheterization was ultimately performed and demonstrated an LVEF of 45% with normal coronary arteries. The patient was treated with guideline directed medical therapy and discharged home. 

This patient presented with highly atypical chest pain, no evidence of an acute ischemic event with negative cardiac enzymes. The patient could have been managed during a period of observation and any testing completed during that time period.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic Congestion Syndrome

Treatment: outpatient services (37241 x 1)

The insurer denied coverage for outpatient services (37241 x 1.)

The denial is overturned.

This case pertains to a patient who presented for their annual gynecological visit. The patient reported having a recent ultrasound. The patient is experiencing pain and nausea all the time along with some lower back pain. The patient has been struggling with constant pelvic pain x 6 months. Ultrasound showed two likely small fibroids in addition to a 5.6 centimeter (cm) slightly complex cyst on the left ovary. 

A magnetic resonance imaging (MRI) of the pelvis showed numerous dilated periuterine varices within the adnexa. There is a 1.4 cm fibroid within the posterior fundus and a round well-defined 1.3 cm cystic lesion in the endocervical canal felt to represent a Nabothian cyst. Impression is diffusely thickened junctional zone compatible with adenomyosis and small fundal intramural fibroid. Dilated periuterine varicosities may also indicate a component of pelvic congestion syndrome. 

A month later, the patient presented for an interventional radiology appointment. The patient reports pelvic pain that is stabbing and continuous that worsens at night. The patient notes seeing Obstetrics and Gynecology (OB/GYN) multiple times with the problem without any intervention. Pelvic MRI revealed thickened junctional zone and dilated periuterine varices. The patient has findings for pelvic congestion syndrome and their symptoms are compatible with the same. The recommended treatment for pelvic vein sclerosis was bilateral gonadal vein embolization. 

The insurer sent a letter to the patient notifying the patient that their request for the bilateral gonadal vein embolization had been denied. They noted the role of this service remains uncertain. It has not been fully proven that it improves health outcomes over usual standard care. The health plan does not cover this service. 

The patient sent a letter of appeal. The patient noted that the pelvic pain has gotten progressively worse and is affecting their daily life and work. The patient notes the pain has reached their lower back and bilateral legs. The patient has heaviness in their legs and groin. 

The review of literature found that the Society for Vascular Surgery and the American Venous Forum published in 2011, embolization with coils, plugs, or sclerotherapy is now recommended as the standard approach for management of pelvic congestion syndrome and pelvic varices. Definitive diagnosis with venography, computed tomography (CT), or MRI can validate the need for this procedure. The MRI showed numerous dilated periuterine varices. As such the coverage of outpatient services (37241 x 1) is medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for outpatient services (37241 x 1) is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Rheumatoid Arthritis
Treatment: Orencia 
The insurer denied Orencia.
The determination is upheld.


This is a female patient with rheumatoid arthritis (RA). Prior treatments included Cimzia, intravenous (IV) Orencia, subcutaneous (SQ) Orencia and Plaquenil (stopped due to gastrointestinal (GI) side effects). The patient has been on Orencia in the past and her provider would like to re-start it. Subcutaneous (SQ) Orencia is being denied by the health plan as the preferred formulary drugs have not been tried. The primary preferred formulary drugs, include Humira, Hyrimoz, Rinvoq and Xeljanz. The secondary preferred drug is Kevzara. Of note, the patient has a latex allergy. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

All formulary medications would be as effective for the treatment of RA. However, Humira and hyrimoz (Humira biosimilar) are not options as the patient has a latex allergy and the needle cover of prefilled syringe and autoinjector of these medications may contain latex. Xeljanz, Rinvoq and Kevzara do not contain latex and thus there is no medical reason the patient cannot try one of these preferred medications as they are indicated for the treatment of RA. For example, as published in N Engl J Med in 2012, "in patients with active rheumatoid arthritis, tofacitinib monotherapy was associated with reductions in signs and symptoms of rheumatoid arthritis and improvement in physical function". Moreover, a paper in Arthritis Rheumatol in 2017 concluded that "sarilumab 150 milligrams (mg) and sarilumab 200 mg every 2 weeks plus conventional synthetic disease modifying anti-rheumatic drugs (DMARDs) improved the signs and symptoms of RA and physical function in patients with an inadequate response or intolerance to anti-tumor necrosis factor (TNF) agents. Safety data were consistent with interleukin-6 receptor blockade and the known safety profile of sarilumab". Like Orencia, Xeljanz, Rinvoq and Kevzara would need to be stopped when pregnant as well. As stated, Humira is not an option due to the patient's latex allergy. There is no reason the patient cannot try one of the latex free drugs on the health plan's formulary.