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

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Surgical Services. 
The insurer denied the Intracept Procedure. 
The denial is upheld.

The patient is male with complaints of axial low back pain. The pain has been present for many years. The patient has a history of a lumbar microdiscectomy in recent years. The patient has been utilizing multiple medications. He has done physical therapy. He has undergone lumbar epidural steroid injection. The patient's diagnoses include low back pain. Magnetic resonance imaging (MRI) of the lumbar spine multilevel degenerative changes. The subject under review is the request for the Intracept procedure.

No. The requested Intracept references intraosseous basivertebral nerve ablation (IBVN). Currently, this modality 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 low back pain patients with type I or II Modic changes who were randomized to IBVN 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 but there is no long-term data supporting the use of this modality. Insufficient evidence exists that this treatment is better than conventional modalities. Given the above, the proposed health service or treatment Intracept is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Surgical Services. 
The insurer denied the Intracept Procedure. 
The denial is overturned.

The patient is a male who has a long-standing history of low back pain. He had a microdiscectomy with alleviation of his leg pain, but the back pain continued. He underwent extensive conservative treatments including acupuncture, physical therapy (PT), home exercise, lumbar epidural steroid injection, and pain medications without pain relief. His pain level is severe (6/10 to 8/10) with significant impact on his activities of daily living (ADL). The physical exam (PE) revealed decreased range of motion (ROM) of lumbar spine. His magnetic resonance imaging (MRI) revealed degenerative endplate changes at lumbar (L)3-4 L4-5 and L5-sacral (S)1 levels.
The subject under review is whether the patient will have more benefit from the Intracept procedure than other treatments.

The proposed health service or treatment Intracept is likely to be more beneficial for this patient.
The Intracept system 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 for vertebrogenic pain. This patient has persistent back pain consistent with end plate degenerative changes with significant impact of ADL. He had tried conservative treatments including pain medications, PT, and epidural injections without success. He is a candidate for the Intracept procedure based on current clinical evidence. The other potential option is lumbar fusion, which is clearly more invasive and associated with higher risks and complications. Given these facts, the Intracept procedure is the most appropriate as the next step in the patient's treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain and Swelling of Forearm.
Treatment: MRI scan of Arm.
The insurer denied the MRI scan of Arm.
The determination is overturned.

The patient has a two-week history of pain and swelling over the distal third of the left forearm. There is no known history of injury. She has pain with pronation and supination of the forearm, and the distal third of the forearm appears larger on the left compared to the right. At issue is whether a magnetic resonance imaging (MRI) scan of the forearm is medically necessary.
The MRI scan is medically necessary. Unexplained swelling of an extremity, in the absence of injury or other clear explanation, requires investigation. Possible causes of the swelling could include an unrecognized injury, inflammatory disease, bone or soft tissue infection, or tumor. Evaluation might include blood work to look for evidence of an inflammatory process, and imaging studies to try to characterize the swelling (e.g., distinguishing between edema and neoplasm.) Although other imaging modalities such as ultrasound might be considered, MRI would provide a more definitive and better-localized picture of what is going on. Physical therapy has no reasonable role in the evaluation of a soft tissue mass. Analgesic or anti-inflammatory medication can reasonably be expected to help with pain, but do not help to establish the diagnosis, which is the chief concern when evaluating a soft tissue mass.
The MRI would be considered medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine
Treatment: Ubrelvy
The insurer denied Ubrelvy. 

The health plan's determination is upheld. 

The patient is a  woman with chronic migraines. Treatment with Ubrelvy is the subject of this review. The drug was denied because the patient has not tried and failed two triptans drugs and Ubrelvy will be used in combination with Aimovig. The provider appealed the determination. The patient has tried and failed rizatriptan.

A formulary exception is not indicated. The patient has tried and failed rizatriptan and Nurtec ODT (oral disintegrating tablet). The formulary includes multiple other triptan medications including Frovatriptan, Naratriptan, Eletriptan, Almotriptan, Sumatriptan, Nurtec ODT, Zembrace Symtouch, and Zomig,
The remaining formulary alternatives are triptan drugs. The patient has only tried and failed one triptan drug, rizatriptan. Failure to one triptan drug does not predict failure to other triptan medications as these drugs have various routes of administration including injection, nasal spray, and orally disintegrating tablets. The drugs also different by potency and half-life. As such, it cannot be said that the formulary drugs will be in effective or it would not be as effective as the non-formulary drug, Ubrelvy.

The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Otezla 30 milligram tablet. 
The denial is upheld.

The patient is a male with psoriatic arthritis. Per a letter from the patient's provider, the patient has been on Otezla for four years. Cosentyx was added to his treatment regimen five months ago. He has tolerated both medications well without side effects and with improved relief of symptoms. Prior treatment that he has tried and failed include Remicade, methotrexate (MTX), sulfasalazine (SSz) and calcipotriene. Otezla was denied by the health plan, with the reason cited as not medically necessary as this drug is being prescribed with Cosentyx. The subject under review is the medical necessity for Otezla for this patient.

The health plan's determination is upheld.

Otezla 30 milligram (mg) tablet is not medically necessary for the patient at this time. While there is some data supporting the use of Otezla with a biologic, biologics are most widely used as monotherapy or in combination with a disease modifying anti-rheumatic drug (DMARD) and not Otezla. The majority of data on Otezla is when it is given as monotherapy or in combination with MTX. A study published in the Journal of Rheumatology in 2015 concluded that "continuous apremilast treatment resulted in sustained improvements in psoriatic arthritis (PsA) for up to 52 weeks. Apremilast had an acceptable safety profile and was generally well tolerated." This combination of drugs, (Otezla with a biologic), has not been well studied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an increase in PCA hours. 
The denial is upheld. 

The patient is a female with a past medical history significant for dementia, hypertension, hyperlipidemia, diabetes, heart disease, emphysema, osteoarthritis, anxiety, schizophrenia, and neurocognitive disorder. the patient has had a progressive decline of her cognitive ability secondary to dementia versus psychiatric illness. The patient currently receives 42 hours a week of services. Services were denied based on medical necessity. The patient is appealing the decision.
At issue is an increase in Personal Care Aide(PCA) Level 2: 8 hours per day-7 days per week-for a total for 56 hours per week.

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

The requested health service of Increase in Personal Care Aide (PCA) Level 2: 8 hours per day-7 days per week-for a total for 56 hours per week is not medically necessary for this patient.
Services were partially approved by the health plan increasing her hours from 38.5 hours a week to 42 hours a week stating she does not meet the criteria for additional services. Her activities of daily living (ADL) status were the same for dressing upper body, personal hygiene, walking, locomotion, toilet transfer, toilet use, eating, medication management and housework. The following abilities declined, dressing lower body bed mobility, bathing, and meal preparation. Services were increased 3.5 hours a week due to the decline.
Tasking tool noted a total of 42 hours a week of services. A physician statement recommends 40 hours a week , 5 days a week times () 8 hours a day. In a progress note, the patient was reported as psychiatrically stable.
The patient has had a noted decline in her physical abilities including dressing lower body, bed mobility, bathing, and meal preparation. She was previously approved for 38.5 hours a week. Due to this decline her services were increased to 42 hours a week. The patient and family are requesting an increase in services to 56 hours a week, however there is insufficient documentation provided to support increased hours beyond 42 hours a week. The additional hours requested were for help to remind the patient to eat appropriately and take her medication at specific times due to her decreasing cognitive abilities from dementia. Additional services for reminding and prompting the patient without specific ADLs being performed are not medically necessary. In order for services to be considered medically necessary, the aid must be performing a service such medically necessary ADL or Instrumental activities of daily living (IADL).
Therefore, the requested health service of Increase in Personal Care Aide (PCA) Level 2: 8 hours per day-7 days per week-for a total for 56 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Hepatitis.
Treatment: Mavyret Tab 100-40mg .
The insurer denied Mavyret Tab 100-40mg (12 weeks). 
The health plan's determination is overturned in part. 

The patient is a female with chronic Hepatitis C, genotype 3. She has failed PEG-interferon with ribavirin for 24 weeks. Viral load was 2,600,000. FibroScan showed liver stiffness of 7.0. She is reported to be non-cirrhotic. Under review is the use of Mavyret 100-40 milligrams (mg) for 12 weeks for the treatment of chronic Hepatitis C, genotype 3.

Mavyret 100-40 mg is medically necessary for 8 weeks in non-cirrhotic genotype 3 patients with chronic Hepatitis C. The current medical literature does not support 12 weeks of Mavyret therapy based on the provided documentation. According to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic Hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions (Class I, Level A recommendation). According to the guideline, the guideline "no longer contains retreatment recommendations for interferon or interferon plus first generation protease inhibitor failures because the cure rates with modern direct-acting antiviral regimens in these populations were comparable to treatment naive patients" . In cirrhotic or non-cirrhotic genotype 3 patients who have failed an interferon regimen such as this patient, Mavyret for 8 weeks is recommended as first-line therapy. This is based on a 95% cure rate in the ENDURANCE-3 trial, as well as multiple subsequent studies.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine myomas
Treatment: Laparoscopic Ablation of Uterine Fibroids
The insurer denied the Laparoscopic Ablation of Uterine Fibroids
The denial is upheld.

The patient is a female with symptomatic uterine myomas. She was recommended treatment with a laparoscopic ablation of uterine fibroids using radiofrequency technology. Coverage was denied since the procedure is deemed by the health plan to be experimental or investigational.

No, the health plan should not cover the Laparoscopic Ablation of Uterine Fibroids.
The use of this technology in the management of uterine myomas is deemed to be experimental/investigational, and thus should not be covered. This treatment lacks data from well-conducted, prospective studies to show that it has efficacy and long term safety. It is not standard of care. It is not supported by peer-reviewed data, and would be appropriate to offer in the setting of a clinical trial, requiring IRB (institutional review board) approval and patient signed informed consent.

No, the Laparoscopic Ablation of Uterine Fibroids is not more beneficial.
The use of this technology in the management of uterine myomas is deemed to be experimental/investigational, and thus should not be covered. This treatment lacks data from well-conducted, prospective studies to show that it has efficacy and long term safety. It is not standard of care. It is not supported by peer-reviewed data. It is not supported by professional societies and lacks data to show that it equivalent, or superior and as safe as other treatment options.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrotic Syndrome

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld.

The patient has chronic kidney disease secondary to focal segmental glomerulosclerosis was admitted for swelling and volume overload.   She was found to have hyperkalemia; however the specimen was hemolyzed. She was treated with diuretics and was discharged in stable condition.

The patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, no documentation of refractory pain.  She was able to tolerate oral diet and did not require total parenteral nutrition and her condition responded to intravenous fluid and antibiotics.

There is no evidence-based literature supporting inpatient level of care was medically necessary.  Her condition could be treated safely under lower level of care.  

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Myocardial perfusion imaging (MPI) 
The insurer denied myocardial perfusion imaging (MPI).
The determination is overturned.

The patient has cardiac risk factors of hypertension, hyperlipidemia and obesity. She presented to the emergency department complaining of chest pain. When seen in follow-up, she reported recurrent episodes of pain. Cardiac stress testing with single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) was recommended. The medical necessity for the MPI is at issue.
 Based on the information provided the requested service is medically necessary.
This patient, with multiple cardiac risk factors, has complaints of chest pain. Based on her age, gender and risk factors she is at least at intermediate risk for atherosclerotic cardiovascular disease. The diagnostic accuracy of testing with imaging is superior to that of electrocardiographic (ECG) stress testing alone. In addition, in most studies, stress imaging is estimated to provide a benefit over exercise ECG at a reasonable cost, commensurate with accepted values for cost effectiveness, a result driven primarily by more frequent angiography and adverse cardiovascular events for those with a negative exercise electrocardiogram. For this reason, current guidelines, including the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons (ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS) 2013 Multimodality Appropriate Use Criteria for the Detection and Risk Assessment of Stable Ischemic Heart Disease and the 2021 American Heart Association, American College of Cardiology, American Society of Echocardiography, American College of Chest Physicians, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance (AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain, support the use of stress testing with myocardial perfusion imaging in patients such as this patient, who are at least at intermediate risk for obstructive coronary artery disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Headaches
Treatment: Emgality 120mg (milligram)/ml ((milliliter) Per Injector, Pre-service
The insurer denied the Emgality 120mg/ml Per Injector, Pre-service
The denial is upheld.

The member is a female with migraine headache disorder. She has tried and failed Aimovig. She is currently treated with Botox, bupropion, duloxetine and naratriptan. The provider indicated that beta-blockers and calcium channel blockers are contraindicated due to "pre-syncopal" and topiramate is contraindicated due to being underweight. The provider has requested Emgality. This was denied coverage as she is not at least 18 years of age.

No. The proposed treatment is not medically necessary.
There are no high quality clinical trials or standard of care guidelines to support the safety or efficacy of CGRP (calcitonin gene-related peptide) inhibitors for the treatment of migraine in person under the age of 18. Expert opinion indicates that CGRP (calcitonin gene-related peptide) inhibitors should only be considered in circumstances in which the patient has tried and failed conventional treatments (Szperka et al.). Here, the member has not tried available conventional treatment and anticipatory side effects (e.g. "pre-syncopal" or weight loss) do not preclude the use of zonisamide, topiramate, beta-blockers or verapamil for this member. In addition, this member is currently treated with Botox. There are no high quality clinical studies or standard of care guidelines demonstrating that Emgality is safe or effective when used with Botox for the prevention of migraine. The pivotal trial leading to the FDA (Food and Drug Administration) approval of Emgality (Detke et al.) for migraine prevention excluded persons who were treated with Botox at study commencement. Recent review (Pellesi et al.) concluded that "there is currently only indirect preclinical evidence to support a rationale for dual therapy with anti-calcitonin gene-related peptide monoclonal antibodies and botulinum toxin type A for chronic migraine prevention" and that "Rigorous studies evaluating clinical efficacy, safety, and effectiveness are needed."  Therefore, the safety and efficacy of Emgality combined with Botox remains undetermined.

Yes. The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Fibroids

Treatment: Current procedural terminology (CPT) code 37243 vascular embolization occlusion or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction and CPT code 36247 selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family x 2 and associated codes

The insurer denied coverage for current procedural terminology (CPT) code 37243 vascular embolization occlusion or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction and CPT code 36247 selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family x 2 and associated codes.

The denial is overturned.

The patient was diagnosed with symptomatic fibroids.  The magnetic resonance imaging (MRI) of the pelvis with and without contrast revealed an exophytic left uterine fibroid.  The patient's worst symptom was severe pelvic pain, cramping in nature, coinciding with her menstrual cycle.  The patient underwent a uterine fibroid embolization. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

For treatment of symptomatic uterine fibroids, uterine fibroid embolization (UFE) is a safe and effective nonsurgical alternative to hysterectomy and myomectomy. Uterine artery embolization is a known efficacious minimally invasive therapeutic procedure for the treatment of symptomatic uterine fibroids for patients that are poor surgical candidates or who desire to not have a hysterectomy or myomectomy.  The American College of Radiology (ACR) appropriateness criteria noted that uterine artery embolization (UAE) was appropriate when compared to other treatments including myomectomy and other noninvasive treatments. Up to Date similarly notes that UAE is a treatment option for uterine fibroids.  

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 current procedural terminology (CPT) code 37243 vascular embolization occlusion or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction and CPT code 36247 selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family x 2 and associated codes is overturned. Medical Necessity is substantiated.