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

Diagnosis: Tooth decay
Treatment: Endodontic therapy: D2750 - dental crown - porcelain fused to high noble metal, teeth 3, 7, 8, 9, 10, 19, and 30
The insurer denied coverage for: Endodontic therapy: D2750 - dental crown - porcelain fused to high noble metal, teeth 3, 7, 8, 9, 10, 19, and 30
The denial is: Overturned
Based on the submitted documentation which includes copies of periapical and panoramic radiographs, and insurer correspondence, it appears that this patient presented to the dentist for comprehensive dental care. Endodontic therapy was noted on teeth 7, 8, 9, 10, 19 and 30. The recommended treatment was for full coverage crowns on these teeth subsequent to the endodontic therapy and replacement crown on tooth #3. This recommendation was rendered secondary to failing pre-existing crown restoration. The insurer has denied the full coverage crowns stating that the services are not medically necessary as overall the documentation did not demonstrate medical need to support the treatment and what is provided does not meet their clinical medical necessity criteria. The patient is appealing the decision.

Upon review of the radiographs, it supports the recommended treatment. Review of radiographs indicates a failing pre-existing crown #3 and endodontic therapy on numbers 7, 8, 9, 10, 19 and 30. The standard of care in general dental practice would be placement/replacement of crowns on endodontically treated teeth which would have an excellent long-term prognosis with the recommended treatment. As regards tooth #3 there is a large pre-existing failing restoration which upon removal would require replacement with full coverage crown for restoration of function. Further full coverage crowns are a standard of care in general dental practice for prosthetic rehabilitation of endodontically treated teeth. As such the recommended full coverage crowns are considered medically necessary.

Note: As per enclosed documentation the denial for full coverage crowns on teeth 7 and 9 were already overturned by the insurer with full coverage crowns approved on these teeth.

Reverse denial and approve coverage for D2750- dental crown - porcelain fused to high noble metal, teeth 3, 7, 8, 9, 10, 19 and 30 as medically necessary as the clinical and radiographic documentation supports these services, and these services would be a standard of care in general dental practice.

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 D2750 - dental crown - porcelain fused to high noble metal, teeth 3, 7, 8, 9, 10, 19, and 30 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented to the emergency department (ED) complaining of chest pain. She had been seen in an urgent care center and was referred to the ED due to an abnormal electrocardiogram (ECG). Her medical history was remarkable for hyperlipidemia. Her electrocardiogram (ECG) showed sinus rhythm with inferolateral T wave inversions. Her serum troponin level was normal and remained normal when re-measured. The patient was treated with acetaminophen, aspirin and omeprazole and was admitted to the hospital. Myocardial perfusion imaging was performed and showed no evidence of ischemia. The patient was discharged. At issue is the medical necessity of an inpatient admission.
Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented with chest pain that was thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers. While her electrocardiogram was abnormal, it was not diagnostic for acute ischemia. 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 "observation" status. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline
for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: Intracept procedure (intraosseous ablation of the basivertebral nerve)

The insurer denied coverage for Intracept procedure (intraosseous ablation of the basivertebral nerve).

The denial is upheld.

Reviewer #3:

This patient has chronic low back pain (CLBP). The patient has had Physical Therapy and a Home Exercise program.  The patient has had Epidural Steroid Injections, Medial Branch Blocks and radiofrequency ablation (RFA). The patient's medication trials have included Cyclobenzaprine, Diclofenac, Ibuprofen, Oxycodone, Tizanidine Tylenol and Xanax. The patient's magnetic resonance imaging (MRI) shows Modic changes at L (lumbar) 3-L4, L4-L5 and L5-S (sacral) 1.  It also shows spinal stenosis at L1 to L3 and an extruded disc at L4-L5 which displaces the L5 nerve root.  The request is to perform the Intracept procedure at L3, L4, L5 and S1.

In 2018, Fischgrund and colleagues (1) published a double-blind, sham-controlled randomized controlled trial (RCT) evaluating the Intracept system and radiofrequency (RF) ablation of the Basivertebral nerve (BVN) for the treatment of chronic low back pain. A total of 225 participants with chronic (>= 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n=78) or treatment (n=147) intervention. In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85Celsius for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Oswestry disability index (ODI) of 30 points (on 100 point scale) and a minimum visual analog scale (VAS) of 4 centimeters (cm) (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13%) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance.

In sum, 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.

In sum, this procedure is NOT likely to be more beneficial than the standard of care.

In summary, the denial of an Intracept procedure (intraosseous ablation of the basivertebral nerve) 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: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain

Treatment: Intracept procedure (intraosseous ablation of the basivertebral nerve)

The insurer denied coverage for Intracept procedure (intraosseous ablation of the basivertebral nerve).

The denial is upheld.


Reviewer #2:

In assessing whether intraosseous basivertebral nerve ablation using the Intracept device is considered more beneficial for this patient than standard treatments or procedures, it is important to know that the publications in peer-reviewed literature to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. Furthermore, despite Food and Drug Administration (FDA) approval, there are many exclusion criteria.

For individuals who have vertebrogenic low back pain who receive ablation of basivertebral nerves (BVN), the evidence includes two randomized controlled trials (RCTs) (SMART and INTRACEPT trials, both sponsored by device manufacturer Relievant Medsystems, Inc.). Relevant outcomes were symptoms, functional outcomes, quality of life and treatment-related morbidity. In one RCT, at 12 months, 73% of patients crossed over to the active treatment group and therefore long-term comparative data is not available. Limitations to the other RCT include lack of a sham control and short duration of follow-up.

There are other evidence-based medications and treatments available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. Any invasive procedure has risk of bleeding, infection, nerve injury or retained foreign body compared to non-invasive treatments.

In summary, the supporting publications to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. Despite FDA approval, Centers for Medicare and Medicaid (CMS) guidelines limit the use of basivertebral nerve ablation to a very select group of patients who do not have evidence of other pain etiology such as disc extrusion. The Intracept procedure is unlikely to be more beneficial than standard treatments/procedures for this patient. The denial is upheld.

In summary, the denial of an Intracept procedure (intraosseous ablation of the basivertebral nerve) 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 in Part

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is Partially Overturned.

The patient is an adult female with medical history of obesity, hypertension, and hypothyroidism. The patient presented to the emergency room with complaints of right lower extremity swelling and redness. The patient gave history of a fall six days prior, for which she was seen in urgent care and underwent X-ray of the leg and was started on Keflex. The patient evaluated by her doctor on two days with worsening pain and no improvement of her cellulitis. The patient was sent to the emergency room for intravenous antibiotics. The patient's initial vitals were blood pressure 150/87, heart rate 72, respiratory rate 18, temperature 36.7 Celsius (98.1 Fahrenheit), and pulse oximetry 96%. Examination showed, erythema was noted on right lower extremity below knee that extended to the posterior area with 
warmth present. No fluctuance or abscess was noted. X-ray of her right lower extremity (tibia - fibula) demonstrated diffuse soft tissue swelling throughout the entire imaged extremity. In the emergency room, the patient received cefazolin intravenous. The patient was admitted to inpatient hospital stay for treatment and monitoring. Subsequently, on day #2, the patient was noted to be hypoxic and required monitoring and oxygen administration to stabilize her. On da #3, the patient was also noted to be hypoxic. The patient was continued on intravenous antibiotics and improved.

The Inpatient admission was medically necessary, in part.

Specifically, inpatient hospital stay was appropriate for the initial 4 days. Inpatient hospital stay was not medically necessary onward, and the patient could have been managed adequately at a lower level of care. The patient had failed outpatient antibiotics given orally and presented with progressive cellulitis and X-ray that showed soft tissue swelling throughout the lower extremity. Intravenous antibiotic administration and admission was appropriate to ensure administration of intravenous antibiotics and to confirm that the patient was responding well to treatment before a plan for discharge was made. Admission was medically appropriate. By the end of day #4, the patient had responded adequately to treatment and evaluation showed that she was not developing any new problems or issues to require continued inpatient stay. The patient was able to take oral intake, was afebrile, and had stable vital signs. The patient had responded adequately to treatment by the end of day #4. Therefore, the requested health service was partially medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with type 1 diabetes mellitus, coronary artery disease status post stent placement, hip surgery who was brought into the emergency room for hyperglycemia from a rehabilitation facility. The patient had surgery on her left hip a week and a half prior who had been at a rehabilitation facility for 2 days but had not received any insulin. The patient's glucose was greater than 400 that morning and she received two units of insulin and was sent in from the facility to rule out diabetic ketoacidosis. In the emergency room, her glucose was 496. The patient was given glargine and Lispro and was admitted. The patient received electrolyte replacement. She was seen by physical therapy who recommended subacute rehabilitation. The patient was placed on her home insulin regimen. She was discharged to subacute rehabilitation. At issue is the medical necessity of a full hospital admission.

The admission was not medically necessary for a full admission. The patient presented to the emergency room with hyperglycemia with a potential hydrogen (pH) that was not indicative a metabolic acidosis.  The clinical picture was indicative of hyperglycemia without diabetic ketoacidosis. As the patient was not in diabetic ketoacidosis nor did she have a metabolic acidosis, the patient should have received subcutaneous (SQ) insulin therapy and possibly fluids and could have been discharged from the ED (2). For patients who are not in diabetic ketoacidosis, but instead hyperglycemic, discharge from the emergency room did not result in any increased risk of repeat emergency room visits or hospitalization by aggressive control of blood glucose while in the emergency room (1). Starting subcutaneous insulin and fluid resuscitation could occur at a lower level of care as it would not be expected to take greater than (>) 2 midnights and management is not complex (Centers for Medicare and Medicaid Services (CMS) guidelines).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628)
The insurer denied: Intraosseous Basivertebral Nerve Ablation 
(64628)
The denial is overturned.

The patient is an adult female. Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease that resulted in vertebrogenic pain identified by degenerative endplate changes known as Modic on MRI (magnetic resonance imaging). The patient had pain and failed treatment for greater than 6 months. Prior treatments include back surgery, intrathecal pain pump, medication, physical therapy, SI (sacroiliac) joint injections, and trigger point injections.
The patient's MRI (magnetic resonance imaging) demonstrated Modic type changes at T11/T12 and L3/L4.

The health plan should cover the requested health service.

Based on the documentation provided and per current literature, the requested procedure is recommended in this case. The patient has a history of continued low back pain and despite prior treatments including therapy, medication, activity modification as well as lumbar surgery and intrathecal pump placement, the patient continues to be symptomatic. MRI (magnetic resonance imaging) demonstrated Modic type changes. Given the patient's history, symptoms and findings, the request is recommended in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628)
The insurer denied: Intraosseous Basivertebral Nerve Ablation 
(64628)
The denial is upheld.

The patient is an adult female with chronic low back and neck pain. Her past treatments for the lumbar spine include T12-L3 fusion and removal of hardware, Nevro SCS (spinal cord stimulator) trial, intrathecal pain pump, physical therapy, paravertebral erector spinae block, epidural steroid injection, sacroiliac joint injection, oxycodone, and tizanidine. The pain affects her ADLs (activities of daily living), such as sitting and standing. MRI (magnetic resonance imaging) of the lumbar spine from 3 years ago shows Modic type 2 changes at T11/12 and L3/4, post-surgical changes L2-L5, facet arthropathy at L5/S1, and stable degenerative changes. The request for the Intracept procedure was denied coverage by the health plan as 
experimental/investigational. The denial is being appealed.

The health plan should not cover the requested health service.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes, as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, 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 requested health service.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628)
The insurer denied: Intraosseous Basivertebral Nerve Ablation 
(64628)
The denial is upheld.

The patient is an adult female with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), injections, and IT (intrathecal) pump. The patient has failed multiple medications, including potent opiate medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. The patient has failed previous lumbar spine surgery, in the form of a lumbar interbody fusion at L2-L5.

The health plan should not cover the requested health service.

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is no likely to be more beneficial than standard treatments. The patient is an adult female with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), injections, and IT (intrathecal) pump. The patient has failed multiple medications, including potent opiate medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. The patient has failed previous lumbar spine surgery. The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA)-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, the patient in this case has an instrumented fusion with interbody spacers at L2-L5. Vertebrogenic pain should not be a pain generator, given that the vertebral bodies are fused and immobile. Furthermore, intradiscal spacers exist, contributing to the perceived Modic changes. Given the limited utility in this particular case, the requested Intracept procedure is not medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and vomiting. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient has a history of an iatrogenic ureteral injury and multiple small bowel obstructions. She presented with abdominal pain and vomiting. She was afebrile and the vital signs were stable. The abdomen was distended but there was no rebound or guarding. An abdominal computed tomography (CT) scan revealed a small bowel obstruction. A nasogastric (NG) tube was inserted and her symptoms improved. The NG tube was removed the following morning. The urologist advised that her hydronephrosis did not require any interventions and was to be expected after a ureteral reimplantation. 

Milliman Care Guidelines (MCG) guideline M-210 lists clinical indications for admission for Intestinal Obstruction. The patient needs to have signs and symptoms of obstruction that are severe and persistent. Severe signs include feculent vomiting, hypotension, electrolyte abnormalities, or evidence of bowel ischemia or perforation. Persistent symptoms refer to having the need for the nasogastric (NG) suction to be continued. In this case, she did not have severe symptoms and the NG tube was able to be removed by the following morning. 

This patient had recurrent small bowel obstructions since having the ureteral injury. However, she was not having severe symptoms from the obstruction and her symptoms resolved quickly. She did not meet Milliman Care Guidelines (MCG) criteria for admission for small bowel obstruction. The nasogastric tube insertion and intravenous (IV) hydration could have been done during observation care. 

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.