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

Diagnosis: Low Back Pain. 
Treatment: Intraosseous Basivertebral Nerve Ablation. 

The insurer denied: Intraosseous Basivertebral Nerve Ablation. 
The denial is upheld. 

The patient is an adult male 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 facet injections/RFA (radiofrequency ablation). MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. 

The health plan should not cover the Intraosseous Basivertebral Nerve Ablation. 

The patient is an adult male 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 facet injections/RFA (radiofrequency ablation). MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. 

The procedure is an FDA (United States Food and Drug Administration)-approved procedure for axial low back pain. It has been shown to be effective in RCT (randomized controlled trials) with 5-year results. The Intracept procedure (interosseous basivertebral 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 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, the patient in this case has not failed or attempted sacroiliac joint injections, which are common causes of axial low back pain. There is no documentation of failed PT (physical therapy) or medication use. The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternatives sacroiliac injections 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: Overturned

Diagnosis: Crohn's disease
Treatment: Therapeutic Drug Level Monitoring Test
The insurer denied: Therapeutic Drug Level Monitoring Test
The denial is overturned

The patient is an adult male with moderate-to-severe Crohn's disease treated with Humira (adalibumab). His provider is requesting serum adalibumab drug and antibody levels to guide treatment.

The health plan should cover the Therapeutic Drug Level Monitoring Test.

Medical literature supports the use of therapeutic monitoring of drug and antibody levels of biologics to help guide the use of treatment of inflammatory bowel disease with biologics. In fact, it is widely accepted to provide such drug levels before dose intensification of biologics. Therefore, the requested Humira drug and antibody levels is clinically appropriate and accepted standard of care, and should be covered by the health plan.

The Therapeutic Drug Level Monitoring Test is more beneficial.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Therapeutic Drug Level Monitoring Test
The insurer denied: Therapeutic Drug Level Monitoring Test
The denial is overturned

The patient is an adult male with a history of ileocolonic and gastric IBD-CD (inflammatory bowel disease-Crohn's disease) for the past 15 years. He had been initially managed on mesalamine and 6-MP (mercaptopurine). He has been treated with adalimumab.

Earlier this year the patient's therapeutic drug levels as well as antibodies were tested and was found to be within appropriate levels without antibodies. The therapeutic drug levels and antibodies testing was denied coverage by the health plan as 
experimental/investigational. The denial is being appealed.

The health plan should cover the Therapeutic Drug Level Monitoring Test.

Therapeutic drug monitoring is a useful strategy to optimize biological medications for inflammatory bowel disease not responsive to standard dose regimens. Drug monitoring is effective for anti-TNF (tumor necrosis factor) agents in the setting of loss of response, and optimizing drug dosing when patients are in remission is beneficial as well.

Many patients with IBD (inflammatory bowel disease) require biological therapy to achieve and maintain clinical and endoscopic remission, and the anti-TNF (tumor necrosis factor) antibodies remain the first-line biologic therapy in most areas of the world. Therapeutic drug monitoring has been shown to be a useful tool to manage patients on anti-TNF (tumor necrosis factor) treatment including monitoring for dose escalation, de-escalation or to switch treatment.

The Therapeutic Drug Level Monitoring Test is more beneficial.
In the clinical setting, therapeutic drug monitoring has been proven to be useful in managing IBD (inflammatory bowel disease) patients, and its use in the reactive setting, as an additional tool to help manage patients with treatment failure, is being promoted as newer guidelines and consensus groups implement therapeutic drug monitoring as part of management plan.

Therapeutic drug monitoring will aid treatment and dose decisions for this individual patient based on monitoring trough concentrations and antidrug antibody levels. Following drug levels and antibody levels is medically appropriate the medical management of IBD (inflammatory bowel disease) patients.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Therapeutic Drug Level Monitoring Test
The insurer denied: Therapeutic Drug Level Monitoring Test
The denial is overturned

The patient is an adult male with a history of Crohn's Disease. The disease is located in the stomach, ileum and colon.
The patient's prior treatment includes mesalamine, 6MP (mercaptopurine) and adalimumab. The patient had an adalimumab trough level checked earlier this year, which showed he had a therapeutic drug level (15) and no antibodies present.
The health plan denied coverage of the Humira level lab for the drug level monitoring, because it was deemed to be investigational/experimental per the insurance policy. The denial is being appealed.

The health plan should cover the Therapeutic Drug Level Monitoring Test.

Per the American Gastroenterology Association (AGA) consensus statement and guidelines 2019 (1), they recommended checking drug/antibody concentration testing for the following situations:
"1.  It is appropriate to order drug/antibody concentration testing at least once during maintenance for patients on all anti-TNFs [tumor necrosis factors].
"2.  It is appropriate to order drug/antibody concentration testing of anti-TNFs [tumor necrosis factors] at the end of induction in primary non-responders.
"3. It is appropriate to order drug/antibody concentration testing for all anti-TNFs [tumor necrosis factors] in patients with confirmed secondary loss of response."

The first stipulation of it being appropriate to order testing at least once during maintenance for patients on all anti-TNFs (tumor necrosis factors) applies to this patient. Therefore, the health plan should cover the Therapeutic Drug Level Monitoring Test. 

The Therapeutic Drug Level Monitoring Test is more beneficial.
Biologics level monitoring and Ab (antibody) evaluation is currently considered the standard of care in management of inflammatory bowel disease. Based on the test results, dose adjustment or switching to different agent can be considered and, thus it provides valuable information to the clinician.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Increase in personal care aide (PCA) services in the amount of 56 hours per week

The insurer denied the increase in personal care aide (PCA) services in the amount of 56 hours per week.  The denial is upheld.

The patient is a female with past medical history of coronary artery disease, congestive heart failure hypertension, hyperlipidemia, and osteoarthritis. The patient lives at home with her family.

An increase in services was requested, thus the patient underwent a reassessment. The patient was assessed to have minimally impaired cognition with memory problems as independent with no memory problems. She has adequate hearing and vision. She requires maximal assistance with meal preparation, total dependence with the task of ordinary housework, and maximal assistance with shopping. The patient was assessed at maximal assistance with task of bathing, extensive assistance with personal hygiene, extensive assistance with the task of dressing upper body, maximal assistance for dressing lower body, extensive assistance with walking and locomotion, extensive assistance with transfer toilet and limited assistance with toilet use, bed mobility and independent with eating. She was noted with no change in activities of daily living (ADL) status in the last 90 days. Occasionally she is bowel and bladder incontinent. The patient has moderate intermittent daily pain controlled on a regimen. A total of 38.5 hours was assessed to meet her needs. No hospitalization or falls were reported in the past 90 days.

The subject under review is the medical necessity of increasing her Personal Care Aide (PCA) services, to the amount of 56 hours per week.

The health plan's determination is upheld.

The requested increase in Personal Care Aide (PCA) services, in the amount of 56 hours per week is not medically necessary for this patient.

The patient is noted to require assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Based on the assessment completed, there has not been a significant change in functional status or increased levels of assistance needed to ensure activities of daily living (ADLs) tasks are safely completed. The tasking tool reported a total of 38.5 hours required to be necessary for her activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) on reassessment. The patient lives at home with family and has informal support. There is no documented recent hospitalizations or changes in condition and functional change to require additional hours. There were no new reports regarding recommendations for additional aide service which would be medically necessary for the patient above and beyond those documented with the previous nursing assessments, thus additional hours are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back pain
Treatment: Radiofrequency ablation of sacroiliac (SI) joint 
The insurer denied: Radiofrequency ablation of sacroiliac (SI) joint 
The denial is: Upheld

The patient is a female with complaints of low back pain. Physical exam demonstrated mildly antalgic gait, facet loading test positive on the left, Faber test was positive on the left, lumbar spine range of motion was restricted. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated unremarkable MRI. The pain is noted to be in the left lumbar region, described as aching, and throbbing. The patient had prior sacroiliac joint radiofrequency ablation with benefit. There is a request for radiofrequency ablation of sacroiliac (SI) joint.
The subject under review is the medical necessity for the radiofrequency ablation of the SI joint.

The health plan's determination is upheld.

The requested radiofrequency ablation of SI joint is not medically necessary for this patient. The procedure the provider is requesting is not recommended due to the lack of evidence supporting use of this technique. Currently the treatment remains investigational. More research is needed to refine the technique of SI joint denervation, better assess long-term outcomes, and to determine what combination of variables can be used to improve candidate screening. Current research available for evaluation indicates the procedure is performed with various techniques, with no consensus on which nerves are most appropriate to lesion. If pain relief occurs, there can therefore be some question as to what pain generator (or generators) was actually addressed. There is also no consensus as to what the most appropriate diagnostic test is to use pre-procedure, and regardless of the diagnostic procedure used, results do not appear to vary substantially. Overall, the requested radiofrequency ablation of SI joint is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment: Dental implants area #19 and #21. 

The insurer denied the Dental implants area #19 and #21. 
The determination is overturned. 

This is a patient who is missing teeth number (#) 19, #20 and #21. The patient had implants placed in the #19 and #21 areas with bone graft at the time of implant placement. The health plan denied the treatment as the implants do not appear to be the only method of tooth replacement available. At issue is the medical necessity of the requested dental implants. 

Yes, the placement of implants in the #19 & #21 areas is appropriate for the symptoms and treatment of the condition and provided for the diagnosis and direct treatment of the condition. The treatment is within the standards of good medical practice and is the most appropriate procedure which can safely be provided. The evidence shows that benefits from implants are clinically significant and produce a greater benefit without risk of harm for the patient than the alternatives. Implants are the standard of care. They are the closest thing to natural teeth, preserve the bone and are not susceptible to caries. The bone graft at the time of implant placement is needed to cover exposed threads of the implants to allow for proper healing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: atopic dermatitis
Treatment: Opzelura
The insurer denied Opzelura. The health plan's determination is upheld. 

The patient is a female with paresthesia of the skin (notalgia paresthetica) associated with mild to moderate atopic dermatitis. The patient's rash is described as a hyperpigmented patch of the left upper back with excoriations and underlying edema. The health plan has alternative formulary topical medications that have not been used to date: mometasone, triamcinolone, betamethasone, 0.025% (percent) fluocinolone, and 0.05% fluocinonide.

Opzelura is not medically necessary for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line and formulary topical steroid medications (mometasone, triamcinolone, betamethasone, 0.025% fluocinolone, and 0.05% fluocinonide) used for eczematous skin conditions such as this patient's notalgia paresthetica. The patient also has no failure or contraindication to more time-tested nonsteroidal topical alternatives such as the calcineurin inhibitors tacrolimus and pimecrolimus. Therefore, consistent with current dermatology literature, the requested Opzelura cream is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient presented with fever, rash, and decreased oral intake. She was well until a week prior to presentation when she fell from her bed and hit her head. Later that evening, she felt warm to the touch, had decreased activity, and vomited. She was taken to the pediatrician at that time and was sent home with ibuprofen. However she continued to have fevers up to 102 F (degrees Fahrenheit), and then developed blisters on her hands. Despite a negative respiratory viral panel, she was thought to have a coxsackie infection. The blisters extended over her body and she also complained of pain with eating and was refusing both water and food. She was therefore brought to the emergency department for evaluation.

Inpatient Hospital Admission was medically necessary for this patient.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 24th edition, Dehydration; Pediatric, hospitalization is indicated for patients with dehydration and an inability to maintain oral hydration that persists after emergency department treatment. This patient was dehydrated based on physical examination with dry mucous membranes and no tears, and was refusing oral intake in the setting of increased fluid needs due to vomiting and fever. Therefore, the inpatient admission was necessary for intravenous fluids and close monitoring.
Appeal type: Medical necessity
Decision: Upheld

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

This woman presented to the emergency department complaining of one week of intermittent chest pain. Her medical history was remarkable for diabetes, hypertension, chronic lower extremity ulcers, iron deficiency anemia and spastic paraparesis which rendered her bed bound. Her blood pressure was 104/60 mmHg (millimeters of mercury) with a heart rate of 83 beats/minute. Her room air oxygen saturation was 100%. She was afebrile. Her cardiac exam was unremarkable. An electrocardiogram showed sinus rhythm with right bundle branch block. There were no acute changes. Her serum troponin level was normal. Her serum creatinine level was 0.5. Her hemoglobin level was 7.9. 

Based on the documentation provided an inpatient level of care was not medically necessary.
This patient presented with chest pain that was thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for her chest pain did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be both safe and effective and is in accordance with current guidelines.
After admission, this patient was diagnosed with a urinary tract infection (UTI). She was also found to have right ureteral obstruction which would classify the UTI as a complicated UTI. However, the patient was afebrile, with a normal white blood count and, based on the documentation provided, there was no evidence of systemic inflammatory response syndrome or sepsis. No acute intervention for relief of the obstruction was deemed necessary. Thus, the medical record does not document that treatment of the patient's UTI warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Crown tooth # 15.
The insurer denied the Crown tooth #15.
The determination is overturned.

The patient presented for evaluation and treatment of tooth number (#) 15. Provided for review are previous letters of appeal and denial, a single radiographic image, a panoramic radiograph, multiple copies of American Dental Association (ADA) claim forms, health plan language, and clinical notes. At issue is the medical necessity of a porcelain crown for tooth #15.
The requested health service/treatment of porcelain crown tooth 15 is medically necessary for this patient due to the presence of a fracture running along the mesial cusp. The patient was also symptomatic of pressure, in addition to the physical presence of the fracture. Previously, there was also a large restoration on the occlusal surface of the tooth. In this case, as there is cuspal involvement and a direct restoration is not indicated as it will be unsupported making the indirect restoration the only option.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: upper respiratory infection.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

At the time of her admission, the patient with a previous history of asthma and autism was brought to the emergency department with one day of fever, upper respiratory infection (URI) symptoms, decreased intake, increased sleepiness, and crankiness. Per the parent, she hadn't had any wet diapers for 12 hours. No vomiting or diarrhea was noted. At triage, her temperature was 38.8oC and oxygen saturation was 98% on room air. She was described as active and not in acute distress. Her physical exam was normal, including moist mucus membranes and a capillary refill of fewer than two seconds. Her bicarbonate was 15, and her sodium 129. Flu, respiratory syncytial virus (RSV), and cover testing were negative. She was given two normal saline boluses intravenous (IV) in the emergency department. The emergency department (ED) documented that she did not tolerate a "PO (by mouth) challenge," so she was admitted to the hospital. 

The inpatient hospital admission was not medically necessary. This was an autistic two-year-old, who presented with fever, URI symptoms, reportedly no wet diapers for twelve hours, mild hyponatremia, and mild acidosis. She was not clinically dehydrated. On exam, her capillary refill was intact and her mucus membranes were moist. To whatever extent she was somewhat "dry" or mildly dehydrated, this problem was corrected after receiving two normal saline boluses in the emergency department. She had been volume repleted and could have been observed for a longer period in the emergency department for return of oral intake or, given her autism and likelihood of doing better at home in a familiar environment, she could have been discharged home with close follow up to re-evaluate her hydration status.