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

Diagnosis: Lumbosacral Radiculopathy at lumbar spine level 4-5 (L (lumbar) 4-5). 

Treatment: Back surgery (procedure code 62380). 

The insurer denied coverage for back surgery (procedure code 62380). 

The denial is overturned. 

This is the case of a female patient with a past medical history of disc displacement, lumbosacral radiculopathy at lumbar spine level 4-5 (L4-5), foraminal stenosis, low back pain, lumbar radiculopathy, other intervertebral disc displacement, lumbosacral region. The patient underwent right L4-5 lumbar endoscopic foraminoplasty and discectomy. 

The statement by the North American Spine Society (NASS) notes this procedure should be a covered treatment for lumbar disc herniation with radiculopathy. The procedure has been performed for greater than 10 years with satisfactory outcomes. Issues with learning curve and lack of experience contributed to complications. There were several references noting improvement in comparison to open discectomy (OD). There is less morbidity due to surgical approach. Visualization with endoscope versus direct view with microscope would not result in change of procedure. 

The procedure has been recognized by the Food and Drug Administration (FDA) for the diagnosis. 

The records showed consistency of the pain generator and failure to improve with conservative management. 

Based upon clinical presentation and skill set of treating practitioner, the procedure would be the best available treatment at this time. 

The requested service would be more likely to be more beneficial than the standard OD, i.e. less morbidity secondary to limited surgical exposure. There was direct visualization and management of pathology. 

The literature does not show increased adverse risk over standard treatment. 

The carrier's denial of back surgery (procedure code 62380) should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lumbosacral Radiculopathy at lumbar spine level 4-5 (L (lumbar) 4-5). 
Treatment: Back surgery (procedure code 62380). 

The insurer denied coverage for back surgery (procedure code 62380). 

The denial is upheld. 

This is the case of a female patient who has chronic low back pain with a past medical history of lumbar disc displacement, lumbosacral radiculopathy at lumbar spine level 4-5 (L4-5), foraminal stenosis. She has tried physical therapy, chiropractic therapy, epidural steroid injection, facet injections with radiofrequency ablation (RFA) and a back brace. She is taking Gabapentin, Percocet and had a Medrol dose pack for pain. The patient underwent right L4-5 lumbar endoscopic foraminoplasty and discectomy. 

The literature supporting endoscopic spine surgery is mostly Level 3 and does not demonstrate superiority over traditional surgical approaches. Chen et al (1) conducted a randomized controlled study and found: "Over the 1-year follow-up period, percutaneous transforaminal endoscopic discectomy (PTED) did not show superior clinical outcomes and did not seem to be a safer procedure for patients with lumbar disc herniation compared with microendoscopic discectomy (MED). PTED had inferior results for median disc herniation, whereas MED did not seem to be the best treatment option for far-lateral disc herniation." 

Lewandrowski et al (2) pointed out the deficiency in the current literature: "Spinal endoscopy stands a good chance of gaining more traction in such way mainly if efficacious spine care can be provided at a lower long-term societal cost due to longer duration of treatment benefits, lower utilization of other concomitant treatment services, reduced rate of iatrogenic problems requiring follow-up revision surgeries, and better return to work rates. Proving these empirical benefits well known to most spine surgeons who perform endoscopic surgery at a higher-grade clinical evidence level is critical to improving its acceptance into mainstream and the implementation of reimbursement structures that incentivize surgeons, ambulatory surgery centers (ASCs) and hospitals to break with the old ways." 

This supporting data is still not published in the literature and therefore, it is not possible to say that the provided service was more beneficial than the standard approach or that it had less risk. 

The carrier's denial of back surgery (procedure code 62380) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: tremors

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is upheld. 

This male patient has a history of hypertension, arrhythmia, hyperlipidemia, and a pacemaker.

There was no documentation of hemodynamic instability or other findings warranting an inpatient admission. They note the requested admission was warranted based on Milliman Care Guidelines 24th Edition using the guideline of Supraventricular Arrhythmias ORG: M-510 (ISC).

The patient had transient hand tremors that brought patient to ED. By the time patient reached ED tremors had resolved. These tremors had occurred in the past and also had previously resolved. The patient had an ECG (electrocardiogram) which showed atrial flutter with a controlled ventricular response.

The work-up of the transient tremors did not require hospitalization nor did the evaluation and treatment of the atrial flutter. The patient was hemodynamically stable. In fact, the patient was without complaint once the tremors had resolved. All the elements of diagnosis and treatment of the patient's atrial flutter including pacemaker interrogation, anticoagulation, echocardiography and cardioversion could have been accomplished on an outpatient basis. Full hospital admission was not necessary for medical reasons.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: gestational diabetes

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This female patient has a history of obesity, hypertension, and poorly controlled gestational diabetes.

People with diabetes are usually admitted if they have the following: life-threatening acute metabolic complications of diabetes, or severe chronic complications of diabetes that require intensive treatment or other severe conditions unrelated to diabetes that significantly affect its control or are complicated by diabetes.

The patient had gestational diabetes. She was stable, her blood pressure was normal, she was not ketoacidotic or in any danger, and the fetus was not in any jeopardy. The patient's blood sugar could have been easily controlled as an outpatient. Sugar control and diabetic teaching are done routinely as an outpatient. Nutritional counseling does not require admission. 

Based on the above, admission for glucose control was not medically necessary. The patient could have been followed daily in the clinic for dose adjustment. This is in accordance with the standard of care and Milliman guidelines.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Wellen's syndrome

Treatment: acute inpatient admission

The insurer is denied coverage for acute inpatient admission

The denial is upheld. 

This is a male patient with no significant medical history.

The patient presented with a syncopal event. His symptoms were treated and stabilized in the ER (emergency room). Due to no other comorbidities or complications, the patient's care could have been rendered in the ER or observational status admission. Despite a concern for Wellen's syndrome on EKG (electrocardiogram), the cardiac biomarkers were normal, and the patient was experiencing no chest pain. The etiology of his syncopal event was determined to be dehydration with physical exertion. There were no other medical conditions warranting inpatient admission status, including end-organ dysfunction, cerebrovascular insufficiency, or hemodynamic instability.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the acute inpatient admission is upheld / overturned.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chest pain /alcohol withdrawal
 
Treatment: inpatient hospitalization

The insurer is denied coverage for inpatient hospitalization

The denial is overturned. 

This male patient has a history of bipolar disorder, schizoaffective disorder, Parkinson's disease, arthritis, diabetes, hypertension, alcoholism, alcoholic cirrhosis, withdrawal seizures, prostate cancer, chronic thrombocytopenia, asthma, rib fracture and chronic back pain.

In this case the patient had comorbid medical conditions complicating the management of withdrawal including a workup for acute coronary syndrome as he reported chest pain and he also had a history of withdrawal seizures which requires inpatient detoxification treatment. He was drinking large amounts of alcohol including two fifths of vodka per day and had disorientation on admission, so he required inpatient detoxification treatment and protocol of Librium if needed to prevent severe, complicated, or life-threatening withdrawal as he had past reported alcohol withdrawal seizures which requires inpatient medical detoxification treatment.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use large amounts of alcohol daily despite multiple past inpatient detoxification hospital treatments and negative consequences to alcohol use including medical issues, and he was at risk for another withdrawal seizure or more complicated or life threatening withdrawal such as delirium tremens. The risk of delirium tremens can occur 3-4 days after alcohol use so he was considered at high risk for this, and he had past withdrawal seizures. He had a recent inpatient detoxification treatment a few weeks prior to admission requiring Librium detoxification treatment. He had multiple medical issues complicating the management of withdrawal in an outpatient setting as he had reports of past severe thrombocytopenia and neutropenia, alcohol cirrhosis, past prostate cancer, and asthma in addition to withdrawal seizures and current presentation of chest pain. He also had comorbid psychiatric conditions including major depressive disorder with psychotic features. He did require 24-hour medical hospital treatment due to his history of alcohol withdrawal seizures and multiple medical issues and he was homeless and unable to be treated safety in a less restrictive setting other than an inpatient hospital setting.

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

The carrier's denial of coverage for the inpatient hospitalization is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Pancolitis. 

Treatment: Xeljanz 10mg. 

The insurer is denied coverage for Xeljanz 10mg. 

The denial is overturned. 

This female patient has a history of ulcerative pancolitis.

Xeljanz is Food and Drug Administration (FDA) approved for the treatment of adult patients with moderately to severely active ulcerative colitis (UC). The patient is being prescribed Xeljanz for a diagnosis of ulcerative pancolitis. It was noted the patient was previously treated with Apriso, Valcyte, Entyvio, and infliximab. It was noted the patient was not advised to switch to Humira as she had failed Remicade as evidenced by adequate doses and levels with no antibodies. The American Gastroenterological Association (AGA) recommends "In adult outpatients with moderate-severe ulcerative colitis who have previously been exposed to infliximab, particularly those with primary non-response, the AGA suggests using ustekinumab or tofacitinib, rather than vedolizumab or adalimumab for induction of remission." The patient started Xeljanz. Continuation of Xeljanz 10mg twice daily is medically necessary given the failure of other alternatives and duration of use. 

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

The carrier's denial of coverage for the Xeljanz 10mg  is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status Post Knee replacement
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female who underwent a left total knee replacement. Her post-surgical course was complicated by respiratory problems, where she sought treatment at another hospital. She was provided with anticoagulation medication as management for possible pulmonary embolus. She developed a "blood blister on wound area." She also underwent testing for suspected Covid.

The patient was evaluated by her physician, who reported drainage, effusion, bruising and limited motion. There was blister formation. Her laboratory studies showed anemia (Hct [hematocrit] 19). She was transfused after admission. She also underwent additional cardiac testing. The wound continued to drain, but gradually decreased. A Prevena VAC (vacuum-assisted closure) dressing was subsequently applied.

Yes, the Inpatient admission was medically necessary.
The medical record was supportive for the admission and length of stay. The significant factors were as follows:

#1. The patient had a complicated post-surgical course with documentation of at the very least respiratory problems. She was evaluated for pneumonia and required antibiotics.

#2. The patient was found to have severe anemia. Her hemoglobin of 6 and hematocrit of 19 required timely and urgent management. She required transfusion and Lasix.

#3. There was concern for the patient's cardiac condition to warrant subspecialty consultation with urgent testing. The cardiologist recommended Troponin levels, Duplex studies, transfusion and repeat ECG (electrocardiogram).

#4. The patient was found to have wound complications with ongoing drainage. She had a large effusion. There was significant concern for possible infection. She was already being treated for pneumonia and it would be important to rule out possible hematogenous spread. Presence of a hemarthrosis was of concern, and her physician had planned for possible return to operating room if her condition did not stabilize. She was evaluated by Wound consultant and eventually had application of the Prevena VAC (vacuum assisted closure).

The patient's condition was complex and unique to require admission and length of stay. The combination of respiratory, cardiac, anemia and wound complication warranted the service provided. There would be no other level of service applicable.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right above knee amputation. 
Treatment: Prosthetic (L5856). 

The insurer denied the Prosthetic (L5856). 
The denial is upheld. 

The patient is a male with a history that includes traumatic right above knee amputation due to a motor vehicle accident.  He has been a K3 (Ability or potential to ambulate with variable cadence) level ambulator with a prosthesis. 

The patient presented to a prosthetist, noting that his C-Leg microprocessor knee (serviced several times over the course of several years) was "acting strange."  There were instability episodes.  It was deemed that the knee was damaged and in need of replacement.  It was noted that the knee was over three years old and no longer covered by warranty.  A loaner knee was installed and the plan was a replacement C-Leg microprocessor knee. 

The patient received a new loaner knee. 

The patient received a new C-Leg microprocessor knee and a new College Park Odyssey K3 foot. 

The health plan denied coverage of the service under review as it concluded that the costs of the service exceed the costs for a repair of the prior prosthesis. 

The service provider has argued that the price for the repairs exceeded the price of a new device. 

No, the Prosthetic (L5856) was not medically necessary.

The records indicate that the member had a C-Leg microprocessor knee for his right leg prosthesis received several years prior.  The C-Leg knee was serviced multiple times.  The knee was approximately 3.5 years old, but causing difficulties, including instability.  The records indicate that it could have been repaired.  Therefore, there was no medical necessity of a replacement prosthetic knee. 

The records indicate that the device in question was approximately 3.5 years old and could have been repaired.  The records do not show that the knee could not have been repaired.  There are multiple quotes that have been generated by the service provider, which do not consistently indicate prices for the services in question.  The invoice that was generated on the actual date of service indicated a much more substantial cost for the new replacement prosthetic knee in question (even after removing the costs for the prosthetic foot-ankle) than the quote for the repair of the older knee.  There are no clear indications, overall, that the service that was provided was reasonable from the standpoint of use of the patient's benefits.  The denial of coverage as noted in the health plan's correspondence, therefore, was appropriate.  The argument made by the service provider that the cost of the replacement knee was lower than the repair cost is contradicted in the available documentation. 

Regardless of cost issues, as stated above, the replacement was not medically necessary, as the original device could have been repaired.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intracept Procedure (intraosseous basivertibral nerve ablation- procedure (22899, C9752 & C9753).
The insurer denied the Intracept Procedure (intraosseous basivertibral nerve ablation- procedure (22899, C9752 & C9753).
The denial is upheld.

The patient is a male with a history of chronic low back pain that is worse with extension and flexion. He has failed epidural steroid injections. He has done physical therapy and seen a chiropractor. He has tried various medications. No physical exam is included in the clinical notes. An Intracept procedure has been recommended.

The procedure was denied as experimental/investigational. This was appealed.

No, the health plan should not cover the intracept procedure.

No, the intracept procedure is not likely to be more beneficial.
The patient is a male with a history of chronic low back pain that is worse with extension and flexion.  He has failed epidural steroid injections. He has done physical therapy and seen a chiropractor.  He has tried various medications.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new FDA (United States Food and Drug Administration)-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. Alternatives, such as spinal fusion, do not have good long term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion. Spinal cord stimulation is also an alternative, however has not been shown to have excellent results in primarily axial mechanical/discogenic type pain. Chronic opiates are not without risk, and can lead to addiction and overdose.

Therefore, while the Intracept procedure is an FDA (United States Food and Drug Administration) approved procedure that is not experimental/investigational, and is a reasonable option, it should be employed after all conventional and evidence proven alternatives have failed. SI (sacroiliac) joint interventions have been shown to be effective in low back pain. Given that the alternatives do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.

However, despite the above, this patient has not failed or attempted sacro-iliac joint interventions, which is a common cause of axial low back pain.  The patient's pain is axial; there is notation of facet arthropathy on the MRI (magnetic resonance imaging).  Modic changes can be present in no vertebrogenic back pain.  No physical exam is included in the submitted notes.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intracept Procedure (intraosseous basivertibral nerve ablation- procedure (22899, C9752 & C9753).
The insurer denied the Intracept Procedure (intraosseous basivertibral nerve ablation- procedure (22899, C9752 & C9753).
The denial is upheld.

The patient is a male with history of chronic lower back pain. His pain worsens with activity, associated with tingling and numbness of right toes. He has tried physical therapy, gabapentin, Zanaflex, Lidoderm patches. His pain worsens on routine activities. The patient has also tried caudal ESI (epidural steroid injection), lumbar RFA (radiofrequency ablation) with minimal effect. Examination revealed positive for tenderness in the back, facet loading positive.

MRI (magnetic resonance imaging) Lumbar spine read by the radiologist revealed modic type  I, II changes at L3-4 (third lumbar spine vertebra - fourth lumbar spine vertebra), L4-5 (fourth lumbar spine vertebra - fifth lumbar spine vertebra), L5-S1 (fifth lumbar spine vertebra - first sacral vertebra).

MRI (magnetic resonance imaging)  Lumbar spine revealed multilevel degenerative changes, diffuse disc bulges, facet arthropathy, hypertrophy of ligamentum flavum, epidural lipomatosis resulting in mild to moderate spinal stenosis and moderate to severe foraminal narrowing bilaterally at multiple levels.

This is a request for basivertebral ablation. The health plan denied the request as experimental/investigational.

No, the health plan should not cover the intracept procedure.
The patient has history of chronic lower back pain. The patient has tried epidural steroid injections, Lumbar RFA (radiofrequency ablation), physical therapy, home exercises and pain medications. The pain affects his quality of life.

Although it is FDA (United State Food and Drug Administration) approved, as per the medical literature, reproducible large RCTs (randomized controlled trials) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF (radiofrequency) ablation in the management of CLBP (chronic low back pain) and improve the quality of life of CLBP (chronic low back pain) patients in the near future.

No, the intracept procedure is not likely to be more beneficial.
It is considered investigational, as short and long-term outcomes are not proven.

As per the medical literature, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF (radiofrequency) ablation in the management of CLBP (chronic low back pain) and improve the quality of life of CLBP (chronic low back pain) patients in the near future.