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

Diagnosis: Back pain
Treatment: procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation
The insurer denied coverage for procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation.
The denial is upheld.

This woman has chronic low back pain. She has used a back brace, Facet blocks and radiofrequency ablation (RFA), Heat, Ice, Physical therapy and a Home Exercise program as well as an Epidural Steroid injection.  Her pain medications include Aspirin, Mobic, Robaxin and Duloxetine.  Her magnetic resonance imaging (MRI) shows vertebral compression fractures at thoracic (T)12, lumbar (L)1, L2 and L3 as well as Modic changes at L3, L5 and sacral (S)1.		

The publications to date have been company sponsored and had methodology flaws.  There is 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.

Conger et al (4) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the basivertebral nerve (BVN). Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (5) while favorable pointed out the limitations of the current literature:
-Industry funding is a potential source of study bias for the available data reviewed.
-Limited number of studies.
-Short-term follow up for the majority of studied patients.
-Unknown effect on the primary degenerative process

This procedure is NOT likely to be more beneficial than the standard of care.

In summary, the denial of procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation and coverage for the requested service/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: Back pain
Treatment: procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation
The insurer denied coverage for procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation.
The denial is upheld.

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% (percent) 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.

The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Basivertebral nerve (BVN) ablation using the Intracept procedure is Food and Drug Administration (FDA) approved in a very select group of patients who have - A history of chronic low back pain (cLBP) of at least 6 months duration; and - Failed to respond to at least 6 months of non-surgical management; and - magnetic resonance imaging (MRI) demonstrated Modic Type 1 or Type 2 changes at one or more vertebrae from L (lumbar) 3 to S (sacral) 1; and - Activities of daily living that are limited by persistent low back pain; AND - All other reasonable sources of pain have been ruled out.

This patient is not a good candidate for intraosseous basivertebral nerve ablation. 

There are other evidence-based treatments available to this patient. 

This procedure is unlikely to be more beneficial than the standard approaches. 

The basivertebral nerve ablation procedure with the Intracept device is not the best available treatment for this patient.

In summary, the denial of procedure codes 64628 and 64629, intraosseous basivertebral nerve ablation and coverage for the requested service/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: Upheld

Diagnosis: Pelvic mass
Treatment: PET Scan with Concurrently Acquired CT; Skull Base to Mid-Thigh (Code 78815)
The insurer denied: PET Scan with Concurrently Acquired CT; Skull Base to Mid-Thigh (Code 78815)
The denial is upheld.

The patient is an adult female with a pelvic mass. The patient underwent further evaluation by positron emission tomography/computed tomography (PET/CT).

The proposed treatment was not medically necessary. 

The patient was diagnosed with a pelvic mass. She underwent further evaluation by positron emission tomography/computed tomography. The use of positron emission tomography/computed tomography as done in this case has not been shown to improve health outcomes. It is not supported by peer-reviewed data. It is not standard of care. The standard of care includes imaging by computed tomography of the abdomen and pelvis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia
Treatment: Xeljanz
The insurer denied: Xeljanz
The denial is upheld.

The patient is an adult female with severe alopecia areata of the scalp with almost complete hair loss. She has been treated with intralesional and oral steroids, as well as topical medication without effect. The condition makes her depressed and causes social problems. This is a request to approve Xeljanz for the treatment of her alopecia.

The requested Xeljanz is not medically necessary.

The patient has severe alopecia areata that has failed intralesional and oral steroids, as well as topical medications. Her physician is requesting Xeljanz, which the patient has not taken in the past. Xeljanz is not FDA (United States Food and Drug Administration) approved for the treatment of alopecia areata, although there have been a number of case reports and small clinical trials reporting promising outcomes of tofacitinib. In view of the fact that another JAK (janus kinase) inhibitor, Olumiant (baricitinib), is FDA (United States Food and Drug Administration) approved for the treatment of alopecia areata and there is no documentation that the patient has used it, Xeljanz cannot be considered medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld


Diagnosis: atrophic vaginitis 
Treatment: Estring 
The insurer denied Estring 
The health plan's determination is upheld.

The patient is a female with postmenopausal atrophic vaginitis and recurrent urinary tract infections. Her past medical history is positive for a kidney transplant. She previously used Estrace cream and found this difficult to use. 

The formulary drug would be as effective as the non-formulary drug and would not be expected to have adverse effects.
Because the lack of circulating, natural estrogens is the primary cause of atrophic vaginitis, hormone replacement therapy is the most logical choice of treatment and has proved to be effective in the restoration of anatomy and the resolution of symptoms. Estrogen replacement restores normal potential hydrogen (pH) levels and thickens and revascularizes the epithelium. Routes of administration include oral, transdermal and intravaginal. The amount of estrogen and the duration of time required to eliminate symptoms depend greatly on the degree of vaginal atrophy and vary among patients. Treatment with a low-dose transvaginal estrogen has proved effective in relieving symptoms without causing significant proliferation of the vaginal epithelium. There are no current recommendations regarding support for one transvaginal route over another and therefore a specific medication would not be standard of care for all patients. Formulary medications such as estradiol vaginal cream, Vagifem or Imvexxy would be expected to be as effective as Estring.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Parkinson's Disease
Treatment: Formulary Exception for Ropinirole ER (extended release) 4MG (milligrams) Tablet
The insurer denied: Formulary Exception for Ropinirole ER (extended release) 4MG (milligrams) Tablet
The denial is upheld.

The patient is an adult male with Parkinson's disease (PD). The provider has requested Ropinirole extended release (ER). The requested medication was denied coverage as the patient has not tried and failed three preferred formulary agents for his condition.

The health plan should not cover the proposed formulary exception for Ropinirole extended release (ER) 4 milligrams (MG) tablet.

There is no reason the patient cannot be treated with the preferred formulary agents. All of the preferred agents are considered standard of care treatment options for his condition.  There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Ropinirole extended-release relative to the preferred oral agents.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left hand pain and swelling

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

Patient is an adult with a past medical history significant for hypertension who presented to the emergency department with complaints of left hand pain and swelling following a fall.

Vitals on presentation included: Temperature 97.0 degrees Fahrenheit, Blood Pressure 127/92, Pulse 100 beats per minute, Respiratory Rate 16 breaths per minute, oxygen saturation 98% (percent) on room air. Laboratory results included the following: White blood cells (WBC) 5.9, Hemoglobin 12.0, Hematocrit 34.6, Creatinine 0.5, Glucose 117, C-reactive Protein (CRP) 3.7, Lactate 1.5.

The patient was started empirically on intravenous antibiotics (Unasyn and Bactrim) for left arm cellulitis. X-ray of left hand was negative for fracture. The patient remained afebrile, hemodynamically stable, and clinically improved. Patient left the hospital against medical advice (AMA).
 
According to documentation, patient presented with left arm cellulitis. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal White Blood Cell (WBC). There was no evidence of a disseminated infection and no surgical intervention was required. Based on above findings, the patient met criteria for observation level of management. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient level of care admission. 
The insurer denied coverage for the inpatient level of care admission. 
The health plan's determination is upheld. 

This woman was transferred to the hospital from another facility for cardiac catheterization. The patient had a history of chronic back pain and developed acute neurologic deficits after a fall. She underwent lumbar spinal fusion. Her postoperative course was complicated by intestinal ileus that resolved. Cervical spine decompression was planned. However, it was postponed when the patient had an episode of chest pain. An electrocardiogram showed inferior and septal T wave inversions that were new compared to prior tracings. Her serum troponin levels were normal. She was treated with heparin, aspirin and clopidogrel. An echocardiogram performed and showed normal left ventricular systolic function. Coronary computed tomography (CT) angiography suggested a significant stenosis in the first diagonal coronary artery and moderate disease in the left anterior descending coronary artery (LAD). 

Based on the documentation provided, the inpatient hospital services were not medically necessary. This woman was transferred for cardiac catheterization after an episode of chest pain nine days prior. While her electrocardiogram showed T wave inversions, the records do not indicate that there were any acute ST segment changes. Her serum troponin levels were normal and an echocardiogram showed normal left ventricular systolic function. She was hemodynamically stable without ongoing chest pain. Cardiac catheterization showed no obstructive disease. 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath.
Treatment: Pulmonary ventilation and perfusion imaging (a special imaging test that measures air and blood flow in your lungs) (78582).
The insurer denied: Pulmonary ventilation and perfusion imaging (a special imaging test that measures air and blood flow in your lungs) (78582).
The denial is upheld.

This patient is an adult female with a history of pulmonary embolism. She was prescribed a ventilation/perfusion (V/Q) scan. The patient was seen in the office in 6 months ago and had shortness of breath. The ventilation/perfusion scan was ordered to evaluate for pulmonary embolism. It was denied due to lack of medical necessity. This denial is being appealed.

The requested health service was not medically necessary.

This patient with a history of pulmonary embolism now had shortness of breath. However, the patient does not have any contraindication to computed tomographic angiography (CTA) of the chest to evaluate for pulmonary embolism. Computed tomographic angiography is the standard of care for the evaluation of pulmonary embolism in the setting of prior embolism and current shortness of breath. Therefore, the requested ventilation/perfusion (V/Q) scan is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypersensitivity Pneumonitis.
Treatment: Home ventilator (code E0466).

The insurer denied coverage for home ventilator (code E0466).  The denial is upheld.

The patient has a diagnosis of Hypersensitivity Pneumonitis. The patient had rales on lung exam halfway up. The patient's pulmonary function test (PFT) revealed a restrictive pattern with reduced diffusing capacity of the lungs for carbon monoxide (DLCO).The patient's medications included Cellcept, Prednisone and Ofev. The patient had been diagnosed with Covid and was treated with Paxlovid.

As per last exam, the patient was ambulating to 600 feet. Respiratory Rate was 24. Oxygen (O2) saturations were in the mid to high 90's.

This patient was prescribed a Home Ventilator.

Based on documents sent for review, criteria were not met to justify a home ventilator.
No Arterial Blood Gas results to show any ventilatory failure - either hypercarbic or hypoxic. The was not any documentation provided to show that this patient was compliant with the device (which is defined as use of device for 70% of the nights for an average of four or more hours in a 24 hour period).

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 a home ventilator (code E0466) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Diverticulitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient presented with left lower quadrant (LLQ) abdominal pain, nausea, and vomiting. The patient was afebrile, and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. A computed tomography (CT) scan showed diverticulitis without an abscess or perforation. The patient was treated with antibiotics. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-150 for acute diverticulitis. Clinical indications for admission include hemodynamic instability, peritoneal signs, persistent gross bleeding, and a significant abnormality on an imaging study. This abnormality can be a fistula, obstruction, or frank perforation. Other indications include the need for a drainage procedure, bacteremia, severe vomiting, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had uncomplicated diverticulitis. This could have been treated with a course of oral antibiotics as an outpatient. No surgical or drainage procedures were needed. Intravenous (IV) hydration and serial abdominal examinations could have been done with observation status. The patient did not meet Milliman Care Guideline (MCG) criteria for admission for acute diverticulitis. 

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructive hydrocephalus
Treatment: Continued Stay in Skilled Nursing Facility (SNF)
The insurer denied: Continued Stay in Skilled Nursing Facility (SNF)
The denial is upheld.

This adult female has obstructive hydrocephalus. She had external ventricular drain (EVD) placement, bifrontal craniotomy, and tumor resection. Post-operatively, the patient developed sepsis due to osteomyelitis of her lower back and decubitus ulcer. She was admitted to a skilled nursing facility (SNF) level of care. On review 2 months later, the patient's vital signs were stable, and she was afebrile. She was feeding via percutaneous endoscopic gastrostomy (PEG) tube. She was receiving lab monitoring every four weeks. She had completed intravenous antibiotics. She was on oral antifungal and antibiotic medication for tinea corporis and Clostridium (C) difficile. Ongoing physical and occupational therapy is recommended. Physical therapy re-evaluation shows the patient remains dependent with bed mobility, transfers, and locomotion. Occupational therapy shows the patient remains dependent with lower body dressing and toileting.

The proposed treatment is not medically necessary.

A skilled nursing facility level of care is indicated when the patient requires skilled nursing services or skilled rehabilitation services; the patient requires these skilled services on a daily basis; it is practical for daily skilled services to provided only on an inpatient basis in a skilled nursing facility; and the services are reasonable and necessary for the treatment of the patient's illness or injury. Custodial care is care primarily for the purpose of assisting a patient in activities of daily living (ADLs) or in meeting personal rather than medical needs and is not specific treatment for an illness or injury. It is care that cannot be expected to substantially improve a medical condition and has minimal therapeutic value. Such care includes assistance with walking, bathing or dressing; transfer or positioning in bed; normally self-administered medicine; meal preparation; feeding by utensil, tube, or gastrostomy; oral hygiene; ordinary skin and nail care; catheter care; suctioning; using the toilet; enemas; or preparation of special diets and supervision over medical equipment or exercises or over self-administration of oral medicine. The clinical records do not support an ongoing skilled nursing facility level of care effective as of the dates in question. This patient's functional status has plateaued. The patient is dependent with mobility and with activities of daily living. There is no expectation that a skilled nursing facility level of care will substantially improve a medical condition. The patient does not have skilled nursing needs. The patient is receiving custodial care, because there is no therapeutic value to an ongoing skilled nursing facility level of care. The requested continued skilled nursing facility level of care is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incomplete abortion

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient presented with an incomplete abortion. Ultrasound was consistent with 7 weeks and 5 days gestation. The patient underwent an uncomplicated dilation and curettage (D&C) and was discharged later that day. 

Dilatation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration or sharp curettage. Admission to an acute level of care is not customary or medically necessary. There was no reason submitted why the patient was admitted. Post operatively, the patient was stable. The patient was voiding and tolerating oral intake.

The procedure was uncomplicated and there was no concern for a surgical complication like injury to bladder, bowel or uterine perforation.

Please note that following the D&C, the patient could have been observed in the recovery room like all patients undergoing an ambulatory procedure and once the provider ascertained that the patient was stable they could have been sent home. 

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 inpatient admission is not substantiated.