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

Diagnosis: Vertebrogenic Low Back Pain
Treatment: Pain Management (ablation, 1 Unit)
The insurer denied: Pain Management (ablation, 1 Unit)
The denial is overturned.

The patient is an adult male. Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease that resulted in Modic changes. The patient has pain and failed treatment for greater than six months. The patient has tried lumbar epidural steroid injections, medication, physical therapy, radio frequency of lesions and SI (sacroiliac) joint injections. The patient's pain is averaging 7/10. The pain is aggravated with daily activities. Per notes dated five months ago, the patient presented with bilateral low back pain that is 7/10. The patient continues to have joint pain, numbness, tingling of the affected limbs with spasms and difficulty ambulating. Exam lumbar revealed spasm and tenderness along with tight muscle bands 
noted. Range of motion is diminished. Foot dorsiflexor is diminished and first toe extensor is diminished. Positive facet loading bilateral was. Diagnosis includes low back pain, lumbar radiculopathy, sacroiliitis, lumbar spondylosis without myelopathy or radiculopathy, pain in right hip, myalgia, pain in left hip, and encounter for adjustment of peripheral nerve stimulator. The patient's MRI (magnetic resonance imaging) from last year noted Modic type changes.

The health plan should cover the requested health service.

Based on the documentation provided, the requested procedure is recommended in this case. 

The patient has a history of continued back pain despite all prior conservative treatments as well as interventional treatments. The patient has Modic type changes on MRI (magnetic resonance imaging) provided. Given the patient's continued symptoms and given FDA (United States Food and Drug Administration) approval for treatment for patients with Modic type changes, the request is recommended in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Vertebrogenic Low Back Pain
Treatment: Pain Management (ablation, 1 Unit)
The insurer denied: Pain Management (ablation, 1 Unit)
The denial is overturned.

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 conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, RFA (radiofrequency ablation), sacroiliac joint injections, TPIs (trigger point injections), and home exercises. The patient has failed multiple medications including NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, and pain medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury.

The health plan should cover the requested health service.

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 conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, RFA (radiofrequency ablation), sacroiliac joint injections, TPIs (trigger point injections), and home exercises. The patient has failed multiple medications including NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, and pain medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury.
The Intracept procedure (intraosseous 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 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. The procedure is a Food and Drug Administration (FDA) approved procedure for axial low back pain. It has been shown effective in randomized clinical trials (RCT) with five-year results. Given that this patient has failed and/or attempted all conventional and typical options for common causes of axial low back pain, the requested procedure should be covered. 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. Alternatives at this time are more invasive and would include surgery, without good results shown in RCT (randomized controlled trials) for back pain. Given that the alternatives do not show favorable outcomes in the literature, have higher risk and morbidity, and all conservative treatments have failed, the requested Intracept procedure is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Vertebrogenic Low Back Pain
Treatment: Pain Management (ablation, 1 Unit)
The insurer denied: Pain Management (ablation, 1 Unit)
The denial is upheld.

The patient is an adult male with low back and right hip pain. His past treatments include epidural steroid injection, radiofrequency ablation, sacroiliac joint injection, physical therapy, baclofen, Medrol dose pack, Naprosyn. MRI (magnetic resonance imaging) of the lumbar spine from last year shows lumbar four to five (L4-5) disc bulge, lumbar four (L4) nerve root impingement bilaterally, moderate spinal stenosis, mild Modic type II changes, and mild facet joint arthropathy, as well as multilevel degenerative changes. The request for Intracept was denied coverage by the health plan as investigational/experimental. 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. The requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease. Additional studies/trials are necessary to determine efficacy as compared to other conventional therapies. The requested health service or treatment has not been proven to be more beneficial than any standard treatment for the patient's condition or disease.
Other standard treatment options that exist in the medical literature may include non-opioid medications (i.e. nonsteroidal anti-inflammatory drugs, membrane stabilizing agents, and/or muscle relaxants), modalities (i.e. physical therapy, home exercise program, chiropractor treatments), and interventions (i.e. epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Weakness and difficulty walking
Treatment: Pediatric wheelchair and accessories
The health plan denied: Pediatric wheelchair and accessories
The determination is: Overturned

The patient is a female child with multiple medical issues including the following: macrocephaly, obesity, congenital bilateral foot deformities, cerebral palsy with bilateral lower extremity spasticity/hypertonicity, and global developmental delay. She is non-verbal and essentially non-mobile. She is able to stand up at home, transfer with assistance, and take a few steps by report. X-rays revealed that she was completely non-weight-bearing. The family was gifted a wheelchair that was too small. They were using a Graco stroller that the child outgrew. According to the note, the child had been fitted for a specific wheelchair, but the chair that arrived was not the same, so the mother refused to accept it. Despite the child's weight of more than 60 pounds, the mother carries her over her shoulder everywhere outside of the home. The current request is for an appropriately outfitted wheelchair. A mobility evaluation was completed. The wheelchair chosen by Physical Therapy included additions and modifications to accommodate for her lower extremity spasticity and hypertonicity, poor pelvic alignment, limited adduction at the hips, poor trunk alignment, inability to hold her head up and midline, and significant global developmental delay with inability to follow directions.
At issue is the medical necessity of the wheelchair.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of a wheelchair with additions and modifications is medically necessary for this patient.
According to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents With Chronic Disease, "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens.[1]" Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities.[1] "
This female child has limited mobility and significant disability as a result of her cerebral palsy, bilateral foot deformity, lower extremity spastic diplegia, and global developmental delay. She is non-ambulatory and dependent on equipment or family to transport her throughout her environment. She has outgrown her previous stroller, so now her mother carries her over her shoulder. This is not safe or appropriate given the child's size and degree of disability. She underwent wheelchair evaluation, and an appropriate chair was selected. Specific modifications and additions were made to the wheelchair so as to meet her functional needs without increasing the risk of morbidity. The requested wheelchair with associated accessories is medically necessary and appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Intraosseous basivertebral nerve ablation (procedure code 64628, 64629). 
The insurer denied the intraosseous basivertebral nerve ablation (procedure code 64628, 64629). 
The health plan's determination is upheld. 

The patient is a male with low back pain. The pain began over 2 years ago. Past treatment has included physical therapy, medications, as well as injections. Pain impacts activities of daily living (ADL). Pain ranges from 7-9 out of 10. Magnetic resonance imaging (MRI) lumbar spine showed Modic type II changes at L (lumbar) 4-5 and L5-S (sacral)1. 

The proposed Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The patient has complaints of low back pain. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. An Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. 
In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care. Given the above, the proposed Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Intraosseous basivertebral nerve ablation (procedure code 64628, 64629). 
The insurer denied the intraosseous basivertebral nerve ablation (procedure code 64628, 64629). 
The health plan's determination is upheld. 

This is a male patient diagnosed with chronic low back pain. Records indicate the patient was recommended to undergo the Intracept procedure (intraosseous basivertebral nerve ablation), which was denied by the insurance carrier. 
The provider states that the patient has a history of chronic low back pain that began more than 2 years ago. The patient has tried medication management, physical therapy, sacroiliac joint injections and transforaminal epidurals during injections. Medications have included diclofenac, Flexeril, gabapentin, Lyrica, Percocet, prednisone and Valium. Nothing has provided significant or sustained improvement and pain is impacting the patient's activities of daily living. 

Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic type II changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). This procedure is not standard of care as there is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain. 
Treatment: Intraosseous basivertebral nerve ablation (procedure code 64628, 64629). 
The insurer denied the intraosseous basivertebral nerve ablation (procedure code 64628, 64629). 
The health plan's determination is upheld. 

This patient is a male who has a 2-month history of low back pain with radiating pain to the left thigh. His pain is described as sharp, throbbing with occasional sensation of pins and needles. Pain level is 9/10. He had tried prednisone, diclofenac and Percocet with some pain relief. He had 80% pain relief from the prior left L (lumbar) 4 and L5 transforaminal epidural steroid injections (TFESI). Physical exam (PE): limited lumbar spine range of motion (ROM), tenderness to palpation (TTP) over left sacroiliac (SI) joint, positive straight leg raise (SLR) and positive Faber tests.

Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The Intracept system is designed to treat low back pain from vertebral body by ablating Basivertebral nerves. The available medical records did not reveal adequate evidence that vertebrogenic pain is the primary pain generator in this case. This patient has left thigh pain with pins/needles sensation, that responded to the prior lumbar TFESI. PE documented positive SLR tests. MRI (magnetic resonance imaging) of lumbar spine showed Left L3/4 disc bulge with resultant left L3/4 foraminal stenosis, disc bulge at L4/5 with mild bilateral L4/5 foraminal stenosis, facet arthropathy and disc bulge at L5/S (sacral) 1 with moderate bilateral foraminal stenosis. Truumees's study supported the efficacy of Intracept procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded. 
Given this patient's medical history, lumbar and hip MRI readings, and current clinical evidence, the Intracept Procedure is not likely to be more beneficial than the standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is overturned

The patient was sent to the hospital from the clinic with complaints of (C/O) tachycardia, shortness of breath (SOB) and cough. The patient had a temperature of 102 degrees Fahrenheit (F). Oxygen saturations were 93% on room air. Patient has a history of being treated for community acquired pneumonia (CAP) with oral (PO) Azithromycin and then PO Augmentin, steroids and DuoNebs. As the patient did not feel better they were referred to the emergency department (ED).

In the ED the patient was noted to have decreased breath sounds and rhonchi. Peak expiratory flow (PEF) was 150, temperature 99.8 degrees F, pulse 116, blood pressure 122/77, White blood cells (WBC) were 7.9, and hemoglobin was 12. Patient was started on Vancomycin and Cefepime.

This patient had failed outpatient management of Pneumonia. The patient had worsening of symptoms. Admission was appropriate.

The patient received nebulizers and after that PEF improved to 250. The patient was seen by the Infectious Disease doctor who recommended to treat with intravenous (IV) Rocephin and Azithromycin. Computed tomography angiography (CTA) was recommended. It was negative for pulmonary emboli (PE). Imaging studies were consistent with left lower lobe pneumonia.

Since the patient had not responded to outpatient therapy with 2 types of antibiotics,  Azithromycin in February and Augmentin in March, it was appropriate to admit the patient for further treatment with intravenous (IV) antibiotics. The patient responded to IV antibiotics and once improved was switched to PO antibiotics and discharged home.

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 the hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: difficulty urination
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned.

The patient is a male with history of hypertension who initially presented to the emergency department with concerns of difficulty with urination, fever, chills, and left-sided flank pain with radiation to suprapubic. Urinalysis was with pyuria and bacteriuria. Chest radiograph was unremarkable. A computed tomography (CT) abdomen/pelvis revealed findings concerning for chronic bladder outlet obstruction, enlarged prostate, or prostatitis. A Foley catheter was placed. Intravenous fluids and empiric antibiotics were administered. The patient was placed in the hospital thereafter with an impression of urinary retention, sepsis secondary to urinary tract infection, and flank pain. 

The inpatient hospital admission was medically necessary. The patient was male who presented with fever, suprapubic tenderness, leukocytosis, pyuria, bacteriuria, and urinary retention. Computed tomography (CT) imaging revealed findings concerning for bladder outlet obstruction. A Foley catheter was inserted to address this and tamsulosin was initiated. Empiric antibiotics were initiated with eventual clinical improvement. Once hemodynamics were stable and urine cleared up, a voiding trial was performed and successful. The patient was promptly discharged thereafter. Moreover, clinical indications for admission to inpatient care were met. The patient presented with systemic inflammation secondary to a urinary tract infection complicated by significantly impaired bladder emptying requiring placement of an indwelling Foley catheter.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is an adult female with a history of obesity who presented to the emergency department (ED) with complaints of cough and shortness of breath (SOB) for 1 week. The patient denied any prior history of asthma.

On presentation to the emergency department (ED) the patient's vital signs were: Temperature 97.7 degrees Fahrenheit, Respiratory Rate 18 breaths per minute, Blood Pressure 156/90 mmHg (millimeters of mercury) and Heart Rate of 79 beats per minute.

Peak expiratory flow (PEF) 160 with an unknown baseline. Oxygen saturation was 91% (percent) on room air and 94% (percent) on 2 Liters of oxygen. Bilateral audible wheezing was heard. The patient was in no apparent distress and was alert and oriented to person, place and time.

The white blood cell (WBC) count was 9.6K (potassium) and potassium (K+) was 3.3 millimoles per liter (mmol/L). The chest X-ray (CXR) showed no acute infiltrates. The patient was admitted with likely viral syndrome.

The patient was treated with Nebulizers, steroids and Magnesium. After treatment, Temperature 98.1 degrees Fahrenheit, Respiratory Rate 19 breaths per minute, Blood Pressure 100/60 mmHg (millimeters of mercury) and Heart Rate 100 beats per minute. Oxygen saturation was 95% (percent) on oxygen. Computerized tomography (CT) of the chest ruled out pulmonary emboli (PE). The patient likely had bronchitis.

The patient was seen by Pulmonary specialty and was recommended to be treated with oral Prednisone for a few days, Inhaled Steroids, oral azithromycin and oxygen as needed to keep saturation at 92% (percent).

This patient did not need acute inpatient hospitalization. She could have been placed in Observation status while diagnostic studies and treatments were initiated. The patient was afebrile and hemodynamically stable. Pulmonary Embolus and Pneumonia were ruled out. 
She possibly had some mild hypoxia and she could have been sent home on low flow oxygen if needed. The patient was treated with oral Steroids, antibiotics, inhaled corticosteroids and Nebulizers.

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.