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

Diagnosis:  Chest pain.
Treatment:  Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is overturned.

The patient is a male with a past medical history significant for coronary artery disease, status post stent placement, atrial fibrillation on chronic anticoagulation, and hypertension, who presented to the hospital after he developed substernal chest pain that he rated as 7/10 in intensity. The chest pain started shortly after he completed his lunch. The pain became constant in nature. There was no radiation. He had some improvement after taking nitroglycerin. The patient denied any exacerbating factors. He had some diaphoresis.

The patient was in no acute distress. He looked mildly ill-appearing. He was awake, alert, and oriented x 4. The head, eyes, ears, nose, throat (HEENT) exam was within normal limits. The neck was supple without lymphadenopathy, masses, jugular vein distention (JVD), and carotid bruits. Lungs were clear to auscultation without wheezes, rales, or rhonchi. The patient had a regular rate and rhythm, without murmurs, rubs, or gallops.

His abdomen was moderately distended but soft and non-tender. He had normal bowel sounds.

There was no redness, swelling, or tenderness in the extremities. The neurologic exam was unremarkable.

Chest x-ray demonstrated no acute cardiopulmonary disease.

Laboratory evaluation revealed that white blood cell count was 6.9, hemoglobin 15, hematocrit 42, and platelets 185. Sodium was 139, potassium 3.3, chloride 107, bicarbonate 23.7, blood urea nitrogen (BUN) 18, creatinine 0.94, and glucose 209. Troponin was minimally elevated at 0.070.

The patient was admitted to the hospital for evaluation of substernal chest pain to rule out acute coronary syndrome. The patient underwent a left heart catheterization. Post-procedure the patient remained in stable condition and was discharged home.

The health plan's determination is overturned.

The inpatient hospital admission was medically necessary.

This patient had acute coronary syndrome, which is considered a life-threatening condition requiring immediate intervention and close monitoring, justifying admission at the acute inpatient level of care.

Based on the patient's symptoms, elevated troponin level, and the findings on the left heart catheterization, the patient had acute coronary syndrome. This patient was diagnosed with non-ST elevation myocardial infarction (NSTEMI), which required intervention including stent placement.

Patients with acute coronary syndrome require close monitoring, as well as an ultimate coronary intervention, as was performed in this clinical case.

Taking into consideration the severity of the patient's condition and the complexity of services provided, the inpatient hospital admission was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral artery disease
Treatment: Blood vessel procedure
The insurer denied the blood vessel procedure.
The health plan's determination is overturned.

The patient is a man with a history of multiple deep vein thrombosis (DVT) not on anticoagulation and peripheral arterial disease who was seen in follow up. The patient was diagnosed with atherosclerosis of the left lower extremity (LLE) causing claudication.

The requested blood vessel procedure is medically necessary for this patient.

The patient had a left lower extremity arterial duplex exam performed that demonstrated severe atherosclerotic plaque formation in the lower extremity arterial system with hemodynamically stenosis at the knee. There was a total occlusion of the popliteal artery and tibioperoneal trunk. The occlusion was 11.33 centimeter (cm) in length.

The patient has peripheral arterial disease and left lower extremity claudication. The requested procedure is medically necessary and is the standard of care for the treatment of peripheral arterial disease and lower extremity claudication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Relapsing remitting multiple sclerosis 
Treatment: Natalizumab (Tysabri) Infusion 
The insurer denied Natalizumab (Tysabri) Infusion.
The health plan's determination is overturned.

The patient is a female with relapsing remitting multiple sclerosis who is requesting treatment with Tysabri. Continuation of this medication was denied by the plan because there was not documentation that the patient was stable or improved with treatment.

Natalizumab (Tysabri) Infusion is medically necessary for this patient.

The patient has relapsing remitting multiple sclerosis. This is a Food and Drug Administration (FDA) approved indication for treatment with Tysabri. The provider indicates that the patient has been treated with Tysabri. The provider also indicates that the patient has been both neurologically and radiographically stable on this medication. It is not the standard of care to discontinue treatment with this medication unless there is therapeutic failure or an adverse reaction that is intolerable. As such, continuation of Tysabri is medically necessary for treatment of the patient's relapsing remitting multiple sclerosis and preventing neurologic disability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute change in mental status and slurred speech

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient with history of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), anxiety, and hypertension presented to the Emergency Department (ED) with acute change in mental status and slurred speech after taking Xanax. Patient was not a good historian but reported taking 5 pills of 0.25 milligrams (mg) Xanax. Vital signs in the ED were unremarkable. In the ED, the patient reportedly fell to the ground. On exam, the patient was disoriented to place, time, confused, slurred, restless, unsteady, and sleepy. Head computerized tomography (CT) scan showed no acute condition. He was admitted to inpatient level of care. 

Given that the patient was cognitively altered in the ED, had fallen, and had evidence of ataxia on exam with slurred speech, inpatient level of care was medically necessary in order to rule out an acute cerebrovascular accident.

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

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibromyalgia, rheumatoid arthritis, severe anxiety and depression, migraines, and asthma. 
Treatment: Increase Consumer Directed Personal Assistance Services to a total of 48 Hours/Week
The insurer denied: Increase Consumer Directed Personal Assistance Services to a total of 48 Hours/Week
The denial is upheld

The patient is an adult female with fibromyalgia, rheumatoid arthritis, severe anxiety and depression, migraines, and asthma. The patient does have chronic diffuse body pains and migraines, dizziness, and severe anxiety that worsens when she leaves her home, as well as forgetfulness.

Per the Uniform Assessment System report the patient's cognitive skills showed modified independence with some difficulty in some situations, requires maximum assistance with meal, preparation and ordinary household tasks, extensive assistance with shopping, limited assistance with bathing and personal hygiene requires extensive assistance in dressing lower body. The patient requires assistance with activities of daily living due to pain, the patient is occasionally bladder incontinent.

The request is to increase the patient's Consumer Directed Personal Assistance Services to 48 hours/week.

The requested Increase Consumer Directed Personal Assistance Services to a total of 48 Hours/Week is not medically necessary.

The patient requires assistance with activities of daily living, and requires maximum assistance with meal preparation, ordinary household tasks, extensive assistance with shopping, and limited assistance was bathing and personal hygiene. She requires extensive assistance in dressing lower body. The patient requires assistance with activities of daily living due to pain.

The patient does have pain and migraines with anxiety, as well as forgetfulness. She does need doctor visits. She currently receives 4 hours for 5 days of home care per week, which is adequate for the patient.

The health plan's approved hours are sufficient for the patient's needs. The requested 48 hours/week of assistance services are in excess of the patient's needs. Therefore, the request for 48 hours/week assistance is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Insomnia, breast cancer
Treatment: Zolpidem tartrate 10 mg
The insurer denied zolpidem tartrate 10 mg.
The determination is upheld.

This is a patient with advanced breast cancer and difficulty sleeping. Zolipdem tartrate 10 milligrams (mg) was prescribed and is under review for medical necessity.

The requested health service/treatment of zolpidem tartrate 10 mg tablets is not medically necessary for this patient
The authors of UpToDate state that in the treatment of patients with insomnia, "... Under most circumstances, treatment should be initiated at the lowest dose to assess tolerability and then cautiously advanced to a higher dose only when necessary for greater efficacy...". They go on to state that the dose can be titrated as clinically indicated but that "...The effectiveness and safety of medications prescribed for insomnia must be monitored regularly. We generally recommend a clinical visit or phone follow-up within a few weeks of an initial prescription to review effectiveness, pattern of use, and adverse effects..". There is a paucity of documentation describing the patient's sleep difficulties and comorbidities. There is no evidence in the included documentation that the patient has tried a lower dose of therapy or failed an alternative agent. The approach taken in this case is also at odds with recommendations in national guidelines. For these reasons, medical necessity cannot be established for this service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease of both small and large intestine without complications
Treatment: Stelara subcutaneous (SQ) 90mg.
The insurer denied coverage for Stelara SQ 90mg.
The health plan's determination is overturned.

The patient is a male with a history of Crohn's disease. He was started on Stelara at the standard dose, 90 milligrams (mg) every 8 weeks. However, he continued to have active disease. He was escalated to 90 mg every 4 weeks, Entyvio was added and he responded well.
At issue is the medical necessity of Stelara 90 mg every 4 weeks.

Stelara, subcutaneous (SQ) 90mg is medically necessary for this patient. Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease. Chavannes M et al., reported a multi-centered cohort study supporting the safety and efficacy of Stelara in pediatric patients with Crohn's disease.
Another report shows that Ustekinumab (Stelara) is efficacious and safe in pediatric patients with inflammatory bowel disease. 
The clinical practice guidelines support the use of Stelara in pediatric Crohn's patients who failed tumor necrosis factor (TNF) -alpha inhibitors. Therefore, Stelara use in children with Crohn's disease is appropriate and well supported by peer reviewed evidence. However, some patients do not respond adequately to the standard dose. Dose escalation is often required in biologics in order to achieve therapeutic levels. There are many peer reviewed literature reports showing that low Stelara levels were associated with a poor clinical response. The requested dose of Stelara 90 mg every 4 weeks is proven to be effective in patients who fail the standard dose.
Per Ollech, Jacob E., et al.: "Shortening the Ustekinumab (Stelara) 90 mg dose interval to 4 weeks for patients with Chron's Disease (CD) who did not respond to doses every 8 weeks had improved clinical and biological indices of disease activity. Patients who lose response to the standard dose of Ustekinumab might benefit from dose interval shortening, which was effective and safe."

Per Cohen, Erica et al.: "A majority of patients with moderate to severe CD benefited from Ustekinumab (UST) dose escalation suggesting the clinical utility of optimizing dosing in the treatment course. "
This member has a history of refractory Crohn's disease and failed to respond to Stelara standard dose (90 mg every 8 weeks). He responded well to the requested dose and maintained clinical remission. Therefore, continuation of Stelara as requested is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cystic fibrosis
Treatment: Synagis
The insurer denied Synagis. 
The health plan's determination is overturned.

The patient is a female born at 39-3/7-weeks' gestation with prenatally diagnosed cystic fibrosis (without gastrointestinal manifestations). Birth weight was 3373 gms (grams), discharge weight was 3170gms. Newborn screen was positive, with elevated IRT (immunoreactive trypsinogen) (93.8), two variants detected. Deoxyribonucleic acid (DNA) testing (polymerase chain reaction (PCR) and next-generation sequencing) indicated presence of two allele variants in the CFTR (cystic fibrosis transmembrane conductance regulator) gene. 

Synagis is medically necessary for this patient.

In 2014, the American Academy of Pediatrics issued new guidelines for the administration of Synagis for RSV (Respiratory Syncytial Virus Infection) prophylaxis based on review of current peer-reviewed literature related to burden of RSV in infants and children with emphasis on those at highest risk of severe disease. The following groups of patients are considered at highest risk, with recommendations for administration of Synagis: infants born before 29 weeks' gestation younger than 12 months of age at the start of RSV season; infants with chronic lung disease of prematurity born before 32 weeks' gestation during the first year of life, with some consideration during the second year of life if continued medical support is necessary; infants 12 months of age or younger with hemodynamically significant congenital heart disease (excluding those with lesions adequately corrected by surgery unless medication is necessary for ongoing congestive heart failure); consideration for infants 12 months of age or younger with anatomic pulmonary abnormalities or neuromuscular disorders that have difficulty clearing secretions; consideration for infants less than 24 months of age that are profoundly immunocompromised; and consideration for infants with Down syndrome or cystic fibrosis that have evidence of other risk factors such as chronic lung disease or congenital heart disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: chronic low back pain (CLBP)

Treatment: Intracept procedure (CPT (current procedural terminology) codes 64628/64629)

The insurer denied coverage for Intracept procedure (CPT codes 64628/64629)

The denial is upheld 

This is an adult patient with a history of vertebrogenic lower back pain. A magnetic resonance imaging (MRI) was performed that showed Type l Modic endplate changes along the right aspect of lumbar (L) 4-L5. Per the progress note the doctor notes that the patient had Modic Type l, ll on the lumbar MRI at the L4, L5, sacral (S) 1 levels. The patient had failed more than 6 months of conservative pain care. The physician recommended the Intracept procedure to treat lower back pain.

It is unclear if the scientific evidence in peer-reviewed literature supports a result of improvement in health outcomes. From the Office Disability Guidenes (ODG, 2022, Intracept), "Not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. If approved despite non-recommendation, there should be at least 6 months of chronic low back pain following a defined injury, refractory to conservative care, as well as Modic type I or II changes between L3 and S1 on magnetic resonance imaging.

The Food and Drug Administration has granted approval for marketing. It has not provided guidance nor recommendations for use or benefit. 

This patient is not a good candidate for Intracept procedure (CPT codes 64628/64629). The medical records show that ths patient has a complex history. The patient had undergone 4 spinal procedures, multiple injections and courses of different treatments, as well as several hip surgeries. No specific pain generator has been defined. The patient has been treated for stenosis, instability, disc disease and hip arthritis. The report of the basivertebral nerve being causative for the patient's condition has low credence. Although there are MRI findings of Modic changes to two levels, one cannot discount the presence of the patient's laminectomy defects, ongoing stenosis and herniations to several levels. The clinical record is consistent with a post laminectomy or failed back syndrome. The recommended procedure has low likelihood of success. 

The Intracept procedure (CPT codes 64628/64629) is not the best available treatment for this patient at this time. It would be more likely to consider a spinal cord stimulator.

The adverse risks are increased over standard treatment/servicies. The Intracept Procedure is invasive and complications can occur, such as infection and instrument breakage.

Based on the above, the denial of Intracept procedure (CPT codes 64628/64629) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is upheld.

This is a patient who has a history of low back pain. Prior treatments have included home exercises, multiple medications, as well as heat and ice. Activities of daily living (ADLs) are impacted by the pain. No sustainable relief has been garnered from the prior treatments. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated Modic type I changes at lumbar (L) 4-5. The patient's diagnoses are listed as vertebrogenic low back pain. At issue is whether the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment 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. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A 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 health service or treatment 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: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is upheld.

This is a patient with pain in the neck and lower back. His pain started after a hockey injury. He described his pain as burning, sharp, and shooting with radiation to the right hip and groin. The review of symptoms (ROS) documented numbness in the right thigh and gait disturbance. The physical exam (PE) revealed painful thoracolumbar flexion with positive straight leg raise (SLR) bilaterally. Magnetic resonance imaging (MRI) showed a large disc bulge with superimposed central disc herniation at lumbar (L) 4/5 and impingement upon the thecal sac and encroachment of the descending L5 nerve roots and Modic changes at L4/5. This patient had tried physical therapy (PT) and massage. He was recommended for the Intracept procedure at L4 and L5.

At issue is whether the Intracept procedure is 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 was designed to treat low back pain from the vertebral body by ablating intraosseous nerves. The available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. His PE revealed positive SLR bilaterally. An MRI revealed a large disc bulge with superimposed central disc herniation at L4/5 and impingement upon the thecal sac and encroachment of the descending L5 nerve roots. Numbness in the right thigh was documented in the review of symptoms. These clinical findings are not consistent with vertebrogenic pain. Current clinical studies supported the efficacy of the Intracept procedure for vertebrogenic back pain. However, patients with radiographic evidence of other pain etiologies including severe spinal stenosis, disc bulge, nerve impingement and facet arthrosis were excluded from these studies. Reference 1. (Table 1 exclusion criteria in this study).
Given this patient's MRI findings, PE findings and symptoms, he is not an appropriate candidate for the Intracept procedure. It is unlikely he will benefit from the Intracept procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental caries
Treatment: Outpatient dental work to be done at the hospital
The insurer denied outpatient dental work to be done at the hospital
The determination is overturned.

The patient has a history of acute reaction to stress (F43.0), generalized anxiety (F41.1) and behavioral concerns (F98.9) and presented with severe dental caries. The current treatment plan includes tooth extractions and fillings, to be done in an operating room with anesthesia, based on the patient's medical history. At issue is the medical necessity of outpatient dental work to be done at the hospital.

Based on the radiographs provided, this patient needs the dental work done to prevent further pain, infection, or sepsis. The sequelae of infection and/or sepsis have been noted in pediatric cases with severe dental caries. As noted in peer reviewed literature, the proportion of children with sepsis increases markedly with caries experience. Pediatric patients with the following medical diagnoses (F43.0, F41.1, F98.9) that also present with severe dental caries (K02.9) are best treated in an operating room with anesthesia to ensure safe delivery of care. The dental care is provided more efficiently as it is completed during one visit. The treatment presented by the provider is congruent with the diagnostic images and medical history for the patient and the patient's treatment is supported due to medical necessity and prevention of further medical complications for the patient.