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

Diagnosis: Peripheral Neuropathy.
Treatment: Implantation of the percutaneous neurostimulator electrode.
The insurer denied implantation of the percutaneous neurostimulator electrode.
The determination is upheld.

This is a female patient with complaints of neuropathic pain. It is noted that the patient has had the pain for more than 5 years. She has trialed and failed multiple neuropathic pain medications. Medications make her drowsy. She also has a history of gastric issues. The patient has chronic bilateral leg pain and peripheral neuropathy that limits her activities of daily living. There is a request for a spinal column stimulator, and this is under review.
The proposed health service or treatment implantation of the percutaneous neurostimulator electrode is not likely to be more beneficial than any standard treatment or treatment for the insured's life-threatening or disabling condition or disease.
There is a request for a spinal column stimulator for chronic peripheral neuropathy/pain. Spinal cord stimulation involves implanting a spinal cord stimulator lead into the epidural space, either percutaneously or by surgical laminectomy or laminotomy. Electrical impulses are generated by a pulse generator that is implanted subcutaneously. For diabetic neuropathy, a systematic review and meta-analysis of 2 randomized controlled trials (93 patients) evaluating the efficacy of spinal cord stimulation for the management of painful neuropathy found, at 6-month follow-up, that spinal cord stimulation was associated with a significant reduction in pain intensity and a greater proportion of patients achieving at least a 50 percent (%) reduction in pain as compared with best medical therapy. However, the authors recommended future trials due to the small sample size and high risk of bias of the included studies.  In general, there is a lack of substantial support for this procedure for chronic peripheral neuropathy/pain, and it is currently not considered the standard of care for chronic peripheral neuropathy/pain.
Given the above, the proposed health service or treatment implantation of the percutaneous neurostimulator electrode is not likely to be more beneficial than any standard treatment or treatment for the insured's life-threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Peripheral Neuropathy.
Treatment: Implantation of the percutaneous neurostimulator electrode.
The insurer denied implantation of the percutaneous neurostimulator electrode.
The determination is overturned.

This is a female patient with a history of chronic pain from peripheral neuropathy. She underwent implantation of a spinal cord stimulator. At issue is whether implantation of the percutaneous neurostimulator electrode is likely to be more beneficial than any standard treatment or treatment for the insured's life-threatening or disabling condition or disease.
The proposed health service or treatment implantation of the percutaneous neurostimulator electrode is likely to be more beneficial than any standard treatment or treatment for the insured's life-threatening or disabling condition or disease.
.	Spinal cord stimulators may be indicated for the following conditions:
.	Failed back surgery syndrome (FBSS) with low back pain and significant radicular pain; or
.	Complex regional pain syndrome (CRPS) (also known as reflex sympathetic dystrophy (RSD)); or
.	Inoperable chronic ischemic limb pain secondary to peripheral vascular disease; or
.	The treatment of moderate to severe (5 or more on a 10-point Visual Analog Scale (VAS) scale) chronic neuropathic pain of certain origins (i.e., lumbosacral arachnoiditis, phantom limb/stump pain, peripheral neuropathy, post-herpetic neuralgia, intercostal neuralgia, cauda equina injury, incomplete spinal cord injury, or plexopathy) that is refractory to 12 or more months of standard therapy (including non-steroidal anti-inflammatory drugs, tricyclic antidepressants, and anticonvulsants).
In this case, the patient does meet the criteria for a spinal cord stimulator as she had a diagnosis of peripheral neuropathy.
Appeal type: Medical necessity
Decision: Upheld

Trauma/injury
Inpatient stay

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

This case involves a woman evaluated in the hospital after falling down from a bicycle while not wearing a helmet. Family members reported no loss of consciousness. The patient was evaluated by trauma and was placed in a C-collar. The evaluation noted bilateral knee abrasions and abrasion, left lateral chest wall tenderness, and C-spine tenderness. Vital signs appeared stable, with slightly elevated blood pressure of 156/95 on admission. Laboratory studies were stable, including normal complete blood count (CBC) and chemistry panel. Chest x-ray showed no evidence of cardiopulmonary disease. Pelvic x-ray showed no fractures or dislocations. Hand x-rays showed no fracture. A computed tomography (CT) scan of the cervical spine showed no evidence of cervical spinal injury. Head CT was unremarkable. A CT of the chest without contrast showed displaced left lateral fifth and sixth rib fractures with no pneumothorax. 

Inpatient hospital admission was not medically necessary. Based on the provided information, the patient was observed overnight to ensure stability from the sustained traumatic fall. She suffered rib fractures without pneumothorax. Vital signs remained stable, labs were stable, and there was no evidence of life-threatening injury. The documentation states there are no intracranial or intra-abdominal injuries. There is no documentation of uncontrolled pain requiring frequent parenteral narcotics beyond the observation timeframe. Blood transfusions were not necessary. The patient was discharged home within 24 hours of presentation. There is no indication for inpatient admission. A lower level of care was appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Cancer

Treatment: FoundationOne CDx testing

The insurer denied coverage for FoundationOne CDx testing.

The denial is upheld.

According to the medical records, the patient has bilateral breast cancer, both early stage and low risk. The attending provider (AP) has performed FoundationOne CDx testing, which is under review.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.      

The FoundationOne CDx testing provided does have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is not a good candidate for FoundationOne CDx testing provided.     

FoundationOne CDx testing provided was not the best available treatment for this patient at this time.     
  
The adverse risks are increased over standard treatment/services.     

The use of next-generation sequencing (NGS) panel testing as a means to select anti-cancer therapy in advanced cancer remains an area of active research with ongoing studies of thermoplastic polyurethanes (TPUR) and Molecular Analysis for Therapy Choice (MATCH). The concept of this approach is that all cancers are unique and each cancer has a specific individual molecular driver which can be identified using this testing. Once identified, specific therapy can be given to the patient directly treating their tumor. The majority of studies of this approach are fraught with methodological design issues such as lack of randomization and inclusion of large numbers of patients with established molecular drivers (i.e. breast cancer with ER and HER2) and then claiming that the identification and targeting of said known drivers contributes to benefit. There has been only one well designed trial of this approach, SHIVA (Tumor Molecular Profiling Versus Conventional Therapy for Advanced Cancer), which demonstrated that this testing approach does not improve clinical outcomes for patients with advanced cancer. Therefore, this would be considered experimental therapy for the reasons outlined above, and not medically necessary.

"Although these results are preliminary, significant discordance also has been noted between reports comparing tissue-based next-generation sequencing tests and, in a recent report, between results from FoundationOne (F1) and Guardant360 (G360) testing. Our findings indicate that in-depth comparisons of next-generation sequencing tests across larger numbers of patients with cancer are needed to improve concordance and clinical utility" (Kuderer, N. M. et al. 2017).
In summary, the denial of FoundationOne CDx testing provided and coverage for the requested service 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 not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute migraines
Treatment: Zavzpret (zavegepant
The insurer denied Zavzpret (zavegepant
The health plan's determination is overturned. 

The patient is a female with acute migraine. Treatment with Zavzpret is the subject of this review. The drug was denied because there was no documentation that the patient had tried and failed two triptan medications.

Zavzpret is medically necessary for treatment of this patient's condition. The patient has acute migraines. This medication is Food and Drug Administration (FDA) approved and literature supported for treatment of acute migraines. The physician indicates that the patient has tried and failed both sumatriptan and zolmitriptan. As such, the use of the requested medication is medically indicated and appropriate. Zavzpret has a different mechanism of action than triptans.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department (ED) complaining of one month of intermittent chest pain. Her medical history was remarkable for coronary artery disease, percutaneous coronary intervention, hypertension, hyperlipidemia and obesity. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin level was normal. A chest x-ray showed no acute pathology. Chest computed tomography (CT) angiography showed no aortic dissection. The patient was treated with aspirin, clopidogrel, atorvastatin and metoprolol and was admitted to the hospital.  An echocardiogram showed a left ventricular apical aneurysm; the left ventricular ejection fraction was 40-44 percent (%), which was decreased as compared to prior studies. Cardiac catheterization showed significant stenoses in the mid and distal left anterior descending coronary artery that were treated with stents. The procedure was uncomplicated. Post-procedure the patient had some bleeding from the radial arterial access site that was treated with a pressure dressing. No hematoma developed and no further treatment was needed. She was discharged. At issue is the medical necessity of an inpatient stay.
Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received for her chest pain did not require an inpatient admission and could have been provided at a lower level of care. 
This patient underwent uncomplicated cardiac catheterization and percutaneous coronary intervention (PCI). While some period of observation immediately following percutaneous coronary intervention (PCI) is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. Based on the documentation provided, this patient did not require an inpatient level of care after her PCI.
Appeal type: Medical necessity
Decision: Upheld

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

This is a case of a male admitted for abdominal pain. The patient presented with diffuse abdominal pain for one day prior to admission. Vital signs demonstrated temperature 98.1F, pulse 49, respiratory rate 16, blood pressure 120/81 and O2 (oxygen) saturation 100%. Physical exam showed no acute distress or altered mental status. Abdomen showed mild tenderness to the left lower quadrant. Creatinine was 0.59 with sodium 139. Alkaline phosphatase was 434 with aspartate aminotransferase (AST) 285 and alanine aminotransferase (ALT) 755. An Ultrasound of the abdomen was unremarkable. A computed tomography (CT) of the abdomen and pelvis showed no acute pathology. 

The inpatient hospital admission was not medically necessary. 
According to the documentation submitted, the patient had abdominal pain but did not have a cause of abdominal pain established as an abdominal catastrophe. The patient did not have shock, peritonitis, or altered mental status. The patient did not have an abdominal aortic aneurysm, aortic dissection, mesenteric ischemia, peritonitis, intestinal gangrene, abscess, biliary sepsis, splenic rupture, pancreatitis, urinary sepsis, ectopic pregnancy, spontaneous bacterial peritonitis, gangrene, toxic megacolon, or toxic shock syndrome. A computed tomography (CT) of the abdomen and pelvis showed constipation and he was treated with MiraLAX. He had elevated liver enzymes, but they were normalized on repeat exam without specific intervention.
Although the patient required services in the hospital setting the monitoring, diagnostics testing, and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Screening colonoscopy
Treatment: Colonoscopy (flexible; with biopsy, single or multiple) (45380/PT) in the outpatient hospital setting
The insurer denied: Colonoscopy (flexible; with biopsy, single or multiple) (45380/PT) in the outpatient hospital setting
The denial is upheld.

This is an adult male with mild obesity and a body mass index (BMI) of 36 with mild asthma. He underwent a screening colonoscopy as a hospital outpatient.

The requested health service was not medically necessary.

Colonoscopy can safely be performed at an ambulatory surgery center or physician's office in patients with a body mass index (BMI) of greater than 40, a body mass index between 35-40 in a 
patient with sleep apnea or end stage renal disease patients on dialysis with hyperkalemia, coronary artery disease, or uncontrolled asthma. As this patient has a body mass index of 36 with mild controlled asthma and no other comorbidities, the requested colonoscopy at an outpatient hospital center was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: peritonsillar abscess
treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This is a case of a male admitted for diagnosis of peritonsillar abscess. The patient presented with chief complaint of sore throat and pain with swallowing. Vital signs demonstrated blood pressure 146/78, pulse 109, respiratory rate 18, temperature 36.1C and O2 saturation 99%. Physical exam showed no acute distress. There was a peritonsillar abscess extending toward midline of the pallet. Airway was patent. 

The inpatient hospital admission was not medically necessary. 
The patient in this case had a peri-tonsillar abscess which required incision and drainage but did not have a complication such as airway obstruction, aspiration pneumonia, septicemia, jugular vein thrombosis, carotid artery rupture, pseudoaneurysm, mediastinitis, necrotizing fasciitis or group A streptococcus. After incision and drainage, he was noted to not have any complications. He was able to be treated with oral clindamycin and then discharged for outpatient follow-up. There was no hemodynamic instability or hypoxia.
Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male. He was hospitalized for chest pain. He presented to the emergency department for evaluation of chest tightness and palpitation. His past medical history was unremarkable. The patient's vitals were stable. His exam was unrevealing. Urine toxicology was negative. EKG (electrocardiogram) showed SR (sinus rhythm) and sinus arrhythmia and no acute changes. There were no arrhythmias or elevated troponin documented. LDL (low-density lipoprotein) was 87. Chest x-ray and barium swallow study were negative. Echocardiogram with Doppler was normal. The clinical impression was anxiety disorder, rule out panic attacks. The patient remained stable and was discharged to home. The requested coverage for the inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, including the MCG (Milliman Care Guidelines) guidelines for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The that the patient received for chest pain from anxiety like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
Treatment: Percutaneous laminotomy/laminectomy for 
decompression of neutral elements under indirect image guidance/ MILD (0275T)
The insurer denied: Percutaneous laminotomy/laminectomy for 
decompression of neutral elements under indirect image guidance/ MILD (0275T)
The denial is upheld.

The patient is an adult male with low back pain. Past treatments include gabapentin, Valium, lumbar radiofrequency ablation, and home exercises. Magnetic resonance imaging (MRI) of the lumbar spine shows multilevel spondylosis and facet arthrosis most pronounced at L4-5 where there is severe spinal stenosis. The request for L4-5 minimally invasive lumbar decompression (MILD) procedure was denied coverage by the health plan as 
experimental/investigational. The denial is being appealed.

The health plan should not cover the requested health service.

The evidence for the use of minimally invasive lumbar decompression (MILD) for treatment of spinal stenosis has been continuously debated. Overall, it is considered that while the procedure is likely safe, there is only modest evidence for effectiveness. The available studies are limited in patient size and/or duration. A 2021 publication of a prospective study does show efficacy and lack of adverse reactions at six months with 155 patients ages 50-80 (3). Based on a 2021 review 
of the available current scientific literature (1), the novel interventions for symptomatic lumbar spinal stenosis, such as the MILD procedure and the Superion interspinous spacer, generally are evidenced to be safe and effective. However, there is no valid scientific evidence to show that the expected health benefits from the procedure are clinically significant and will have a greater 
chance of benefit, without a disproportionately greater risk of harm or complications, than other conventional treatments. There is a possibility in the future that these interventions could disrupt current treatment algorithms for lumbar spinal stenosis. However, more studies need to be done. As such, at this time, minimally invasive lumbar decompression is unproven or experimental/investigational (E/I).
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 nonopioid medications (i.e., non-steroidal anti-inflammatory drugs [NSAIDs], membrane stabilizing agents, and/or muscle relaxants), modalities (that is (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: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
Treatment: Percutaneous laminotomy/laminectomy for 
decompression of neutral elements under indirect image guidance/ MILD (0275T)
The insurer denied: Percutaneous laminotomy/laminectomy for 
decompression of neutral elements under indirect image guidance/ MILD (0275T)
The denial is overturned.

The patient is an adult male with a history of chronic low back pain due to lumbar stenosis. He has failed conservative measures including physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, anticonvulsants, and sacroiliac joint injections to no avail. Magnetic resonance imaging (MRI) of the lumbar spine showed more advanced spondylosis at L4-5 with moderate-severe facet arthritis along with moderate disc bulge, all causing moderate central canal stenosis and moderate foramina narrowing. The request by the 
treating physician is for a minimally invasive lumbar decompression/percutaneous image-guided lumbar decompression (MILD/PILD) procedure to be performed at the L4-5 level. The treating physician stated that the patient is not a candidate for surgical decompression due to age, high body mass index, general anesthesia risk, bleeding disorders, healing disorders, and comorbidities. The health plan denied coverage of the requested procedure, noting that it is experimental and investigational. The denial is being appealed.

The health plan should cover the requested health service.

The requested health service is medically appropriate for this patient with lumbar stenosis, as it is United States Food and Drug Administration (FDA)-approved for spinal decompression in spinal stenosis and is not experimental or investigational. The patient has failed conservative management and previous magnetic resonance imaging showed moderate stenosis at L4-5.
According to Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment, there is Level 1 evidence for percutaneous image-guided lumbar decompression as superior to lumbar epidural steroid injections, five controlled prospective studies, and 17 other retrospective studies, case series, meta-analyses, etc., published in peer-reviewed journals. The requested procedure is at least as effective as other pain procedures, less invasive, and effective in improving pain and as such is achievable in standard conditions of medical practice as published in multiple peer-reviewed journals, some listed in the references below.