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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services (All).  
The insurer denied INTRACEPT Procedure. 
The denial was upheld.

This patient is a male with a history of low back pain. He had a prior discectomy. He has tried physical therapy and medications without relief. The neurologic exam shows no motor or sensory deficits. The lumbar magnetic resonance imaging (MRI) scan showed Modic changes at lumbar (L)4-5 and L5-sacral (S)1. The provider has recommended an INTRACEPT procedure.
At issue is whether the proposed health service or treatment INTRACEPT Procedure is likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.

The health plan's determination is upheld in whole.

The proposed health service or treatment INTRACEPT Procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
While the procedure has promise as an emerging technology, the studies done so far are small and are industry-driven rather than independent studies. Urits et al cite "Chronic low back pain (CLBP) is a difficult yet common diagnosis that affects a significant portion of patients worldwide. In efforts to combat this debilitating disease, researchers have made great progress in understanding the pathophysiology of low back pain (LBP) in addition to unveiling the anatomy of the vertebrae in search of appropriate treatment options. As a result, with the growing evidence supporting the vertebrogenic model that involves the basivertebral nerve (BVN), radiofrequency (RF) ablation of the BVN has emerged as a possible minimally invasive procedure to treat LBP. Several studies have supported the safety, durability, and efficacy of RF ablation of the BVN. There is also convincing evidence that BVN ablation is more beneficial than the current standard of care for the treatment of CLBP. However, reproducible large randomized controlled trial (RCT)s are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of CLBP and improve the quality of life of CLBP patients in the near future." Conger et al cite "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 BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."
Therefore, the proposed health service or treatment INTRACEPT Procedure is not likely to be more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services (All).  
The insurer denied INTRACEPT Procedure. 
The denial was upheld.

The patient is a male, with severe chronic low back and leg pain. He was recommended for an INTRACEPT procedure for treatment of his low back pain. The magnetic resonance imaging (MRI) scan of the lumbar (L) spine showed L4-5 decompression and L3-4-disc herniation.
At issue is whether the proposed health service or treatment INTRACEPT Procedure, is likely to be more beneficial than any standard treatment or treatments for the patient's condition.

The health plan's determination is upheld in whole.

The proposed health service or treatment INTRACEPT Procedure is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
There have been no large long-term studies that have shown clinical safety and efficacy in such a patient cohort, and thus more studies are needed. This patient has had prior lumbar decompression and has L3-4-disc herniation along with other areas of lumbar stenosis on the MRI report. Becker et al noted "Ablation of the basivertebral nerve (BVN) for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period." This study, however, did not include patients with prior surgeries and ongoing nerve root compression.
Therefore, the proposed health service or treatment INTRACEPT Procedure is not likely to be more beneficial than any standard treatment or treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Systemic Lupus Erythematosus (SLE)

Treatment: Rituximab

The insurer is denied coverage for Rituximab.

The denial is overturned. 

This female patient has a history of rheumatoid arthritis with lupus overlap, asthma, depression, bulimia, and hyperthyroidism.

The patient has an overlap syndrome of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). She has persistent arthritis and neurological complaints resistant to multiple treatments for RA/SLE and requiring high doses of prednisone to control. Rituxan is used in RA (Food and Drug Administration (FDA)-approved) and is recommended for refractory severe SLE, especially neuropsychiatric disease (see 2019 Update of EULAR (European Alliance of Associations for Rheumatology formerly the European League Against Rheumatism) Recommendations for the Management of SLE). The issue here is therefore not its use but the lack of data on safety of Rituxan given less than every 4 months.
Regimens using Rituxan every 4-6 months are the standard. The use of Rituxan at intervals of less than 4 months was reviewed using Uptodate chapters "Rituximab: Principles of use and adverse effects in rheumatoid arthritis", "Overview of biologic agents and kinase inhibitors in the rheumatic diseases", and "Treatment of rheumatoid vasculitis". This regimen is not addressed. All recommendations follow the every 4-6 month use. The articles submitted for review support the use of Rituxan in rheumatoid vasculitis but not this regimen. A Search of Pubmed fails to reveal any articles addressing such a regimen.
But this is an unusual case of a rare situation The patient has failed many other therapies and has persistent symptoms requiring high and toxic doses of prednisone. There has been failure of other regimens and the known toxicities of the major remaining alternative, Cytoxan, are potentially severe. There is no guarantee Cytoxan will work or how long it will take.
It seems prudent to try a cycle of every 3 months, judge the adequacy of the response and decide whether it is worth pursuing.

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

The carrier's denial of coverage for Rituximab is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I Occlusion.
Treatment: Braces.
The insurer denied Braces. 
The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion with 6-millimeter (mm) overbite and 3mm overjet. She has significant maxillary and mandibular spacing. She is treatment planned for Braces to correct her malocclusion. This is the subject of this review.

Braces are not medically necessary for this patient. While the patient has spacing, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 mm. If her teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. Therefore, braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

This female was hospitalized for dyspnea on exertion. Her past medical history was remarkable for osteoporosis and contrast allergy. Vital signs were stable. She was afebrile and pulse oximetry was 97% (percent) on room air. She had nonlabored breathing on exam. Urinalysis and culture revealed Escherichia (E) coli and she was treated for the urinary tract infection (UTI) with fluids, antibiotics and supportive care. Echocardiogram showed left ventricular ejection fraction (LVEF) of 65%. The additional clinical impression was orthostatic hypotension from dehydration due to the urinary tract infection (UTI).

No, the proposed treatment is not medically necessary.

Based on the peer reviewed medical literature and my expert medical opinion, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient hospitalization are not met, including hemodynamic instability, respiratory distress, sepsis, abscess, pyelonephritis, pulmonary edema, pulmonary embolism, pneumonia, or any other medical condition that warranted inpatient hospitalization. The care the patient received for an uncomplicated urinary tract infection (UTI) is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current standard of care, there was not a medical need for the acute inpatient hospital stay for dates of service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Other. 
Treatment: Dental/Orthodontic Procedure. 

The health plan denied the requested dental treatment plan as not medically necessary. 
The health plan's determination is upheld. 

The patient is requesting an external review for the medical necessity of full mouth deep scaling and root planning. 
Medical records and the panoramic x-rays provided were reviewed. At issue is the medical necessity of the requested dental treatment plan. 

The health plan's determination of medical necessity is upheld, in whole. 

Deep gum and root cleaning on all four quadrants are not medically necessary for this patient. Upon reviewing imaging provided, no radiographic evidence of calculus built up on the root of the teeth, and there is no radiographic evidence of noticeable loss of bone support. 

It is determined that there is no evidence bone loss, no calculus built up subgingival, therefore, there is no medical necessity for scaling and root planning. Deep scaling is indicated when there is evidence of bone loss, loss of attachment, subgingival calculus, and gingival inflammation to diagnose any stage of Adult Periodontal Disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: melena

Treatment: inpatient stay

The insurer is denied coverage for inpatient stay

The denial is overturned. 

This male patient has a history of lupus anticoagulant syndrome.

Clinical indications for admission for Upper Gastrointestinal Bleeding are listed in Milliman Care Guidelines (MCG) M-180. Ongoing active bleeding, such as a decreasing hematocrit, is an indication for admission. In addition, a peptic ulcer with a high-risk endoscopic feature such as a visible vessel, is also an indication for admission. The patient met the criteria for admission. This patient had a dropping hemoglobin and an ulcer with a visible vessel.

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

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

Diagnosis: Malocclusion

Treatment: comprehensive orthodontic treatment of the adolescent dentition (code D8080)

The insurer denied coverage for comprehensive orthodontic treatment of the adolescent dentition (code D8080)

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient present for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary and mandibular spacing, and anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. 

It is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 	

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care us this criterion. 

In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 10 points (3 overjet, 4 anterior open bite, 3 labiolingual spread).

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for comprehensive orthodontic treatment of the adolescent dentition (code D8080) is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD)

Treatment: Vyvanse 50 mg (milligrams) capsule

The insurer denied coverage for Vyvanse 50 mg capsule.

The denial is overturned.

The patient has been treated for Attention Deficit Hyperactivity Disorder (ADHD) and has suffered from this condition for over 9 years.  The patient has tried and failed Concerta.  He was prescribed Vyvanse and had a remarkable and sustained improvement.  His prescribing provider is recommending approval of Vyvanse, which has provided the patient with stability of his ADHD for years. 

Lisdexamfetamine dimesylate (LDX) Vyvanse is the first prodrug stimulant used for the treatment of ADHD dosed once daily.  Due to its long-acting properties, LDX remains pharmacologically inactive until an enzymatic process predominantly associated with red blood cells converts it to the active ingredient, d-amphetamine and the amino acid lysine.  The efficacy of LDX over placebo has been demonstrated in several studies in adults with moderate to severe ADHD with significant improvements noted in ADHD rating scales, Clinical Global Improvement scores, and assessments of executive function, for all doses of LDX (30-70 mg daily).  Lisdexamfetamine dimesylate has demonstrated efficacy of long hours post dose in adults and may be used as a long-acting stimulant for managing ADHD symptoms, which may extend late into the day.  Lisdexamfetamine dimesylate has demonstrated a safety profile consistent with long-acting stimulants use.

Per current medical literature, medication adjustment for treatment of ADHD is necessary when a given medication does not work or causes intolerable side effects, which does not apply to this patient.  This patient has been treated with Vyvanse for many years and has been stable with respect to his ADHD symptoms.  Changing his current medication regimen in order to meet the formulary criteria of his carrier is not consistent with current medical standards and ethics. 

Changing his medication now would increase risk of worsening his ADHD and causing harm to the patient.  Thus, the requested drug would be more effective.

The insurer's denial of coverage for Formulary Exception for Vyvanse 50mg is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plaque Psoriasis
Treatment: Stelara (every 56 days)
The insurer denied the Stelara (every 56 days).
The denial is overturned.

The patient is a woman with psoriasis who has been on Stelara for the past several years with good results. Recently, she has started having breakthrough lesions on her legs. The flare appears 2 weeks before her scheduled next injection. She is receiving 45 mg (milligrams) every 12 weeks. Her dermatologist is requesting to increase the frequency of the injections from 1 every 12 weeks to 1 every 8 weeks.

Yes, the Stelara every 56 days is medically necessary.

Clinical trials have shown that increasing the dosing schedule from every 12 weeks to every 8 weeks results in improvement for some partial respondents on Stelara.

Poulin, et al and Kimball, et al described results related to dosing interval reduction through year 3 in the PHOENIX 1 trial.

At week 28, 23% of patients in the STELARA 45-mg group and 16% of patients in the STELARA 90-mg group were partial responders (at least 50% improvement in Psoriasis Area Severity Index [PASI 50] to < [greater than] 75) and had their dosing interval reduced from q12w (every 12 weeks) to q8w (every 8 weeks).

Overall, 79.8% (601/753) of STELARA-treated patients remained in the study through year 3, including 78.6% (297/378) of patients in the 45-mg group and 81.1% (304/375) in the 90-mg group.

Among partial responders adjusted to q8w dosing, a substantial proportion achieved PASI 75 response by week 52 (45 mg: 51.7%; 90 mg: 42.3%); with stable and continuous q8w dosing, PASI 75 response was generally maintained (45 mg: 50.9%) or improved (90 mg: 52.0%) through year 3.

Among partial responders, rates and patterns of adverse events (AEs) and infections adjusted for length of follow-up were generally similar before and after dosing adjustment suggesting no increased risk with Stelara q8w dosing.

Peer-reviewed published medical literature supports that increasing the dosing schedule of Stelara in partial responders from every 12 weeks to every 8 weeks results in further improvement.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion, moderate upper and lower crowding, severe overjet, and deep bite.
Treatment:  D8080 Braces
The insurer denied the D8080 Braces.
The denial is overturned.

The patient is a female. The request is for orthodontic benefits. She has Class I malocclusion, moderate upper and lower crowding, severe overjet, and deep bite. She has blocked out lower permanent canines.

The health plan denied coverage for braces due to prior reviewer designating Salzmann scale to be 20.

Yes, the requested braces are medically necessary.
The patient has a significant handicapping malocclusion, which warrants orthodontic benefits. The lower permanent canines are totally out of their proper positions. Without these teeth being properly located and angulated, there can be no "canine guidance." This is when the canines help the lower jaw move properly side to side during the chewing cycle. When there is canine guidance, the lower teeth glide over the upper teeth. Without this guidance, teeth can clash together and ultimately cause fracturing and trauma. Orthodontic treatment is medically necessary to correct this problem for this patient.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prepyloric Ulcer. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This case involves a female who presented to the ED (emergency department) with complaints of abdominal pain. The documentation indicated she was seen and evaluated the prior day with a normal right upper quadrant sonogram and computed tomography (CT) scan showing enteritis. No evidence of acute cholecystitis. She indicated her pain has not improved and has stated she tried to drink some tea however was not able to keep it down. She does indicate the pain is worsened with eating. The patient's vital signs upon physical examination revealed oxygen saturation at 95% (percent) with a blood pressure of 170/116. She had bowel sounds present in all 4 quadrants. There was epigastric and right upper quadrant tenderness with no rebound or guarding. The recommendation was made for laboratory diagnostic studies and to undergo a general surgery consultation. Blood urea nitrogen (BUN)/ creatinine were 11/.55. The documentation detailed her laboratory studies were notable for a troponin of 0.103, .116, .089. Her EKG (electrocardiogram) did appear unchanged, and she denied chest pain. She was noted to have a positive medical history that includes lichen sclerosis. She did have an elevated white blood cell count of 12.9 which improved to 9.0. The hematocrit (Hct) was 44. The recommendation was made to continue cardiac evaluation and admit the patient. The documentation does indicate she did undergo additional abdominal imaging detailing a likelihood of a prepyloric ulcer. The patient was recommended to change diets and continued monitoring was also recommended. She continued to improve and she was evaluated. She did indicate her pain had decreased and she was tolerating a clear liquid diet. She did undergo an EGD (esophagogastroduodenoscopy) and given her improvement she was discharged with instruction to follow-up. 

This patient could have been managed during a period of observation. The findings did not support an acute abdominal process. In addition, the Troponin levels did not support an acute event. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.