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

Diagnosis: Low Back Pain
Treatment: Intracept Procedure-Intraosseous Basivertebral Nerve Ablation
The insurer denied: Intracept Procedure-Intraosseous Basivertebral Nerve Ablation
The denial is overturned.

The patient is an adult male with chronic low back pain for over six (6) months. His pain has not improved significantly despite conservative management (home exercise program, medication management with Ibuprofen and Prednisone, physical therapy, and lumbar epidural steroid injections. His pain ranges from three to eight out of ten (3-8/10), and his magnetic resonance imaging (MRI) of the lumbar spine (L-spine) shows Modic changes at the L4 (fourth lumbar spine vertebra) and L5 (fifth lumbar spine vertebra) vertebral levels. The patient was scheduled for the Intracept procedure; however, the procedure was denied coverage by the health plan for being considered experimental/investigational. The denial is being appealed.

The health plan should cover the requested Intracept procedure.
There Intracept procedure is FDA (United States Food and Drug Administration)-approved, and there is enough data in the medical literature to show it is safe and effective in the treatment of vertebrogenic low back pain. A prospective, randomized, multi-center study by Khalil et al in 2019 and another prospective, randomized, multi-center study done by Fischgrund also in 2019 both presented high quality evidence of efficacy and safety of the procedure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intracept Procedure-Intraosseous Basivertebral Nerve Ablation
The insurer denied: Intracept Procedure-Intraosseous Basivertebral Nerve Ablation
The denial is upheld.

The patient is an adult male with right greater than left low back pain and occasional right groin pain for greater than six (6) months. The patient's pain is rated three to five out of ten (3-5/10). The patient has tried physical therapy, home exercise program, and ibuprofen. MRI (magnetic resonance imaging) of the lumbar spine shows disc bulges, facet hypertrophy, degenerative disc disease, and varying degrees of spinal and neuroforaminal stenosis. The request for Intracept at L4 (fourth lumbar spine vertebra) and L5 (fifth lumbar spine vertebra) was denied coverage by the health plan as investigational. This denial is being appealed.

The health plan should not cover the Intracept procedure.
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 peer reviewed literature and data regarding the long-term outcomes of the procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizophrenia
Treatment: Inpatient Emergency Admission
The insurer denied: Inpatient Emergency Admission
The denial is upheld.

The patient is an adult female with schizophrenia, diabetes, and hypertension who presented to the hospital with behavioral symptoms/psychosis.  The patient was admitted and noted with a creatinine of 1.5 milligrams per deciliter (mg/dl), elevated creatine phosphokinase (CPK) and prolonged QT time. 

The patient was started on intravenous fluids, intravenous antibiotics and was admitted to telemetry. The antibiotics were converted to oral and the patient's renal function stabilized to one milligram per deciliter (mg/dl). The inpatient level of care was denied.

No, the proposed inpatient hospital admission was not medically necessary.

The proposed inpatient level of care for the requested dates of service was not medically necessary. Based on Milliman Care Guideline (MCG) 25th edition acute renal failure, there was no documentation of three-fold rise in serum creatinine from baseline, serum creatinine greater than 4.0 milligrams per deciliter (mg/dL) (354 micromoles per liter) with acute rise greater than 0.5 milligrams per deciliter (44.2 micromoles per liter), reduction of more than 75 percent (%) in estimated glomerular filtration rate, or anuria. 

There was no documentation of acute kidney injury stage-two or worsening clinical status despite observation care, altered mental status, hemodynamic instability, severe hypertension, cardiac arrhythmias of immediate concern, significant respiratory findings that are severe or persist despite observation care treatment. There was no documentation of clinically significant electrolyte abnormality or metabolic abnormality that is severe or persists despite outpatient or observation care treatment, acute treatment of renal failure (eg, dialysis) not feasible or appropriate in observational care setting, other diagnosis requiring inpatient care, other significant finding or clinical condition judged not to be within scope of observation care. 

The requested inpatient stay was not medically necessary as the requested stay would be provided primarily for convenience of the patient or the practitioner, and would not be the least intensive and/or most appropriate alternatives among diagnostic and treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain
Treatment: Nerve Ablation
The insurer denied Nerve Ablation.
The determination is overturned.

This is a female diagnosed with history of low back pain and lumbar disc degeneration. She has low back pain, more to the right, without radiculopathy. She has undergone acupuncture, chiropractic care, home exercises, epidural steroid injections, medial branch blocks, medication management, physical therapy, and radiofrequency ablations (RFA) without any significant relief. Medications have included Cyclobenzaprine, Cymbalta, Duloxetine, Meloxicam, and Naproxen.

A magnetic resonance imaging (MRI) of the lumbar spine shows severe disc degeneration at L (lumbar) 5-S (sacral) 1 with Modic type I endplate changes. There is also severe neuroforaminal stenosis with impingement of the L5 nerve roots. The provider is requesting an Intracept procedure (thermal destruction of intraosseous basivertebral nerve).

At issue is whether the proposed health service or treatment of a nerve ablation 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 nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's disabling condition. The patient has long-standing, medically refractory back pain. There is not an alternative treatment option that she has not already tried, and none that has any substantial success rate. The nerve ablation procedure has had reasonable success in carefully selected patients. Her condition meets the selection criteria for this procedure.

According to Conger, et al (2021), "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".

An updated meta-review of the literature by Conger, et al (2022), concluded that, "there is moderate-quality evidence that basivertebral nerve (BVN) RFA effectively reduces pain and disability in most patients with vertebrogenic LBP (chronic low back pain)."

A prospective, randomized, multicenter study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain compared with standard therapy by Khalil, et al (2019) showed that at 3 months, in the RF ablation arm, 74.5% (percent) of patients achieved a greater than or equal to 10-point improvement in the Oswestry Disability Index (ODI), compared with 32.7% in the standard care arm [p (calculated probability) < (less than) 0.001].

Therefore, the proposed health service is likely to be more beneficial than any standard procedure for the insured's disabling condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain
Treatment: Nerve Ablation
The insurer denied Nerve Ablation.
The determination is upheld.

This is a female with a history of low back pain. She has had physical therapy, injections and medications without relief. The lumbar magnetic resonance imaging (MRI) shows degenerative changes at L (lumbar) 5-S (sacral) 1, Modic changes and severe bilateral foraminal narrowing. The provider has recommended an Intracept procedure.

At issue is whether the proposed health service or treatment of a nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

While the Intracept procedure is a promising technology and treatment, more studies are needed to show its usefulness for low back pain. Urits, et al cite "CLBP (chronic low back pain) 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 LBP (low back pain) 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 trials (RCTs) 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."

Michalik, et al cite "BVN radiofrequency ablation appears to be an effective treatment for a subset of patients with CLBP and evidence of Modic change types 1 and 2 in the L3 to S1 who have failed to respond to conservative treatment. However, all studies performed to date have been industry sponsored, and future non-industry-funded trials will be needed to confirm these results."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low Back Pain
Treatment: Nerve Ablation
The insurer denied Nerve Ablation.
The determination is upheld.

The patient is a female with severe chronic low back pain failing physical therapy (PT), analgesics, chiropractic, acupuncture, lumbar facet blocks and lumbar radiofrequency ablation (RFA). A magnetic resonance imaging (MRI) of the lumbar spine shows L (lumbar) 5-S (sacral) 1 Modic changes with sacroiliac joint remodeling and severe foraminal stenosis with L5 nerve root impingement. L4-5 narrowing of bilateral foramina noted as well.

At issue is whether the proposed health service or treatment of a nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Basivertebral ablation in such a patient cohort has not been established in large long-term studies. In this case, the patient has had prior blocks and has ongoing L4-S1 foraminal stenosis, more severe at L5-S1. Thus, ablation is not recommended, as no large long-term studies have shown clinical benefit in such cases.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lack of Coordination
Treatment: Occupational Therapy Services
The insurer denied: Occupational Therapy Services
The denial is: Upheld.

The patient is a male with a diagnosis of lack of coordination. Clinical records available include occupational therapy (OT) and progress notes. This record also includes results of the Short Sensory Profile 2 which was normal; school comparison indicated difficulty with sensory processing; Peabody Developmental Motor Scale Second Edition (PDMS-2) test of motor abilities which indicates below average in two subtests: locomotion and object manipulation with normal performance in the other 4 subsets assessed with this instrument. The subject under review is the medical necessity for occupational therapy (OT).

The health plan's denial is upheld.

The requested occupational therapy health services are not medically necessary for this patient. No indication of interventions which can only be provided by a skilled therapist, no indication of progress towards goals, and no medically necessary goals are documented in the clinical information submitted nor is there any notation of activities which cannot be performed within the home exercise program environment.
The patient's therapy progress notes documentation do not support medical necessity for standards of practice for occupational therapy. OT is medically necessary when there is documentation that it is improving a patient's current condition, or preventing or slowing further deterioration of the patient's condition, or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition and all of the following elements of the plan are documented in the health care record: the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider; and the services including amount, frequency and duration are reasonable under accepted standards of practice. The goals listed in the progress notes documented as having a start date greater than a year ago. OT conducted is therefore working on goals that are over 9 months old. Since patient has not achieved these goals in that period of time there is no medical justification for continuing therapy that has not produced substantive improvement in function or developmental milestones.
Transition to Home Exercise Program is appropriate when patients have reached a plateau or when the activities performed in therapy can be performed by non-skilled caregivers/parents who have received training by therapists which is the case for this patient. Skilled occupational therapy is not necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rapid Heart Rate.
Treatment: Inpatient Stay.
The insurer denied: Inpatient Stay.
The denial is: Upheld.

The patient is a male who presented to the emergency department (ED) complaining of rapid heart rate that was associated with chest pressure, lightheadedness and transient loss of consciousness. His medical history was remarkable for mild nonobstructive coronary artery disease, morbid obesity, hyperlipidemia, obstructive sleep apnea, left ventricular hypertrophy, impaired left ventricular diastolic function and paroxysmal atrial fibrillation and flutter. In the ED, an electrocardiogram showed sinus rhythm with "very subtle" ST segment depression. The patient's serum troponin I level was 2.1 nanograms/milliliter (ng/ml) and increased to 2.4 ng/ml. His chest x-ray showed no acute pathology. He was admitted to the hospital and treated with intravenous heparin for possible acute coronary syndrome (ACS). While it was not documented by electrocardiogram, his tachycardia was thought to have been due to an episode of atrial fibrillation that terminated spontaneously. He remained in sinus rhythm after admission. His troponin I level was 1.8 ng/ml. He was seen by a cardiologist who opined that ACS was unlikely and recommended discontinuing the heparin. The patient was discharged. The subject under review is the medical necessity for an inpatient level of care.

The health plan's determination is upheld.

This patient presented after an episode of tachycardia that was thought to be due to atrial fibrillation. He was in sinus rhythm and hemodynamically stable at the time of presentation. There was no evidence of decompensated heart failure or significant structural heart disease. He was not at high risk short-term for thromboembolism. His serum troponin level was elevated; however, he had recently had a cardiac catheterization that showed only mild nonobstructive coronary artery disease. Moreover, serum troponin elevations are common with acute atrial fibrillation, even in the absence of coronary artery disease and are not sufficient for the diagnosis of myocardial infarction. In this case, the cardiologist felt that acute coronary syndrome was unlikely, and no acute intervention was deemed necessary. While it was reasonable to monitor the patient overnight to follow his troponin levels and assure that he remained in sinus rhythm, this did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders - Atopic dermatitis.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Dupixent syringe (Syn) 300.
The denial is overturned.

The patient is a female with severe atopic dermatitis involving over 10 percent (%) of her body (neck, face, arms, intertriginous areas), and ankles. She has been poorly controlled on topical therapies (high potency topical corticosteroids) and has required frequent bursts of oral corticosteroids.
At issue is the medical necessity of Dupixent syringe (Syn) 300.

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

The requested health service/treatment of Dupixent Syn 300 is medically necessary for this patient.
The patient has an investigator global assessment greater than (>) 40% and she has failed topical corticosteroids and calcineurin inhibitors. In addition, she has required intermittent treatment with oral corticosteroids. Dupixent is an appropriate option to better control her atopic dermatitis.
Therefore, the requested health service/treatment of Dupixent Syn 300 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with medical history of myasthenia gravis status post thymectomy. She presented to the emergency department with right upper quadrant abdominal pain and postprandial vomiting. Vital signs were unremarkable. Physical examination was notable for focal abdominal tenderness and normal bowel sounds. Labs showed low hemoglobin of 12.1 with normal hematocrit, and unremarkable comprehensive metabolic panel. Right upper quadrant ultrasound showed findings suspicious for acute cholecystectomy with stone in the gallbladder neck and thickened gallbladder wall measuring 6 millimeter (mm), without pericholecystic fluid. She was treated with intravenous fluids, morphine, Zosyn, and acetaminophen. She was made nil per os (NPO). Surgery consultation concluded that she had acute versus acute on chronic cholecystitis.

The inpatient hospital stay is not medically necessary. The patient presented with right upper quadrant abdominal pain, and imaging was concerning for acute cholecystitis. However, there was no persistent hemodynamic instability or other complications such as ascending cholangitis, hepatic abscess, active gastrointestinal bleeding, peritonitis, fistula, or sepsis, which would require a higher level of care. The Laparoscopic cholecystectomy was not complicated by postoperative pneumonia, bile leak, bleeding, sepsis, or other complications. The care provided, including monitoring, labs, imaging, Surgery consultation, and cholecystectomy could have been performed in sequence after presentation, without the need for the inpatient level of care. For these reasons, the patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Overturned in whole.

The patient is a male with moderate persistent asthma who presented with shortness of breath. He was well until the night of presentation when he awoke with a barky cough and shortness of breath. He was given 3 puffs of albuterol as well as a nebulized albuterol treatment, but he did not experience any relief. Due to a lack of response to the medication, his mother called an ambulance. When the emergency medical services arrived, he was noted to have severe shortness of breath and was given a dose of epinephrine, 2 albuterol/Atrovent treatments, and 10 milligrams (mg) of dexamethasone on route to the emergency department. Upon admission he was given 1/2 maintenance intravenous fluids and was placed on continuous cardiopulmonary monitoring. He initially required albuterol every 3 hours. His symptoms had improved, he was able to wean to every 4 hour treatments, and he was felt to be stable for discharge to home with follow-up as an outpatient. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The requested inpatient stay was medically necessary for this patient.
This is a patient who presented with status asthmaticus. He was in respiratory distress at time of presentation with prolonged expiration, retractions, and wheezing. He received aggressive treatment while in transport in the ambulance, and also received appropriate treatment in the emergency department setting, including multiple bronchodilator treatments and corticosteroids. However, he continued to have wheezing and tachypnea. He required inpatient admission for continued treatment with frequent bronchodilators, intravenous fluids, and continuous cardiorespiratory monitoring.
Children with asthma who are moderately to severely ill on arrival and who have little improvement after initial therapy with beta-agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting and poor aeration, and who require beta agonist therapy more often than every 4 hours.
The decision-making at time of admission for this patient was consistent with the patient's age, the presence of status asthmaticus with respiratory distress that continued despite appropriate and aggressive treatments, and the need for continued frequent bronchodilator therapies, initially every 3 hours, along with close monitoring for potential deterioration in status. This patient continued to have significant symptoms after initial intensive therapies and required albuterol treatments every 3 hours with continuous monitoring. Therefore, inpatient hospitalization was necessary.