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

Orthopedic/Musculoskeletal
Surgical Services

Diagnosis: Low back pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is upheld.

This is a male patient whose diagnosis is listed as low back pain. The treating provider recommended that the patient undergo the Intracept procedure.
Letters of appeal were submitted stating that the Intracept is based on 30 years of basic science research linking Modic changes to chronic low back pain and the provider does not feel that the treatment is experimental. The letter states that the patient has a history of chronic low back pain that began more than one year ago. The patient has tried caudal epidural injections, chiropractic treatment, medication and physical therapy. Medication has included Celebrex. There has been no sustainable relief. The provider stated the patient had magnetic resonance imaging (MRI) demonstrating Modic changes at lumbar (L) 4, L5 and sacral (S) 1 vertebral bodies and the provider states that this is the cause of the patient's chronic back pain. 
MRI of the lumbar spine showed degenerative changes in the lumbar spine. The radiologist does not mention any degenerative endplate changes or Modic changes.
The patient was seen for a follow-up visit complaining of pain in the low back and right leg. He has hip osteoarthritis and lumbar stenosis. The pain was rated at 8/10. The physical examination revealed decreased range of motion at the back with bilateral paraspinal muscle tenderness, positive straight leg raise, unable to perform Patrick's test due to pain. The strength was normal in the lower extremities, sensation was normal and reflexes were normal. It was noted the patient would be scheduled for an interlaminar epidural injection at L4 - L5 and they will get approval for Intracept procedure. At issue is the medical necessity of the Intracept procedure.

The requested health service/treatment of Intracept procedure is not medically necessary for this patient. The patient was noted to have a history of chronic back pain that the provider states is related to Modic changes at L4, L5, and S1 seen on MRI. However, the MRI report was submitted and the radiologist does not mention any degenerative endplate changes or Modic changes. There are a lack of high quality studies evaluating the long-term risks and benefits of the requested procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.  There is a lack of high-grade evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. The requested procedure is not considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pyogenic arthritis, infected surgical wound of right knee
Treatment: Alternate Level of Care (Long-Term Care Facility)
The insurer denied the alternate level of care (long-term care facility).
The health plan's determination is overturned. 

The patient is a female with a medical history notable for asthma, chronic obstructive pulmonary disease, and hyperlipidemia. The patient underwent an open reduction and internal fixation of the patella. Two months later, she was readmitted due to concern of an infected surgical wound. She had pain, swelling, and discoloration of the right knee. The patient's wound culture grew coagulase negative Staphylococcus and Corynebacterium. The patient was started on hyperbaric therapy. The plan was to return to the operating room once the infection was under better control. The patient was admitted to the long-term care facility for rehabilitation and wound care. She underwent a prolonged course of intravenous antibiotics. Progress notes indicated that the patient had completed her course of intravenous antibiotics and was awaiting her next surgery.

The facility provided a letter of support which stated the patient had pyogenic arthritis after a recent open reduction and internal fixation of the right knee. They would like alternate level of care services authorized. The reason is that the patient was scheduled to undergo surgery again and then will be returning to the long-term care facility following the procedure. The patient lives alone and requires assistance with all activities of daily living, and the facility did not feel that discharge home for 10 days was in the patient's best interest. Social work notes were provided for review, and they corroborate the information provided in this letter.

At issue is the medical necessity for an Alternate Level of Care (Long-Term Care Facility).
The health plan's determination of medical necessity is overturned, in whole.

The requested health service of Alternate Level of Care (Long-Term Care Facility) is medically necessary for this patient.

The patient had an infected right knee following a procedure for fracture. She required prolonged intravenous antibiotics and a repeat surgery. At the time she was stable for discharge, she was scheduled to undergo surgical revision of the right knee one week later. However, there was not a safe discharge plan in place, as the patient lives alone and requires assistance with activities of daily living. Alternate level of care was the appropriate plan for the patient, as she no longer required skilled nursing level of care. Because the appropriate home support services could not be put in place by the time of discharge, discharge home would not have been safe for the patient. The facility has demonstrated that the patient meets their criteria for alternate level of care. She was expected to be discharged within the next two weeks, but there was a barrier to discharge that was expected to be resolved. Therefore, the requested alternate level of care service was medically necessary and appropriate for the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine
Treatment: Aimovig
The insurer denied Aimovig.
The health plan's determination is upheld. 

The is a female with chronic migraine. Treatment with Aimovig is the subject under review. The drug was denied because the member has not tried and failed the plan's formulary alternatives of Ajovy and Emgality.

A formulary exception is not indicated in this case.

The patient has not tried and failed the available formulary alternatives Ajovy and Emgality. There are no head-to-head studies comparing the efficacy of Aimovig to Ajovy or Emgality. However, all of these drugs inhibit the CGRP (calcitonin gene related peptide) pathway and all of these drugs are Food and Drug Administration (FDA) approved and literature-supported for prevention of episodic and chronic migraine. There is no reason to believe that Ajovy and Emgality would not be effective for treatment of the member's condition. Indirect comparisons in the literature espouse similar efficacy among Ajovy, Aimovig, and Emgality. Data are lacking to show that the formulary alternatives are inferior to Aimovig.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, Abdominal pain, Headache
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who was admitted with complaints of (c/o) a bitemporal headache, abdominal pain, and chest pain after a fall. Her vital signs were notable for hypertension (HTN). The patient was diagnosed with chest pain and a headache and was treated with telemetry, intravenous fluids (IVF), endocrinology consultation for hyperglycemia, acetylsalicylic acid (ASA)/statin, and hypertension (HTN) control. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the emergency department (ED) with complaints of (c/o) chest pain. An electrocardiogram (EKG) did not demonstrate any acute ischemic changes and the patient's HEART [history, electrocardiogram (EKG), age risk factors, troponin] score was 2, indicating that the patient had a low score, and not a high score. In addition, the patient had stable vital signs, no unstable co-morbidities, a non-ischemic EKG and negative cardiac biomarkers, no new left bundle branch block (LBBB) or newly inverted T-waves believed to be ischemic in origin, and no classic anginal symptoms or other serious or life-threatening cardiopulmonary etiologies. For the headache, the patient did not have a life-threatening cause of the headache, evidence of increased intracranial pressure (ICP), tumor, hydrocephalus, intracranial bleed, acute or subacute cerebrovascular accident (CVA), acute central nervous system (CNS) infection (encephalitis, brain abscess) or bacterial meningitis. In addition, the patient did not require immediate surgical intervention, have a hypertensive emergency, acute alteration in mental status, co-existing seizures, nuchal rigidity, acute visual loss, new focal neurologic deficits, abnormal pupils, apnea, abnormal respiratory pattern, or significantly abnormal vital signs. Overall, this patient was treated with acute coronary syndrome (ACS) rule-out and started on anti-hypertensives for headache, and these interventions could have been safely and appropriately treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

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

The patient in this case is a female who has a medical history of End-stage renal disease, chronic obstructive pulmonary disease (COPD) and heart failure and presented to the emergency department for evaluation of headache and hypertension. Reportedly, she had a throbbing headache and was with fluid overload as she was unable to complete her dialysis treatment on the day of admission. She was noted to have hypertension with high blood pressure of 181/113. Tachypnea was noted up to a respiratory rate of 22. She had decreased breath sounds throughout the lung fields as well as an elevation in her creatinine to 6.6. 

The inpatient hospital admission was medically necessary. The patient in this case was admitted with end-stage renal disease, COPD, hypertension that was poorly controlled, and volume overload. The patient also had coronary artery disease/acute coronary syndrome as evidenced by the elevation in the troponin. Based on this, the patient had concomitant comorbidities that require an inpatient level of care. A lower level of care would not have been appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Intracept Surgical Procedure.
The health plan denied the Intracept Surgical Procedure. 
The determination is upheld. 

The patient is a female with low back pain. Magnetic resonance imaging (MRI) of the lumbar (L) spine shows L4-5 disc protrusion with foraminal narrowing and annular fissure. Her provider has recommended the Intracept procedure. 
At issue is whether the proposed health service or treatment is likely to be more beneficial than any standard treatment for the patient's condition. 
The health plan's determination regarding the proposed health service or treatment is upheld in whole. 
The proposed Intracept procedure is not likely to be more beneficial than any standard treatment for the patient's condition. There are no large long-term studies showing clinical benefit in such patients as in this case with imaging of lumbar spine showing ongoing foraminal stenosis with annular fissure. Thus, more studies are needed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic Short Stature. 
Treatment: Nutropin AQ INJ Nuspin 10MG (milligrams) / 2ML
 (milliliters). 

The insurer denied: Nutropin AQ INJ Nuspin 10MG (milligrams) / 2ML (milliliters) 
The denial is overturned. 

The patient is school aged male followed by his pediatric endocrinologist for short stature. His growth chart shows that his height has been tracking significantly less than the third percentile for the past few years. The patient's height five months ago was 105.7 centimeters. His height was 101.9 centimeters last year. His midparental height is 60 inches. The patient's bone age was read as closest to the eight-year standard at 
chronological age two years younger. His insulin-like growth factor one (IGF-1) levels were normal at 112 last year (normal range 43-229). The patient underwent growth hormone (GH) stimulation testing which he passed with peak growth hormone (GH) of 17.8 nanograms per milliliter (ng/mL). The patient's endocrinologist would like to initiate growth hormone therapy for idiopathic short stature (ISS). Coverage was denied for not meeting criteria (idiopathic short stature is not a covered indication for growth hormone treatment). 

The proposed treatment is medically necessary. 

The use of growth hormone therapy is considered medically necessary if the criteria for growth hormone therapy in idiopathic short stature are met. The Food and Drug Administration (FDA) approved the use of growth hormone for the treatment of idiopathic short stature as defined by height standard deviation score (SDS) less than or equal to -2.25 and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and whose diagnostic workup has excluded other causes associated with short stature. 
The United States Food and Drug Administration (FDA) approved growth hormone therapy for these children in 2003. The indication is for children with current height below -2.25 standard deviations of the mean, in whom the epiphyses are not closed. Based on the clinical information provided, the patient's clinical characteristics did meet the criteria for treatment under the Food and Drug Administration-approved indication of idiopathic short stature, as the patient's pre-treatment height is more than 2.25 standard deviations below the mean for age/sex.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Remicade (J1745) Infusion Therapy
The insurer denied: Remicade (J1745) Infusion Therapy
The denial is overturned.

The patient is a school aged female. She has been diagnosed with Crohn's disease. She has been on infliximab (Remicade) 100 mg (milligrams) (5 milligrams per kilogram) every 6 weeks and is doing well. Her doctor requested to continue Remicade every 6 weeks. The health plan denied coverage of the request, citing that there was no recent clinic note to document treatment response. The denial is being appealed.

The requested Remicade is medically necessary.

Infliximab (Remicade) is one of the most commonly used biological agents in children with inflammatory bowel disease including Crohn's disease. The standard dosing is 5 mg/kg (milligram/kilogram) IV (intravenous) every 8 weeks. For children who lose response to standard dose, increasing dose of Remicade, up to 10 mg/kg (milligrams/kilogram) every 4 weeks has been shown to be safe and effective for Crohn's disease in children, as shown by prevailing peer reviewed medical literature (1-4).
Per clinic notes, this patient has been on infliximab 100 mg (milligrams) every 6 weeks. The patient had been doing well, and infliximab drug level was adequate at 14 five months ago. The plan was to continue Remicade infusion every 6 weeks. The 
request is consistent with current medical literature (1-4). Thus, the requested Remicade treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: diabetes, hypertension and osteoarthritis
Treatment: increase Consumer and Self-Directed Personal Assistance services (CDPAS) to 25 hours per week
The insurer denied coverage for increase Consumer and Self-Directed Personal Assistance services (CDPAS) to 25 hours per week
The denial is overturned

This is an elderly female with medical problems including diabetes, hypertension and osteoarthritis.  She lives alone in a private residence. The insurer denied the patient's requested increase for Consumer and Self-Directed Personal Assistance Services (CDPAS) of 25 hours/week, which is currently under review.  

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as minimally impaired.  She reportedly requires maximal assistance for much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She reportedly requires maximal assistance for bathing, lower body dressing.  Extensive assistance is reportedly needed for personal hygiene, upper body dressing, and toilet use.  Limited assistance is reportedly needed for toilet transfer, locomotion and ambulation.  The patient is reportedly at the supervision level for bed mobility and eating. She is reportedly frequently incontinent of bladder and occasionally incontinent of bowel.  

According to the Uniform Assessment System (UAS) report there has been no change in the patient's Activities of Daily Living (ADL) status, self-sufficiency or falls over the prior 90 days.  However, the patient's medical condition, cognitive deficits and physical limitations are at the level or unpredictable as to require the requested increase of Consumer and Self-Directed Personal Assistance Services (CDPAS).  This physician was also persuaded by the letters from her treating physician and daughter describing the patient's medical condition and continued functional decline.  The patient's functional needs are more appropriately provided and maintained with the requested Consumer and Self-Directed Personal Assistance Services (CDPAS) of 25 hours/week, in addition to the already approved 25 hours of Personal Care Services (PCS) to total 50 hours per week of services.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for increase Consumer and Self-Directed Personal Assistance services (CDPAS) to 25 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dental problems
treatment: braces/monthly adjustments
The insurer denied braces/monthly adjustments. The health plan's determination is upheld.

The patient is a female with severe maxillary and mandibular crowding. Tooth 29 is missing. Tooth 13 is blocked out to the lingual, but it is erupted. The patient has a class II occlusion with 4 millimeter (mm) overjet and 4mm overbite. The patient is treatment planned for Full Braces and Monthly Brace Adjustment. 

Full Braces and Monthly Brace Adjustment Visit(s) are not medically necessary for this patient.
While the patient has significant crowding, 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. The patient has a 4 mm overjet but research shows 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 an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease. 
Treatment: Inpatient Hospital Admission. 

The insurer denied the inpatient hospital admission. 
The health plan's determination is upheld. 

The patient is a male with a past medical history significant for prior smoker, hypertension, hyperlipidemia, type 2 diabetes mellitus, chronic angina with coronary artery disease status/post (s/p) multiple prior percutaneous coronary interventions (PCI's) with known in-stent restenosis of the mid right coronary artery (RCA). Given the patient's history of worsening chest pain with known coronary artery disease (CAD), the patient was scheduled for an outpatient left heart catheterization and intervention. Due to patient's chest pain, the outpatient cardiac catheterization was moved up. At the time of catheterization, the patient was hemodynamically stable.
The electrocardiogram (ECG) demonstrated normal sinus rhythm with inferior ventricular repolarization (T) wave inversions. The cardiac catheterization demonstrated tandem in-stent restenosis of the mid right coronary artery (RCA) which was successfully treated with percutaneous transluminal coronary angioplasty (PTCA) with plans for future brachytherapy in 1 month. The left anterior descending (LAD) had mild luminal irregularities and mild disease in the circumflex artery was visualized. The patient tolerated the procedure well without complications. He was admitted for monitoring overnight on telemetry (no events) under inpatient level of care and then discharged home the following day. 
 
The inpatient level of care was not medically necessary in this case for the following reasons. The patient underwent elective outpatient left heart catheterization (LHC) for evaluation of chest pain with plans for coronary intervention given known In-stent restenosis (ISR) of right coronary artery (RCA). The patient remained hemodynamically stable and underwent successful PTCA of RCA ISR without complications. He was monitored overnight post-procedure and there were no events on telemetry. For these reasons, an inpatient level of care was not medically necessary for monitoring post PCI supported by the expert consensus document update from the society for cardiovascular angiography and interventions on length of stay following percutaneous coronary intervention (1). 

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