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

Diagnosis:  Rotavirus.
Treatment:  Inpatient Hospital Admission.

The insurer denied Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult female with a history of orthotopic heart transplant and subsequent primary graft dysfunction and cardiac arrest status post extracorporeal membrane oxygenation (ECMO) who presented to the hospital with complaints of fever, left knee soreness and then generalized body aches and diarrhea. She did not have nausea or vomiting. A review of systems was otherwise negative. The patient did not appear unwell and was non-toxic. Given history of immune suppression, the patient was started on intravenous antibiotics although the illness was thought to be likely viral. Transplant service was consulted, and transplant infectious diseases (ID) was also consulted. The patient received cefepime and vancomycin with Flagyl. Notably, on presentation the patient had leukocytosis, mild fever and tachycardia without tachypnea. The following day, blood cultures were negative, viral respiratory panel was negative and gastroenterology (GI) polymerase chain reaction (PCR) multiplex panel showed Rotavirus. Antibiotics were stopped, and the patient was discharged home in stable condition with a diagnosis of viral infection. The denial is based on not meeting criteria, such as persistent vital sign abnormality, positive blood culture, organ dysfunction including hematological dysfunction, persistent and severe altered mental status, inability to take medicines and food or drink orally due to nausea and vomiting, low oxygen levels, marked lab abnormalities, severe abdominal pain or failure of outpatient treatment.

The requested health service was not medically necessary.

The requested health service is inpatient hospital treatment for this patient's acute febrile illness. Inpatient admission is needed when a patient's symptoms, signs, past history, labs and imaging suggest high risk for imminent deterioration, high intensity of illness or severity of illness and need for interventions that cannot be provided in the observation or outpatient setting. In this patient's case, the lack of toxicity initially, lack of persistent vital signs abnormalities, no change in mental status, no abnormalities on labs that might suggest sepsis, lack of abdominal pain, lack of intractable nausea or vomiting and lack of unstable comorbid conditions made the presentation low risk and low severity; that is why the patient was able to be discharged in stable condition within a short period of time. Although the patient had a history of cardiac transplant, she had stable cardiac function without any concerns for arrhythmia or heart failure.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain

Treatment: 64628; thermal destruction of intraosseous basivertebral nerve (BVN), including all imaging guidance; first 2 vertebral bodies, lumbar (L) or sacral (S) and 64629; thermal destruction of intraosseous BVN, including all imaging guidance; each additional vertebral body, L or S

The insurer denied coverage for 64628; thermal destruction of intraosseous BVN, including all imaging guidance; first 2 vertebral bodies, L or S and 64629; thermal destruction of intraosseous BVN, including all imaging guidance; each additional vertebral body, L or S.

The denial is upheld.


This is a patient who suffers from lower back pain. The treating provider has requested treatment with 64628; thermal destruction of intraosseous basivertebral nerve (BVN), including all imaging guidance; first 2 vertebral bodies, lumbar (L) or sacral (S) and 64629; thermal destruction of intraosseous BVN, including all imaging guidance; each additional vertebral body, L or S, which is under review.

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

Medicare does not have a National Coverage Determination (NCD) specifically for the use of the Intracept procedure in the treatment of chronic low back pain. Local Coverage Determinations (LCDs) do not exist at this time. Intracept remains a procedure without established efficacy. 

Therefore, the request for 64628; thermal destruction of intraosseous BVN, including all imaging guidance; first 2 vertebral bodies, L or S and 64629; thermal destruction of intraosseous BVN, including all imaging guidance; each additional vertebral body, L or S is denied. 

64628; thermal destruction of intraosseous BVN, including all imaging guidance; first 2 vertebral bodies, L or S and 64629; thermal destruction of intraosseous BVN, including all imaging guidance; each additional vertebral body, L or S does not have final approval from the appropriate regulatory bodies for this diagnosis. The patient is not a good candidate for this procedure.

This procedure is not the best available treatment for this patient at this time. The adverse risks are increased over standard treatment/services. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.                                                    

In summary, the denial of 64628; thermal destruction of intraosseous BVN, including all imaging guidance; first 2 vertebral bodies, L or S and 64629; thermal destruction of intraosseous BVN, including all imaging guidance; each additional vertebral body, L or S and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: breast cancer. 
Treatment: Image-Guided Radiation Therapy (IGRT). 
The insurer denied Image-Guided Radiation Therapy (IGRT). 
The health plan's determination is overturned. 

This is a female with a history of recurrent left breast cancer who has been recommended to proceed with salvage external beam radiotherapy with curative intent to her left chest and regional lymph nodes. Under review is Image-Guided Radiation Therapy (IGRT). 

Image-Guided Radiation Therapy (IGRT) is medically necessary for this patient. The treating provider supplied a proton/photon plan comparison which shows that the photon plan was unable to provide adequate safety/precision about the patient's heart and left lung. If delivered, the photon plan would lead to an unacceptable and unnecessary risk for cardiopulmonary morbidity/mortality. The proton radiation plan was able to significantly minimize the patient's heart/lung exposure within known safe tolerance limits. Image-guided radiation Therapy (IGRT) in this patient's setting is supported by the ASTRO (American Society for Radiation Oncology) Model Policy as the provider has shown that photon radiation is unable to meet nationally accepted treatment planning objectives about normal tissue avoidance. Image-guided radiation Therapy (IGRT) is supported by high-quality prospective clinical outcomes reported in the peer-reviewed medical literature and is widely utilized nationwide for similar patients with left breast cancer who cannot be treated safely with photon radiation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne Muscular Dystrophy
Treatment: Amondys
The insurer denied Amondys.
The determination is overturned.

The patient is a male with Duchenne Muscular Dystrophy (DMD). The medical necessity of treatment with Amondys is under review. The drug was denied because the patient is non-ambulatory and has significant pulmonary impairment. The provider appealed the denial of this medication. The medical necessity of treatment with Amondys is under review.
The requested treatment is medically necessary. The patient is diagnosed with Duchenne Muscular Dystrophy. The request is for Amondys 45. Food and Drug Administration (FDA) approval was based upon the surrogate outcome of increased dystrophin production, as shown in an interim analysis of 43 patients (ages 7 to 20 years) with a deletion mutation in Duchenne Muscular Dystrophy (DMD) amenable to exon 45 skipping who were randomly assigned in a 2:1 ratio to treatment with casimersen or placebo. At 48 weeks, the mean increase in dystrophin levels from baseline on muscle biopsy for patients assigned to casimersen was 0.81 percent, compared with 0.22 percent for the placebo group. Clinical benefit was not reported in this preliminary analysis. Continued FDA approval may depend upon confirmation of clinical benefit in further trials. However, the drug is currently approved for all patients with Duchenne Muscular Dystrophy who might benefit from exon 45 skipping. The patient meets this criteria and there is no reason to believe that exon skipping in this patient would also not result in more dystrophin protein and possible improvement or stabilization of the disease despite his pulmonary or ambulatory status.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alcohol Abuse
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is partially overturned.

This is a female patient with a past medical history (PMH) of generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), panic attacks, and major depressive disorder (MDD) who was admitted with complaints of (c/o) a need for detoxification (detox) from alcohol. Her vital signs were unremarkable. The physical exam was notable for Clinical Institute Withdrawal Assessment (CIWA) 32. Lab work was notable for alcohol 213, transaminitis. Imaging studies included a chest x-ray (CXR) which showed no acute pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with alcohol withdrawal and intractable vomiting and treated with CIWA, benzodiazipines (BZDs), intravenous fluids (IVF), electrolyte repletion, and anti-emetics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was medically necessary at an acute inpatient level of care, in part. The patient had a medical history and physical exam clinically concerning for acute alcohol intoxication in the setting of CIWA scores consistent with severe alcohol withdrawal and impending delirium tremens. This presentation was further compounded by the patient's severe agitation requiring chemical sedation, and these types of patients are not appropriate for an observation level of care due to the close clinical monitoring that is required to ensure no respiratory depression and adverse events, especially in the setting of clinical concern for seizures, delirium tremens, and intractable vomiting. Due to the patient's medical history, she required close clinical monitoring for potential intervention that could not have been safely provided at a lower level of care.
However, the patient was noted to be tolerating her diet well, the CIWA was documented to be 4, the alcohol level was less than (<) 10, and she was on a tapering does of BZDs, and thus the patient was clinically stable enough to be treated at a lower level of care for service dates. The first day of the stay was medically necessary at an inpatient level of care, and the rest of the stay was not medically necessary at an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of hypertension. His presenting complaints were hypoxia noted at the patient's primary care visit in addition to dyspnea and a cough. The physical exam was notable for mild rhonchi and shortness of breath on speaking. Lab results were notable for elevated D-dimer, leukocytosis, sodium 129, blood urea nitrogen (BUN) 21, and elevated creatinine. Radiology was notable for computed tomography angiography (CTA) of the chest with left lower lobe consolidation. The patient was diagnosed with pneumonia and admitted to an inpatient level of care. At issue is the medical necessity of an inpatient stay.
The requested inpatient admission was not medically necessary.
The patient presented with community acquired pneumonia fitting with a pneumonia severity index risk class III. The patient did not demonstrate significant hypoxia, respiratory distress, or comorbidities. A lower level of care would have been reasonable to begin treatment for pneumonia and monitor the patient's response to therapy with transition to outpatient management. An inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: substance use disorder

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is an adult old male admitted to inpatient substance rehabilitation treatment. He reportedly was drinking 1 pint of vodka 3-6 times per week with a 38 year history, and smoking crack/cocaine up to $300 per day with a 34 year history. He had a positive toxicology for cocaine and benzodiazepines. He reportedly had multiple past treatment episodes including past inpatient substance detoxification and rehabilitation treatments but could not maintain abstinence due to lacking coping skills and sober supports as well as ability to identify relapse triggers. He reportedly attended individual and group therapy and was discharged on with a referral to residential treatment at Odyssey House for long term alcohol/substance treatment.
 
The medical records provided enough specific evidence to support that he required inpatient level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case this patient was considered in need of 24-hour inpatient substance/alcohol rehabilitation treatment as he lacked sufficient coping skills and relapse prevention skills to identify triggers, and sober supports to remain abstinent in a less restrictive setting. He reportedly was homeless and unemployed. He reportedly was at risk for medical issues due to his large amount of crack/cocaine use daily and large amount of alcohol use and also was at risk for overdose or medical complications from crack/cocaine and alcohol use. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Guidelines he met criteria for inpatient substance rehabilitation treatment based on the quantity, frequency and history of serious substance of use. He reportedly had multiple past substance detoxification and rehabilitation treatments and could not maintain abstinence. This is specific evidence that he required at least the inpatient substance rehabilitation treatment to try to learn better coping skills and relapse prevention skills to try to maintain abstinence. Without this structured and supervised therapeutic inpatient substance rehabilitation treatment, he likely would have relapsed as evidenced by his inability to stop use and his relapses after multiple past inpatient substance treatments, and due to his lack of coping skills, inability to identify relapse triggers, and lack of sober supports as he was homeless. 

Based on the above, the insurer's denial must be reversed. 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 the inpatient substance abuse admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: D8080 Braces
The insurer denied: D8080 Braces
The denial is overturned.

This patient is an adolescent female. The request is for orthodontic benefits. The patient has a Class I malocclusion with mild upper and lower crowding. She has a left side posterior crossbite and moderate protrusion of the upper and lower anterior teeth. The prior denial was due to a handicapping index scale of 15 points.

The requested health service is medically necessary.

The patient has a deep, impinging overbite with severe soft tissue damage to the palate. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem; therefore, the case has medical necessity.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Nasal Obstruction and Sinus Symptoms.
Treatment:  CPT (current procedural terminology) Code - 30465 [Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)], CPT Code - 31253 [Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed], and CPT Code - 30465 [Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)].

The insurer denied CPT Code - 30465 [Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)], CPT Code - 31253 [Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed], and CPT Code - 30465 [Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction)].  The denial is partially overturned.

The patient is an adult male with a history of chronic nasal obstruction and chronic sinusitis. There is a history of previous nasal and sinus surgery. Exam reports a deviated septum with inferior turbinate hypertrophy and nasal valve pathology. Bilateral polyps are also noted. Medical therapy has included nasal and oral steroids, antibiotics and montelukast. Sinus computed tomography reported pansinus disease. The provider is requesting coverage of CPTs (current procedural terminologies) 30465, 30465 and 31253. The request was previously denied, and the provider is appealing the denial.

The requested health service is medically necessary. However, CPT (current procedural terminology) 30465 is a bilateral CPT (current procedural terminology) so only one 30465 is allowable. 

There is a history of chronic sinusitis and nasal obstruction. There is a history of previous nasal and sinus surgery. Exam reports a deviated septum with inferior turbinate hypertrophy and nasal valve pathology. Bilateral polyps are also noted. Medical 
therapy has included nasal and oral steroids, antibiotics, and montelukast. Symptoms remain. Sinus computed tomography reported pansinus disease. There are patient photos provided that document internal nasal valve pathology. Based on the 
above, with the documented pathology on exam, computed tomography, photos, and the failure of medical therapy, the medical necessity of the CPTs (current procedural terminologies) 30465 (one), 31253 would be confirmed. The requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Severe pedal edema, urinary incontinence, blindness.
Treatment:  Personal Care Services, Level 2, 12 Hours a Day, 7 Days a Week, for a Total of 84 Hours per Week.

The insurer denied: Personal Care Services, Level 2, 12 Hours a Day, 7 Days a Week, for a Total of 84 Hours per Week.  The denial is overturned.

The patient is an elderly female with a history of gait and mobility deficits, severe pedal edema, urinary incontinence, blindness, osteoporosis, fatigue, coronary artery disease, congestive heart failure, recurrent falls, and skin cancer. Personal Care Services, Level 2, 12 Hours a Day, 7 Days a Week, for a Total of 84 Hours per Week is being requested.

The request to increase Personal Care Services for a total amount of 84 hours per week is considered medically necessary.

Multiple appeal letters and multiple assessments have been reviewed up to date. This patient has physical debility and falls; she is needing more help with activities of daily living (ADLs) including ambulating, toileting, transferring, and completing personal hygiene that occur throughout the day. The patient is requiring extensive assistance with meal prep, housework, shopping, bathing, personal hygiene, dressing upper and lower body, walking, transfer, toilet use, and escorting to doctor's appointments due to underlying blindness. Regarding assessments from last year to 4 months ago, the patient has required extensive assistance with walking, locomotion, and toilet transfers/use. The patient has impairment in short-term memory, she totally depends on personal care aides for meal prep, ordinary housework, and shopping. She has increased weakness, dizziness, and difficulty walking. She needs one person assistance holding her underneath her arm. Gait is slow and steady, she is incontinent of bladder, needs assistance to change from lying to seating position and to turn from side to side in bed. The patient needs assistance with feeding at times due to blindness. The appeal letter states the patient's capacity for normal activities has diminished. Without frequent daily assistance, she cannot toilet, ambulate, get up from the bed, or eat on her own; with an increase in personal care services to 12 hours per day, performance of these functions will improve. The patient lives alone and has no informal supports to provide assistance with activities of daily living to meet her personal care needs on a regular basis. The patient is on anticoagulation and requires help to take her medications as directed. She also needs reminders and administration of her medications. The daughter states that the patient has no available caregiver to assist after the personal care aide (PCA) hours. The personal care aide has to lock and unlock the front door. The patient has 
had two or more falls in the last 30 days due to dizziness and unsteadiness. This has been corrected with assistance from the personal care aide. Based upon this information, the request for an increase in Personal Care Services, Level 2, 12 Hours a Day, 7 Days a Week for a Total of 84 Hours per Week is considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine. 
Treatment: Emgality 120 milligrams. 
The insurer denied Emgality 120 milligrams. 
The health plan's determination is overturned. 

The patient is a female with Migraine without Aura and with Status Migrainosus, Not Intractable; Cervicalgia. Treatment with Emgality is prescribed. The drug was denied because the plan indicated that the member has not tried and failed two oral migraine preventative therapies for at least two months each. The provider appealed the determination. 

Emgality is medically necessary for this patient. 
The patient is diagnosed with chronic migraine. This is a Food and Drug Administration (FDA) approved indication for treatment with Emgality. The patient has tried and failed an anticonvulsant (divalproex) and antidepressant (bupropion) for prevention of migraine. These medications were ineffective. The patient attested that antihypertensives, such as beta-blockers and candesartan, are not appropriate alternatives for the patient because she has a low resting blood pressure and heart rate. The use of an injectable CGRP (Calcitonin gene-related peptide) inhibitor is appropriate after a patient has used multiple oral preventative medications. Therefore, Emgality is appropriate in this case.