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

Diagnosis: Hidradenitis Suppurative. 
Treatment: Simponi SOSY (Solution Prefilled Syringe) 100MG/ML (milligrams per milliliter). 

The insurer denied: Simponi SOSY (Solution Prefilled Syringe) 100MG/ML (milligrams per milliliter). 

The denial is Upheld. 

The patient is an adult female with severe hidradenitis, treated with antibiotics, infliximab, and anti-androgens. The provider is requesting Simponi (golimumab). The patient is morbidly obese (over 400 pounds) and the provider does not want to use Humira. The health plan denied coverage as Simponi is not Food and Drug Administration (FDA) approved for hidradenitis suppurative (HS). 

The proposed treatment is not medically necessary. 

While the attending physician wishes to not use Humira due to a high body mass index, there is not clinical literature to support this concern. Other biologics have been studied in hidradenitis suppurative (HS) but the studies with golimumab were done in patients who had tried and failed Humira. The cohort study by Melendez-Gonzalez et al included 13 patients who had all tried and failed infliximab and/or Humira. Therefore, a trial of Humira would be appropriate for this patient. There is no justification for not using Humira; Simponi is a fixed dose also. The patient has no documented contraindications to Humira. Golimumab also uses fixed dosing, and no literature was found regarding the use of fixed dosing and body mass index.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and Monthly Visits
The insurer denied Braces and Monthly Visits.
The determination is overturned.

This is a male patient. He has a Class II malocclusion with crowding and protrusive maxillary incisors. He has a 6-millimeter (mm) overjet and 5 mm overbite. He has severe maxillary crowding and severe mandibular spacing. He is treatment planned for 24-30 months of orthodontics to correct the crowding, deep bite, protrusion. At issue is the medical necessity of braces and monthly visits.

There is strong medical evidence that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. (1) Orthodontic treatment can make the teeth significantly less protrusive. If orthodontic treatment reduces the protrusion, it will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. Additionally, there is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) millimeter (mm) overjet's, which this patient has. (2,3) For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anaplastic astrocytoma

Treatment: Xpovio 40 mg (milligrams) eight tablets every 28 days for six months

The insurer denied coverage for Xpovio 40 mg eight tablets every 28 days for six months

The denial is upheld

 
The patient presents with anaplastic astrocytoma. The patient's prior therapy has included radiation, temodar, lomustine, avastin, Keytruda, and olapri. The treating provider is requesting plan approval for Xpovio 40 mg eight tablets every 28 days for six months.

The drug Xpovio is not currently approved, or compendia supported to treat glioblastoma (GBM). The National Comprehensive Cancer Network (NCCN) does not recognize the use of Xpovio as a valid therapy for GBM outside the context of a clinical trial. As such the proposed use of Xpovio is not in line with accepted standards of practice. Phase I (1) trials are not acceptable evidence of efficacy. Therefore, the request is denied.

"Conclusions: At 80 mg weekly, single-agent Selinexor (Xpovio) induced responses and clinically relevant six-month progression free survival (PFS6) with manageable side effects requiring dose reductions. Ongoing trials are evaluating safety and efficacy of Selinexor in combination with other therapies for newly diagnosed or recurrent glioblastoma." This was a 6-month phase 2 study with one complete and 2 partial responses in 30 patients given the maximum dose. (Lassman, et al., 2022).

NCCN does not mention the use of Selinexor for any central nervous system (CNS) tumors. 

This PDQ (Physician Data Query) cancer information summary has current information about the treatment of adult central nervous system tumors. It is meant to inform and help patients, families, and caregivers. It does not give formal guidelines or recommendations for making decisions about health care.

National Cancer Institute formed Editorial Boards write the PDQ cancer information summaries and keep them up to date. These Boards are made up of experts in cancer treatment and other specialties related to cancer. The summaries are reviewed regularly, and changes are made when there is new information. The date on each summary ("Date Last Modified") is the date of the most recent change. The information in this patient summary was taken from the health professional version, which is reviewed regularly and updated as needed, by the PDQ Adult Treatment Editorial Board." (PDQ Adult Treatment Editorial Board, 2023).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Xpovio 40 mg eight tablets every 28 days for six months is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Inpatient Hospital Admission. 

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

The patient is an adult female with history of asthma. She presented to the ER (emergency room) with shortness of breath. The patient has been on oral prednisone for recent asthma exacerbation. The patient was found to have asthma exacerbation in the ER (emergency room) and received IV (intravenous) steroids and nebs. The patient was admitted to the hospital for further management. 

The acute hospitalization was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed. 

The Inpatient Hospital Admission was not medically necessary. 

The patient presented with asthma exacerbation. The patient's shortness of breath improved with ER (emergency room) treatment. The patient was not in any distress. The patient's oxygen levels were above 90% on room air. The patient was ambulating and tolerating diet. Given that the patient's signs and symptoms due to mild asthma exacerbation improved significantly with ER (emergency room) care, the patient's treatment course would have been expected to be safe and effective at a lower level of care. The treatment provided to this patient was reasonable but did not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with no significant medical history. He presented to the emergency department with abdominal pain, more prominent on the left than the right, and nausea with vomiting for three days and intolerance of oral intake. Vital signs were notable for tachycardia with pulse rate of 102/minute. Physical examination was notable for soft, non-distended abdomen with generalized abdominal tenderness and normal bowel sounds. He reported postprandial heartburn and unintentional weight loss. 

The inpatient hospital admission was not medically necessary. The patient presented with abdominal pain, nausea, and vomiting consistent with gastroparesis, and imaging showing possible gastroparesis. However, there was no small bowel obstruction, acute pancreatitis, active gastrointestinal bleeding, peritonitis, abscess, fistula, or sepsis, which would require the inpatient level of care. Although the patient presented with nausea and vomiting, he did not have persistent hypotension, organ failure, or other stigmata of severe volume depletion; his symptoms improved quickly. Esophagogastroduodenoscopy showed esophagitis and a gastric ulcer, as well as a large amount of food in the stomach consistent with gastroparesis, but did not show any active bleeding or other high-risk findings. The patient ultimately improved with conservative therapy including acid suppression and sucralfate. The interventions performed, including labs, monitoring, imaging, Gastroenterology consultation, and esophagogastroduodenoscopy, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and headache
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This patient has a past medical history of diabetes mellitus and hypertension and presented to the hospital complaining of a severe headache and intermittent chest pain. Chest pain was described to be pleuritic in character. On arrival to the hospital, vital signs were stable (blood pressure 168/96, pulse 100). Physical examination revealed no major abnormality. 12 lead electrocardiogram (EKG) revealed sinus rhythm with no evidence of ischemic ST (interval on EKG) or T (interval on EKG) wave abnormalities and poor R (interval on EKG) wave progression. Serum troponin level was mildly elevated (4.62). Computed Tomography (CT) of the chest revealed coronary artery disease (CAD) with calcified plaque and 70% (percent) luminal narrowing causing occlusion of the left anterior descending artery. The patient was treated with antihypertensive medication.

This patient presented with atypical chest pain and a past medical history of hypertension and diabetes mellitus. Although the patient had calcified CAD on the CT of the chest, the patient did not present with an acute myocardial infarction (MI). The pretest probability of CAD was low (1). Utilizing the HEART (history, EKG, age, risk factors, initial troponin) score, the patient was considered low risk (2). Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (3). Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati, et al. (3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as MI, need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care and in fact was medically stable for transfer to another facility for cardiac catheterization.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar II disorder.
Treatment: Methylphenidate 36MG (milligrams) Extended-Release Tablets.
The insurer denied: Methylphenidate 36MG (milligrams) Extended-Release Tablets.
The denial is upheld.

The patient is an adult female diagnosed with bipolar II disorder. She has poor attention and concentration affecting her academic functioning and worsening her anxiety due to school failure. Methylphenidate hydrochloride extended release (ER) 36 milligrams (MG) extended release tab was requested and was denied because the plan covers the drug when it is being used for a Food and Drug Administration (FDA)-approved or compendia supported indication and there is no documentation provided to confirm a diagnosis of attention deficit hyperactivity disorder (ADHD) or attention deficit disorder (ADD).

The treatment is not medically necessary.

While it is stated the patient has poor attention and concentration, there is no documented diagnosis of attention deficit hyperactivity disorder or attention deficit disorder. The only documented diagnosis is bipolar II disorder. Methylphenidate is not indicated for treatment of bipolar II disorder.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty swallowing
Treatment: Per-Oral Endoscopic Myotomy (POEM) Procedure
The insurer denied the POEM procedure.
The determination is upheld.

This is a patient under evaluation for achalasia. The patient had an endoscopy and barium esophagram and there is aperistalsis. Esophageal manometry did not confirm the diagnosis of achalasia as the integrated relaxation pressure (IRP) was normal [i.e. (that is), normal relaxation]. The manometry study concludes there is "low suspicion for achalasia". The patient failed lower esophageal sphincter (LES) injection with Botox.
The provider has requested approval to perform a peroral myotomy as definitive treatment. This request was denied by the health plan and is under review for medical necessity.
 
The use of peroral endoscopic myotomy (POEM) for the treatment of achalasia has gained acceptance throughout the world. Introduced into clinical practice about 10 years ago, it represents a non-invasive, permanent treatment for achalasia. It has been compared in head-to-head trials with both pneumatic dilation and laparoscopic Heller myotomy and has a similar efficacy. It is much more durable than pneumatic dilation. The main side effect, due to destruction of the LES, is the development of symptomatic reflux disease. 

However, this patient does not have achalasia. He has normal relaxation of the LES and therefore there is no rationale for performing a myotomy. It is possible that over years he may evolve into classic achalasia, but right now the main consideration is that he has scleroderma-like features. A myotomy may induce severe, symptomatic reflux due to his inability to clear the esophagus of refluxed contents. Therefore, it is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tracheostomy, non-verbal
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a male patient with a medical history of hypertension, diabetes mellitus, and traumatic brain injury who is non-verbal at baseline and status post a tracheostomy on 6 liters/minute of supplemental oxygen. He was admitted from the pulmonary clinic to assess for a possible speaking valve. The patient was hemodynamically stable without tachycardia, was afebrile, and had an oxygen saturation of 100 percent (%) on his baseline 6 liters/minute of oxygen, was not in any respiratory distress. On exam, he was in no acute distress and had clear breath sounds bilaterally on auscultation of the chest. His chest x-ray demonstrated no evidence for acute infiltrates, consolidations, pneumothorax, pleural effusions, or fractures. He was admitted and had his tracheostomy downsized and eventually decannulated. At issue is the medical necessity of an inpatient hospital stay.

The requested health service/treatment of an inpatient hospital stay was not medically necessary for this patient.

Based upon the severity of illness and intensity of required therapy, the inpatient hospital stay was not medically necessary.

This patient was admitted form the pulmonary clinic to assess for a possible speaking valve. In the emergency room, the patient was hemodynamically stable without tachycardia, afebrile, had an oxygen saturation of 100% on his baseline 6 liters/minute of oxygen, respiratory rate of 20 breaths per minute. On admission, he did not have evidence for impending or actual respiratory arrest, a severe airflow or ventilation abnormality or severe respiratory findings not responsive to observation level of care treatment, he did not have a history of chronic lung disease with severe deterioration, tuberculosis, severe pulmonary arterial hypertension, right heart failure, pulmonary vascular disease, cystic fibrosis, bronchiectasis, sarcoidosis, interstitial lung disease, allergic pneumonitis, lung injury or complications of tracheostomy [eg (for example), decannulation or obstruction requiring intubation, hemorrhage, tracheoesophageal fistula] requiring an inpatient level of care. In addition, he did not have a temperature less than 95 degrees Fahrenheit (F) (35 degrees Celsius [C]) or greater than 103.1 degrees F (39.5 degrees C), hemodynamic instability, he was not immunocompromised, he did not have a history of severe chronic obstructive pulmonary disease (COPD), or severely symptomatic congestive heart failure. Therefore, the requested health service/treatment of inpatient hospital stay was not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
treatment: Thermal Destruction of Intraosseous Basivertebral Nerve, Including All Imaging Guidance. 
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve, Including All Imaging Guidance. 
The health plan's determination is upheld.

The patient is a female with low back pain. The pain began several years ago. The pain is rated 7 out of 10 and impacts activities of daily living (ADL). Prior Treatments have included epidural injections, chiropractic care, massage, as well as medication management. Magnetic resonance imaging (MRI) lumbar spine showed Modic disc space L3-4 and L4-5 changes. 

The proposed intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. An Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
treatment: Thermal Destruction of Intraosseous Basivertebral Nerve, Including All Imaging Guidance. 
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve, Including All Imaging Guidance. The health plan's determination is upheld.

This is a female patient with a diagnosis of Vertebrogenic Low Back Pain. The patient was recommended to undergo the Intracept procedure (intraosseous basivertebral nerve ablation), which was denied by the insurance carrier.

No, the proposed health service or treatment Thermal Destruction of Intraosseous Basivertebral Nerve, Including All Imaging Guidance is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient is noted to have chronic back pain and has failed multiple conservative treatments including therapy, medications and injections. The provider notes that the patient has Modic changes at L3 - L4 and L4 - L5 and believes that this is the source of the patient's chronic back pain (although this was only noted at L3 - L4 according to the actual MRI report). However, the magnetic resonance imaging (MRI) shows multiple significant findings including multilevel disc herniations, nerve root compression, fecal sack deformity, and varying degrees of facet arthropathy, all of which can be possible pain generators.

This treatment is not currently considered standard of care in the general medical community. There is insufficient 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. Additional studies are needed to evaluate long-term risks and benefits of this procedure.
Appeal type: Experimental/Investigational
Decision: Upheld


Diagnosis: back pain
treatment: Thermal Destruction of Intraosseous Basivertebral Nerve, Including All Imaging Guidance. 
The insurer denied Thermal Destruction of Intraosseous Basivertebral Nerve, Including All Imaging Guidance. 

The health plan's determination is upheld.

This is a female who has chronic low back pain for several years. Her pain is aching, sharp, stabbing with radiating pain to the left leg. She reports more severe pain in the morning. She had 2 epidural injections last year with some improvement. She had tried pain medications and physical therapy (PT) without success. Physical exam (PE) was unremarkable except lumbar spine decreased range of motion (ROM), motor strength 4/5 hip flexion, and tenderness to palpation (TTP) in the lumbar paraspinal region, and pain with flexion.
Magnetic resonance imaging (MRI): levoscoliosis, multilevel degenerative disc disease (DDD) with facet arthropathy, a left L (lumbar) 4/5 foraminal disc herniations causing deformity of the exiting left L4 nerve, and a small left L2/3 disc herniation with mild deformity of left L2 nerve. This patient was recommended to have radiofrequency ablation of basivertebral nerves (Intracept procedure) at L3, L4, and L5 levels.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral palsy.

Treatment: Seven additional occupational therapy (OT) visits.

The insurer denied coverage for seven additional occupational therapy (OT) visits.

The denial is upheld.
 

This patient is a pre-teenager with diagnoses that include autism spectrum disorder, muscle weakness and cerebral palsy. Treatment included occupational therapy which is currently under review.

The occupational therapy (OT) treatment notes made available for review are inadequate and do not provide sufficient objective clinical information to support the medical necessity of occupational therapy for the dates of service under review. The clinical records do not establish the medical necessity of continuing a structured out-patient OT treatment program for the time period under review. There are no specific impairment ratings, quantitative assessments or documented measurable response to treatment. The therapy notes simply provide check off boxes describing non-specific ranges of abilities without establishing a credible baseline, interval measurements or reasonable timeline for anticipated improvement. There is a lack of credible documented quantitative functional improvement to support the provided treatment as medically necessary. This physician also agrees with the insurer regarding the lack of evidence demonstrating a severe impairment that would require restorative or rehabilitative OT. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for seven additional occupational therapy (OT) visits is not substantiated.