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

Reviewer #1:

Diagnosis: Low back pain.

Treatment: Procedure code 64628, thermal destruction of intraosseous basivertebral nerve and code 64629, thermal destruction of intraosseous basivertebral nerve.

The insurer denied coverage for procedure code 64628, thermal destruction of intraosseous basivertebral nerve and code 64629, thermal destruction of intraosseous basivertebral nerve.

The denial is upheld.

The patient is an adult male who has a diagnosis of low back pain and Modic changes. The request is for approval for Intracept procedure, which is under review.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

While results may appear promising, additional studies are necessary to determine efficacy as compared to other conventional therapies. 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. 

Procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, Lumbar or sacral does not have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is not a good candidate for 64628 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, Lumbar or sacral.     

Procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral; 64629 Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, Lumbar or sacral is not the best available treatment for this patient at this time.     
  
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 procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral 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: Upheld

Diagnosis: Appendicitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld.

The patient has a past history of human immunodeficiency virus (HIV), chronic obstructive pulmonary disease (COPD), and hypertension (HTN) and returned to the hospital after being discharged earlier in the day. The patient had presented with abdominal pain and was treated for appendicitis with intravenous (IV) antibiotics and improved. When the patient got home the pain worsened. In the Emergency Room (ER) the patient had a low-grade fever and a tachycardia. The ER physician found abdominal guarding but no rebound. The computed tomography (CT) scan showed appendicitis without a perforation but with increased ascites. The patient was again treated with IV antibiotics, and the symptoms improved. The patient was afebrile, and the leukocytosis resolved. 

The hospital has referenced Milliman Care Guidelines (MCG) guideline MG-SIC for Systemic or Infectious Condition. Clinical indications for admission include hemodynamic instability, severe electrolyte abnormalities, and an infection with bacteremia, hypoxemia, acute renal failure, altered mental status or a necrotizing soft tissue infection. The patient did not have these conditions. 

MCG guideline MG-GAS for Gastroenterology lists non-operative management of acute appendicitis. An inpatient admission is indicated if there is a hemoperitoneum. The patient did not have a hemoperitoneum. The patient also did not have mesenteric ischemia or free air. 

This patient had acute appendicitis. If there was a consideration to doing a laparoscopic appendectomy, this procedure could have been done as ambulatory surgery. The patient returned to the hospital and required additional antibiotics, as they had only received one day of treatment. The antibiotics could have been given with observation status. The fever and leukocytosis improved with treatment. The patient did not meet MCG criteria for admission for either Systemic or Infectious Condition or Gastroenterology. An inpatient admission was not medically necessary. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, heart failure, and history of strokes with left-sided weakness
Treatment: Increase Consumer Direct Personal Assistance (CDPAP) Services for a Total Amount of 168 Hours per Week (Split Shift)
The insurer denied Increase Consumer Direct Personal Assistance (CDPAP) Services for a Total Amount of 168 Hours per Week (Split Shift).
The denial is overturned.

This is an elderly female patient that has medical conditions that include dementia, heart failure, and history of strokes with left-sided weakness. The denial of an increase in consumer direct personal assistance (CDPAP) services for a total amount of 168 hours per week (split shift) is being appealed. The health plan approved a total of 59.5 hours per week. The Uniform Assessment System evaluation completed 3 months ago shows moderately impaired cognition and functional status of maximal assistance to total dependence with all activities of daily living (ADLs), except limited assistance with eating. She has bowel and bladder incontinence. Appeal statements report the patient needs assistance with all activities of daily living. She is wheelchair bound. She currently has stage II and III decubitus ulcers and requires turning and repositioning in bed every two hours. She sleeps inconsistently and needs someone when she wakes up at night. She needs assistance with activities of daily living and is unsafe to be left alone.

The requested health service is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions, including dementia and hemiplegia after strokes. The denial of an increase in consumer direct personal assistance (CDPAP) services for a total amount of 168 hours per week (split shift) is being appealed. The health plan approved a total of 59.5 hours per week. The Uniform Assessment System (UAS) evaluation completed 3 months ago shows the patient requires maximal assistance to total dependence with all activities of daily living (ADLs), except limited assistance with eating. She has incontinence of bowel and bladder. The appeal statements support the patient is dependent with all activities of daily living. She currently has stage II and III decubitus ulcers and requires turning and repositioning in bed every two hours. This patient has continuous needs that support the requested consumer direct personal assistance (CDPAP) for a total amount of 168 hours per week (split shift) as medically indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pancreatic cancer/abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

The patient is a female with medical history of pancreatic tail adenocarcinoma status post distal pancreatectomy and splenectomy, left salpingo-oophorectomy, and multiple rounds of chemotherapy (including experimental therapy) with recurrence, portal vein thrombosis, and elevated transaminases. She presented with abdominal pain, bloating, nausea, and vomiting, with poor oral intake, and no substantial bowel movements for seven days. Vital signs were unremarkable. Physical examination showed soft, non-distended abdomen with epigastric tenderness and hypoactive bowel sounds. 

The inpatient hospital admission was medically necessary due to the severity of the patient's underlying conditions. The patient presented with pain, nausea, vomiting, and constipation in the setting of pancreatic cancer and portal vein thrombosis. She had severe pain requiring intravenous medications for pain control well into the hospital stay, days after presentation. Additionally, she had elevated liver enzymes initially concerning for biliary obstruction and risk of cholangitis. Once imaging had been performed and endoscopic ultrasound with celiac plexus neurolysis (a procedure associated with risk of bleeding and infection) had been performed with improvement in pain, discharge became appropriate. For these reasons, evaluation and monitoring at the inpatient level of care was supported in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated Red Blood Cells
Treatment: Gene test (Gene mutation testing of JAK2 (Janus kinase 2) and related genes)
The insurer denied Gene test (Gene mutation testing of JAK2 and related genes).
The determination is upheld.

This is a patient with a history of heterozygosity for alpha thalassemia who was evaluated for a high red blood cell (RBCs). The patient is asymptomatic. Serologic studies to evaluate for a myeloproliferative neoplasm were obtained; Janus kinase (JAK2) mutation testing was obtained and is under review for medical necessity.
This patient had no symptoms and no laboratory studies concerning for a myeloproliferative disorder. The RBC count is increased in thalassemias and is not indicative of a myeloproliferative neoplasm. JAK2 mutations are found in virtually all patients with polycythemia vera (PV) and approximately 50 percent of those with either essential thrombocythemia (ET) or primary myelofibrosis (PMF). This patient, however, has no signs or symptoms of any of these diagnoses. PV is considered to be present when an otherwise unexplained increased hematocrit/red blood cell mass is accompanied by the presence of a JAK2 mutation (not present). PMF is characterized by the presence of bone marrow fibrosis that cannot be attributed to another myeloid disorder (not present). ET is a diagnosis of exclusion, representing clonal or autonomous thrombocytosis (not present). In this scenario, testing for JAK2 is not supported by the peer-reviewed literature, national guidelines, nor by the authors of UpToDate; thus medical necessity cannot be established for this service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 40 Hours per Week
The health plan's determination is overturned. 

This is a female patient with a history of interstitial cystitis, tear of lateral right meniscus, primary generalized osteoarthritis, fatigue, muscle spasm, glaucoma, migraines, and severe back pain with herniated discs in cervical, thoracic, and lumbar spine. The patient lives alone. The patient and her care team requested Consumer Directed Personal Assistance Services (CDPAS): 40 Hours per Week.

The Consumer Directed Personal Assistance Services (CDPAS) for 40 hours per week is medically necessary.
There is documentation in the recent Uniform Assessment System (UAS) of the patient requiring at least limited assistance with tasks of transfer toilet and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs. A tasking tool should not have been used to calculate the hours given the patient's assistance with unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) of medical necessity of increased CDPAS services. The patient lives alone and does not have informal support for the entire time outside of the previously assigned CDPAS hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS hours is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Elevated liver enzymes.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is overturned. 

The patient is a male with history of renal cell carcinoma with metastases to lungs, liver, muscle status/post (s/p) lenvatininib/pembrolizumab complicated by hepatitis with improvement in liver function tests s/p cytoreductive left radical nephrectomy, who initially presented with worsening liver function tests. The patient was diagnosed with grade 3 immune checkpoint blockade inducted hepatitis. The hospital course included investigation into possible cholecystitis versus choledocholithiasis versus biliary obstruction. There was no obvious obstruction on computed tomography (CT) imaging or magnetic resonance cholangiopancreatography (MRCP). General surgery was consulted and did not recommend surgical intervention. A liver biopsy was performed, which confirmed the diagnosis of immunotherapy induced hepatitis. Cellcept was initiated in conjunction with high dose systemic corticosteroids. A taper was initiated; however, corticosteroids were increased again, due to worsening liver function tests.

The inpatient hospital admission on the days in question was medically necessary. In this particular situation, the patient presented with immunotherapy mediated hepatitis. This was confirmed during the hospital stay by liver biopsy. The hospital course was complicated by significantly elevated liver function tests. Intravenous methylprednisolone was initiated and transitioned to oral prednisone. Following the transition, liver function tests were noted to worsen. This resulted in return to intravenous methylprednisolone with subsequent increase in the dosage until liver enzymes stabilized and improved. Electrolyte abnormalities (hyponatremia of 126) and total bilirubin 3 times the upper limit of normal remained requiring ongoing intravenous systemic corticosteroids and intravenous fluids. Once the transition to oral prednisone was performed with assurance of liver function test stability, the patient was promptly discharged.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fetal Death

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.

The patient was referred for delivery after ultrasound documented fetal death. The patient was admitted for delivery.  The patient was given Cytotec. The fetus and placenta were delivered the following day.  The patient was discharged later that day.

It has always been the standard of care to admit patients for delivery. This patient was pregnant with a diagnosis of fetal death. Admission was medically necessary to deliver the fetus.

The admission is primarily to induce labor, observe for the progression of labor, monitor the patient for any complications (uterine rupture) and for delivery and postpartum management (retained placenta, bleeding).  

According to The American College of Obstetricians and Gynecologists (ACOG) coding guidelines, the following services are included in the delivery services: 

1)	Admission to the hospital 
2)	The admission history and physical examination 
3)	Management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps, with or without vacuum extraction), or cesarean delivery, external and internal fetal monitoring provided by the attending physician 
4)	Intravenous (IV) induction of labor via oxytocin (CPT codes 96365 - 96367) or misoprostol.
5)	Delivery of the placenta; any method 
6)	Repair of first or second degree lacerations

Milliman Care Guidelines (MCG) also states clearly that admission is medically necessary for delivery.

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder

Treatment: Applied Behavioral Analysis

The insurer denied coverage for Applied Behavioral Analysis.  The denial is overturned. 

This pre-teen male reportedly had developmental delays in social interaction and communication and had a diagnosis of Autism Spectrum Disorder. He reportedly had an individual education plan (IEP) and received speech language, occupational therapy, and physical therapy. He reportedly had repetitive restrictive patterns of behavior and interest, inflexibility in routines, maladaptive behavior, difficulty with social interaction and communication. The patient reportedly was receiving applied behavioral analysis therapy (ABA) and it was reported that the frequency of ABA hours was 24 hours per week with 11-20 Parent in training hours per month. 

The insurer denied coverage for applied behavioral analysis therapy (ABA) as not medically necessary treatment. The insurer stated that the medical records did not support the need for applied behavioral analysis therapy (ABA).

The medical records provided did provide enough specific documentation to support that this patient required treatment of applied behavioral analysis therapy (ABA). Autism spectrum disorder is a neurodevelopmental disorder that is considered permanent and there are many associated deficits with this disorder so treatment is complex and (ABA) applied behavioral analysis is considered medically necessary treatment and standard treatment for Autism Spectrum Disorder. This patient had deficits developmentally and behaviorally that required the treatment of applied behavioral analysis therapy (ABA) treatment. As a result, the recommendation is to reverse the previous decision and approve coverage for ABA, applied behavioral analysis therapy, for this patient. 

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 Applied Behavioral Analysis is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient reportedly was admitted to this inpatient hospital treatment for alcohol detoxification treatment. It was reported that the patient had 2 witnessed alcohol withdrawal seizures by Emergency Medical Services (EMS) and had repetitive seizures after a binge drinking episode and reportedly drank 2 pints of vodka the day prior to admission. It was reported that the patient had past alcohol withdrawal seizures. The patient reportedly had other alcohol withdrawal symptoms including tremors, sweats, headache, anxiety, elevated heart rate of 98, and elevated blood pressure of 153/98. The patient reportedly had other significant medical problems including significant lactic acidosis, pancytopenia, transaminitis, and hypokalemia. The patient reportedly had a medical history also significant for peptic ulcer and gastrointestinal (GI) bleeding. The patient reportedly was given Ativan and Librium for detoxification treatment as well as intravenous (IV) fluids and was on the telemetry unit. The patient reportedly was discharged when stable enough for discharge.
  
The reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as the medical record provided enough specific evidence to support that the patient required this level of care then. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens are in need of inpatient hospital treatment for the management of withdrawal and reports that patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. 

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 an inpatient hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: anterior crossbite on tooth 10
Treatment: Insertion of Braces (Comprehensive Orthodontic Treatment of the Adolescent Dentition) and Adjustment of Braces (Periodic Orthodontic Treatment Visit) 
The insurer denied Insertion of Braces (Comprehensive Orthodontic Treatment of the Adolescent Dentition) and Adjustment of Braces (Periodic Orthodontic Treatment Visit) 
The health plan's determination is overturned. 

The patient in question is a teenage female with an anterior crossbite on tooth 10. She presents with a skeletal Class I malocclusion with minor crowding in the maxilla and mandible. 

Insertion of Braces (Comprehensive Orthodontic Treatment of the Adolescent Dentition) and Adjustment of Braces (Periodic Orthodontic Treatment Visit) is medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 10. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
Tooth 23 is already being pushed labially in the dental arch as seen in the mandibular occlusal radiograph. If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.