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

Diagnosis: Developmental Delay
Treatment: Genetic Testing
The insurer denied the genetic testing.
The health plan's determination is overturned.

The patient is a female with developmental regression, gastrointestinal (GI) dysmotility, ptosis, fatigue and leukodystrophy. Previous comprehensive genetic testing including mitochondrial gene panel on blood sample, leukodystrophy gene panel and whole exome sequencing was unrevealing. Current medical management is symptomatic due to lack of confirmed diagnosis.

The proposed health service or treatment of genetic diagnostic testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Based on her clinical features, there is high suspicion for mitochondrial disorders. Gold standard testing for these disorders is biochemical (enzyme and electrophoresis) and molecular testing of mitochondrial deoxyribonucleic acid (DNA) on muscle biopsy sample. There are established guidelines for screening, treatment and follow up for mitochondrial disorders as well as specific medications to avoid. These treatment guidelines cannot be given unless there is confirmation of diagnosis. Different testing on muscle biopsy will determine specific treatment to offer.
Muscle is primarily used for ruling out Mitochondrial DNA (mtDNA) deletions/depletion, based on clinical suspicion if it was not detected in blood. The role of muscle biopsy used to be central, in fact the "gold standard," in the diagnosis of mitochondrial diseases testing is essential to guide future management and treatment (Witters et al.).
Muscle (and/or liver) biopsies should be performed in the routine analysis for mitochondrial disease when the diagnosis cannot be confirmed with DNA testing. Parikh et al.
Pretreatment with saponin increases the recovery of complex I, complex I plus (+) III, and complex II + III activity from isolated mitochondria. The treatment leads to improved sensitivity and reduced variability in the measurements of these enzymes. Wibom et al.
Electrophoresis helps determine oxidative phosphorylation function to determine the appropriate therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Genetic Diseases
Genetic Testing

Diagnosis: Developmental Delay
Treatment: Genetic Testing
The insurer denied the genetic testing.
The health plan's determination is overturned.

The patient is a female with developmental delay, vomiting and trouble feeding. Genetic testing Whole Exome Sequencing (WES) was offered but it was denied by her health plan.

The proposed health service or treatment of genetic diagnostic testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Whole Exome Sequencing (WES) would not be experimental or investigational. WES would be evidence-based, cost effective and medically necessary for this patient. Etiology of the patient's developmental delay and feeding difficulty with vomiting as well as genetic diagnosis have not been established. Based on her clinical phenotype, there's a high likelihood of genetic etiology. Finding a type of genetic disease that could contribute to her developmental delay and seizures would be crucial for the patient's management, prognosis and recurrence risks. For instance, finding a mutation in one of the genes predisposing developmental delay may qualify the patient for more effective therapies for that genetic condition. Several areas of possible health concerns may not be addressed if the patient's doctors don't know where to look (in case there's multisystemic involvement) and therefore potentially life-threatening complications may not be prevented.
WES can be used to identify the underlying molecular basis of a genetic disorder in an affected individual (1). WES can test the largest number of genes than any other genetic test because it uses next-generation sequencing (NGS) technology that allows all genes to be sequenced simultaneously and therefore saves time and cost (2). WES tests entire coding deoxyribonucleic acid (DNA) with approximately 20,000 genes and parental samples are tested to help with interpretation of the results. Multiple studies have demonstrated over the past decade (since WES was first developed in 2009) its vast power to identify disease-associated genetic variants across a diverse spectrum of human diseases which directly affects treatment (3,4). WES has been very effective as a clinical tool. Since the patient's presentation is not specific for any disorder, WES would be the most cost-effective method with the highest yield and it would allow to bypass multiple tests that would have lower yields. WES would indeed be the best option.

The health plan's determination is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

Diagnosis: Low back pain.
Treatment:  Thermal destruction of intraosseous basivertebral nerve first 2 vertebral bodies (code 64628).

The insurer denied coverage for thermal destruction of intraosseous basivertebral nerve first 2 vertebral bodies (code 64628).  The denial is upheld.

This patient has chronic low back pain. He has tried Heat, Ice, and a home exercise program. His pain medications include Tylenol, Lidoderm patches, Hydrocodone, and Cyclobenzaprine. His magnetic resonance imaging (MRI) shows Modic changes at lumbar (L)2-L3. It also shows multi-level facet arthropathy with multi-level foraminal stenosis. No surgical consultation is documented.  The request is for radiofrequency (RF) Ablation of the Basivertebral nerves (BVN).	

The publications to date have been company sponsored and had methodology flaws.  There are no published data on long term complication rates.   There are other evidence- based interventions available to this patient.  This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al. (3) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (4) while favorable pointed out the limitations of the current literature:  1) Industry funding is a potential source of study bias for the available data reviewed; 2) Limited number of studies; 3) Short-term follow up for the majority of studied patients; and 4) Unknown effect on the primary degenerative process.

Urits et al. (5) also commented on the need for more research on this promising technique:  "reproducible large RCTs are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of CLBP and improve the quality of life of CLBP patients in the near future."

This procedure is NOT likely to be more beneficial than the standard of care.

In summary, the denial of thermal destruction of intraosseous basivertebral nerve first 2 vertebral bodies (code 64628) 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: COPD (chronic obstructive pulmonary disease), 
CHF (congestive heart failure), DM (diabetes mellitus), and HTN (hypertension).
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male with history of COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), DM (diabetes mellitus), and HTN (hypertension). He presented to 
the ER (emergency room) with leg swelling. The patient was admitted to the hospital for CHF (congestive heart failure) exacerbation. The patient received IV (intravenous) Lasix in the ER (emergency room). The patient was admitted to the 
hospital for further management. For the entirety of the hospital stay, the patient was treated for CHF (congestive heart failure) exacerbation. The patient had echo as well as DVT (deep venous thrombosis) studies performed. The patient was treated with oxygen, diuretics as well as nebulization treatments. The patient had acute on chronic hypoxic and hypercapnic respiratory failure and was on BIPAP (bi-level positive airway pressure) and high FiO2 (fractional inspired oxygen concentration).
The inpatient admission was denied coverage by the health plan as not medically necessary. This denial is being appealed.

The Inpatient Hospital Admission is medically necessary.

The patient was admitted with acute on chronic hypoxic and hypercapnic respiratory failure due to CHF (congestive heart failure) exacerbation and right heart failure. The patient was aggressively treated with IV (intravenous) diuretics, high FiO2 (fractional inspired oxygen concentration) and NIV (non-invasive ventilation). The patient had worsening symptoms of chronic heart failure, which led to respiratory failure and had slow response to hospital treatment. The acute hospitalization was medically necessary, as the patient could not have been safely and effectively treated at any other level of care than inpatient level of care. The requested hospitalization was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bloody Stool. 
Treatment: Inpatient admission. 

The insurer denied: Inpatient admission. 
The denial is upheld. 

The patient is a toddler female. She had bloody stools and was hospitalized. A brief summary of the hospital stay is as follows: 
Per the ED (emergency department) note and admission H&P (history and physical), the patient was referred to the ED (emergency department) for bloody stools since the day prior. She had had stools; Labs were normal. It was noted her issues were likely due to chronic constipation with anal fissure. Concern for Meckel's diverticulum was noted. The plan was to admit and perform Meckel's scan the following day.
Per the day #2 progress note, there were no acute events overnight; the patient had a normal Meckel's scan. She was discharged home. 

The inpatient admission was not medically necessary. 

As documented in clinical notes and appeal letter, this patient had bloody stools that were most likely caused by chronic constipation and anal fissure. Labs were normal. There was a concern for Meckel's diverticulum, and the patient was admitted for Meckel's scan the next morning. During hospital stay, the patient was clinically stable with no acute events. Meckel's scan in a clinically stable patient is usually performed as an outpatient procedure (1-2). For this patient with likely constipation and anal fissure, Meckel's scan could have been performed safely at outpatient setting. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke 
Treatment: Inpatient hospital admission 
The insurer denied coverage for the inpatient hospital admission. 
The denial is overturned. 

This is an adult male who presented to the hospital complaining of difficulty speaking, nausea and right eye pain. Past medical history was significant for diabetes mellitus and hypertension. Upon arrival to the hospital, he was hypertensive, Blood Pressure (BP) 188/82 mmHg (millimeters of mercury). Pulse was regular and 62 beats per minute. No abnormal findings were noted on physical examination. 12 lead electrocardiogram revealed normal sinus rhythm with no evidence of ischemic ST or T (cardiac rhythm) wave abnormalities. Serum blood testing demonstrated acute kidney injury (AKI) with Creatinine 1.7 and hyperglycemia, glucose 399 mg/dl (milligrams per deciliter). Magnetic Resonance Imaging (MRI) of the brain demonstrated a subacute cerebellar infarct and an old right basal ganglia lacunar infarct. The patient was admitted to the hospital for observation and treatment. Echocardiogram demonstrated normal wall motion and no evidence of patent foramen ovale or atrial septal defect. Holter monitor showed normal sinus rhythm without atrial arrhythmia. Antihypertensive medications and hypoglycemic agents were titrated to ensure better BP and glucose control, respectively. The patient was ultimately discharged home. 

This patient presented with neurologic symptoms consistent with transient ischemic attack or stroke. Moreover, he was hypertensive, hyperglycemic, and had signs of AKI on serum blood testing. Hypertensive emergency is defined as BP > 180/120 with target organ damage. (1) In this patient target organ damage was demonstrated on brain MRI demonstrating a subacute cerebellar stroke. AKI was also noted. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (2) Average length of stay in patients presenting with stroke was five days on a large national study that included more than four million subjects. (3) Given findings of a recent stroke on MRI, admission to the hospital for aggressive BP management and diagnostic evaluation was medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for inpatient level of care is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post dental implant
Treatment: 
The health plan denied the Endosteal Implant. 
 The denial has been upheld.

The proposed treatment was not medically necessary.
Of note, the consultation and rationale were not available for decision to proceed with dental implant replacement.
The patient is a male with unknown past medical history and prior replacement of multiple teeth with dental implants per the available radiographs. The request is for Endosteal Implant (D6010). Record of the procedure performed includes simple placement of a dental implant in site # (number) 6. The health plan denied coverage of the requested, citing that conventional options for dental replacement were still viable outside of a dental implant. The denial is being appealed.

Dental implants do not represent a medical necessity under this circumstance. There were valid conventional alternatives that could have been employed to solve the problem of a missing tooth in the affected area.  Conventional methods are first line and should be exhausted prior to use of an implant. The plan outlines alternative options for tooth replacement using conventional methods, which is reasonable and of sound judgement.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain.
Treatment: 64628 - Intraosseous Basivertebral Nerve Ablation
The health plan denied 64628 - Intraosseous Basivertebral Nerve Ablation. The health plan's denial is upheld.

The patient is an adult female. Per the appeals letter, the patient has a history of chronic low back pain due to degenerative disc disease. She has developed Modic changes on MRI (magnetic resonance imaging). The patient had pain and failed treatment for greater than six months. Prior treatments include heat, ice, home exercises, laminectomy, lumbar discectomy, medication, physical therapy, radiofrequency ablations and SI (sacroiliac) joint injections. The patient's pain is aggravated with bending, lifting and standing.

Per a note, the patient presented with low back pain ongoing for many years. The patient also has tailbone pain, thoracic pain and right buttocks pain. The patient underwent a radiofrequency ablation on November 2022. Intracept procedure was discussed in the past. The patient had prior lumbar laminectomy and discectomy. Diagnosis includes right sided sacroiliitis, lumbar spondylosis, lumbar spondylolisthesis, post laminectomy syndrome and Modic type I endplate changes at L3-L4.

Although the patient has a history of chronic low back pain and had tried prior treatment, there was lack of documented Modic type changes noted on the provided MRI (magnetic resonance imaging). Without evidence of Modic changes, the request is not recommended at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain.
Treatment: 64628 - Intraosseous Basivertebral Nerve Ablation
The health plan denied 64628 - Intraosseous Basivertebral Nerve Ablation. The health plan's denial is overturned.

The patient is an adult female with chronic low back pain in whom an Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational.

The patient has failed conservative treatment in the form of physical therapy, radiofrequency ablation, sacroiliac joint injections, physical therapy, and home exercises. The patient has failed multiple medications. The patient had two prior spine surgeries. Magnetic resonance image shows degenerative endplate changes, which can be taken to mean Modic changes. The patient's physical exam does not reveal any neurological injury.

The patient has attempted all conventional conservative treatments. The patient has failed conservative treatment in the form of physical therapy, radiofrequency ablation, sacroiliac joint injections, physical therapy, and home exercises. The patient has failed multiple medications. The patient had two prior spine surgeries. Magnetic resonance image shows degenerative endplate changes, which can be taken to mean Modic changes. The patient's physical exam does not reveal any neurological injury.

The Intracept procedure (interosseous basovertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA)-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. The procedure is a Food and Drug Administration (FDA)-approved procedure for axial low back pain. It has been shown effective in randomized clinical trials (RCT) with five year results.

Given that this patient has failed or attempted all conventional and typical options for common causes of axial low back pain, the requested procedure is medically appropriate.  Alternatives include spinal fusion, which has not shown to have satisfactory results for axial low back pain without instability.  Given that the alternatives do not show favorable outcomes in the literature, the requested Intracept procedure is medically appropriate in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain.
Treatment: 64628 - Intraosseous Basivertebral Nerve Ablation
The health plan denied 64628 - Intraosseous Basivertebral Nerve Ablation. The health plan's denial is overturned.

The patient is an adult female with history of chronic low back pain of more than 30 years. The pain has affected her ADLs (activities of daily living) and functionality. The treating physician concluded that the patient's pain is vertebrogenic, and that the patient will benefit from Intracept intraosseous nerve ablation for the ablation of basivertebral nerves at L3 and L4.

The patient's MRI (magnetic resonance imaging) lumbar spine showed Modic types 1 signal changes at L3/L4.

The patient has failed conservative measures, including lumbar laminectomy, lumbar discectomy, Physical therapy, home exercise program, spinal injections, multiple medications including Aspirin, neurontin, percocet, lidoderm patch, etc.

The request is medically appropriate based on general standard of care for vertebrogenic pain. It also meets the recommended requirements by Relievant, the Intracept Medical device manufacturer, as per the FDA (United States Food and Drug Administration)-approved requirements and indication for which the device is approved (3). 

The patient in this case presents with a history of chronic low back pain of more than 12 months. She has tried and failed conservative measures including lumbar laminectomy, lumbar discectomy, Physical therapy, home exercise program, spinal injections, multiple medications including Aspirin, neurontin, percocet, lidoderm patch, etc, all treatments exceeding 12 months. The pain has affected her functionality. The magnetic resonance imaging (MRI) of the lumbar spine showed Modic type 1 changes at lumbar three/four (L3/L4) vertebral body.

Therefore, based on the submitted information, current peer-reviewed literature and the current standards of care, the requested Intracept Procedure would be considered medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult male patient with a history of heroin use and withdrawal presented complaining of withdrawal symptoms that include headache, nausea, vomiting, diarrhea, and abdominal pain. The patient was requesting detox. His vital signs were stable. His heart rate was 56 and respiratory rate was 16. The patient's exam was unremarkable. Pertinent labs include a white blood cell count of 21.41. The patient's electrocardiogram showed no ST changes. His chest x-ray; kidney, ureter, and bladder (KUB); and abdominal/pelvic computed tomography (CT) revealed no acute disease. The patient was admitted. Opioid withdrawal was resolved. The patient was to consider methadone taper. On day #2, the patient's vital signs were stable. Nausea and vomiting had resolved. The patient was to start Suboxone. On day #4, nausea was improving. Maximal temperature was 100.9. Clinical opiate withdrawal scale (COWS) score was eight. The diet was advanced to regular. The patient was continued on a methadone taper. The patient continued the methadone taper. On day #5, the patient complained of nausea and diarrhea. Clinical opiate withdrawal scale score was three. The patient was to continue methadone. There were no rehab beds available. The patient was discharged to rehab on day #7.

The proposed treatment was not medically necessary.

This patient was admitted for opiate withdrawal. His history was not remarkable for elevated risk due to historical or comorbid factors. The patient was hemodynamically stable with asymptomatic bradycardia. He did not have arrhythmia. He had nausea, vomiting, and diarrhea. The patient's labs were unremarkable. He did not have electrolyte abnormalities or dehydration. The patient was admitted with a plan for medication assisted treatment and clinical opiate withdrawal scale (COWS) protocol. Treatment included methadone/Suboxone. The patient was awaiting transfer to rehab. He remained hemodynamically stable during the hospital stay and did not have symptoms of severe withdrawal. He did not have symptoms that required an acute inpatient level of care. He had not failed management in a lesser level of care. The requested inpatient hospital admission was not medically necessary.