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

Diagnosis: back pain
Treatment: Intracept procedure
the insurer denied the Intracept procedure. The health plan's determination is upheld. 

This patient is a female who has intermittent focal right side low back pain for more than 10 years. Her pain is dull and achy. Pain level is 6/10. She has had epidural injections and non-steroidal anti-inflammatory drugs (NSAIDs), which have improved her symptoms. Her physical exam (PE) was unremarkable except pain with more flexion than extension. Magnetic resonance imaging (MRI) revealed disc bulges at L (lumbar)3/4 L4/5 and a high intensity zone in posterior L5/S (sacral)1 annulus. The provider recommended bilateral L4/5 transforaminal epidural steroid injections and BVN (basivertebral) ablation at L4-L5 level (possible L5/S1 level as well).

Intracept Procedure 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 Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient responded to the prior epidural injection. Her MRI (Magnetic resonance imaging) revealed disc bulges at L3 (lumbar)/4 L4/5 and a high intensity zone in posterior L5/S1 (sacral) annulus. Truumees's study supported the efficacy of Intracept procedure for vertebrogenic back pain. However, the primary inclusion criteria is Type 1 or Type 2 Modic changes on an MRI (Magnetic resonance imaging) at one or more vertebral bodies from L3 through S1. In addition, the patients with radicular pain and radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were in the exclusion criteria. (1)
Given this patient's clinical presentation, MRI findings and current clinical evidence on the Intracept procedure, it is unlikely that it is more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intracept procedure
the insurer denied the Intracept procedure. The health plan's determination is upheld. 

This is a patient diagnosed with Vertebrogenic Low Back Pain; Disc Degeneration, Lumbar; Lumbar Disc Herniation. According to the records, the patient was recommended to undergo the Intracept procedure. This is the subject of this review.
It was noted the patient has a history of low back pain that began more than 10 years ago and has had multiple treatments including chiropractic care, injections, medication management and physical therapy. Medications have included non-steroidal anti-inflammatory drugs (NSAIDs). Pain is impacting her ability to bend, lift and stand. Nothing has provided significant relief. Pain is rated at 6/10. The provider states the patient had an magnetic resonance imaging (MRI) demonstrating Modic changes at disc spaces L (lumbar)4 - L5 and the provider believes this is the source of the patient's chronic back pain.

Intraosseous Basivertebral Nerve Ablation Procedure 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 a history of chronic back pain. The provider states that the patient has failed conservative treatment, though it was noted on a recent for progress note that the patient had recently undergone a lumbar epidural injection resulting in 80% (percent) relief of symptoms, improved functionality and decreased medication use and it was felt the patient would be a candidate for repeat injection. The provider stated that the patient's magnetic resonance imaging (MRI) showed Modic changes, and the provider felt that this was the source of the patient's back pain. However, the MRI did not mention Modic changes, but rather does show multilevel annular fissures that are a likely source of pain.

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: Intracept procedure
the insurer denied the Intracept procedure. The health plan's determination is upheld. 

The patient is a female with chronic LBP (low back pain) since starting after a herniation of the nucleus pulposus causing an impact on her activities of daily living (ADL), including sitting, lifting, and bending. The patient rates her pain on Visual Analog Scale (VAS) on average 6/10. The pain characteristics are not well defined but in one note said it was focal on the right side. There were no radicular/myelopathic symptoms or muscle weakness. The LBP (low back pain) is exacerbated by flexion and extension. She has received epidural steroid injections with significant improvement > 80% (percent) relief with not only improvement in pain but also her activity and a decrease in nonsteroidal anti-inflammatory drug (NSAID) medications. She has used NSAIDs, chiropractic treatment, and physical therapy (PT).

Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
In this case, the patient has limitations due to her chronic lower back pain (LBP). The requesting physician notes that the pts pain is significant and limits ADLs but there is no ODI (Oswestry Disability Index) score. Additionally, the magnetic resonance imaging (MRI) report does not detail the types of Modic changes. The radiologist did not include the diagnosis of end plate Modic 1 and 2 changes. Therefore, the patient does not meet the criteria demonstrated in studies that predict she will benefit from the procedure. Due to the lack of substantiating evidence, it is not likely to be more beneficial for this patient than standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The insurer denied the Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a patient with a past medical history (PMH) of lumbar degenerative disc disease (DDD) status/post (s/p) lumbar laminectomy times (x) 3 and chronic lower back pain times (x) 20 years. The pain is reported to be along the lower back with radiation to the right (R) hip, thigh and calf. He has associated numbness in his leg and feet. The pain is worsened with lifting and walking. His physical examination was notable for tenderness along the lumbar paraspinals and pain with facet loading. Prior treatments have included lumbar epidural steroid injections (LESI) (with some relief), physical therapy (PT), medications (gabapentin, nonsteroidal anti-inflammatory drugs (NSAIDs)). It is reported that the pain impacts his activities of daily living (ADLs). The pain ranges from 7-10 on the Visual Analog Scale (VAS). He had a magnetic resonance imaging (MRI) scan which demonstrated moderate degenerative changes of the lumbar spine including multilevel facet arthropathy and canal stenosis and lumbar degenerative disc disease (DDD).  At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

At this time, the proposed health service is not likely to be more beneficial than any standard treatment. Evaluation suggests the possibility of facet mediated pain and medial branch blocks were ordered. There was evidence of facet arthropathy on MRI with concordant physical examination findings. This reviewer could not find evidence of Modic changes per MRI report. Additionally, there is support for facet mediated pain and a separate procedure was ordered (MBB) at the time of the visit.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The insurer denied the Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a male patient with low back pain which began over 20 years ago. Prior treatment has included heat/ice, spine surgery, epidural injections, and medications, as well as therapy. The pain impacts the patient's activities of daily living (ADLs). The pain ranges from 7-10/10. Magnetic resonance imaging (MRI) of the lumbar spine showed Modic changes at lumbar (L) 4-5 and L5-sacral (S) 1. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment 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. There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A 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.
Given the above, the proposed health service or treatment 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous basivertebral nerve ablation
The insurer denied the Intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a patient with diagnoses of low back pain, spondylosis without myelopathy or radiculopathy, lumbar region. The patient was recommended to undergo the Intracept procedure.
Per a progress note, the patient was seen regarding a 20 year history of chronic low back pain that radiates to the right hip and thigh down to the calf with associated leg numbness and pain. The pain is rated at 7-10/10. Patient has treated with heat, ice and physical therapy as well as epidural injections. On exam, the range of motion was limited with pain and there was tenderness to palpation of the bilateral paraspinous musculature. There was positive facet loading bilaterally and positive facet loading with extension. The patient was recommended for lumbar medial branch blocks and was also recommended to undergo the Intracept procedure at L4, L5 and S1. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No, the proposed health service or treatment intraosseous basivertebral nerve (BVN) ablation procedure 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 a history of chronic back pain present for 20 years that has not responded to conventional conservative treatment. The provider stated that the patient had Modic changes at disc spaces L4, L5, and S1 and believes that this is the source of the patient's chronic back pain. However, it should be noted that there were multiple findings on magnetic resonance imaging (MRI) including nerve root impingement and facet arthropathy, but no mention of Modic changes or degenerative endplate changes. There is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female patient who presented to the emergency department (ED) with abdominal pain and abnormal lab data (elevated alkaline phosphatase). Comorbid health conditions included morbid obesity, prior myocardial infarction and pulmonary embolism.  She was mildly tender in the right upper quadrant. The white blood cell count (WBC) was normal at 9.02 thousand (K). The complete metabolic panel identified elevated liver enzymes (alanine aminotransferase (ALT) of 311 and aspartate aminotransferase (AST) of 104) and normal bilirubin. An ultrasound showed a gallbladder with gallstones and the bile duct was mildly dilated.
She was admitted to the hospital and initially treated with intravenous (IV) fluid and antiemetics. A follow up AST and ALT trended down.  She was treated with a laparoscopic cholecystectomy. The operative dictation records completion of the procedure without complications, with findings of chronic cholecystitis.
The patient was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, antibiotics, and antiemetics. The immediate post-surgical recovery was uncomplicated. The patient remained clinically stable and was discharged from the inpatient setting.
At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically necessary in this case. The patient presented to the ED with a report of elevated liver enzymes. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. While the serum transaminases were elevated, the WBC was normal at the time of presentation and follow up liver enzymes trended toward normalization. The patient was admitted from the ED. The treatment plan included surgery. The progress notes state that the patient was stable for discharge from the hospital on the first post-surgical day. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Full Hospital Admission
The insurer denies the full hospital admission.
The health plan's determination is upheld.

The patient is a female with a past medical history (PMH) of osteoarthritis (OA), diabetes mellitus type 2 (DM2), gastroesophageal reflux disease (GERD), hyperlipidemia (HLPD), hypertension (HTN), and osteoporosis status/post (s/p) spinal fusion surgery. She was admitted with complaints of (c/o) chest, hip, and back pain without urinary incontinence. Her vital signs were notable for pulse 109, and her temperature was 100.2. The physical examination was notable for normal sensation, strength, and reflexes in bilateral lower extremities. The laboratory work was notable for elevated inflammatory markers.
The computed tomography (CT) of the chest showed no pulmonary embolism (PE) the magnetic resonance imaging (MRI) of the lumbar vertebrae (L)-spine and hips showed no acute pathology. The patient was diagnosed with chest, hip, and back pain and treated with pain control, intravenous fluids (IVF), anti-emetics, and physical therapy (PT) and occupational therapy (OT). Pain medicine was consulted, and recommended nonsteroidal anti-inflammatory drugs (NSAID's), Robaxin, and Oxycodone. The patient was discharged in stable condition. 

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o back pain without evidence of severely compromised neurological function. The patient received a thorough diagnostic and imaging work-up, which did not demonstrate any acute fractures or dislocations. The patient did not have an abdominal aortic aneurysm, aortic dissection, cauda equina syndrome, epidural abscess or hematoma, acute spinal fracture, meningitis, osteomyelitis, progressive neurologic deficits, fever, discitis, or tumor. The patient received intravenous (IV) pain control, pain medicine consultation, radiologic work-up, and PT, all of which could have been safely provided at an alternate level of care.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial arrhythmia. 
Treatment: Full hospital admission. 
The insurer denied coverage for full hospital admission. 
The denial is overturned. 

This is the case of an adult male that presented to the hospital complaining of lightheadedness and palpitations. Past medical history was significant for hypertension and gastroesophageal reflux disease.  Upon arrival, the patient was tachycardic with a pulse of 133 beats per minute. Blood pressure was stable [118/97 millimeters of mercury (mmHg)]. Physical exam revealed no positive findings other than an irregularly irregular heart rhythm. Serum blood testing revealed an elevated B type natriuretic peptide [214 picograms per milliliter (pg/ml)]. 12 lead electrocardiogram revealed atrial fibrillation with rapid ventricular rates. The patient was treated with intravenous diltiazem and oral anticoagulant therapy. He was admitted to the hospital and underwent successful direct current cardioversion (DCCV).  After sinus rhythm was restored, he was discharged home. 

Patients presenting with atrial arrhythmia with rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (Reference 1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. American Heart Association/American College of Cardiology Guidelines for the management of patients with atrial fibrillation recommend telemetry monitoring for patients treated with atrial fibrillation requiring treatment with rate control and antiarrhythmic therapies. The current standard of care is consistent with hospital admission when patients present with new onset symptomatic rapidly conducted atrial fibrillation. In conclusion, inpatient admission was medically necessary in this case. 

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

Diagnosis: Dentofacial deformity
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The medical records indicate the patient underwent orthognathic surgery to treat a dentofacial deformity. This included a LeFort 1 and bilateral sagittal split ramus osteotomy (BSSRO) to correct the skeletal deformities. The patient was administered intravenous (IV) medications for nausea, pain and infection prevention. The patient was documented to have swelling of the face after the procedure.  The patient was admitted and discharged following surgery.

The medical records, provided for review, are not supportive for an inpatient hospital stay. The patient reportedly tolerated the surgery and anesthesia well and there was no evidence of need for an elevated level of care that would require a formal inpatient stay. 

As such, the inpatient level of care was not medically necessary in this case.

"The advantage of performing selected orthognathic surgery in an outpatient setting is early patient mobilization and ability to recover in a familiar home environment surrounded by family. This reduces the psychological stress that a hospital environment can cause. There is also a decreased risk of being exposed to hospital-borne infections and a lower risk of cancelled operations. Hospital resources are freed up for other patient groups in need of inpatient care" (1).

"Poor facial cosmesis resultant from dysgnathias usually accounts for a range of these individuals' psychological and social problems. Disturbances of both esthetics and function are caused by jaw deformity and associated structures' deformity such as malocclusion. The correction of these deformities is one of the most challenging and intriguing aspects of maxillofacial surgery. Despite having become routine only relatively recently, rigid internal fixation has advanced rapidly, its results are consistent and predictable and thus, its knowledge applies in orthognathic surgery besides other areas of maxillofacial surgery. The bilateral sagittal split osteotomy (BSSO) is a common orthognathic procedure performed on the mandible. First described by Trauner and Obwegeser in 1957, modified by Dal Pont and refined by Epker, several modifications of the BSSO have been introduced aiming to enhance surgical convenience, minimize morbidity, and maximize stability. The aim of this article is to review the literature of this technique from the historical perspective and to present a standard operation technique" (2).                                                         

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 the inpatient admission is not substantiated.