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

Diagnosis: Appendicitis
Treatment: Inpatient admission
The health plan denied: Inpatient admission
The determination is: Upheld

The patient is a female who presented to the emergency department with abdominal pain. She was found to be tender in the right lower quadrant. She had an elevated white blood cell (WBC) count to 14.9. She underwent a computed tomography (CT) scan which showed acute appendicitis, with possible small perforation at the tip. She also had nonspecific gall bladder wall edema. The patient was admitted and received intravenous (IV) antibiotics and fluids. She was evaluated by surgery. The patient underwent a laparoscopic appendectomy. She recovered well and was discharged with follow up with the surgical team.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient admission was not medically necessary for this patient. Based on all information submitted, the patient did not warrant inpatient admission, and an alternate level of care would have been appropriate. A study from 2016 found that an overwhelming majority of patients diagnosed with acute appendicitis are treated operatively, necessitating admission to the hospital for at least a short time. Timing of appendectomy has also been studied extensively, with no increase in complications if a delay of 12-24 hours if the patient was admitted to the hospital during that time. This patient was not on any blood thinners, which can lead to an increase in bleeding risk. The literature has time and again shown that acute appendicitis without perforation is not an emergency, even though surgical dictum once called it as such. There is a small minority of appendicitis patients that present with severe systemic illness, and from the documented vital signs as well as laboratory studies and exam findings, she did not have severe disease. Before, during, and after the case, the patient remained hemodynamically stable per documentation. There was no care provided that was above and beyond the standard, and therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.

Treatment: Braces and monthly visits.

The insurer denied coverage for braces and monthly visits.

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite and posterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 32 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining only 16 points on the HLD index by internal reviewers. The orthodontist is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, the use of an orthodontic Index, the HLD Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist completes the second portion of the index arriving at 32 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Braces and monthly visits are considered medically necessary for this patient.

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 braces and monthly visits is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: Braces and monthly visits.
The insurer denied coverage for braces and monthly visits.
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite and posterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 32 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining only 26 points on the HLD index by internal reviewers. The orthodontist is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, the use of an orthodontic Index, the HLD Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist completes the second portion of the index arriving at 32 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Braces and monthly visits are considered medically necessary for this patient.

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 braces and monthly visits is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness/dizziness
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient is a female with a past medical history significant for hypertension, diabetes, and gastroesophageal reflux disease (GERD) who presented to the emergency department for evaluation of generalized weakness, dizziness, and paresthesias in her upper extremities. Her symptoms had been intermittent for approximately 2 weeks. She was seen by her primary care physician and was started on gabapentin, which did not help. The patient also complained of dizziness, which she described as a sensation of the room spinning around. It was associated with nausea. 

The inpatient hospital admission was not medically necessary for this patient. Based on the information provided, an admission at a lower level of care was the most appropriate. The patient did not exhibit any signs of hemodynamic instability, persistent or recurrent focal neurologic signs, altered mental status, or clinically significant cardiac disorders. Furthermore, there was no evidence of severe electrolyte imbalances or persistent dehydration. While the patient had elevated blood pressure that was difficult to control with multiple medications, there was no evidence of a true hypertensive emergency or the need for continuous administration of antihypertensive medications intravenously, necessitating continuous invasive blood pressure monitoring. In the absence of any emergent medical conditions or complex medical needs, the patient could have been admitted for observation to rule out acute stroke and perform the necessary workup, which was indicated considering the clinical circumstances.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Low Back Pain.
Treatment: Surgical Services/Intraosseous basivertebral nerve ablation.
The health plan denied the requested Intraosseous basivertebral nerve ablation as experimental/investigational. 
The health plan's determination is upheld.

The patient is a male with complaints of low back pain and leg pain. His pain is rated 8 out of 10 and it radiates into the legs. Physical exam demonstrated tender to palpation left and right lumbar paraspinal muscles. A magnetic resonance imaging (MRI) of the lumbar spine showed (lumbar-sacral) L5-S1 disc protrusion, and (lumbar) L4-5-disc protrusion. There is a plan for an Intraosseous basivertebral nerve ablation.
At issue is whether the proposed health service or treatment of an 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.

I uphold, in full, the health plan's determination regarding the proposed health service or treatment.

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 an 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 a lack of data to recommend this procedure as a 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: Orthopedic/Musculoskeletal/Low Back Pain.
Treatment: Surgical Services/Intraosseous basivertebral nerve ablation.
The health plan denied the requested Intraosseous basivertebral nerve ablation as experimental/investigational. 
The health plan's determination is upheld.

This patient is a male who has complaints of back and leg pain. Pain level is 8/10. His pain is sharp, throbbing and shooting with numbness, worse with working, walking and standing prolonged periods. He has radiating pain into anterior and posterior aspects of both legs. He had tried physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs) without improvement. On physical exam, there are trigger points in the lumbar paraspinal regions, positive facet loading tests, positive straight leg raise (SLR) on the right, and positive Faber and Patrick's test. A magnetic resonance imaging (MRI) showed (lumbar) L4-5 central and right disc bulge and foraminal disc protrusion, severe right L4/5 foraminal stenosis progressed comparing to the prior study.
At issue is whether the proposed health service or treatment of an 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.

I uphold, in whole, the health plan's determination regarding the proposed health service or treatment.

The Intracept system was designed to treat low back pain from the vertebral body by ablating basivertebral nerves. The available medical records did not reveal adequate evidence that vertebrogenic pain is the primary pain generation. This patient has shooting pain and numbness in the lower extremities. The physical exam documented positive facet loading and SLR tests. An MRI showed L4-5 central and right disc bulge and foraminal disc protrusion, severe right L4/5 foraminal stenosis progressed comparing to the prior study. Truumees's study supported the efficacy of the Intracept procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded. [1]
Given this patient's medical history, MRI reading, and the current clinical evidence, it is unlikely that the proposed Intracept procedure is more beneficial than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
The patient had a history of lymphadenopathy of unknown origin and fever of unknown origin and presented with abdominal pain and vomiting. Her symptoms had been present for over a month. She was afebrile but initially was hypertensive. There was no abdominal rebound or guarding. There was no leukocytosis. The renal function was normal. The lactic acid was normal. A computed tomography (CT) scan of the abdomen was negative for an acute process. Intravenous (IV) hydration, proton pump inhibitor (PPI) therapy, and Zofran were given. She underwent a colonoscopy which was normal. 

Clinical indications for admission for Undiagnosed Abdominal Pain per Milliman Care Guidelines (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an outpatient basis. The patient did not have these conditions. 

Clinical indications for admission for Vomiting (MCG M-370) include having a severe metabolic derangement, such as ketoacidosis, severe vomiting that does not respond to antiemetics severe electrolyte abnormalities, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient was having abdominal pain and vomiting. IV hydration, PPI therapy, and antiemetics, could have been given with observation care. The colonoscopy could have been done as an outpatient. She did not meet MCG guidelines for admission for either Undiagnosed Abdominal Pain or Vomiting. 

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 hospital admissions not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankle Fracture

Treatment: (E0261 x 10) semi-electric hospital bed rental with (E0305) side rails

The insurer denied coverage for (E0261 x 10) semi-electric hospital bed rental with (E0305) side rails

The denial is upheld 

This patient sustained a left ankle fracture and subsequently underwent surgical open reduction internal fixation (ORIF). The patient was placed in a cast and instructed to non-weight bear on the left lower extremity. The treating physician recommended physical therapy and (E0261 x 10) semi-electric hospital bed rental with (E0305) side rails.  

The clinical records do not support the medical necessity for the requested (E0261 x 10) semi-electric hospital bed rental with (E0305) side rails. As noted by the insurer, there is no documentation that the patient requires frequent change in position, head of the bed elevated more than 30 degrees, or a need for traction equipment that cannot be attached to a standard bed. In addition, the requested hospital bed is not needed for preventing contractures, avoiding respiratory infections or decreasing the risk of pressure ulcers. The recommended physical therapy will instruct the patient regarding proper transfer technique when transferring on/off a standard bed while maintaining left lower extremity non-weight bearing precautions.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical probability, (E0261 x 10) semi-electric hospital bed rental with (E0305) side rails is 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 (E0261 x 10) semi-electric hospital bed rental with (E0305) side rails is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke
Treatment: Continued Stay in Sub-Acute Rehabilitation Facility
The insurer denied: Continued Stay in Sub-Acute Rehabilitation Facility
The denial is overturned

The patient is an adult male with history of cerebrovascular accident (CVA) secondary to right MCA (middle cerebral artery) thrombosis with left hemiparesis. He is status post emergency craniotomy and craniectomy to relieve intracranial pressure. He has had complications, including seizure, meningitis and infarction of right frontal lobe. The patient's relevant past medical history includes depressive disorder, hypertension, pneumonia, epilepsy, anemia, GERD (gastroesophageal reflux disease), etc. He developed COVID-19, which affected his progress in rehabilitation. Prior to admission, the patient was living in a private residence. Prior to that, he was living alone in a condo and was independent with all functional mobility and ADLs (activities of daily living), no assistive devices and required no cognitive assistance.
The patient was readmitted totally dependent for most ADLs (activities of daily living). As of the week prior to the dates under review, he was dependent for toileting, toilet transfer, required moderate assistance for upper body dressing, required maximum assistance with lower body dressing, bed-rolling, sit-to-lying, lying-to-sitting, decrease balance. By Day #9, the patient required supervision for bed-rolling, moderate assistance for sit-to-lying, lying-to-sitting, able to ambulate 25 feet x 3 using right handrail with moderate assistance x 2, toileting/toilet transfer dependent, upper body dressing moderate assistance and lower body dressing maximum assistance.

The requested Continued Stay in Sub-Acute Rehabilitation Facility is medically necessary.

The patient has decreased balance, persistent weakness, and limitations. He has continued to show progress in rehabilitation. Progress was also curtailed by his having developed pneumonia and COVID-19 infections. The patient was readmitted totally dependent for most ADLs (activities of daily living). As of the week prior to the dates under review, he was dependent for toileting, toilet transfer, required moderate assistance for upper body dressing, required maximum assistance with lower body dressing, bed-rolling, sit-to-lying, lying-to-sitting, decrease balance. By Day #9, he required supervision for bed-rolling, moderate assistance for sit-to-lying, lying-to-sitting, able to ambulate 25 feet x 3 using right handrail with moderate assistance x 2, toileting/toilet transfer dependent, upper body dressing moderate assistance and lower body dressing maximum assistance. While the patient continues to show progress, he is still requiring moderate-maximum supports for some ADLs (activities of daily living) while being a risk for falls.
Therefore, the requested health service is medically necessary, for up to 6 weeks, with further review being required at that point, depending on the patient's progress.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Menopausal vaginal dryness and atrophy
Treatment: Imvexxy Maintenance Pack
The insurer denied coverage for Imvexxy Maintenance Pack
The denial is upheld

The patient is an adult with a diagnosis of menopausal vaginal dryness and atrophy requesting coverage for Imvexxy.

The insurer has denied coverage for Imvexxy Maintenance Pack. In their Final Adverse Determination letter, they write that the documentation provided by the patient's healthcare provider did not indicate reasons that they could not use the alternative, preferred drug(s) estradiol tab, estradiol td (transdermal) gel, estradiol twice weekly patch, estradiol weekly patch, Premarin, or Vivelle-Dot. There is no documentation that the patient has a contraindication or significant drug interaction to the preferred drugs. 

Vaginal atrophy (also referred to as vulvovaginal atrophy, urogenital atrophy, or atrophic vaginitis) is the cause of dyspareunia. It results from estrogen loss and is often associated with vulvovaginal complaints (dryness, burning, dyspareunia) in menopausal women. The primary indication for treatment of vaginal atrophy is the relief of bothersome symptoms in a menopausal woman who is distressed by them. 

Estrogen is the most effective treatment for moderate to severe symptoms of vaginal atrophy. Use of estrogen therapy is appropriate for women with symptoms of vaginal atrophy in the setting of low estrogen levels, provided that there are no contraindications to this therapy (certain women with estrogen-dependent tumors). 

Adequate estrogen therapy leads to restoration of the normal vaginal acidic pH (potential of hydrogen) and microflora, thickening of the epithelium, increased vaginal secretions, and decreased vaginal dryness. The agents for vaginal estrogen therapy that are commercially available in the United States are conjugated estrogens (cream) and estradiol (cream, tablet, and ring). A systematic review of 19 randomized trials including over 4000 women that investigated local estrogen treatment found that creams, tablets, and rings were all similarly effective in relieving symptoms of vaginal atrophy. In other words, Imvexxy is no more beneficial than the formulary products.
There is no medical exception as supported by current medical literature for the requested medication, Imvexxy. The patient should be able to use the formulary products.

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug(s) is unlikely to cause the patient an adverse reaction.  

The formulary drug(s) has not been ineffective based on the patient's clinical history.  

The not formulary drug is not expected to be more effective that the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Imvexxy Maintenance Pack is upheld.