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

Diagnosis: Tear, medial meniscus

Treatment: Osteochondral allograft of the knee (code 27415)

The insurer denied coverage for osteochondral allograft of the knee (code 27415).

The denial is upheld.

This is the case of a female with a history of left knee pain. On examination, there was crepitus and popping. Possible tear of the medial meniscus was suspected. She was seen by an Orthopedist. Magnetic resonance imaging was done. She underwent physical therapy (PT). Surgery with open osteochondral allograft of the knee was recommended and it was done.

The facts were this patient was evaluated with the chief complaint of discomfort to left knee when active. She underwent placement of an articular cartilage allograft combined with her blood/platelets to the trochlea. 

The criteria have been reviewed as well as recent published literature.

The facts are there was no documentation of functional limitations. There was no previous procedure performed prior to operation. There was no documentation of at least 3 months of conservative management. There was no report of her body mass index (BMI).

Nevertheless, the criteria specifically report this type of procedure is not indicated for the patellofemoral area. The physician performed the operation on the trochlea which is part of the patellofemoral joint. The results for this type of surgery have not been shown to be effective for the location.  There were no extenuating circumstances to substantiate necessity. 

Based upon current literature and criteria, the procedures performed to the patient's
trochlea would not be considered medically necessary. 

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

Osteochondral allograft of the knee (code 27415) is not considered medically necessary for this patient.

The insurer's denial of coverage for osteochondral allograft of the knee (code 27415) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing loss
Treatment:  Cochlear Implant (right ear)
The insurer denied the  Cochlear Implant (right ear)
The denial is overturned

The patient is a male with right-sided hearing loss. His history is significant for multiple ear surgeries secondary to a cholesteatoma.

The patient's adiogram shows a severe to profound right-sided hearing loss with normal left-sided hearing. The patient cannot use an in-the-canal hearing aid due to his previous ear surgery.

There was no improvement with a CROS (contralateral routing of signals) hearing aid.

A right sided cochlear implant has been proposed.

Yes, the Cochlear Implant (right ear) is medically necessary.
The patient has single sided, severe-to-profound hearing loss. There are no options to restore normal hearing. Cochlear implant for single-sided deafness is FDA (United States Food and Drug Administration)-approved for adults.

There are well-designed studies in the peer-reviewed literature demonstrating efficacy of this procedure (see references). The request is considered standard of care in the United States. This is not considered an unproven procedure. This request is not for the convenience of the patient or provider.

There are no reasonable alternatives for the treatment of this patient's hearing loss. Due to the severity of his loss and his altered ear anatomy from multiple surgeries, there are no reasonable medical or surgical alternatives to help this patient hear.

A standard hearing aid will not provide any useful hearing due to the degree of loss, and a bone-anchored hearing aid will not provide sound localization or clarity in everyday hearing environments.

The request is FDA (United States Food and Drug Administration) approved and considered standard of care treatment.

Therefore, given the above, the requested cochlear implant is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: low back pain.
Treatment: epidural steroid injection (ESI).
The insurer denied an epidural steroid injection (ESI). 
The health plan's determination is overturned.

This is a male with a history of back and right leg pain. He has had physical therapy, injections and medications without relief. He is a current smoker. The neurologic exam shows no documented motor or sensory deficits. The lumbar magnetic resonance imaging (MRI) shows an L (lumbar) 5-S (sacral) 1 disc bulge with moderate bilateral recess stenosis. The patient had an L5-S1 epidural steroid injection (ESI) with 75% relief of symptoms, but continues with some leg pain. The provider has recommended a repeat L5-S1 ESI.

The repeat ESI is medically necessary. The patient had a good response to an initial L5-S1 ESI but continues to have a degree of leg pain. The literature supports the use of ESI for radicular pain, and also supports the use of multiple injections.
Cohen et al cite "ESIs are perhaps the most commonly used interventional treatment for lumbosacral radiculopathy and have been shown to reduce pain and improve function in well-selected patients, often for months. ESIs play an integral role as part of a multimodal treatment strategy to treat lumbar and cervical radicular pain and theoretically present fewer risks than surgical interventions". Manchikanti et al cite "American Society of Interventional Pain Physicians (ASIPP) Guidelines recommend a diagnostic phase of up to 2 procedures separated by at least 2 weeks. If these injections provide at least 50% relief for 8 weeks, then repeat injections can be provided at a minimum of 8-week intervals, with a maximum of 4 injections per year". Hong et al cite "we recommend several ESI trials in moderate disability patients prior to surgical treatment, which might broaden the treatment options for the disease".
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholangiocarcinoma. 
Treatment: Radiation Therapy. 

The insurer denied coverage for radiation therapy. 

The denial is overturned. 

The patient has a history of cholangiocarcinoma.  The patient had a right hepatectomy.  The computed tomography (CT) of the chest without contrast revealed re-demonstration of a stable lytic lesion with osseous erosion at the lumbar (L)1 vertebral body which correlates with the enhancing lesion seen on the prior magnetic resonance imaging (MRI).  The nuclear bone scan revealed findings attributed to metastatic disease involving the central/left aspect of the L1 vertebral body.  The request was made for radiation therapy. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

Radiation therapy is considered medically necessary for this patient. The patient has metastatic disease to the L1 vertebral body noted on MRI. Metastatic work up shows no other areas of disease. The patient intends to deliver stereotactic radiation to the L1 vertebral body. 

Palliative radiation therapy (RT) can be delivered in either 3D (three dimensional) or SBRT (Stereotactic Body Radiation Therapy) techniques. The American Society of Radiation Oncologist (ASTRO) Model Policy for SBRT indicates that SBRT is appropriate for patients with recurrent/metastatic disease that cannot be treated as effectively or safely by other methods due to requiring a high level of accuracy and precision to minimize the risk of injury to surrounding normal tissues. The patient has one area of disease. Standard treatment would expose unnecessary amounts of normal tissue to excess radiation. SBRT will limit dose to normal surrounding structures and provide a biologically more effective palliative/ablative dose. Thus, using SBRT will minimize normal tissue volumes radiated, which will also protect her from unnecessary overall treatment side effects. National Comprehensive Cancer Network (NCCN) Guidelines for Hepatocellular (Biliary) Cancer V 5.2021 also notes that "SBRT to metastases can be considered in patients with oligometastatic progression where progression-free survival is the goal." The patient does fit the criteria for this situation. She has good performance status and limited metastatic disease that can be treated with SBRT fields. The intention is to improve progression free survival. Per Guidelines noted above, the patient is a candidate for SBRT treatment for her clinical situation and the SBRT request can be approved. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for radiation therapy is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung Cancer

Treatment: PET/CT (positron emission tomography/computed tomography) scan (CPT 78815)

The insurer denied coverage for PET/CT scan (CPT 78815).

The denial is overturned.

The patient has lung cancer, stage IIB squamous cell carcinoma that was not resectable. She was treated with Docetaxel, but had progression of the disease and is now being treated with Pembrolizumab. Her Oncologist is requesting a positron emission tomography/computed tomography (PET/CT) scan. She had her last PET/CT a few months prior with response. The patient underwent CT of the chest, and abdomen and pelvis.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  
    
The PET/CT scan (CPT 78815) is considered medically necessary for this patient.
The patient had progression of the disease and is now being treated with Pembrolizumab. She had her last PET/CT a few months prior, with response. The patient underwent CT of the chest, and abdomen and pelvis. Considering that sequential PET scans were being used for assessment of therapy and that there is support for such use in this patient's clinical scenario medical necessity has been established. 

"In lung cancer patients, PET/CT is vitally important for optimal patient management. PET/CT is essential in determining staging and re-staging of disease, detecting recurrent or residual disease, evaluating response to therapy, and providing prognostic information. PET/CT is also critically important in radiation therapy planning by determining the extent of active disease, including an assessment of functional tumor volume. The current approach in tumor imaging is a significant advance over conventional imaging" (Greenspan et al 2017). Therefore, the request for PET/CT scan (CPT 78815) is considered medically necessary for this patient.

"FDG [fluorodeoxyglucose] PET/CT is a valuable imaging tool for assessing treatment response for patients with lung cancer, though evidence for its comparative effectiveness with chest CT is still evolving. FDG PET/CT is most useful when there is clinical suspicion or other evidence for disease recurrence or metastases." (Sheikhbahaei, S., Mena, E., Yanamadala, A., Reddy, S., Solnes, L. B., Wachsmann, J., & Subramaniam, R. M.,).

"FDG PET/CT plays a crucial role in the evaluation of therapeutic response in lung cancer and guides management." (Kandathil, A., Sibley, R. C., III, & Subramaniam, R. M.,).                
                                         
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a PET/CT scan (CPT 78815) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Skyrizi 150mg/ml SC SOSY, Pre-service
The insurer denied the Skyrizi 150mg/ml SC SOSY, Pre-service
The denial is overturned

The patient is a female with psoriasis, treated with Otezla and topicals.  She has involvement to the scalp, face and extremities.  The provider is requesting Skyrizi.  The Health plan requires a trial and failure to preferred agents Enbrel, Siliq and Cosentyx.

Yes, the proposed treatment is medically necessary.
The Health plan requires a trial and failure to preferred agents Enbrel, Siliq and Cosentyx.
Skyrizi is an approved, appropriate and effective medication for psoriasis.  A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. Sklyrizi is among the most effective therapies for psoriasis according to current peer-reviewed literature.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara 90 mg/ml syringe every 6 weeks
The insurer denied the Stelara 90 mg/ml syringe every 6 weeks.
The denial is overturned.

The patient is a female with Crohn's disease. She is status post partial colectomy.  The request is for dose escalation of Stelara from every 8 weeks to every 6 weeks.

The patient has failed Remicade, Natalizumab, Entyvio.

Yes, the health plan should cover the Stelara every 6 weeks.

Dose escalation of Stelara may be required in some patients. In a retrospective multicenter cohort study was performed on patients with CD (Crohn's disease), dose escalation was required in 17 patients (16.3%); response was recaptured in 9/17 (52.9%) (Ma C et al, Inflamm Bowel Dis.). In another multicenter open-label study, dose escalation was effective in 8 of 11 (73%) patients (Khorrami S et al. Inflamm Bowel Dis.).  In a single center retrospective open-label observational study, dose escalation was required in 47.7% of the patients and was successful in 61.1% of them (Kapylov et al.  J Crohns Colitis.).

In a retrospective study to determine the effectiveness of ustekinumab dose interval shortening, 506 patients with CD (Crohn's disease) who received subcutaneous ustekinumab 90 mg (milligrams) every 8 weeks at a single center was reviewed.  Data from 110 patients who initially received subcutaneous ustekinumab 90 mg (milligrams) every 8 weeks and then had their interval shortened to every 4 weeks was studied.  Harvey Bradshaw Index (HBI) scores before and after the dose interval shortening was available for 78 patients in the cohort (71%), levels of C-reactive protein (CRP) for 60 patients (55%), and levels of fecal calprotectin for 8 patients (7%). Following dose interval shortening, the patients' median HBI (Harvey Bradshaw Index) decreased from 4.5 to 3, the median level of CRP (C-reactive protein) decreased from 8 mg/L (milligrams per liter) to 3 mg/L (milligrams per liter), and median level of fecal calprotectin decreased from 378 ug/g (micrograms per gram) to 157 ug/g (micrograms per gram). Among patients who had an HBI (Harvey Bradshaw Index) > (greater than) 4, a level of CRP (C-reactive protein) 5 mg/dL (milligrams per deciliter), a level of fecal calprotectin > (greater than) 250 ug/g (micrograms per gram), or endoscopic evidence for disease activity before dose interval shortening, after the dose interval was shortened, 28% achieved clinical remission (an HBI [Harvey Bradshaw Index] score 4), 22% had a normal level of CRP (C-reactive protein) (< (less than) 5 mg/dL [milligrams per deciliter]), 50% had reduced levels of fecal calprotectin, and 36% achieved endoscopic remission (Ollech JE et al, Clin Gastroenterol Hepatol.).

Yes, the Stelara every 6 weeks is more beneficial.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thyroid nodule.
Treatment: Thyroid Radiofrequency Ablation.
The insurer denied the Thyroid Radiofrequency Ablation.
The denial is overturned.

The patient is a female diagnosed with solitary right 6 cm (centimeter) thyroid nodule. This request is for Thyroid Radiofrequency Ablation.

As reported, the patient has history of indeterminate thyroid biopsies. Her most recent ultrasound showed normal cervical lymph nodes and no evidence of left nodule. Her FNA (fine needle aspiration) showed right nodule 6 cm (centimeters) (Bethesda category 3). Thyroseq was negative. Her FNA (fine needle aspiration) approximately two years ago showed right nodule 4 cm (centimeters); suspicious for follicular Neoplasm; hurthle cell (Bethesda category 4); Thyroseq was negative.

Yes, the Thyroid Radiofrequency Ablation is medically necessary.
The American Association of clinical endocrinologists guidelines [1] recommend radiofrequency ablation of solid thyroid nodules if they are large or symptomatic. This is grade A evidence. The solid component of the nodules should be sampled prior to ablation to show the absence of malignancy. This is supported by multiple studies including a meta-analysis [2].

The patient has a large nodule that was previously shown to be benign. She has a large and enlarging nodule that is now 6 cm (centimeters).

The request is not for the convenience of the patient or provider. It is not part of a study. It is clinically appropriate. The request for radiofrequency ablation of the nodule is consistent with generally accepted standards of medical practice and is therefore medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient, as the request is medically necessary as described above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain.
Treatment: Surgery and inpatient admission.
The insurer denied the Surgery and inpatient admission.
The denial is upheld.

The patient is a female who presented with history of neck pain.  She had no history of myelopathy.

The patient had no bladder or bowel dysfunction.  She had 5/5 strength bilaterally with no pronator drift. She was treated with toradol and Decadron without resolution. CT (computed tomography) scan showed disc herniation C3-4 (third cervical spine vertebra-fourth cervical spine vertebra).  MRI (magnetic resonance imaging) cervical spine revealed C3-4 (third cervical spine vertebra-fourth cervical spine vertebra) disc herniation with mild/moderate compression on the spinal cord. Anterior Cervical disectomy and fusion were performed.  Patient tolerated the procedure well.

No, the Surgery and inpatient admission were not medically necessary.
There is no clear indication for the proposed and performed anterior cervical discectomy and fusion of C3-4 (third cervical spine vertebra-fourth cervical spine vertebra). The surgery was requested based on spinal cord compression.  However, there is no evidence of cervical myelopathy by exam.  Additionally, the official reading of the MRI (magnetic resonance imaging) scan of the cervical spine indicated that there was only mild to moderate mass effect on the ventral cord. The patient only had axial neck pain without radiculopathy or myelopathy.

"Cervical spondylotic myelopathy (CSM) is a major cause of disability, particular in elderly patients. Awareness and understanding of CSM [cervical spondylotic myelopathy] is imperative to facilitate early diagnosis and management. This review article addresses CSM [cervical spondylotic myelopathy] with regard to its epidemiology, anatomical considerations, pathophysiology, clinical manifestations, imaging characteristics, treatment approaches and outcomes, and the cost-effectiveness of surgical options." (Bakhsheshian, J., Mehta, V. A., & Liu, J. C.).

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

There is no clear-cut indication for the performed anterior cervical discectomy and fusion.  The patient had axial neck pain without radiculopathy or myelopathy.  The provided imaging does not demonstrate significant spinal cord or nerve root compression. The patient does not meet the criteria for anterior cervical discectomy and fusion.

Furthermore, there is no indication for an inpatient admission for this condition. Given the patient's history, physical findings and imaging, this patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: D8080 Braces And D8670 Monthly Visit x 12, Pre-service.
The insurer denied the D8080 Braces And D8670 Monthly Visit x 12, Pre-service.
The denial is overturned.

The patient is a male. The request is for orthodontic benefits.  Has a severe handicapping malocclusion due to teeth 5, 12 and 13 (upper right and left premolars) in complete buccal crossbite. Reason for denial was the Salzmann score was 20 by the provider and 12 by the initial review.

Yes, the braces and monthly visits are medically necessary.
The patient has 3 out of his 4 upper right and left premolars in "buccal crossbite." This means they are way out more in to the cheeks than they should be. This also means that they do not touch the lower premolars during biting. When upper teeth do not touch their lower counterparts, there is a high probability that the upper teeth will "super-erupt." This means that these teeth will elongate, since they have no opposing tooth to hit. Over time this will cause a big discrepancy in the bite and cause trauma to multiple teeth, because they will bang into each other in an uncontrolled way during the chewing cycle. These 3 upper premolars need to be orthodontically positioned to allow for all the teeth to glide along each other, rather than traumatize themselves while chewing. Teeth can fracture or be severely loosened this way. Orthodontic treatment is medically necessary to correct handicapping malocclusion.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces and monthly visits.
The insurer denied Braces and monthly visits.
The determination is upheld.

The patient has maxillary and mandibular crowding and several unerupted permanent teeth, including tooth 8. There is no written diagnosis or treatment plan, however, the supplied Handicapping Labio-Lingual Deviation Index (HLD) scale indicates the provider believes that tooth 8 is impacted. At issue is the medical necessity of braces and monthly visits.

Orthodontic treatment is not medically necessary for the patient at this time. He is in the process of losing his remaining primary teeth as they are replaced with permanent teeth. There are not guidelines specifically for impacted central incisors but the risk factors for impacted canines (2) can be applied:
1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does not have this, as shown in the panoramic radiograph.)
2) The canines cannot be palpated and occlusal development is advanced (occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption.)
3) The lateral incisor is proclined and tipped distally (Photographic evidence does not indicate proclined lateral incisors.)
The patient does have maxillary crowding; however, the patient does not exhibit any of the criteria to suspect tooth 8 is impacted. Orthodontic treatment is not medically necessary at this time.