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

Diagnosis: Cerebral palsy. 
Treatment: Durable medical equipment/outpatient services E0483RRx3. 
The insurer denied coverage for durable medical equipment/outpatient services E0483RRx3. 
The denial is upheld. 

This is a child who was diagnosed with cerebral palsy, spastic quadriplegia and bronchopulmonary dysplasia. The patient receives feedings through a gastrostomy tube and requires continuous positive airway pressure (CPAP) respiratory support at night. The patient was hospitalized with respiratory syncytial virus (RSV) in the past and was started at home with the Phillip's In Courage High-Frequency Chest Wall Oscillation (HFCWO; the Vest) to address airway clearance problems. The patient also receives albuterol on an as-needed (PRN) basis for respiratory symptoms. There is no record of recent respiratory illness requiring emergency room visit or hospitalization. There is no record of any need for follow up consultation with Pediatric Pulmonology to address ongoing respiratory concerns. The only record of a medical visit was a routine visit to Summit Pediatrics which was one year ago. Ongoing treatment with the High-Frequency Chest Wall Oscillation (HFCWO; the Vest) was not recorded in the medical record. 

There is no data in the medical record to support ongoing chronic respiratory symptoms and the child has not been followed by a Pediatric Pulmonologist. The child has not required any emergency room visits or hospitalizations in the past year and the child's only respiratory treatment is albuterol for as-needed (PRN) use. There is no documentation from the pediatric staff that the child is using this therapy on a routine basis. 

The medical record does not support the need for ongoing daily treatment with the high frequency airway clearance device. 

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 durable medical equipment/outpatient services E0483RRx3 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tremors and blurred vision
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who was admitted due to having tremors and blurred vision for 1 week. Computed tomography of the head did not show acute intracranial process. Neurology consult occurred. Neurologic examination was unremarkable with the exception of positive Nylen-Barany (Dix Hallpike). It was opined that the patient was having vertigo most consistent with benign paroxysmal positional vertigo (BPPV). Migraines were also noted. The patient was recommended for vestibular therapy. She was started on propranolol, meclizine and recommended for Doppler study. The patient's dizziness improved, and she was discharged. The inpatient admission was denied for not meeting level of care.

The inpatient admission was not medically necessary.

Milliman Care Guidelines criteria, neurology, indicate admission is warranted with severe focal neurologic deficits. This was not the case with this patient. Nylen-Barany maneuver (Dix Hallpike) was positive which indicates benign paroxysmal positional vertigo, and this is not a condition that warrants inpatient admission. Symptoms were from a condition that is not known to result in morbidity or mortality.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Obesity.

Treatment: Mounjaro 5 milligrams (mg) / 0.5 milliliters (ml) pen injector.

The insurer denied coverage for Mounjaro 5 milligrams (mg) / 0.5 milliliter (ml) pen injector.

The denial is overturned.

 
The patient has a diagnosis of obesity, hepatic steatosis, and an elevated cholesterol level. The patient has been undergoing lifestyle modifications with diet and exercise. The patient had a body mass index (BMI) of 40.9 and then started Mounjaro. On the Mounjaro, the patient's BMI came down to 28.1. After being forced to stop the Mounjaro due to cost factors the patient regained 10 pounds in 4 weeks.

Up To Date has an article titled "Obesity in Adults: Drug Therapy." The article discusses the choice of pharmacologic agents. Options include glucagon-like peptide 1 (GLP-1) agonists such as Semaglutide and liraglutide. Semaglutide has demonstrated efficacy in weight loss as well as improvement in glycemia and lipids. Another category of drugs is the dual-acting GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists. Mounjaro falls into this category and is beneficial for weight loss. In an open-label trial including over 1800 patients comparing Semaglutide with Tirzepatide, reduction in body weight with all doses of Tirzepatide was greater compared with Semaglutide. 

The Food and Drug Administration (FDA) has recently approved Tirzepatide for chronic weight management. This drug can be used for obese patients even if they do not have diabetes. This patient had already had a very good response to Mounjaro and then started to gain weight back when she was forced to stop the drug. The scientific literature supports the use of Mounjaro for weight loss in patients with a BMI of 30. It is necessary to continue the medication to maintain the weight loss. The health care plan did not act reasonably or in the best interest of the patient. Mounjaro is medically necessary for this patient. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Mounjaro 5 milligrams (mg) / 0.5 milliliter (ml) pen injector is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is overturned.

The patient is an adolescent male. The request is for orthodontic benefits and monthly visits. The patient has a Class I malocclusion with a deep bite. The prior denial was due to a rescored handicapping index of 17 points.

The requested health service is medically necessary.

The provider scored the handicapping index scale value at 32. The examiner rescored the case at 17, which is incorrect. The provider's value is correct, at 32. Since this score is higher than the threshold of 26 points needed for benefits, this case should be provided orthodontic benefits. The monthly visits are needed to make sure the case progresses correctly. This case has medical necessity and orthodontic treatment is needed to correct the malocclusion.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches
Treatment: Trigeminal nerve block
The insurer denied Trigeminal nerve block.
The determination is upheld.

According to the submitted medical records, the patient has a listed diagnosis of headaches. The limited documentation states that she presented with severe "trigeminal neuralgia" pains, following root canal Prior treatment trials included low dose oxcarbazepine; the patient is unsure if carbamazepine was previously tried even though an appeal letter states she failed it. A trigeminal nerve block is requested and under review for medical necessity.
Medical necessity has not been established by the limited documentation submitted. The  treatment is not currently considered standard of care, and documentation does not show that the patient failed appropriate trials of standard of care medications. There is insufficient evidence from high-quality peer-reviewed literature, large, well-designed, blinded, randomized trials to support long term safety and efficacy of the requested procedure, trigeminal nerve blocks, for the requested indication in this patient, as documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Occipital Neuralgis
Treatment: Occipital nerve block.
The insurer denied Occipital nerve block.
The determination is overturned.

This is a male patient with occipital neuralgia. The treatment with occipital nerve blocks is the subject of this review. The procedure was previously denied because there was not documentation that member had tried and failed three months of conservative therapy. The patient has tried and failed amitriptyline, gabapentin, and. pregabalin. The nerve blocks have previously been helpful for several months to treat the patient's pain. At issue is the medical necessity of occipital nerve block.
Occipital neuralgia causes chronic, sharp, stabbing pain in the upper neck, back of the head, and behind the ears that can radiate to the front of the head. The letter of medical necessity indicates that the patient has previously tried and failed conservative therapy, including physical therapy and massage therapy. These interventions were not helpful. The patient has also tried and failed standard medications for treatment of neuropathic pain including gabapentin, pregabalin, and amitriptyline. An occipital nerve block is an injection of anesthetic medication and/or steroids near an occipital nerve to provide pain relief and help inflammation from headaches or other conditions. Since the patient has previously tried and failed other alternatives, the use of occipital nerve blocks is appropriate and medically necessary. These injections are both diagnostic and curative for treatment of the condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Neck Pain
Treatment: Intradiscal electrothermal annuloplasty and discography to cervical discs with disc decompression
The insurer denied intradiscal electrothermal annuloplasty and discography to cervical discs with disc decompression.
The determination is upheld.

This is a patient who is diagnosed with cervical radiculopathy. Records show that the patient was recommended to undergo intradiscal electrothermal annuloplasty and discography to cervical discs with disc decompression, which was denied by the health plan as experimental and investigational. It was noted this procedure has not demonstrated through prevailing peer-reviewed medical literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed. 
A letter of appeal from the treating provider states that the patient had failed all conservative treatments including oral steroid therapy, physical therapy, epidural blocks, reduced activities and analgesics. The patient has been in severe pain including cervical weakness, numbness and tingling that has limited her daily life activities. The patient had difficulty sleeping, exercising, working and household work. Her pain has been present for over a year. The provider references her cervical magnetic resonance imaging (MRI). The provider states that they performed the procedure and since then the patient has had tremendous relief and has returned exercising. Her sleep has never been better. The provider requests reconsideration for coverage of this procedure that was already performed. At issue is whether the requested procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Records provided indicated the patient had a history of chronic neck pain with radiculopathy, although there were no actual physician progress notes submitted for review documenting complaints and exam findings and no imaging studies submitted. This procedure comes with significant risks and insufficient evidence in the peer-reviewed medical literature supporting this treatment to be effective or more beneficial than standard treatments for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Neck Pain
Treatment: Intradiscal electrothermal annuloplasty and discography to cervical discs with disc decompression
The insurer denied intradiscal electrothermal annuloplasty and discography to cervical discs with disc decompression.
The determination is upheld.

This is a female patient with complaints of neck pain. She has a diagnosis of cervical radiculopathy. She patient underwent intradiscal electrothermal annuloplasty and discography to cervical disks with disc decompression. At issue is whether intradiscal electrothermal annuloplasty and discography to cervical discs with disc decompression is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The requested procedure was not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This procedure is not recommended. Intradiscal electrothermal annuloplasty (IDET) is also known as intradiscal electrothermal annuloplasty. The procedure is suggested for discogenic pain that is nonradicular and that has not responded to conservative treatment as an alternative to a fusion procedure. There is virtually no research of the role of medications including opioids and other polypharmaceutical regimens on the outcome of IDET. There is insufficient support in the medical literature for this procedure. Possible complications include discitis, epidural abscess, vertebral osteomyelitis, and bacterial meningitis. Overall, the proposed health service or treatment intradiscal electrothermal annuloplasty and discography to cervical discs with disc decompression was 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: Neck Pain
Treatment: Intradiscal electrothermal annuloplasty and discography to cervical discs with disc decompression
The insurer denied intradiscal electrothermal annuloplasty and discography to cervical discs with disc decompression.
The determination is upheld.

This is a female patient who has severe pain, numbness and tingling. She had failed prior treatments including oral steroid, epidural blocks and analgesics. Magnetic resonance imaging (MRI) shows cervical (C3)/4 C4/5 C5/6 and C6/7 disc herniations with thecal sac compression at C4/5.
At issue is whether intradiscal electrothermal annuloplasty and discography to cervical discs with disc decompression 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 treatment is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. There is limited evidence for thermal annuloplasty for low back pain. However, there is no well-designed clinical trial to support the efficacy and safety of cervical annuloplasty. The two supporting articles submitted by the provider are studies on anterior cervical discectomy and fusion (ACDF), not on thermal annuloplasty. Cervical annuloplasty is an intervention associated with significant risks including spinal cord injury. Currently, there are no clinical studies to support the safety and efficacy of thermal annuloplasty in the treatment of cervical disc herniations. There is limited evidence for thermal annuloplasty for low back pain. However, there is no well-designed clinical trial to support the efficacy and safety of cervical annuloplasty. The two supporting articles submitted by the provider are studies on ACDF, not on thermal annuloplasty.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: swallowed a fish bone

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 

The patient swallowed a fish bone and presented with throat pain. He was afebrile and the vital signs were stable. The abdominal exam was benign. An endoscopy was performed and no foreign body was found. Proton pump inhibitor (PPI) therapy and Carafate were given for esophagitis.

Clinical indications for admission for Gastroenterology are listed in Milliman Care Guidelines (MCG) MG-GAS. Severe dysphagia is an indication for admission under certain circumstances. These include caustic ingestion, severe dehydration, inability to manage secretions, hemodynamic instability, severe electrolyte abnormalities, and acute renal failure. The patient did not have these conditions.

The hospital has referenced MCG criteria for Ambulatory Surgery Exception Criteria MCG CG-AEC (Comprehensive guidance Ambulatory Care). Inpatient care is indicated for a severe infection, altered mental status, dangerous arrhythmia, hypotension, and hypoxemia. The patient did not have these conditions. He also did not need a complex surgical procedure or have an adverse postoperative event.

This patient required an endoscopy after presenting with throat pain and there was a concern about having a foreign body in the esophagus. He tolerated the procedure and no complications were reported. The endoscopy could have been performed on an ambulatory basis. He did not meet inpatient admission criteria for Gastroenterology or for the Ambulatory Surgery Exception Criteria. 

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 services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hyperglycemia and diabetes

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This is a adult male is diagnosed with hyperglycemia and diabetes. The request is for coverage of admission. 

The patient presented to the emergency room (ER) after a primary care physician (PCP) referral for a 2-week history of dizziness, epigastric pain, nausea, frequent urination, and bilateral lower extremity pain with a blood glucose (greater than) > 600. The patient is noncompliant with his insulin treatment. He has a history of benign prostatic hyperplasia, type II diabetes, hyperlipidemia and hypertension.

Labs evaluation: Glucose 636, creatinine 1.39 (acute kidney injury (AKI)), Blood urea nitrogen (BUN) 22, Sodium 129, Potassium 4.3, chloride 93, neutrophilia (5.8), Beta hydroxy butyric acid 0.55, anion gap 8, Bicarbonate (HCO3) 30.6, Potential of hydrogen (PH 7.33), Partial pressure carbon dioxide (PCO2 58), Partial pressure of oxygen (PO2) 27, Urinalysis: >1,000 glucose, trace ketones, trace proteins.

Acute inpatient admission for patients with symptomatic diabetes is necessary when the patient has evidence of ketoacidosis or a hyperosmolar state (1-6) or other comorbid conditions such as acute kidney injury.  

This patient had symptomatic diabetes with hyperglycemia in addition to acute kidney injury with a creatinine of 1.39 . Acute kidney injury in the setting of uncontrolled diabetes and severe hyperglycemia is a sign of severe dehydration that requires inpatient admission. 

The patient required inpatient care for symptomatic hyperglycemia severe dehydration and Acute kidney injury. 

The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic low back pain

Treatment: pain injection (64493, 64494) x 1

The insurer denied coverage for pain injection (64493, 64494) x 1

The denial is overturned

 
This adult female has chronic low back pain. She has had Physical therapy and Chiropractic therapy. Her medication trials have included Aleve, Motrin, Naprosyn and Cyclobenzaprine. Her Magnetic Resonance Imaging (MRI) shows facet disease at lumbar (L) 4-L5 and L5- sacral (S)1.  The request is for diagnostic facet blocks.

Clinical practice guidelines (1) support the performance of facet blocks in this patient:

.	The level of evidence is I to II with moderate to strong strength of recommendation for Lumbar Spine: diagnostic facet joint nerve blocks.
.	Ten relevant diagnostic accuracy studies with 4 of 10 studies utilizing controlled comparative local anesthetics with concordant pain relief criterion standard of greater than or equal to (>=) 80 percent (%) were included.
.	The prevalence rates ranged from 27% to 40% with false-positive rates of 27% to 47%, with >= 80% pain relief.

Similarly, consensus guidelines support the performance of facet blocks. 

This patient meets ALL of the criteria.  The request is medically reasonable and necessary.

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 pain injection (64493, 64494) x 1, is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: tibial fracture

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This is an adult female who sustained an injury and was diagnosed with a right tibial plateau fracture. She did not have significant underlying medical problems. She was admitted to the hospital for elective surgery. She underwent open reduction internal fixation (ORIF) to the lateral tibial plateau with meniscal repair. Her post-surgical course was non complicated.

The medical records demonstrate a non-complicated post-surgical course with no underlying comorbidity. The surgery was completed in a satisfactory manner. There was no drain placed. The vital signs were stable. There was no evidence of bleeding. Pain medication was tolerated. There were no delays in physical therapy (PT) services. There was no need to monitor for compartment syndrome as they were reported to be soft. There was no need for additional subspecialty consultation nor imaging. There were no circumstances to substantiate the treatments at the acute level of care after operative services could have been provided at a lower level of care. This took into consideration the type and extent of surgery completed, i.e., surgical incision, placement of hardware, blood loss and hardware placement.

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 level of care is not substantiated.