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

Diagnosis: nystagmus and foveal hypoplasia 
Treatment: Genetic testing

The insurer denied Genetic Testing: GeneDx Foveal Hypoplasia Custom Panel. 

The health plan's determination is overturned.

This case refers to a female diagnosed with foveal hypoplasia and nystagmus. She was seen to have 10/100 visual acuity in each eye and foveal hypoplasia on exam and optical coherence tomography (OCT) imaging. She has no known family history of the disease or any associated medical problems (albinism or aniridia) that may cause foveal hypoplasia. While there is no treatment for foveal hypoplasia, the question here remains whether to allow genetic testing to better characterize her disease.

The GeneDx Foveal Hypoplasia Custom Panel testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling disease. As stated in the medical records and appeal from the doctors' office, having a clear genetic diagnosis for idiopathic foveal hypoplasia would effectively rule out other causes that have systemic and potentially life-threatening risks, such as Hermasky-Pudlak syndrome. Some genetic disorders have better or worse prognoses which can help with planning and follow up care. Many studies additionally argue that information for families regarding genetic disease can help with further family planning and may help with future targeting treatments. In summary, genetic testing is more beneficial than no genetic testing in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: nystagmus and foveal hypoplasia 
Treatment: Genetic testing

The insurer denied Genetic Testing: GeneDx Foveal Hypoplasia Custom Panel. 

The health plan's determination is overturned.

The patient is a female with congenital nystagmus and blindness due to foveal hypoplasia. She has no clinical signs of albinism or aniridia. The working diagnosis is isolated foveal hypoplasia (FH). In order to confirm the diagnosis, her doctor recommended a custom genetic panel for 4 genes through Gene Dx. 

Genetic Testing: GeneDx Foveal Hypoplasia Custom Panel is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Foveal hypoplasia may be found in patients with aniridia, albinism and nystagmus but rarely occurs in isolation. Isolated Foveal hypoplasia (FH) has been described and is commonly sporadic, but association with PAX6 (Paired box protein) missense mutations have also been identified. Recessive Homozygous mutations in SLC38A8 have been also found to cause FH. Nystagmus and reduced vision but no anterior segment abnormalities were present. Furthermore, although the term "aniridia" suggests absence of the iris, the actual amount of iris remnant varies among individuals. Therefore, the diagnosis of aniridia can be easily missed in cases of PAX6 missense mutations because PAX6 mutations can cause various phenotypes that can range from a readily visible almost complete absence of the iris to small slit-like defects in the anterior layer of the iris. It is these latter presentations that can be overlooked, particularly in children. Aniridia can be associated with Wilm's tumor, cerebellar ataxia and intellectual disability.

The PAX6 gene portion of the custom was ordered to identify this potential mutation. The SLC38A8 was ordered to identify an autosomal recessive disorder FH, optic nerve decussation defects and anterior segment dysgenesis (FHONDA), which has significant overlap of phenotypical characteristics with albinism.
The GPR143 (G-protein coupled receptor 143) portion of the panel is to evaluate for an x-linked form of potential ocular albinism. Albinism can be part of a syndrome such as Hermansky Pudlak disease, ChediaK Higashi syndrome or Waardenburg syndrome. Identifying the syndromes allows for care directed at early identification and treatment of associated systemic disease such as blood clotting disorders or lung disease.

Finally, the FRMD7 (FERM domain containing 7) gene is another xlinked gene associated with infantile nystagmus that presents in both males and females.

Therefore, identifying the underlying cause of FH can guide treatment for the patient and in the future help with family planning.
Appeal type: Experimental/Investigational
Decision: Overturned


Diagnosis: nystagmus and foveal hypoplasia 
Treatment: Genetic testing
The insurer denied Genetic Testing: GeneDx Foveal Hypoplasia Custom Panel. The health plan's determination is overturned.

The patient is a female with nystagmus and foveal hypoplasia for whom coverage of Genetic Testing: GeneDx Foveal Hypoplasia Custom Panel is the subject of review. 

Yes. The Genetic Testing: GeneDx Foveal Hypoplasia Custom Panel is 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, coverage for genetic testing which screens for a panel of 4 genes is requested for a patient with nystagmus and foveal hypoplasia.
It is consistent with the recommendations of the American Academy of Ophthalmology. It is established as standard of care and for the patient's disease. Infantile nystagmus (IN) is a genetically heterogeneous disorder arising from variants of genes expressed within the developing retina and brain. IN presents a diagnostic challenge and patients often undergo numerous investigations. The genetic information from the panel will lead to personalized diagnosis and management of IN and enable accurate genetic counselling. This will allow development of a new clinical care pathway for IN.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left humeral shaft fracture.

Treatment is an inpatient admission.

The insurer denied coverage for an inpatient admission.
 
The denial is upheld.

This is a female with no significant past medical history. She presented to the emergency room (ER) with complaints of arm pain after falling down steps. Imaging revealed a left humeral shaft fracture. The patient was admitted to the Orthopedic unit. Pain control was given as needed (PRN). She underwent an open reduction internal fixation (ORIF) of a left humerus fracture. Ancef was given. Her diet was advanced as tolerated and she was encouraged to use an incentive spirometer. 

The medical record demonstrates the young woman sustained an isolated fracture to her humerus. The mechanism was of low energy. She was previously evaluated in the emergency department (ED) and advised to return for surgery. Her presentation to the ED was significant for a pain level of 0, no numbness nor tingling and current pain medication being Ibuprofen. These findings do not substantiate the reported concern for acuity of condition. Upon evaluation, she was reportedly scheduled for surgery. The operation was completed on that date. It was straight forward without complication. Her post-surgical course was satisfactory. 

There were no conditions nor circumstances showing intolerable pain nor neuromuscular compromise to require the emergent admission. Imaging had already been completed. Preoperative workup could have been completed as outpatient. There were no other factors which would require the level of service and admission. 

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld.

The patient is an adult female with history of hyperlipidemia, Hashimoto's, and mitral valve prolapse who presented to the emergency department (ED) complaining of cough, shortness of breath and wheezing for about 3 days. The Patient reported oxygen saturations in the low 90% (percent). Vital sign in the ED were Temperature 98.5 degrees Fahrenheit, Heart Rate 68, Respiratory Rate 16, Blood Pressure 114/75 and oxygen saturation 94% on room air. Bilateral wheezes heard on auscultation. The patient was in no distress. 

The white blood cell (WBC) count was 7.1, hemoglobin 12, electrolytes, blood urea nitrogen (BUN) and creatinine within normal levels. Cardiac enzymes were negative, and electrocardiogram (EKG) showed no acute ischemic changes. Chest X-ray showed no acute pathology. The patient was treated with Lasix, prednisone and duonebs.

The patient was admitted to the hospital for further management. During admission, the patient's cardiac enzymes remained flat, no evidence of acute congestive heart failure (CHF) and no suspicion of Asthma or chronic obstructive pulmonary disease (COPD). Computerized tomography (CT) angiogram was negative for pulmonary embolism (PE). ECHO (echocardiogram) Normal LVEF (left ventricular ejection fraction) 55% EF (ejection fraction). The patient was maintained on low flow O2 (oxygen) and a steroid taper was started.

The patient did not need acute inpatient hospitalization. She could have been placed in observation status up to 48 hours while diagnostic studies and treatment were initiated.
The patient could be in observation status for up to 48 hours.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke.
treatment: Inpatient Admission for Nursing and Rehabilitation.

The insurer denied Inpatient Admission for Nursing and Rehabilitation. The health plan's determination is upheld. 

The patient is a female who was hospitalized for an acute stroke with residual cognitive impairment. Post-hospitalization, she was discharged to acute rehabilitation with subsequent discharge home. At home, she was requiring increased caregiver support and was admitted for Nursing and Rehabilitation.

Inpatient Admission for Nursing and Rehabilitation was not medically necessary for this patient.

The patient is a female who was hospitalized for an acute stroke with residual cognitive impairment. Post-hospitalization, she was discharged to acute rehabilitation with subsequent discharge home. At home, she was requiring increased caregiver support and was admitted for Nursing and Rehabilitation. However, there was no documentation by the facility assessing the patient's medical condition and alternate medical care placement needs prior to or within 24 hours of the patient's assignment to alternate care status. In addition, there has been no documentation from the skilled nursing facility of patient assessment standards promulgated by the Department of Health (DOH) or a DOH-approved equivalent to determine the alternate care level to which the patient shall be assigned. Also, there is no documentation that the patient assessments were reviewed and updated periodically during the patient's alternate level of care stay according to the continuing stay review intervals specified by DOH. Therefore, the requested Inpatient Admission for Nursing and Rehabilitation was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Abfraction lesions
Treatment: Porcelain veneers over teeth numbers 6, 7, 8, 9, 10, and 11
The insurer denied coverage for porcelain veneers over teeth numbers 6, 7, 8, 9, 10, and 11
The denial is overturned in part.

Upon review of the submitted documentation including radiographs, panoramic x-rays, and intraoral clinical images, as well as the insurer correspondence, it appears that this patient presented for veneers on teeth # 6, 7, 8, 9, 10 and 11. The dentist identified abfraction lesions, enamel fractures on teeth # 8 and 9, incisal wear and sensitivity as reasons to justify the veneers. The insurer has denied coverage for orthodontic treatment as not medically necessary as they stated these teeth did not have extensive loss of tooth structure due to decay or fracture. The definition of abfraction lesions indicates that loss of tooth structure has occurred.

Due to the poor quality of the x-rays and intra-oral pictures received, only the medical/dental necessity of restorative treatment on teeth # 8 and 9 could be determined. 

The health plan acted reasonably in part.

Veneers for teeth # 8 and 9 is considered dentally necessary for the patient. The insurer's denial of coverage for veneers on teeth # 6, 7, 10 and 11 is upheld 

The insurer's denial of coverage for porcelain veneers over teeth numbers 6, 7, 8, 9, 10, and 11 is modified. Medical Necessity is substantiated for teeth # 8 and 9.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite, Class I skeletal relationship, Class III canines
Treatment: D8080 - Braces; D8670 - Monthly Visits
The insurer denied the braces and monthly visits.  
The denial is upheld.

The proposed treatment of braces and monthly visits, pre-service is not medically necessary.
The patient is a male. The request is for dental benefits for braces, monthly visits, pre-service. Per the Provider's dental clinical summary--the patient presents with Class I skeletal relationship, Class III canines, moderate maxillary and mandibular crowding, deep bite, impacted third molars, and anterior crossbite with gingival attachment loss.
The health plan denied the claim because the patient did not score a 26 on the Handicapping Labio-Lingual Deviation (HLD) Index Report, the score necessary for braces to be approved.

The Provider appealed the decision because per the Provider's dental clinical summary the patient has an anterior crossbite with gingival attachment loss.
The anterior crossbite with gingival attachment loss is not supported in the information submitted. In normal occlusion, the upper teeth bite just outside of the lower teeth when the mouth is closed. An anterior cross bite occurs when the upper teeth bite inside of the lower teeth. In the photos submitted it does not show that the upper left canine tooth is biting inside of the lower canine tooth.

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

The diagnosis of an anterior crossbite is not supported by the information submitted, therefore the treatment of braces is not warranted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: 2019 Novel Coronavirus (COVD-19) Pneumonitis
Treatment: full hospital admission
The insurer denied coverage for full hospital admission
The denial is overturned.

This is a patient with a past medical history significant for hypertension and tobacco abuse who presented to the emergency room with complaints of fever, cough, and shortness of breath.  Vitals on presentation included: Temperature-98.4 Fahrenheit, blood pressure-112/64, Pulse-89, Respiratory rate-16, oxygen saturation-93% (percent) on room air. Laboratory values were notable for the following: white blood cell count-5.34, Hemoglobin-14.0, hematocrit test-41.6, creatinine-0.8, glucose-124, COVID (coronavirus) positive.  The patient was admitted to the hospital for COVD-19 pneumonitis. Chest X-ray showed patchy bilateral lower lobe infiltrates. The patient's oxygen saturation decreased to 87% on room air with ambulation. The patient required supplemental oxygen and was started on intravenous dexamethasone and Remdesivir. The patient remained afebrile and hemodynamically stable. He was discharged to continue outpatient management.

Although, COVID treatment and management guidelines continue to evolve. The decision to hospitalize patients with COVID infection is typically based on presence of severe dyspnea (dyspnea at rest and interfering with the ability to speak in complete sentences), oxygen saturation on room air  <= (less than or equal to) 90% (regardless of severity of dyspnea), alternations in mentation (i.e., confusion, change in behavior), and other signs of hypoperfusion or hypoxia. Similarly, the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel suggests hospitalization for patients with any of the following: an oxygen saturation of < (less than) 94 percent on room air, respiratory rate of >(greater than) 30 breaths/minute, PaO2/FiO2 (partial pressure of oxygen/fractional inspired oxygen) <300 mmHg (millimeters of mercury), or lung infiltrates >50 percent. According to medical records, the patient had oxygen saturation at 87% with ambulation, abnormal chest X-ray, and remained at high-risk due to obesity and her unvaccinated status. 

Based on the above findings, hospital admission was medically necessary.

Prior determination of denial of inpatient hospitalization is overturned.
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 full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower Back Pain.
Treatment: Outpatient procedures (64483 x 1, 64484 x 1) pain management.
The insurer denied coverage for outpatient procedures (64483 x 1, 64484 x 1) pain management. The denial is overturned.

This woman has a history of arthritis, back pain, neck pain, broken bones, brain injury, heart failure, heart murmur, and asthma. The patient was seen by Pain Management for a 3-month follow-up for lower back pain and predominant left leg sciatica in the lumbar (L4-L5) distribution. The patient's physical exam revealed straight leg raise between 30-60 degrees on the left leg, sciatica in the L5 distribution, equivocal on the right, and radiating pain down the left leg with forward flexion and extension. Diagnostic imaging showed posterior fusion and decompression at L4-L5, trace listesis at L1-L2, a moderate-sized paracentral disc protrusion, facet arthropathy at L2-L3, mild canal stenosis, Modic endplate changes from L5- sacral (S1), posterior decompression, disc height loss, and extraforaminal disc osteophyte abutting the L5 nerve roots bilaterally. She has failed months of conservative treatments including nerve medication and opioids. The request is for transforaminal epidural steroid injection.

Clinical practice guidelines (1) support performing an epidural steroid injection in this case. The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality randomized controlled trial (RCT) with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. The request is medically reasonable and necessary.

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 outpatient procedures (64483 x 1, 64484 x 1) pain management is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection (UTI)
Treatment is an inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient was admitted for a urinary tract infection (UTI) and started on intravenous (IV) fluid and antibiotics. Her condition responded appropriately, and she decided to leave the hospital.

The patient was admitted for a UTI. During this hospital stay, the patient remained hemodynamically stable and responded appropriately to antibiotics therapy and discharged within 48 hours.

Patients with an uncomplicated UTI (example: no fever, no flank pain) are treated as outpatients (if no other indication for admission is present). [1, 2]

Some patients with an uncomplicated upper UTI (example: hemodynamically stable, able to maintain hydration orally) do not require an inpatient admission. [3] Database analysis including 572,479 adult visits to an emergency department for UTI found an inpatient admission rate of 17%. [4] Another analysis of a national database found that out of more than 1.5 million visits to the emergency department for pyelonephritis, 27% were admitted to inpatient care. [5]

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: Intraosseous Basivertebral Nerve Ablation. 

The insurer denied: Intraosseous Basivertebral Nerve Ablation. 
The denial is upheld. 

The patient is an adult male. He has right greater than left sided low back pain. He had a left sided radiofrequency ablation with benefit. MRI (magnetic resonance imaging) of the lumbar spine shows moderate multilevel degenerative change without high-grade spinal canal stenosis with Modic marrow signal change type 1 at L5-S1, type II at L3-5, multilevel neuroforaminal stenosis, and impingement of the exiting nerve root at the right L5-S1. Request for Intracept was denied coverage by the health plan as experimental/investigational. The denial is being appealed. 

The health plan should not cover the requested health service. 

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. 

At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. 

Other treatment options may include non-opioid medications (i.e., NSAIDs [nonsteroidal anti-inflammatory drugs], membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., physical therapy, home exercise program, chiropractor treatments), and interventions (i.e., epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: Intraosseous Basivertebral Nerve Ablation. 

The insurer denied: Intraosseous Basivertebral Nerve Ablation. 
The denial is overturned. 

The patient is an adult male with chronic axial low back pain for over two years which has not been responsive to conservative management for over 6 months. His treating provider diagnosed him with vertebrogenic low back pain (Modic type changes in the L3 - L5 vertebral bodies) and recommended the Intracept procedure; however, the procedure was denied coverage by the health plan due to it being considered experimental/investigation and therefore not medically appropriate. The denial is being appealed. 

The health plan should cover the Intraosseous Basivertebral Nerve Ablation. 

The Intracept procedure is FDA (Food and Drug Administration) approved and there is enough data in the medical literature to show it is safe and effective in the treatment of vertebrogenic low back pain.  A prospective, randomized, multi-center study by Khalil et al in 2019 and another prospective, randomized, multi-center study done by Fischgrund also in 2019 both presented high quality evidence of efficacy and safety of the procedure.