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

Diagnosis: Osteoarthritis
Treatment: J7326 - Hyaluronan or derivative (Gel One), for intra-articular injection, per dose 

The J7326 - Hyaluronan or derivative (Gel One), for intra-articular injection, per dose, is not medically necessary.

The patient is a female with right knee pain for months in duration. She had received PT (physical therapy), NSAID (nonsteroidal antiinflammatory drugs) and Cortisone without benefit. She had excellent response from viscosupplementation in the past. 

The patient's physical examination was significant for limp, swelling, crepitus, motion -3-110 and tenderness to joint line. X-rays reported severe cartilage space narrowing. Her physician diagnosed osteoarthritis. 

The physician provided an injection of cortisone and recommended viscosupplementation. She had received these injections years ago, which provided benefit. 

The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis if all other courses failed prior to surgery. However, the recommendations for use of Viscosupplementation have changed. 

A review of the Clinical Practice Guideline by AAOS  cites:

The 2013 OA knee treatment CPG contains one significant recommendation change from the 2008 CPG, and this is with regard to the issue of viscosupplementation. The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG.

The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from three high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, May 2013.)

The Orthopedic group reports "strongly do not recommend use."

The denial would thus be appropriate and consistent with current practice.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who presents to the office of her dental provider for evaluation and treatment of tooth #20. Included for review are previous letters of appeal and denial, a narrative from the patient, full mouth radiographic images, one page of American Dental Association (ADA) claim forms, and health plan language. In question is the medical necessity of the planned treatment of root canal therapy for tooth #20 (3320) and all metal crown (2791) for tooth #20. Previous denials have been on the basis that the patient needs to have eight back teeth that touch each other when the patient bites down, four in the maxilla and four in the mandible. The requested therapy is that of root canal therapy for tooth #20 (3320) and all metal crown(2791) for tooth #20.

The health plan's determination is upheld.

Nerve treatment and metal crown for tooth # 20 is not medically necessary for this patient. Radiographic documentation shows decay on the distal root of tooth #20 involving the pulp extending apically to the mid root and bone level of the tooth. The location of the decay and the amount of lost structure would leave the tooth with a poor crown to root ratio and thus the treatment is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III malocclusion, maxillary crowding and mandibular crowding, excessive overjet and anterior crossbite with gingival attachment loss (mandibular canines).

Treatment: Braces (D8080).

The insurer denied coverage for Braces (D8080). The denial reversed.

This patient is a male who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to Class III malocclusion, maxillary crowding and mandibular crowding, excessive overjet and anterior crossbite with gingival attachment loss (mandibular canines).  The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  The insurer has denied coverage for orthodontic treatment as not medically necessary.

Upon review of the submitted documentation, 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, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet insurer and plan criteria to justify 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.  This is confirmed by several studies.  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.  

Reverse denial as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

The healthcare plan did not act reasonably or with sound medical judgment or in the best interest of the patient.  Braces (D8080) are considered medically necessary for this patient.  

Based on the above, the medical necessity for Braces (D8080) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal Knee Problem - Pain
Pharmacy/Prescription Drugs

This case describes a female patient with a complaint of left knee pain and known osteoarthritis. She had undergone a Monovisc injection (hyaluronic acid) into the left knee 6 months prior. The provider in this case has requested authorization for an additional injection for the left knee.

The requested Monovisc injection in this case is not medically necessary.
The rationale for this determination is based on a review of the current, peer-reviewed orthopedic literature with regard to the efficacy of viscosupplementation injections for the treatment of knee osteoarthritis. Two recent studies published in the Journal of Bone and Joint Surgery found that viscosupplementation injections have minimal clinical efficacy. One study published by Tammachote and colleagues in 2016 concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." A second article published by Jevsevar and associates in 2015 concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid (HA) treatment over placebo." Thus, the current, peer-reviewed orthopedic literature has found that viscosupplementation injections, such as the Monovisc requested in this case, are not clinically effective and are therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with complaints of loud snoring, witnessed apneas, and daytime fatigue.  A polysomnogram revealed an apnea hypopnea index of 53.2.  Continuous positive airway pressure was recommended, but he could not tolerate the device.  A weight loss of 50 pounds (lbs) is documented.  He was seen for a custom oral appliance but could not tolerate the procedure secondary to temporomandibular pain.  His exam revealed "clear obstruction from tonsils, palate and the base of tongue" which was large".  The patient purchased an over the counter mandibular advancement device which fit well, though he did not wish to use it forever and was looking for a possibility of a cure.  Reduction of the base of tongue (CPT 41530) was recommended and is the service under review for medical necessity.
The health plan's determination is upheld.  Based upon a review of the existing evidence, there are currently no clear indications for this technology.
Studies in the peer reviewed literature demonstrate cohorts that are small with little evidence of long term follow up.  In a 2009 prospective non-randomized series by Ceylan radiofrequency volume reduction of the tongue base was found to be only comparable to CPAP in treatment success in patients followed for 12 months with mild to moderate obstructive sleep apnea.  This is a patient with severe obstructive sleep apnea.  In a 2009 study by Fibbi el al. radiofrequency reduction of the tongue base of tongue deteriorated in effectiveness after 2 years.  The authors concluded that the minimally invasive treatment for tongue base surgery can only guarantee long-term results only in 33% of patients.  Baba et al. (2015) reported in a review of the literature regarding radiofrequency volume reduction of the base of tongue, that the studies were generally of low quality with significant heterogeneity, which did not allow strong conclusions.  The authors recommended that studies with longer term outcomes would be useful in evaluating the benefits of this radiofrequency volume reduction.  Based upon the peer reviewed literature, radiofrequency volume reduction of the base of tongue (41530) is not appropriate, not standard of care, and is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Premature Birth
Inpatient hospital

The patient is a female who was at 25 5/7 weeks gestation as dated by last menstrual period (LMP) and 23 week ultrasound who presented to triage with complaint of vaginal bleeding approximately 4 hours prior to admission. The patient is noted to have a complete placenta previa. She reported passing a moderate amount of blood. She denied any pelvic pain or contractions. The patient underwent repeat ultrasound that again noted a complete previa. She was noted to have late onset prenatal care. She had a plan of bilateral tubal ligation. She also was noted to have suspected Klinefelters syndrome in the fetus based upon prior NIPS testing. The patient also had a history of anemia. All prior deliveries were reported to be vaginal deliveries.

The health plan's determination is upheld. The inpatient stay was not medically necessary. At the time of admission, this patient was stable with a diagnosis of placenta previa and vaginal bleeding. There was no active bleeding on examination and given that the patient was 1 cm and had blood in the vagina, the medical team took the appropriate actions of magnesium for neuroprotection and a course of betamethasone was administered by 2 doses on 24 hours apart. There was no cervical change documented. There was no diagnosis of preterm labor. In diagnosis of preterm labor, there would be both contractions and cervical change.
In this case, the cervical change was absent and there was also a negative evaluation for premature rupture of membranes (PROM) or active bleeding. The fetal status remained reassuring. The American College of Obstetrics and Gynecology would support the use of steroids, GBS prophylaxis antibiotics and magnesium for neuroprotection when the pregnancy is less than 32 weeks and there is threatened preterm labor present. These interventions are in agreement with the Milliman Care Guidelines (MCG) Care Guideline for "Preterm Labor, Threatened". The American College of Ob/Gyn outlines the diagnosis and management of preterm labor and is also supported and endorsed by the Society for Maternal Fetal Medicine guidelines in this management. The MCG Guideline is based upon national utilization of care guidance and also confirms to these American College of Obstetricians and Gynecologists (ACOG) and SMFM (Society for Maternal-Fetal Medicine) Guidelines.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented for evaluation and treatment of tooth number (#) 27. Provided for review are previous letters of appeal and denial, full mouth radiographic images, and multiple pages of American Dental Association (ADA) claim forms. At issue is the medical necessity of the planned treatment of root canal therapy for (3310) for #27, post and core (2954) for #27, and porcelain ceramic crown #27 (2750).

Previous denials have been on the basis that nerve treatment requires that the patent have a radiographic evidence of a deep cavity, a crack in the tooth, have had injury to the tooth, or the tooth has been sensitive to hot and cold, none of which have been documented or offered by the treating doctor. The requirement for crown coverage is that radiographic evidence supports the loss of extensive amounts of tooth structure due to fracture or decay, none of which have been provided by the doctor. At issue is the medical necessity of a white glass with high gold content crown, tooth 27.

The health plan's determination is upheld.

No, the requested service/treatment is not medically necessary. The provided documentation does not support the need for this treatment. As the radiographic images of tooth #27 do not show decay extending to the pulp and do not show decay involving the majority of the tooth, the treatment is not supported. Further, there was no pulpal testing performed nor any pulpal diagnosis to support the treatment.
Appeal type: Medical necessity
Decision: Overturned

Breathing Problem
Inpatient hospital

The patient is a female with Hemoglobin C disease who presented to medical attention with a three-day history of fever, with progressively increased work of breathing.  In the emergency department, she was tachypneic to 60 breaths per minute.  She was wheezing and retracting on physical examination.  Albuterol and steroids were administered.  She was admitted to the hospital, where she received every three-hour albuterol treatment, steroids, and asthma education.  She was discharged home when albuterol treatments were spaced to every four hours.  The issue at hand is the medical necessity for hospital admission.

The health plan's determination is overturned.  The Inpatient Hospital Admission is medically necessary for this patient.  This patient presented with an asthma exacerbation that required care at a level that could not be delivered in an outpatient setting.  Pulmonary consultation and education were provided, which also support hospital admission.  This is in line with national standards for admission and readiness for discharge.  A recent publication surveyed Ohio pediatric hospitals.  Their standards for discharge ranged from every four to six-hour albuterol administration.
Appeal type: Medical necessity
Decision: Upheld

Short Stature
Pharmacy/Prescription Drugs

The patient is a female who is seeking growth hormone (GH) treatment for idiopathic short stature (ISS). She was born after 34 weeks of gestation and her birth weight was 4 lbs 5 oz. Her past medical history is significant for large ventricular septal defect (VSD) for which she received Lasix and it resolved by age 3 years. Her mother's height is 64 inches and father's height is 65 inches (mid parental height of 62+/-2''). Her mother was late in her puberty and had reached menarche at age 14 years. Previous growth points shows that her height was 94 cm (17.44 %tile: -0.94 SD [standard deviation]) while her weight was 14.2 kg (34%tile: -0.4 SD). Growth hormone is under review. 

The health plan's determination is upheld. Humatrope 12 mg Cartridge is not medically necessary for this patient. Overall, this patient's height dropped from 17.44%tile to 1.42 %tile and weight from 34%tileto 8%tile in 3.5 years which suggest nutritional growth failure. NGR patients may cease to gain appropriate weight and fail to grow in height even without exhibiting body weight deficits for height. Her slow growth cannot be considered idiopathic. As this patient's height percentiles have dropped over the period of few years along with weight percentiles, and her height her never been 2.25 SD below the mean for age, she does not qualify for GH treatment under the indication of ISS.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with no past medical history who presented to the emergency room (ER) with facial swelling present since the night before. He denied fevers, chills, nausea, vomiting, visual disturbance, or other complaints.
On presentation, he was afebrile with blood pressure (BP) 143/90, heart rate (HR) 71, respiratory rate (RR) 18, and oxygen saturation 99% on room air (RA).. The exam otherwise noted swelling and erythema with increased warmth to the left face from the vermillion border up through the left lower eyelid that was indurated without fluctuance or crepitus. Lab results showed white blood cell count (WBC) 9.3, hemoglobin (HGB) 13.7, platelets (Plt) 245, sodium (Na) 141, potassium (K) 3.8, blood urea nitrogen (BUN) 12, creatinine (Cr) 0.8, international normalized ratio (INR) normal, magnesium (MG) 2.3, lactic acid 0.9. Computed tomography (CT) scan of the facial bones showed left facial cellulitis with a 5 millimeter (mm) by 3 millimeter (mm) abscess abutting the left maxially cortex with associated periapical lucency involving the subajacent left maxillary canine tooth representing the source of infection.
The patient was brought into the hospital with a concern for facial cellulitis and plans for intravenous (IV) antibiotics, pain management, blood cultures, and oral surgery consultation.
The health plan's determination is upheld.

This is a patient with a history of dental disease who presented to the ER with facial swelling and redness with a tooth infection. He did not have any signs of sepsis on presentation (no fever, leukocytosis, hypotension, or tachycardia) and did not have other systemic symptoms of infection such as nausea and vomiting. He furthermore did not have uncontrolled diabetes or other immunosuppresion placing him at higher risk of complications or prolonged recovery and had not already failed treatment of his tooth infection with oral antibiotics. He was appropriate to bring into the hospital for IV antibiotics given the extent of his infection. However, he was noted to respond well to IV antibiotics without treatment failure, leukocytosis, hemodynamic instability, or need for emergent surgical debridement. ID noted that he was appropriate to change to oral antibiotics and he appears to have stayed in the hospital  in the setting of waiting for a dentist to see him. Inpatient care was not medically necessary and care could have been provided at a lower level.
In the absence of hemodynamic instability, leukocytosis, abscess needing drainage, uncontrolled diabetes mellitus (DM), or other immunocompromising condition, and in the setting of him improving within a reasonable period of observation and being felt appropriate to discharge on augmentin with follow up with his dentist, care at the inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee osteoarthritis

Treatment: 97140 (manual therapy) times 2

The insurer denied coverage for 97140 (manual therapy) times 2. The denial upheld.

This patient is a female with right knee pain. Based on the MD note from a specified date, the patient's diagnosis is right knee osteoarthritis, and her pain is associated with stiffness and cracking when walking, and is aggravated by standing and ascending/descending the stairs. On exam, the patient had full range of motion but stiffness at end range extension of the right knee, and cracking with active range of motion on bilateral knees. The patient's ligament integrity and meniscal integrity test of the right knee were found to be normal. Based on the assessment/diagnosis of right knee osteoarthritis, the treatment plan was therapeutic exercise, neuromuscular re-education and manual therapy. Manual therapy involved soft tissue mobility and retrograde massage of the right knee. And unlike exercise and physical activity, which is an active range of motion and muscle-strengthening, manual therapy is passive. 

Based on literature review, Teo, et al. (2019) article on "Identifying and Prioritizing Clinical Guideline Recommendations Most Relevant to Physical Therapy Practice for Hip and/or Knee Osteoarthritis", exercise and physical activity is highly ranked recommendations for knee osteoarthritis. These recommendations are supported by high-quality evidence showing that exercise decreases pain and improve function for this patient population.  On the other hand, recommendations that proposed thermotherapy, electrotherapy, and manual therapy as adjunct treatments for people with osteoarthritis are not ranked highly by physical therapists, even though these treatment modalities are within the scope of physical therapy practice globally and are often used by physical therapists. Consistent with Teo, et al. (2019) article, the 2005 Ottawa Panel Evidence-Based Clinical Practice Guideline article recommends the use of therapeutic exercises. While this panel recommends the use of therapeutic exercises alone, or combined with manual therapy for managing patients with osteoarthritis, Abbott, et al. (2013) study showed that the combination of exercise and manual therapy did not produce additional benefit for patients with knee osteoarthritis. 

Considering these literature findings, continuing manual therapy in combination with exercise therapy is not medically necessary to manage this patient's right knee pain due to right knee osteoarthritis. 

The carrier's denial of coverage for 97140 (manual therapy) times 2 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who was diagnosed with Parkinson's Disease. Crowns are being requested at this time and the medical necessity of crowns for teeth numbers 2, 3 and 5 is under review. The health plan's determination is overturned.

Crowns on teeth #2, 3, and 5 are medically necessary for this patient. According to the provided radiographs, teeth #2, 3, and 5 have large existing fillings with recurrent decay. There is not enough tooth structure remaining for a filling to be placed; therefore, a crown is necessary to protect the tooth from fracturing.
Extractions and dentures are not recommended treatment options for this patient as she is diagnosed with Parkinson's Disease. Parkinson's Disease limits one's ability to eat, bite, chew, or swallow efficiently due to poor motor functionality. Weakened ability to chew or swallow can increase the risk of aspiration. Dentures do not provide the same occlusal functionality as natural teeth do; therefore, it decreases the ability for one to chew their food thoroughly. Because this patient has Parkinson's Disease, it is important that the patient retains her natural teeth for proper occlusal functionality in order to chew her food and minimize the risk of aspiration.