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

Diagnosis:  Malocclusion.
Treatment:  D8080 braces.

The insurer denied coverage for D8080 braces.  The denial is overturned.
 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified maxillary crowding and mandibular spacing Class III molars, incisor protrusion and anterior crossbite.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (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. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, 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. 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.  

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 coverage for D8080 braces is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: 64628 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral 
64629 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The insurer denied: 64628 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral 
64629 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The denial is upheld

The patient is an adult male with low back pain. His past treatments include bilateral L4-S1 (lumbar four to sacral one) facet RFA (radiofrequency ablation), Aleve, ice, LESI (lumbar epidural steroid injection), Naprosyn, Tylenol, muscle relaxers, TENS (transcutaneous electrical nerve stimulation) Unit, physical therapy, and home exercise program. MRI (magnetic resonance imaging) of the lumbar spine shows type II Modic changes, disc bulge and annular tear at L4-5 (lumbar four to five), type II Modic change, disc bulge, left disc herniation, and annular tear at L5-S1 (lumbar five to sacral one). The request for L4-S1 (lumbar four to sacral one) Intracept procedure was denied coverage by the health plan as not having been shown to be effective and being experimental/investigational. The denial is being appealed.

The health plan should not cover the requested Intracept procedure.

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. As such, the health plan should not cover the Intracept procedure. 
Other standard treatment options may include nonopioid medications (i.e., other non-steroidal anti-inflammatory drugs), membrane stabilizing agents, and/or muscle relaxants), modalities (i.e., retrial of physical therapy, home exercise program, chiropractor treatments), and interventions (i.e., other 
types and/or repeat epidural steroid injections, medial branch blocks/radiofrequency ablation, spinal cord stimulation, and/or surgical interventions).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: 64628 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral 
64629 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The insurer denied: 64628 - Thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral 
64629 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The denial is upheld

The patient is an adult male with chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, RFA (radiofrequency ablation) and home exercises. The patient has failed multiple medications. MRI (magnetic resonance imaging) shows Modic changes. Physical 
exam does not reveal any neurological injury.

The health plan should not cover the requested health service.

The patient is an adult with chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of PT (physical therapy), epidural steroid injections, facet injections, RFA (radiofrequency ablation) and home exercises. The patient has failed multiple medications. MRI (magnetic resonance imaging) shows Modic changes. Physical exam does not reveal any neurological injury. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA)-approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic-related chronic low back pain. It has been shown to be effective in RCT (randomized controlled trials) with 5-year results. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, the patient in this case is not documented to have failed or attempted sacroiliac joint injections, which are common causes of axial low back pain. In addition, according to the notes, the patient has near 70% improvement in his low back pain at this time following the RFA (radiofrequency ablation). The Intracept procedure should be employed after all conventional and evidence proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis for the denial. Given that the alternatives sacroiliac injections do show favorable outcomes in the literature, have lower risk, and morbidity, the requested Intracept procedure is not medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: 64628 - Thermal destruction of intraosseous 
basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral 
64629 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The insurer denied: 64628 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral 
64629 - Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral
The denial is overturned

The patient is an adult male. Per the appeals letter, the patient has chronic low back pain due to DDD (degenerative disc disease) that has resulted in development of vertebrogenic pain identified by Modic changes on MRI (magnetic resonance imaging). He has tried facet injections, heat/ice, home exercises, LESI (lumbar epidural steroid injection), MBB (medial branch block), RFA (radiofrequency ablation), PT (physical therapy) and TENs (transcutaneous electrical nerve stimulation) unit.
The patient presented with a history of chronic low back pain. It was noted that the patient had bilateral RFA (radiofrequency ablation) with 70% relief. The patient was noted to have occasional pain radiating down left lateral leg to the knee and occasionally to the foot. The pain is constant and worsening. The pain is aggravated with activity. SLR (straight leg raise) test is positive bilateral LE (lower extremities), left greater than right. The patient was noted to have weakness to bilateral lower extremities due to pain. Lumbar ROM (range of motion) is diminished. Diagnoses include vertebrogenic low back pain, lumbar radiculitis, lumbar facet arthropathy. MRI (magnetic resonance imaging) shows Modic changes at L4-S1 (lumbar four to sacral one). 

The health plan should cover the Intracept procedure.

Based on the documentation provided, the requested Intracept is recommended in this case. The patient has a history of chronic low back pain. The patient has tried and failed prior conservative treatment as well as interventional treatments with continued positive findings on exam and pain. MRI (magnetic resonance imaging) does show Modic changes at the levels being treated. Given the patient's history, the request is recommended at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Impacted canine.
Treatment:  Braces and Monthly Visit.

The insurer denied braces and monthly visit.  The denial is overturned.

The patient is a school-aged male. The request is for orthodontic benefits with monthly visits. The prior denial was due to a handicapping index score of 17.

The proposed treatment is medically necessary.

The patient is a school-aged male. The request is for orthodontic benefits with monthly visits. The patient has an impacted upper right permanent canine (tooth #6). This is an automatic qualifier according to the handicapping index scale (impacted permanent anterior tooth where extraction is not indicated). Monthly visits are needed to monitor progress.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services

The denial is upheld 

The patient had a history of alcohol abuse and presented with right upper quadrant (RUQ) abdominal pain. The patient was afebrile, and the vital signs were stable. There were no peritoneal signs. There was no leukocytosis. The patient had thrombocytopenia. There was elevation of the liver enzymes. An abdominal Computed Tomography (CT) scan showed cholelithiasis with suspected acute cholecystitis as well as a small liver mass. There was a plan for a laparoscopic cholecystectomy but it was canceled due to thrombocytopenia. 

Clinical indications for admission for Gallbladder or Bile Duct Inflammation or Obstruction (Milliman Care Guidelines (MCG) M-555) include having acute cholangitis or acute cholecystitis. These conditions need to be manifested by systemic signs of inflammation as indicated by fever or leukocytosis. The patient did not have acute cholangitis. There was a concern about acute cholecystitis but the patient was not having systemic signs of inflammation. The patient also did not have hemodynamic instability, common bile duct (CBD) obstruction, severe vomiting, or bacteremia. 

This patient had evidence of alcoholic cirrhosis and had gallbladder disease. It was decided not to proceed with surgery due to the thrombocytopenia that was caused by the cirrhosis. Intravenous (IV) hydration and antibiotics could have been given with observation status. The patient did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Obstruction. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #3:

Diagnosis:  Alopecia areata.
Treatment:  Xeljanz 10 milligram (mg) tablet.

The insurer denied coverage for Xeljanz 10 milligram (mg) tablet.  The denial is upheld.

This is an adult with alopecia areata who has already tried and failed the only Food and Drug Administration (FDA)-approved medication for alopecia areata. In fact, the patient failed at a dose of 6 milligrams (mg), which is not supported in the medical literature.

In a retrospective study of 90 patients by King et al., Xeljanz was studied and shown to have possible efficacy in treating patients with alopecia. However, there is insufficient evidence by way of large, randomized, controlled cohort prospective trials showing the long-term safety and efficacy of Xeljanz in treating this patient population. As such, there are no clinical guidelines with regards to optimal dosing and duration of therapy. There is also a lack of consensus with regards to the optimal patient scenario. In other words, it is not known which type of patient would best respond to treatment. 
Treatment response always depends on how long the patient has had alopecia and to what extent the hair loss entails. It has been well-documented in the medical literature of the inability of Xeljanz to maintain long-term efficacy. 

It is noteworthy that the patient has failed the only FDA-approved medication, and there is really no indication that the patient could have efficacy with this off-label treatment, given that it, too, has a similar mechanism of action. Therefore, at this time, a medical exception for Xeljanz has not been established.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.

Xeljanz 10 mg tablet does not have FDA approval for alopecia areata.

There is no indication that the patient would be a good candidate for Xeljanz.

Xeljanz is not the most appropriate treatment for the patient at this time. 

There is no indication that the adverse risks are increased over standard treatments or services.

In summary, the denial of Xeljanz 10 mg tablet and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2:

Diagnosis:  Alopecia areata.
Treatment:  Xeljanz 10 milligram (mg) tablet.

The insurer denied coverage for Xeljanz 10 milligram (mg) tablet.  The denial is overturned.

According to the medical records, the patient is an adult diagnosed with severe alopecia areata involving over 60% (percent) of the scalp. She was treated with Dupixent for eight (8) weeks and then switched to Olumiant 4 milligrams (mg) last year. The patient noted worsening of the condition with new patches of hair loss recently, and the dosage of Olumiant was increased to 6 mg. The patient continues to have hair loss with Olumiant 6 mg, so the treating provider is requesting approval of Xeljanz.

Scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. Current medical literature does demonstrate that Xeljanz is an effective treatment option for alopecia areata.

Xeljanz does not have final approval from the Food and Drug Administration (FDA) for use in alopecia areata. There are only a few options for women that are FDA approved; minoxidil and Olumiant. The patient has tried both of these and still experiencing hair loss.     

The patient is a good candidate for Xeljanz 10 mg tablet. The patient has tried and failed prior treatment attempts including topical, intralesional and systemic therapy. She has failed both Olumiant and minoxidil, which are FDA approved. Current literature supports the use of Xeljanz in the treatment of alopecia areata. Therefore, the patient is a good candidate for Xeljanz 10 mg tablet.

Xeljanz 10 mg tablet is the best available treatment for this patient at this time, as she has failed all FDA-approved treatment options.

The adverse risks would not be increased over standard treatment/services. Xeljanz would have an expected similar risk profile as Olumiant, which the patient has tried and failed.

In summary, the denial of Xeljanz 10 mg tablet and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any of the standard treatments/procedures for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #1:

Diagnosis:  Alopecia areata.
Treatment:  Xeljanz 10 milligram (mg) tablet.

The insurer denied coverage for Xeljanz 10 milligram (mg) tablet.  The denial is overturned.

The patient is an adult with a diagnosis of alopecia areata affecting > (greater than) 10% (percent) scalp. The patient has failed therapy with topical steroids, intralesional steroids, oral steroids, oral minoxidil, as well as high dose Olumiant since last year. The requested medication is Xeljanz 10 milligram (mg).  

Olumiant is Food and Drug Administration (FDA)-approved for the treatment of Alopecia areata; however, Xeljanz is only supported by numerous case reports with promising data.

The patient is a good candidate for treatment with Xeljanz 10 mg tablet. 

Xeljanz 10 mg tablet is the best available treatment for the patient at this time.

The patient has extensive disease involvement of alopecia which necessitates systemic therapy. The patient has failed numerous oral and systemic options. The patient has failed oral Olumiant at high doses as well as oral minoxidil. There is no other reasonable alternative for the care of this patient.  

The adverse risks of Xeljanz would not be expected to be greater than that of Olumiant. In this particular clinical situation, Xeljanz is an appropriate treatment option for treatment of the patient's condition at the discretion of the prescribing physician's medical judgment. 

In summary, the denial of Xeljanz 10 mg tablet and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any of the standard treatments/procedures for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission. 
The denial has been upheld.

The proposed inpatient hospital admission was not medically necessary.

The patient is a male with a past medical history of hyperlipidemia and benign prostatic hyperplasia (BPH) who presented to the emergency department for evaluation of atrial fibrillation.  He was seen as an outpatient and was noted to be in atrial fibrillation and given symptoms of syncope he was sent to the emergency department for further care.  

On arrival to the emergency department, the patient was afebrile and hemodynamically stable.  His electrocardiogram (EKG) showed evidence of atrial fibrillation with rapid ventricular response.  Initial labs were notable for a platelet count of 150 and troponin of 0.01.  He was given intravenous Cardizem with improvement of his heart rate.  He was admitted to the inpatient unit and was evaluated by cardiology/electrophysiology.  He was started on oral Cardizem and metoprolol and eventually converted to normal sinus rhythm.  He was placed on Lovenox for anticoagulation which was later switched to aspirin.  He was ultimately discharged with outpatient follow-up with cardiology.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion.  The patient's heart rate was well controlled with atrioventricular (AV) nodal blockade agents and he did not require direct current (DC) cardioversion.  Although the patient was bradycardic, there was no evidence of advanced conduction disease and he did not require implantation of a pacemaker.  There was no evidence of acute coronary syndrome or heart failure consequently, based on the provided documentation. There is insufficient clinical data to support medical necessity for inpatient level of care.       

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

Due to the reasons stated above, there is insufficient clinical data to support medical necessity for admission to inpatient level of care.