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

Diagnosis: Right Upper Lid Ptosis

Treatment: Xeomin injections

The insurer denied coverage for Xeomin injections.

The denial is overturned.

The patient has a right upper lid ptosis due to aberrant regeneration of the facial nerve following Bell's palsy.  Visual acuities were 20/30 in both eyes (OU). One month later, visual acuities were 20/25 in the right eye (OD) and 20/20 in the left eye (OS). Later, visual acuities were 20/40 OD and 20/25 OS. Recently, visual acuities were 20/50 OD and 20/20 OS.  Exam showed moderate right upper lid ptosis with smiling, talking and chewing.  Xeomin injections were recommended.

Visual acuities were 20/70 OD and 20/20 OS.  Xeomin injection was given around right eye. Visual acuities were 20/40 OD and 20/20 OS.  Exam showed moderate ptosis when smiling, talking or chewing.  Myogenic ptosis improved with Xeomin injection and there is no more ptosis on exam.  Visual acuities were 20/40 OD and 20/20 OS.

In a letter, physician stated that the patient was receiving treatment for aberrant regeneration of facial nerve after Bell's Palsy.  The doctor stated that Xeomin is medically necessary for the patient and that Xeomin has benefits over Botox.

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient.  The patient had right ptosis due to aberrant regeneration of the facial nerve status post Bell's palsy.   Botulinum toxin (Xeomin) has been shown to improve facial nerve palsy (Cooper 2017).  Studies also show that botulinum toxin improves the quality of life in patients with facial palsy (Fuzi 2020). 

Xeomin injections are considered medically necessary for this patient.  The patient has facial nerve palsy on the right side due to history of Bell's Palsy.   Facial nerve palsy can cause damage to the ocular surface, so treatment is necessary.  Botulinum toxin has been shown to be effective in treating facial palsy.  

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

Diagnosis: Autism Spectrum Disorder

Treatment: Weekly therapy services

The insurer denied coverage for weekly therapy services.

The denial is overturned.

This case involves a patient who has been diagnosed with autism spectrum disorder.  The documentation indicated he has poor fine motor skills as well as difficulty completing activities of daily living.  He was recommended to participate in physical and occupational therapy sessions due to the above.  The documentation indicated the patient was seen for additional therapy.  The patient demonstrated impairments with handwriting as well as fine motor control imprecision in addition to emotional regulation.  He struggles with anticipation of challenging tasks and regulation in reference to beginning these tasks.  He also will become easily discouraged.  The above impairments limit his ability to successfully participate in activities.  It was recommended he continue to receive additional therapy services in order to maximize his independence in daily functional tasks.  The documentation indicated he required moderate assistance in order to tie shoes.  He requires verbal cueing to utilize strategies for regulation.  He also had a short-term goal of successfully fastening a button.  The documentation indicated he did improve and was able to successfully fasten the button 1 of 3 times on average.  The patient also demonstrated great improvement with correct letter formation and has steadily been increasing in accuracy.  He continued to require moderate to maximum verbal cues to identify at least 3 strategies for self-regulation.  The recommendation was made for continued therapy services.

The provided documentation indicated the patient meets nationally recognized Centers for Medicare and Medicaid Services Criteria for Occupational Therapy Services. The patient has functional deficits in activities of daily living related to his autism spectrum disorder. The records included a plan of care for occupational therapy. Specifically, the occupational therapist is focusing on attention to task, independence in executing gross motor movements, independence with self-care skills, improving emotional regulation skills, and improving visual perceptual skills. The submitted records also include notes to show that the patient has made progress, but continues to have functional deficits and is working toward goals. Given the standard of care is to participate in therapy services to address ongoing deficits related to autism, ongoing services would be appropriate given prior benefit.  

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

Based on the above, the medical necessity for the weekly therapy services is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain (pancreatitis)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male who was admitted to the hospital. The patient was brought to the emergency room for severe mid epigastric pain, 10/10, after excessive use of alcohol.

In the ED (emergency department), the patient's BP (blood pressure) was 185/105, and pulse was 131 / minute.  The WBC (white blood cell) count was 15.64, lactate was 3.5, lipase was 252, glucose was 170.  CT (computed tomography) abdomen showed acute pancreatitis with a concern for necrosis.  The patient received treatment with IV (intravenous) fluids, Dilaudid IV (intravenous), Toradol IV (intravenous), magnesium sulfate IV (intravenous), telemetry monitoring, and NPO (nothing by mouth).

On admission, the patient received ongoing IV (intravenous) fluids, Dilaudid and Morphine IV (intravenous).  The patient had CIWA (clinical institute withdrawal assessment) scale assessment and monitoring.  Surgery consult recommended IV (intravenous) hydration and medical management.  Infectious disease recommended blood cultures, CIWA (clinical institute withdrawal assessment) per protocol, and to start Meropenem.  Gastroenterology had the same recommendations.  The patient was then transferred to another facility for further medical management.

Yes, the Inpatient admission was medically necessary.
Per criteria, admission is indicated for 1 or more of the following:

Acute pancreatitis, as indicated by 2 or more of the following:

Abdominal pain (eg, epigastric, left upper quadrant);
Serum amylase or serum lipase greater than 3 times the upper limit of normal, or urinary trypsinogen-2 greater than 50 ng/mL (nanograms per milliliter);
Characteristic findings from abdominal imaging (eg, pancreatic inflammation, pancreatic necrosis, peripancreatic fluid collection).

The patient in this case had epigastric abdominal pain. His serum lipase was greater than 3 times the upper limit of normal. Additionally, he had characteristic findings from abdominal imaging.

Therefore, given the above, the Inpatient admission was medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Vertebrogenic

Treatment: Procedure code C9752 for the treatment of low back pain - (Intracept Procedure (Intraosseous basivertebral nerve ablation))

The insurer denied coverage for procedure code C9752 for the treatment of low back pain - (Intracept Procedure (Intraosseous basivertebral nerve ablation)).

The denial is upheld.

This patient has chronic low back pain.  She has tried Physical Therapy, Acupuncture, Chiropractic therapy, Epidural steroid injections, facet joint injections and sacroiliac injections as well as medication trials.  She had a discogram performed at L (lumbar) 4-L5 which demonstrated concordant pain.  A Magnetic Resonance Image (MRI) demonstrated Modic changes at L4-L5.  The request is for ablation of the basivertebral nerve.

Fischgrund and colleagues (1) published a double-blind, sham-controlled RCT [randomized controlled trial] evaluating the Intracept system and RF [radiofrequency ablation] ablation of the Basivertebral nerve for the treatment of chronic low back pain.  A total of 225 participants with chronic (greater than or equal to 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n=78) or treatment (n=147) intervention.  In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85 Celsius for 15 minutes.  The duration of the session in the sham group was the same but the RF treatment was only simulated.  Study participants had a minimum Owestry disability index (ODI) of 30 points (on 100 point scale) and a minimum VAS [visual analog scale] of 4 cm (10 cm [centimeter] scale).  The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months.  Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned.  A total of 19 of 147 (13% [percent]) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance.  One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance.

In sum, the Intracept procedure is an experimental/investigational procedure.  The publications to date have been company sponsored and had methodology flaws.  UpToDate (3) has evaluated this procedure and concluded that it is still unproven.  There are other evidence-based interventions available to this patient.  This procedure is unlikely to be more beneficial than the standard approaches.

Based on the above, the procedure code C9752 for the treatment of low back pain - (Intracept Procedure (Intraosseous basivertebral nerve ablation)) is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Vertebrogenic

Treatment: Procedure code C9752 for the treatment of low back pain - (Intracept Procedure (Intraosseous basivertebral nerve ablation))

The insurer denied coverage for procedure code C9752 for the treatment of low back pain - (Intracept Procedure (Intraosseous basivertebral nerve ablation)).

The denial is overturned.

This case involves a female who has a history of chronic back pain.  The documentation indicated the patient has been recommended to undergo the Intracept procedure.  The documentation indicated the patient has had multiple treatments that include physical therapy as well as acupuncture, epidural steroid injections, facet injections, and prior discogram.  The above treatment has not provided significant sustainable relief.  The physician indicated her chronic low back pain has persisted for greater than a year and all non-operative treatments have failed to resolve her pain.  A Magnetic Resonance Image (MRI) reveals a disc bulge at the L (lumbar) 3-4 level with mild bilateral facet arthropathy.  At the L4-5 level, there is a diffuse disc bulge with bilateral facet arthropathy and mild spinal canal stenosis.  There was bilateral lateral recess narrowing and indentation upon the descending L5 nerve roots.  The imaging also showed hypointense and hyperintense focus within the central portion of the S (sacral) 1 vertebral body, which was nonspecific hemangioma and prominent basivertebral plexus was also possibility.  Other etiologies were not excluded and further evaluation with a Computed Tomography (CT) scan was recommended. 

Based on the medical literature, it is shown that basivertebral nerve ablation exhibited sustained clinical benefits and is recommended for patients that fail nonsurgical treatment.

The above requested procedure has approval from the appropriate regulatory body.

Based on the medical documentation, the patient has had multiple treatments that include physical therapy as well as acupuncture, epidural steroid injections, facet injections, and prior discogram.  The above treatment has not provided significant sustainable relief.  The physician indicated her chronic low back pain has persisted for greater than a year and all nonoperative treatments have failed to resolve her pain.  Therefore, the patient is a good candidate for the above requested procedure.

The requested procedure is considered the best available treatment for this patient at this time.  According to the medical literature, the adverse risk is not significantly increased compared to the surgical and non-surgical alternatives.

According to the medical literature, it is shown that basivertebral nerve ablation exhibited sustained clinical benefits and is recommended for patients that fail nonsurgical treatment.  Therefore, the requested service is likely to be more beneficial for the claimant's current symptoms.

Based on the above, coverage for procedure code C9752 for the treatment of low back pain - (Intracept Procedure (Intraosseous basivertebral nerve ablation)) should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied retainer, monthly visits, and braces. 
The denial is overturned. 

The patient is a male with an anterior crossbite on teeth 7 and 10. He presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and the mandible. He is treatment planned for orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity. The subject under review is the medical necessity for retainer, monthly visits, and braces. 

The health plan's determination is overturned. 

The requested treatment is medically necessary for this patient. 

This patient presents with an anterior crossbite on teeth 7 and 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. [1,2,3] The maxillary lateral incisors are in crossbite and will be permanently damaged if they are not aligned with orthodontics. 

If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and complicated to correct than the patient's existing orthodontic problem. Orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders-Cellulitis
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plans determination.

The patient has a past medical history significant for obesity that required gastric sleeve surgery and came to the emergency department with complaints of fever, chills, leg swelling, and redness that started after he had a pedicure.
The patient was seen by his primary care physician who started him on Augmentin because of the lower extremity cellulitis. The patient stated that he took Augmentin, but his symptoms did not improve. 
There was right leg swelling, and erythema up to the knee. The rest of the physical exam was unremarkable. The patient was admitted to the hospital and received treatment with intravenous antibiotics for right lower extremity cellulitis. In the hospital, the patient was seen by an infectious disease specialist. It was recommended to continue treatment with intravenous antibiotic Cefazolin, elevation of the right lower extremity, and monitoring of inflammatory markers. As a result of the treatment with intravenous antibiotics, the patient's clinical condition gradually improved. The patient was transitioned to oral antibiotics and discharged home.

The admission at the acute inpatient level of care was appropriate due to lack of response to treatment with oral antibiotics, progression of the infection, and relatively large area affected by cellulitis. The review of medical records clearly demonstrated the failure of outpatient therapy. Based on the initial evaluation, there was no significant improvement in the patient's symptoms despite taking Augmentin, which is one of the common antibiotics used to treat cellulitis and soft tissue infections. Based on the records, the patient took it for at least 48 hours. Considering the significant progression of cellulitis that started in the foot and spread up to the knee, the initiation of outpatient intravenous therapy was not appropriate based on the acuity and the size of the area affected.
The determination coincides with Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 24th Edition criteria for cellulitis. These criteria were attached to the chart for review. The patient met these criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: nerve treatment molar tooth 2 and 3, crown molar tooth 2 and 3, implants tooth 13, 18, 19, 30 and 31.
The insurer denied nerve treatment molar tooth 2 and 3, crown molar tooth 2 and 3, implants tooth 13, 18, 19, 30 and 31.
The determination is upheld. 

The patient presented for evaluation and treatment of multiple teeth. Provided for review are previous letters of appeal and denial, a narrative from the provider, treatment consent forms, health history form, a panoramic full mouth radiographic image from an unknown date, clinical notes. At issue is the medical necessity of the planned treatment of root canal therapy (3330) for tooth #2 and 3 as well as full cast predominantly base metal crown (2791) for teeth #2 and 3, implant placement (6010) for site #13,18, 19, 30, and 31.

Based on the provided documentation, there is not any decay diagnosed for the patient nor any loss of tooth structure to necessitate crown therapy for the teeth listed, nor is there any pulpal diagnosis for the teeth planned for root canal therapy. There are also no recorded findings or symptoms associated with the teeth planned for treatment. As there is not any diagnosis offered for any of the treatment and no supporting symptoms or findings, none of the requested therapy is indicated as medical necessity is not established. Hence the treatment of root canal therapy (3330) for tooth #2 and 3 as well as full cast predominantly base metal crown (2791) for teeth #2 and 3, implant placement (6010) for site #13,18, 19, 30, and 31 is not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental or orthodontic treatment. 
The insurer denied implants. 
The denial is upheld.

The patient is a female who presented for a dental visit. The patient complains of difficulty chewing. The patient complains that she has a history of difficulty using partials due to nausea and speech difficulty. The dentist states that dentures will fail due to bone atrophy and failing to meet the patient's needs. The last intent of the patient using partials is not specified on Medical / Dental chart, there is no previous history recorded of partials. The patient is a currently missing tooth #1, 2, 9, 14, 18, 31, and 32. She has a non-restorable # 19. Tooth # 8 is periodontally involved. The intended treatment plan is for the extraction of tooth # 8 and 10, and implant placement and crown for # 8, 9, 10, 15, 18, and 19. The subject under review is the medical necessity for the requested implants.

The health plan's determination is upheld.

The requested implants are not medically necessary for this patient. As of clinical exam performed by the treating dentist, the provider indicates that the patient has difficulty with using partials for speaking and causing gag reflex and that patient only uses partials to go out but not to eat. The provider is stating that implants are medically necessary because the patient is unable to wear partials. The reasons provided of dysphasia and nausea do not support the medical necessity for the use of implants.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Slurred Speech, Headache, Decreased Right Sided Body Sensation.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented to the hospital  with complaints of slurred speech with an occipital headache and decreased right sided body sensation. Her medical history was notable for HTN (hypertension) and right basal-ganglionic hemorrhagic stroke. Her NIHSS (National Institutes of Health Stroke Scale) score was 1. Initial neuroimaging in the ED (emergency department) did not show any acute problems. The patient was taken to the floor.

A subsequent MRI (magnetic resonance imaging) of the patient's brain was also negative for acute findings. MRI (magnetic resonance imaging) of the cervical spine showed degenerative changes but nothing to have caused the patient's symptoms. The patient was otherwise noted to have been afebrile and her vitals stable. The patient's neurological examination was otherwise non-focal.

The patient was discharged home upon completion of her work-up with instructions to follow with outpatient neurology.

No, the Inpatient admission was not medically necessary.
In this case, the patient presented with subjective complaints of paresthesia and a complaint of a headache. However, her imaging studies were negative for any acute findings. While work-up for possible stroke was clinically appropriate, such an evaluation is generally performed at a lower level of care.

The patient had no sustained focal neurological findings or deficits. She was afebrile, and her vitals were stable throughout the course of her stay. She had no evidence of any infectious etiology. She had no metabolic abnormalities of concern. In such a context the evaluation that was performed for this patient was more consistent with that provided at a low level of care. The patient's clinical needs did not require inpatient admission.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a history of diabetes and COVID. Late in the evening he presented to the emergency room for worsening pain, swelling, redness, and discharge from his posterior neck. He was seen one day previously and was prescribed an antibiotic ointment and oral antibiotics. On exam, he was well-appearing and was afebrile. Skin exam revealed pustules on the posterior neck with associated swelling, erythema, and tenderness. Labs were notable for a white blood cell (WBC) count of 11,400, glucose 323 milligrams per deciliter (mg/dl), and a urine glucose of greater than (>)10000 mg/dl. A computed tomography (CT) scan of the neck revealed subcutaneous inflammatory changes but no clear collection to suggest an abscess. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The pustules were "drained manually". The patient was admitted for further treatment and evaluation.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. He was afebrile, and there was no hemodynamic instability, mental status changes, or severe metabolic disarray. The diagnosis was not clinically challenging, and the treatment was straightforward. The services provided - intravenous antibiotics and consultations - did not require acute inpatient admission. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.