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

Diagnosis: Back pain.

Treatment: Intraosseous basivertebral nerve ablation (procedure codes: 64628 and 64629) and coverage for the requested treatment.

The insurer denied coverage for intraosseous basivertebral nerve ablation (procedure codes: 64628 and 64629) and coverage for the requested treatment.

The denial is upheld.

This adult patient has chronic low back pain. The patient has tried Physical therapy and is doing a Home Exercise program. The patient has had 2 Epidural Steroid injections. The patient takes Nonsteroidal anti-inflammatory (NSAIDs) for pain. The Magnetic Resonance Imaging (MRI) shows Modic changes at Lumbar (L)4, L5 and Sacral (S)1. It also shows multi-level degenerative changes with disc herniation at L4-L5 which compresses both the L4 and L5 nerve roots and synovial cysts at L5-S1. The request is for Radiofrequency ablation (RFA) of the Basivertebral nerves (BVN) at 2 levels.	

In summary, the publications to date have been company sponsored and had methodology flaws. There is no published data on long-term complication rates. There are other evidence-based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

Conger pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Urits also commented on the need for more research on this promising technique,  
"reproducible large RCTs (randomized controlled trials) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment."

In summary, this procedure is not likely to be more beneficial than the standard of care, the patient is not an appropriate candidate for this procedure at this time, and final approval for the appropriate regulatory bodies have not been provided at this time. 

In summary, the denial of intraosseous basivertebral nerve ablation (procedure codes: 64628 and 64629) 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 and the adverse risk are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient who was admitted to the hospital after an episode of syncope. The patient reported having had three prior episodes of syncope during the preceding month. Upon admission, her heart rhythm was atrial flutter. Her medical history was remarkable for hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), morbid obesity, left bundle branch block and heart failure with a reduced ejection fraction. Her left ventricular ejection fraction (LVEF) was 30 percent (%) despite six months of guideline directed medical therapy. She was transferred to another institution for implantation of a biventricular implantable cardioverter defibrillator, a transesophageal echocardiogram (TEE) and catheter ablation of her atrial flutter. Upon transfer, an electrocardiogram showed atrial flutter with a ventricular rate of 68 beats/minute. A transesophageal echocardiogram (TEE) showed a moderately reduced LVEF and no evidence of intra-cardiac thrombus. The patient's heart rhythm was electrically cardioverted to sinus. The implantable cardioverter defibrillator (ICD) was implanted without complications. The decision was made to perform the catheter ablation at another time. The patient remained stable overnight and was discharged. At issue is the medical necessity of the inpatient admission.

The inpatient stay was medically necessary.  This patient was at considerable risk for major adverse events and required careful and continuous monitoring with the ability to intervene emergently, if needed.  This warranted an inpatient admission.
This patient, with a history of heart failure with reduced ejection fraction, presented with recurrent syncope. While the potential causes of syncope are myriad, the presence of underlying cardiovascular disease is predictive of a cardiac etiology with 85 percent (%) to 94% sensitivity and 64% to 83% specificity. In individuals such as this patient, with depressed left ventricular systolic function, syncope is a poor prognostic factor and is often due to potentially lethal ventricular tachyarrhythmias. Thus, implantable cardioverter defibrillator (ICD) therapy for sudden cardiac death prevention is indicated. Given that this patient had experienced four syncopal spells in one month, she was at considerable risk for recurrent episodes and subsequent mortality. Inpatient stay with continuous cardiac monitoring at a facility where implantable cardioverter defibrillator (ICD) implantation could be accomplished was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic intertrigo

Treatment: Ambulatory surgery

The insurer denied coverage for ambulatory surgery

The denial is overturned

Panniculectomy is performed to remove excess skin and subcutaneous tissue to improve function and decrease morbidities such as ulcerations, non-healing wounds, and hygiene issues. According to the American Society of Plastic Surgeons (ASPS), "panniculectomy could be considered as a functional correction in patients who are of appropriate height and weight and have a history of problems including panniculitis or chronic back pain that have persisted despite an adequate trial of non-surgical management or have a functional impairment in activities of daily living/work." The ASPS also indicates "when panniculectomy is performed to eliminate a large hanging abdominal panniculus done in part to reduce associated symptoms, cellulitis, intertrigo, shoulder pain, neck pain, back pain, thoracic spine pain, lumbago, and panniculitis, this would be considered reconstructive."

Per clinical documentation, the patient is noted to have a small pannus that hangs over the lower abdominal skin fold and a prior Caesarean section scar. The patient was noted on physical examination to have excoriation and chronic intertrigo. The patient has used antibiotics and antifungal creams for at least six months without relief. Per clinical documentation, the health plan did not act reasonably. The patient has intertrigo due to the pannus. The requested panniculectomy is medically necessary.

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

The medical necessity for ambulatory surgery is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

The patient had a history of diverticulitis and presented with abdominal pain and fever. She had a previous diverticulitis attack and was treated with antibiotics. She had a fever of 101.2 degrees F (Fahrenheit). There was no abdominal rebound or guarding. The white blood cell (WBC) count was 17.9. A computed tomography (CT) scan revealed diverticulitis with a fluid collection. Intravenous (IV) antibiotics were given. She improved and was discharged on oral antibiotics. 

Clinical indications for admission for Diverticulitis per Milliman Care Guidelines (MCG M-150- 27th edition) include having a significant abnormality on an imaging study. This abnormality can be a fistula, obstruction, or free perforation. The patient did not have these conditions. Other indications for admission include hemodynamic instability, peritoneal signs, persistent gross bleeding, a drainage procedure required, bacteremia, severe dehydration, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had diverticulitis with a fluid collection. She required antibiotics but did not have a drainage procedure. She could have been given IV (intravenous) antibiotics with observation care. By the next day, her abdomen was reported to be non-tender. She could have then been discharged on a course of oral antibiotics. She did not meet MCG criteria 27th edition for admission for Diverticulitis. 

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 admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: diabetes
Treatment: Ozempic
The insurer denied Ozempic. The health plan's determination is upheld. 

This is a female diagnosed with T2DM (type II diabetes mellitus). This request is for Ozempic. She is stable on Ozempic. The prior authorization form reports that the patient failed metformin and Trulicity due to therapeutic failure. There is no mention of a trial or failure of Victoza. The patient's Hemoglobin (HGB) A1C was 7% while on Trulicity. It was discontinued because of cost. A note from 2014 reports that the patient was started on Victoza. At that point, the HGB A1C was 7.3%.

A formulary exception is not indicated in this case. The formulary alternatives Victoza and Trulicity are not expected to be ineffective or less effective or have more adverse effects than the requested Ozempic.
Ozempic is a GLP1R (glucagon-like peptide-1 receptor) agonist that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes. There are no studies showing superiority of the requested medication over the formulary alternatives. The patient has no evidence of failure of the formulary alternatives in the form of an HGB A1C that is not at goal despite compliance. The patient can try the formulary alternatives.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes. 
Treatment: Afrezza. 

The insurer denied Afrezza. 
The denial is upheld. 

This patient is an adult female with type 2 diabetes complicated by albuminuria. Request for Afrezza is under review. The prior request was denied because "You do not meet the requirements of your plan. Your plan approved criteria covers this drug when you have tried and had an inadequate treatment response or intolerance to the required number of formulary alternatives, or you have a documented clinical reason such as expected adverse reaction or contraindication that prevents you from trying the formulary alternatives, if complete and valid documentation is provided. Your use of this drug does not meet the requirement. This is based on the information that was provided. Formulary alternatives are: Fiasp, Novolin R, Novolog. Requirement: Trial and failure of all the formulary alternatives, but not more than three."
 
The provider is appealing this determination. The patient is being treated with Jardiance, metformin, Novolog, and Lantus. Her glycated hemoglobin (A1C) is 6.2 percent. 

The health plan should not cover the proposed treatment. 

This request is for Afrezza for the treatment of type 2 diabetes. The patient is currently on insulin therapy, including Novolog, with a glycated hemoglobin within goal of 6.2%. The patient does not have documented hypoglycemia, hyperglycemia, lipoatrophy or another medical reason to use Afrezza over Novolog. The American Diabetes Association clinical guidelines do not recommend the use of Afrezza over all of the formulary alternatives in this clinical situation. Therefore, no, the health plan should not cover the proposed Afrezza.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD) exacerbation secondary to influenza.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

Patient is an adult with a past medical history significant for emphysema, COVID-19(Coronavirus Disease 2019), small bowel obstruction, hypertension, diabetes, and internal hernia who presented to the emergency room with complaints of cough, congestion, and shortness of breath.

Vitals on presentation included: Temperature maximum-101.3 degrees F(Fahrenheit), Blood Pressure 141/79, Pulse 105, Respiratory Rate 32, oxygen (O2) saturations 99% on Room Air. Laboratory values were notable for the following: white blood cell count (WBC) 12.9, Hemoglobin (Hgb)-14.4, Hematocrit (Hct)-43, creatinine-0.7, glucose-175.

Patient was empirically started on intravenous (IV) antibiotics (azithromycin and ceftriaxone) for possible pneumonia, as well as solumedrol. Patient tested positive for influenza virus. He was treated with Tamiflu. Patient improved clinically, remained afebrile and hemodynamically stable. He was discharged to continue outpatient management.

According to medical records, patient presented with chronic obstructive pulmonary disease (COPD) exacerbation secondary to influenza viral infection. He was febrile (101.3 degrees F), with tachycardia (heart rate-105), and tachypnea (respiratory rate-32). Laboratory results were notable for elevated WBC (12.9), elevated glucose, and influenza (+). Based on findings including severity of presentation and co-morbid conditions, hospital admission was medically necessary.

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

The medical necessity for the inpatient stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult male with a past medical history of hypertension, hyperlipidemia, and type 2 diabetes. The patient presented to the emergency department (ED) for evaluation of chest pain. On arrival to the ED, the patient was afebrile and hemodynamically stable. He was saturating well on room air. His twelve-lead electrocardiogram (EKG) showed sinus rhythm without acute ST (interval on EKG) changes. His initial labs showed a sodium of 143, potassium of 3.7, chloride of 108, blood urea nitrogen (BUN) of 17, and creatinine of 1.2. Troponins were within normal limits. He was admitted to the inpatient unit and was evaluated by cardiology. He underwent cardiac catheterization which demonstrated a 70% (percent) stenosis in the distal left anterior descending artery. He tolerated the procedure well and was ultimately discharged with outpatient follow-up.

The proposed treatment was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes, and no end organ malperfusion. There was no evidence of acute coronary syndrome (ACS) given that the patient had negative biomarkers and his EKG did not demonstrate acute ST changes. Furthermore, the patient's cardiac catheterization did not demonstrate a culprit occlusive coronary lesion which would support the diagnosis of ACS. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Other/Atopic Dermatitis
Treatment: Dupixent
The health plan denied Dupixent, as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with atopic dermatitis. Per the appeal letter, he has tried and failed Betamethasone, Mometasone, Triamcinolone, and Clobetasol. He has also failed Halobetasol and Tacrolimus. However, no clinical documentation of failure with Tacrolimus ointment is provided.
The medication under review for medical necessity is Dupixent.

The health plan's determination of medical necessity is upheld, in whole.

The requested health service/treatment of Dupixent is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan, such as Tacrolimus ointment, are effective treatments for the management of atopic dermatitis. [1,2]
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, Tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults." [3]
It is noted that the patient has tried and failed topical steroids. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents, such as Tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent.
Therefore, Dupixent is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: progressive familial intrahepatic cholestasis (PFIC).
Treatment: Bylvay.
The insurer denied Bylvay. 
The health plan's determination is overturned.

This patient is a female with a history of progressive familial intrahepatic cholestasis (PFIC), type 2. She has severe pruritus despite biliary diversion. She was started on Bylvay and responded well.

Bylvay is medically necessary for this patient.
Bylvay is Food and Drug Administration (FDA) approved for treating pruritus in patients with PFIC. The safety and efficacy of Bylvay are well established. This patient has PFIC, diagnosed clinically and via liver biopsy. There are new genetic variants of PFIC that cannot be diagnosed on conventional genetic testing. She has already tried and failed medical and surgical therapies for her severe pruritus, including biliary diversion. She responded well to a trial of Bylvay. Therefore, continuation of Bylvay is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Durable Medical Equipment

Diagnosis: decreased mobility
Treatment: Power Operated Vehicle (POV- Scooter)
The insurer denied a Power Operated Vehicle (POV- Scooter). The health plan's determination is upheld.

The patient is a male with type II diabetes, lung cancer treated with radiation therapy, coronary artery disease, ischemic heart disease, hypertension, status post left first and fifth toe amputations due to osteomyelitis and gangrene, claudication, hyperlipidemia, neuropathy, peripheral vascular disease, depression, syncope, and chronic anemia. 

A Power Operated Vehicle (POV-Scooter) is not medically necessary for this patient. A scooter is not an option due to the needs for greater lower extremity support that is not possible with a scooter.
Mobility assessments were submitted by the patient's providers, however despite documentation of decreased cardiopulmonary tolerance, inadequate endurance, the ability of the patient to participate in training, evidence that the patient could independently operate controls, the ability to safely transfer, and no chronic upper extremity pain or dysfunction from long term use of a manual wheel chair, the patient does not have the lower extremity strength and postural stability to allow safe riding in a scooter and therefore, a scooter would not be recommended for this patient. 
Both the Physical Medicine and Rehabilitation physician and the Occupational therapist stated that the patient is not appropriate for a scooter and an electric wheelchair was recommended for this patient.  A scooter is not medically necessary as the patient does not have the postural stability to safely ride on a scooter and the patient requires greater lower extremity support than that provided by a scooter.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
Inpatient hospital

Diagnosis: epigastric pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department with concerns for epigastric and low back pain of 6 day duration. Pertinent history included alcoholic cirrhosis of the liver, pancreatitis, chronic back pain, esophageal varices, thrombocytopenia, and previous lower gastrointestinal bleed. Review of systems was negative for hematemesis, hematochezia, hematuria, or melena. 

The inpatient hospital admission was not medically necessary. Evaluation and management could have been performed at a lower level of care. The patient had a history of compensated alcoholic liver cirrhosis, esophageal varices, pancreatitis and chronic back pain who presented with epigastric and lower back pain of six day duration. This was not associated with hematemesis, hematochezia, or melena. Initial examination documented the patient as afebrile, hemodynamically stable, alert, oriented, and without peritoneal signs. initial evaluation revealed laboratory abnormalities stable from prior results and an abdominal ultrasound negative for ascites, gallbladder abnormalities, biliary dilation, or pancreas abnormalities. Treatment plan included initiation of a proton pump inhibitor and supportive care. An EGD was performed without issue or complication which did not reveal high risk stigmata or a clear etiology for the presenting pain. No other issues or complications were documented. Following observation care, the patient was discharged.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Braces

The insurer denied coverage for braces

The denial is upheld

 
Upon review of the submitted documentation it is evident that the patient exhibits a 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 deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not 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 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 braces is not substantiated.