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

Diagnosis: Severe periodontal bone loss

Treatment: D4263 bone replacement graft - retained natural tooth - first site in quadrant and D4266 guided tissue regeneration - resorbable barrier per site. 

The insurer denied coverage for D4263 bone replacement graft - retained natural tooth - first site in quadrant and D4266 guided tissue regeneration - resorbable barrier per site.

The denial is overturned.

This is a female patient who presented for evaluation and treatment in the area of tooth #30 which was deemed non-maintainable due to periodontal concerns and significant bone loss. The dentist recommended extraction of tooth #30 and placement of a graft and resorbable barrier membrane for ridge preservation. The insurer denied this service stating that the code submitted was incorrect and further the clinical circumstance and services requested does not fulfill the insurer's medical/dental criteria for approval.  

Based on the radiographic images, it is noted that tooth #30 is non maintainable due to severe periodontal bone loss. To maintain ridge height for future prosthetic rehabilitation especially with an endosteal implant in the area, the dentist has recommended the aforementioned grafting procedure and membrane. Ridge preservation procedures with bone grafting are an accepted standard of care service in dental practice and substantiated by peer reviewed literature. As this is a standard treatment, the graft and membrane procedure for ridge preservation is deemed dentally/medically necessary.  Further, the clinical circumstance fulfills the insurer's medical necessity criteria for approval of these services.

However, the insurer is correct in that the procedure code submitted was incorrect as tooth #30 was extracted and the code submitted to the insurer is for grafting with a retained natural tooth. The appropriate code that the dentist should have submitted was D7953.

The decision should modify denial and approve coverage for bone graft (D7953) and D4266 guided tissue regeneration resorbable barrier per site as dentally necessary as they would be a standard of care services in preparation of an extraction site for endosteal implant placement and would be covered services as per the plan's criteria.

The health plan did not act reasonably with sound medical judgement and in the best interest of the patient.
 
Bone replacement graft and D4266 guided tissue regeneration resorbable barrier per site are considered medically necessary for this patient.

The carrier's denial of coverage for D4263 bone replacement graft - retained natural tooth - first site in quadrant and D4266 guided tissue regeneration - resorbable barrier per site should be modified: Correct code from D4263 to D7953; Approve D7953 and D4266.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment Braces
The insurer denied Braces.
The determination is upheld.

The patient has a Skeletal Class II malocclusion, mild maxillary crowding and moderate mandibular crowding, moderate overjet and moderate overbite. The issue for review is the medical necessity for braces.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 15 with no auto qualifiers. Auto qualifiers include a cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 mm or greater and underbite 3.5 millimeters (mm) or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces are not medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic pain

Treatment: service code 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum; and C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure)

The insurer denied coverage for service code 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum; and C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure).

The denial is upheld. 

This is a female patient who has a history of chronic low back pain as a result of a past motor vehicle accident (MVA). The patient's pain radiates across the low back bilaterally as well as down the back of the bilateral thighs. It is exacerbated with any increased physical activity including standing and walking. She has tried physical therapy, heat/ice, medication trials and weight loss. She still has severe pain and her physician wants to perform a multi-level basivertebral nerve ablation.

The Intracept procedure is not the best available treatment for this patient. The publications to date have been company sponsored and had methodologic flaws. UpToDate does not support the use of radiofrequency ablation for low back pain. The Spine Society makes no mention of the Intracept procedure or ablation of the basivertebral nerve using radiofrequency. There are other evidence-based procedures available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

The carrier's denial of service code 22899 Unlisted procedure, spine (Intracept Procedure); C9752 Destruction of intraosseous basivertebral nerve, first two vertebral bodies including imaging guidance, lumbar/sacrum; and C9753 Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  GERD (gastroesophageal reflux disease).
Treatment:  LINX Procedure.

The insurer denied the LINX Procedure.  The denial is overturned.

The patient is a male with heartburn.  He was found to have a hiatal hernia on upper endoscopy, elevated esophageal acid exposure on esophageal pH (potential of hydrogen) monitor, and normal motility on manometry.  He was recommended to undergo LINX.  He has been on Protonix 40mg (milligrams) daily. 

Yes, the health plan should cover the LINX Procedure.

Yes, the LINX Procedure is likely to be more beneficial.

This patient suffers from GERD (gastroesophageal reflux disease).  Even with PPI (proton pump inhibitor) there is refluxing gastric contents.  Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  LINX is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA (Food and Drug Administration).  There is published data on patients, who have had the device for 12 years, showing a very low complication rate and a high resolution of GERD.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  GERD (gastroesophageal reflux disease).
Treatment:  LINX Procedure.

The insurer denied the LINX Procedure.  The denial is upheld. 

The patient is a male with a BMI (body mass index) of 36.12 kg (kilograms)/m2 (meters squared).  He has history of long-standing GERD (gastroesophageal reflux disease) refractory to medications.  He has been on PPI (proton pump inhibitor) bid (twice daily) for more than ten years.  24-hour pH (potential of hydrogen) study revealed an elevated DeMeester score consistent with GERD.  EGD (esophagogastroduodenoscopy) revealed a 3-4 cm (centimeter) hiatal hernia without evidence of Barrett's esophagus.  Esophageal motility was reported to be WNL (within normal limits). 

No, the health plan should not cover the LINX Procedure.

This patient has GERD refractory to medical management.  Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure.  Both of these treatments have been shown in published studies to be more effective than medical management.  LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity.  It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. 

Having said this, relative contraindications to surgical anti-reflux procedures include morbid obesity or BMI (body mass index) > 35 kg (kilograms)/m2 (meters squared), which is excluded for LINX treatment and not recommended for Nissen fundoplication secondary to poor durability of long-term outcomes.  GERD with concomitant severe obesity or BMI >35 kg/m2 should consider bariatric surgery options and/or weight loss and lifestyle interventions, as surgical anti-reflux procedures have had poor long term outcomes in this patient population. 

No, the LINX Procedure is not likely to be more beneficial.

Generally, patients with GERD with concomitant severe obesity or BMI >35 kg/m2 should consider bariatric surgery options and/or weight loss and lifestyle interventions, as surgical anti-reflux procedures have had poor long term outcomes with high recurrence of GERD in this patient population.  Although LINX is a standard procedure for treatment of GERD, exclusions to treatment include: age <21 years, BMI > 35 kg/m2, Barrett's esophagus with dysplasia, hiatal hernia > 4 cm (centimeters) (unstudied), pregnancy, and prior bariatric or gastric surgery. 

This patient has a BMI of > 35 kg/m2 and a 3-4 cm (centimeter) hiatal hernia.  LINX is contraindicated for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Problems (failing restorations on teeth #8, #9, and #10 with fracture of lingual aspects of #8 and #9).

Treatment:  D2752 white glass with gold crown on Tooth 10, D2752 white glass with gold crown on Tooth 8, and D2752 white glass with gold crown on Tooth 9.

The insurer denied coverage for D2752 white glass with gold crown on Tooth 10, D2752 white glass with gold crown on Tooth 8, and D2752 white glass with gold crown on Tooth 9.  The denial is overturned. 

This is a female patient, who presented for comprehensive dental treatment and failing restorations on teeth #8, #9, and #10 with fracture of lingual aspects of #8 and #9 noted.  There is radiographic evidence of open margins.  Based on these clinical findings, the dentist recommended replacement of full coverage crowns on these teeth.  The insurer has denied this service, stating that there are insufficient clinical findings present to justify the need for these services. 

Upon review of the documentation, particularly the radiographs, the preexisting restorations placed on these teeth appear to be failing.  The margins are open.  Radiographically there appears to be possible recurrent caries under the restorations.  Given this clinical circumstance, replacement of these restorations with other full coverage crowns is medically/dentally indicated.  There is adequate bone support of these teeth and adequate coronal structure to successfully support fixed crown restorations.  In this patient, crowns are a conservative restorative option, which would represent a standard of care for this clinical circumstance in general dental practice especially in endodontically treated teeth.  As such, these services, which are also a covered service for this individual, would be deemed medically necessary.

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

The coverage for D2752 white glass with gold crown tooth 10, D2752 white glass with gold crown tooth 8, and D2752 white glass with gold crown tooth 9 is medically necessary for this patient.

Based on the above, the medical necessity for D2752 white glass with gold crown on Tooth 10, D2752 white glass with gold crown on Tooth 8, and D2752 white glass with gold crown on Tooth 9 is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Allergic reaction. 
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is overturned. 

The patient is a girl with a history of asthma who presented with a severe allergic reaction after receiving her vaccinations.

She was well until the day of admission when she developed a rash, as well as swelling of the face, eyelids, and lips approximately 10 minutes after receiving vaccines in the primary care office.  Her symptoms were first noted in the parking lot of the office, and as they were reaching home the swelling had increased and involved both the eyes and the lips.  They returned to the primary care office where emergency medical services were called.  She was subsequently brought to the emergency department for care.  She had no other new exposures, and had previous vaccines with no difficulty.

Upon arrival to the emergency department, she was noted to have angioedema of her skin, all over her body including her periorbital area.  Her eyes were noted to be swollen.  In the emergency Department, she received a bolus of normal saline, intravenous Solu-Medrol, and Benadryl.

The inpatient hospital admission was medically necessary for this patient.

This is a young girl with a history of asthma, who presented with anaphylaxis shortly after receiving her immunizations.  She had a widespread rash, as well as swelling of her eyelids and her lips, and her symptoms were rapidly progressing.  Anaphylaxis requires early recognition and treatment to prevent progression to life-threatening respiratory and or cardiovascular symptoms and signs.  She required intravenous fluids and diphenhydramine, as well as intravenous Solu-Medrol.  She required hospitalization for ongoing treatment as well as continuous cardiorespiratory monitoring with additional therapies as needed to prevent serious morbidity.

Importantly for patients with anaphylaxis, a biphasic reaction may occur with a recurrence of symptoms after the resolution of the first reaction, and the severity of the recurrent symptoms is unpredictable.

The decision-making at the time of admission for this patient was consistent with her young age, the presence of anaphylaxis with a rapid onset after receiving immunizations, including swelling of the eyes and lips and the need for intensive treatment and close monitoring with additional therapies as required to prevent severe morbidity and to observe for a possible biphasic reaction.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a woman who recently underwent sleeve gastrectomy and presented to the emergency department with shortness of breath and dizziness with visual changes. She stated her shortness of breath had gradually worsened. She denied chest pain, fevers, chills, nausea and vomiting. Oxygen saturation was 92% on room air in the emergency department. Past history also included diabetes, morbid obesity, and psoriatic arthritis. Vital signs showed temperature 37.1 Celsius, heart rate 71, and blood pressure 116/57. On exam, heart was regular, breath sounds were normal with no wheezing. Labs showed white blood cell (WBC) 10.1, hemoglobin 10.4, platelets 312, sodium 139, potassium 3.8, creatinine 0.68, and calcium 8.6. Analysis of urine was positive for ketones and bacteria. The computed tomography (CT) angiography of the chest was negative for pulmonary embolus. The patient was admitted for hypoxia and dizziness. The plan of care included supplemental oxygen, incentive spirometry, intravenous (IV) fluids, vitamin B12, thiamine, and physical therapy. 

The inpatient hospital admission was not medically necessary.

The patient presented with dizziness and shortness of breath but had borderline normal oxygen saturation, no evidence of chest pulmonary embolus, no evidence of acutely abnormal electrocardiogram (EKG) changes, and no evidence of acute stroke. Overall, she was hemodynamically stable and primarily received a diagnostic work up. She could have been safely and effectively managed at a lower level of care.

The patient was hemodynamically stable throughout the hospital stay and demonstrated evidence of hypovolemia, with subsequent treatment with IV fluids, but there was no evidence of sepsis, acute stroke, acute seizures, or acute pneumonia explaining her symptoms. She did have recent bariatric surgery, which increases the likelihood of an acute pulmonary embolus, but chest CT angiography was negative in the emergency department.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  GERD (gastroesophageal reflux disease).
Treatment:  LINX Procedure.
 
The insurer denied the LINX Procedure.  The denial is overturned. 

The patient is a woman with reflux and burning going up.  She feels fullness and discomfort.  She has occasional emesis of undigested food.  She was found to have a normal upper endoscopy, elevated esophageal acid exposure on esophageal pH (potential of hydrogen) monitor, and normal motility on barium esophagram with hiatal hernia, delayed gastric emptying, and Gastroesophageal reflux.  Esophageal manometry was normal.  Gastric Emptying Study was normal.  She was recommended to undergo LINX.  She has tried omeprazole twice a day. 

Yes, the health plan should cover the LINX Procedure.

Yes, the LINX Procedure is likely to be more beneficial

This patient suffers from GERD (gastroesophageal reflux disease) causing profound symptoms.  Even with PPI (proton pump inhibitor), there is refluxing of gastric contents.  Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF (Laparoscopic Nissen Fundoplication) make it a less than ideal operation.  LINX is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA (Food and Drug Administration).  There is published data on patients, who have had the device for 12 years, showing a very low complication rate and a high resolution of GERD (gastroesophageal reflux disease).

Therefore, given the above, the health plan should cover the LINX procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  GERD (gastroesophageal reflux disease).
Treatment:  LINX Procedure. 

The insurer denied the LINX Procedure.  The denial is overturned. 

The patient is a female.  She has a reported BMI (body mass index) of 30.1 kg (kilograms)/m2 (meters squared) and history of medically refractory GERD (gastroesophageal reflux disease).  The patient is currently taking PPI (proton pump inhibitor) BID (twice daily).  UGI (upper gastrointestinal series) revealed a small hiatal hernia with GERD (gastroesophageal reflux disease) to the mid-esophagus.  24-hour pH (potential of hydrogen) monitoring revealed significantly elevated DeMeester score consistent with GERD (gastroesophageal reflux disease).  EGD (esophagogastroduodenoscopy) was normal.  Gastric emptying study was normal.  Esophageal manometry was normal.

Yes, the health plan should cover the LINX Procedure.

This patient has GERD (gastroesophageal reflux disease) refractory to medical management.  Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure.  Both of these treatments have been shown in published studies to be more effective than medical management.  LINX is an FDA (Food and Drug Administration)-approved treatment for GERD (gastroesophageal reflux disease) with results that are comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity.  It has been recommended based on the available published literature to be a standard surgical treatment for GERD (gastroesophageal reflux disease) in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. 

There are only a few exclusions to treatment - age < 21 years, BMI (body mass index) > 35 kg (kilograms)/m2 (meters squared), Barrett's esophagus with dysphagia, pregnancy, hiatal hernia > 4 cm (centimeters) and prior gastric or bariatric surgery.  This patient documents no exclusions to LINX treatment, with medically refractory GERD (gastroesophageal reflux disease) and would be considered an acceptable candidate for LINX treatment. 

Yes, the LINX Procedure is likely to be more beneficial.

The patient has failed medical management of GERD (gastroesophageal reflux disease).  LINX procedure has shown comparable mid-to long term durability and efficacy for GERD (gastroesophageal reflux disease) treatment to that or laparoscopic Nissen fundoplication with less morbidity and mortality.  The patient has no exclusions to LINX treatment at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Endocrine/Metabolic/Nutritional/short stature. 
Treatment:  Pharmacy Prescription drugs (Nutropin AQ).

The insurer denied the Pharmacy Prescription drugs (Nutropin AQ).  The denial is overturned in whole.
  
This is a patient diagnosed with idiopathic short stature (ISS).  This request is for Nutropin. 

Yes, the requested Nutropin AQ is medically necessary for this patient.

The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:

Idiopathic Short stature

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4, 5, 6, 7, 8, 9].  Food and Drug Administration approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS [standard deviation score] less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient had a pretreatment height less than or equal to -2.25 SD (standard deviations).  The patient's height velocity and bone age would not allow the patient to reach a normal adult height.  The request therefore meets idiopathic short stature criteria.  The request is consistent with generally accepted standards of medical practice, and is, therefore, medically necessary.