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

Diagnosis: spondylosis, anterior cervical discectomy and fusion (ACDF)

Treatment: cervical (neck) spinal cord stimulator trial

The insurer denied coverage for cervical (neck) spinal cord stimulator trial.

The denial is upheld.

The patient has a past medical history of spondylosis without myelopathy or radiculopathy of the cervical region.  The patient has been treated with cervical medial branch blocks, cervical epidural steroid injections, radiofrequency ablations of the cervical spine, and bilateral greater and lesser occipital nerve blocks.  The patient had a history of an anterior cervical ( C ) discectomy and fusion C4-C7.  The patient had subjective complaints of neck pain, headache, and upper back pain.  The patient denied any radicular symptoms into the upper extremities.  The patient had undergone a cervical radiofrequency ablation and was able to attain 70-80% (percent) improvement for greater than 2 years.  However, a few months prior to the office visit there was a return of neck pain and severe posterior headache pain, upper back pain, and pain in the shoulders.  The patient had been treated with rest, cold/heat, over-the-counter medications, chiropractic care, injections, physical therapy, and a transcutaneous electrical nerve stimulator (TENS) unit without relief.  The provider recommended a dual-lead spinal cord stimulator to treat the pain.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. This patient is not a good candidate for a cervical (neck) spinal cord stimulator trial. Spinal cord stimulator trial is not considered the most appropriate treatment.

Adverse risks are not increased. 

The submitted documentation indicated she has been previously treated with multiple injections in addition to radiofrequency ablations as well as occipital nerve blocks.  She also has a history of a prior C4-C7 fusion.  She however continues to have complaints of neck pain in addition to headaches and upper back pain.  However, she does not complain of any radicular symptoms.  She states she has upper neck pain with headaches as well as upper back pain and pain to the shoulders.  Therefore, this is not the most appropriate treatment, given a spinal cord stimulator is typically placed to treat chronic intractable neuropathic pain involving the trunk or peripheral nervous system. This procedure is not likely to be more beneficial than any standard services.

The carrier's denial of cervical (neck) spinal cord stimulator trial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: spondylosis, anterior cervical discectomy and fusion (ACDF)

Treatment: cervical (neck) spinal cord stimulator trial

The insurer denied coverage for cervical (neck) spinal cord stimulator trial.

The denial is upheld.

According to the documentation submitted, this patient has a history of spondylosis, anterior cervical discectomy and fusion (ACDF) C(cervical)4-C7, and C4-C7 radiofrequency ablation. She presented to the Pain Management physician's office for a follow up visit for neck pain, headaches, and upper back pain. The patient underwent a cervical epidural steroid injection. Pain was rated at a level of 9 out of 10. The patient has tried chiropractic care, injections, over the counter (OTC) medications, physical therapy (PT), and a transcutaneous electrical nerve stimulator (TENS) unit without relief. The treating practitioner recommended a dual-lead spinal cord stimulator to treat pain.  

A search was performed using Pub Med (National Library of Medicine). The key word was cervical spinal cord stimulator. The references reported several instances of complications secondary to use. There were no guidelines nor treatment recommendations made by National Organizations reporting this as standard of care. The condition is complex with an increased risk to benefit ratio. The Official Disability Guideline (ODG) reports "not recommended." See below. (Small series and retrospective analysis). 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. Food and Drug Administration (FDA) approval has been granted but no policy for benefit or standard of care. This is not a good candidate for a cervical (neck) spinal cord stimulator trial. Spinal cord stimulator trial is not the best available treatment for this patient at this time. The adverse risk are increased and cervical spinal cord stimulator is not likely to be more beneficial than any of the standard treatments for this patient.

The carrier's denial of  cervical (neck) spinal cord stimulator trial should be upheld.  It is not more beneficial than any other standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: spondylosis, anterior cervical discectomy and fusion (ACDF)

Treatment: cervical (neck) spinal cord stimulator trial

The insurer denied coverage for cervical (neck) spinal cord stimulator trial.

The denial is overturned.

According to the documentation submitted, this is a female with a history of spondylosis, anterior cervical discectomy and fusion (ACDF) C[cervical]4-C7, and C4-C7 radiofrequency ablation. The patient has tried chiropractic care, injections, over the counter (OTC) medications, physical therapy (PT), and a transcutaneous electrical nerve stimulator (TENS) unit without relief. The treating practitioner recommended a dual-lead spinal cord stimulator to treat pain.  

Baranidharan et al (2) conducted a meta-analysis of available reports and concluded:
"Findings from this systematic review suggest 10 kHz [kilohertz] SCS [spinal cord stimulation] has an acceptable safety profile in patients with upper limb and neck pain indications and was associated with improvements in pain, function, QoL[quality of life], and medication consumption. Importantly, patients reported high satisfaction with the therapy, reinforcing the benefits patients experience with cervical 10 kHz SCS. Neurological injury and paresthesias were not reported in any of the studies included. Overall, the current evidence suggests 10 kHz SCS is a promising, suitable, and minimally invasive therapy for managing chronic upper limb and neck pain indications." 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. The adverse risks are not increased over other procedures.

The carrier's denial of cervical (neck) spinal cord stimulator trial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic pain
Treatment: Revision of dorsal root ganglion stimulator
The insurer denied revision of dorsal root ganglion stimulator.
The determination is overturned.

The patient has a history of right groin pain, and a prior placement of a dorsal root ganglion stimulator lumbar (L) 1-2. The device is approaching the end of life and has dysfunction of the implantable pulse generator (IPG) with resultant increased pain. The provider has recommended a dorsal root ganglion revision.

At issue is the medical necessity of revision of dorsal root ganglion stimulator.

The requested procedure is medically necessary. The patient has chronic groin pain that has been effectively treated with a dorsal root ganglion (DRG) stimulator since it was placed. The IPG, which is the device that provides the electrical impulse, has reached its end of life and requires revision. Replacement of the IPG is commonplace for DRG and spinal cord stimulators. The literature supports DRG stimulation for selective cases.

The patient has had relief for 5 years, and therefore has achieved a good result from the procedure. Huygen, et al cite "DRG stimulation is an effective therapy for multiple chronic pain disorders. It is a safe and widely used therapy for patients that have failed to receive pain relief and quality of life improvements from other interventions. With the advent of new stimulation modulations in recent years, it is important that treatments are tailored to specific diagnoses and conditions. The DRG stimulation therapy is most successful for treating focal pain in carefully selected patients".

Replacement of the IPG is medically necessary due to the end of life of the battery and the patient's resultant increased pain. The IPG for non-rechargeable batteries have a life between 2-5 years and ultimately require replacement. Eldabe, et al cite "the battery of an IPG is located within the device; when it is depleted, replacement requires repeated operation". Hornberger, et al cite "Fully implantable non-rechargeable pulse generators have a battery life of between 2 and 5 years".
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease
Treatment: Positron Emission Tomography (PET SCAN) (78492), Pre-service
The insurer denied the Positron Emission Tomography (PET SCAN) (78492), Pre-service.
The denial is overturned.

The patient is a female with cardiac risk factors of hypertension, DM (diabetes mellitus) type II, dyslipidemia, overweight, family history of CVD (cardiovascular disease), and a sedentary lifestyle. The patient has chest discomfort, SOB (shortness of breath), MI (myocardial infarction) with occluded RPDA (right posterior descending coronary artery), CAD (coronary artery disease) with stents of the LAD (left anterior descending) and LCx (left circumflex coronary artery), edema, TIA (transient ischemic attack), PAD (peripheral arterial disease).

The patient has new chest pain with an abnormal EKG (electrocardiogram) positive for reproducible ischemia. A cardiac SPECT (single photon emission computed tomography) stress test demonstrated a moderate to severe inferior wall defect with equivocal redistribution and moderate inferior wall hyperkinesis, and a cardiac PET (positron emission tomography) scan was recommended.

Yes, the requested positron emission tomography scan is medically necessary.

The patient has new chest pain with an abnormal EKG (electrocardiogram) positive for reproducible ischemia. A cardiac SPECT (single photon emission computed tomography) stress test demonstrated a moderate to severe inferior wall defect with equivocal redistribution and moderate inferior wall hyperkinesis. In the setting of an equivocal cardiac SPECT (single photon emission computed tomography) study, an old inferior wall MI (myocardial infarction), and new symptoms, a cardiac PET (positron emission tomography) scan is the next examination to evaluate for peri-infarct ischemia. This would determine the treatment options and is standard of care.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, prostate cancer, chronic obstructive pulmonary disease

Treatment: Personal Care Aide (PCA) Level 2: live-in per diem, 24 hours per day, 7 days per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: live-in per diem, 24 hours per day, 7 days per week.

The denial is overturned.

According to the documentation submitted, this is the case of male with a history inclusive of diabetes mellitus, prostate cancer, chronic obstructive pulmonary disease (COPD), coronary heart disease, heart failure, osteoarthritis, depression, legally blind, incontinence and falls. Personal Care Aide (PCA) Level 2: live-in per diem, 24 hours per day, 7 days per week is requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services notes:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse."

There are discrepancies in the level of assistance the patient needs. The 2 recent UAS [Uniform Assessment System] and the previous rehab discharge summary have a higher degree of impairment than the more recent rehab discharge summary. It is apparent that the patient has physical and cognitive impairments, incontinence of bowel and bladder and a history of bedsores. Activity log shows several unscheduled nighttime bathroom needs each night that require assistance. He cannot turn and position, transfer, ambulate, use the toilet or manage a soiled pullup on his own. 

The record demonstrates impairments and resultant nighttime needs. These are not stand-alone safety and supervisory needs.

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

Based on the above, the medical necessity for the Personal Care Aide (PCA) Level 2: live-in per diem, 24 hours per day, 7 days per week is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Home Health Care. 
The insurer denied increase in personal care hours to 24 hours live in 91 hours per week. 
The denial is overturned.

The patient is a female with past medical history significant for hypothyroidism, hypertension, diabetes, arthritis, vertigo, hyperlipidemia, hearing loss, gastroesophageal reflux disease, hypokalemia, chronic ulcer of the foot, open angle glaucoma, gait abnormality, shoulder pain, age-related cognitive decline, osteoarthritis, osteoporosis, and shortness of breath.
This review is from the medical necessity of personal care services 24 hours a day live-in services, 91 hours a week. The patient is currently approved for 7 days a week 8 hours a day for a total 56 hours a week. Increase in services were denied by the health plan based on lack of medical necessity.

The health plan's determination is overturned.

Services were denied by the health plan upon review stating the patient is minimally impaired, and alert and oriented to herself, place, and time with forgetfulness. You are able to walk and move between locations with limited assistance. You are able to move from lying position, turn side to side but limited assistant. You are able to use a toilet with limited assistance. You are occasionally incontinent of bladder, and continent of bowel. You are able to eat the food prepared for you in advance prepared by your aide. Your needs can be scheduled. You can direct your own care. 
Patient Care logs were reviewed, and Uniform Assessment System (UAS) State of New York were reviewed. The patient is a female with multiple medical problems with progressive physical mental decline. She was originally receiving 42 hours a week as services, upon review the services were increased to 56 hours. The patient and family requested additional services, 91 hours a week live-in service. The increased services are medically necessary due to the fact that the patient has multiple unscheduled needs that cannot be met during a lot of time. This has been documented by the care log provided. Since the patient requires assistance with ambulation and toileting and has multiple episodes during the day and at night that cannot be scheduled, this would necessitate further assistance with live-in services.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Open Wound, Left Foot
Treatment: Formulary exception for Santyl
The insurer denied the Formulary exception for Santyl.
The denial is overturned.

The patient is a female who developed a mycobacterial infection requiring incision and drainage.  She was left with a chronic wound that did not heal.  Initially several wound care products were utilized, including Silvadene without any improvement.  She had exposed bone and tendon with fibrous slough.  Attempts at acquiring collagenase were unsuccessful due to insurance coverage.

Yes, the health plan should cover the Formulary exception for Santyl (collagenase).
The patient has a wound with slough that is very dangerous, as there is exposed bone tendon and history of severe infection.  She is at risk for limb loss. A wound with the characteristics described in the clinical records requires frequent debridement. This is done both mechanically, as has been done, and chemical or enzymatic debridement.  This is performed using the medication collagenase.  Other medications are not as indicated or effective as medication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary and Mandibular Crowding, Excessive Overjet

Treatment D8080 braces and D8670 monthly visit x (times) 12

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II, maxillary and mandibular crowding, excessive overjet, and deep impinging overbite among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. 

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 an HLD index is utilized. 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 met and does support comprehensive orthodontic care as on examination of the intraoral clinical images there is evidence of palatal gingival recession due to direct impingement of the teeth on the gingival soft tissues. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

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

The insurer's denial of coverage for Denial of coverage for D8080 braces and D8670 monthly visit x 12 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain, Bloating and Vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented with chest pain, bloating, and vomiting. The
patient has a history of gastroesophageal reflux disease (GERD). She had a short
period of low blood pressure and low pulse and she was transferred to another
hospital. That stay was uneventful with no further vomiting or chest pain. She
received intravenous fluids and her vital signs normalized, she was afebrile and
with normal 100% oxygen saturation. She was admitted to telemetry, and had
testing performed that ruled out ischemia or gastrointestinal (GI) pathology. The
diagnosis was acute gastritis.

No, the inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient
receives and, whether a higher level of acuity is needed to give this care. This is
best reflected in the presentation, physical exam findings, and laboratory orders
and their results; and highlighted in the orders for care.

In this case, the symptoms were atypical and unlikely to be representative of acute
coronary syndrome. Exam and cardiac findings were normal. Biomarkers and
electrocardiogram showed no evidence of acute ischemia . Echocardiogram
showed no wall motion abnormality. The physician's treatment did not reflect a
concern for acute coronary syndrome. The patient's hypotension and bradycardia
were transient, likely vasovagal and dehydration, and responded to simple
conservative therapy.

The letter of appeal was carefully considered but it offered no evidence to support
inpatient level of care. The only cardiac care provided was telemetry, frequently
performed in a lower level of care. The patient was admitted for monitoring and
subsequent tests and therapy did not require an inpatient level of care. There was
no complex care that required inpatient care. This patient had no evidence of
coronary artery disease. All tests showed absence of ischemia.

Milliman criteria requirements were not fulfilled as there was never any evidence of
acute coronary syndrome present.

All testing and therapy would be appropriate, safe and guidelines consistent to be in
lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.

Yes, the health plan acted reasonably, with sound medical judgment and in the best
interest of the patient.
Appropriate level of care determination based on sound medical judgement is in
best of interests of patient.