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

Diagnosis: Back pain
Treatment: Facet joint injections (64635, 64636)
The insurer denied: Facet joint injections (64635, 64636)
The denial is overturned.

The patient is an adult female with low back pain. As of office note from last month, it is noted the patient had 50 percent pain relief for greater than six months from previous radiofrequency ablation, she is participating in a home exercise program, she has done physical therapy in the past, and pain is a six out of ten (6/10). Previous radiofrequency procedure note from nine months ago shows right L4-S1 levels were performed. Request for right L4-S1 radiofrequency ablation was denied as not having 50 percent relief for four months from previous radiofrequency ablation and as such not medically necessary.

The proposed treatment is medically necessary.

Consistent with the standard of care, repeat facet joint medial branch conventional radiofrequency neurotomy performed under fluoroscopy or computed tomographic (CT) guidance in the lumbar or cervical regions is indicated when all the following criteria are met:
1. At least six months have elapsed since the previous treatment; (MET)
2. Greater than or equal to 50 percent relief was obtained for at least four months, with associated functional improvement, following the previous treatment; (MET)
3. No more than three spinal levels (unilateral or bilateral) are to be treated at the same session (MET)
Additional information in the office visit provided from last month, which was after the previous denial, now makes the proposed treatment medically necessary as the above clinical policy on facet joint intervention criteria have all been met.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypotension, renal insufficiency
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with diabetes, ischemic cardiomyopathy status post (s/p) ventricular tachycardia (VT) ablation, chronic kidney disease s/p implantation of Heartmate3 left ventricular assist device (LVAD) who presented to the emergency room (ER) with headaches and dizziness. On presentation, he was afebrile with a heart rate of 58 and blood pressure (BP) of 89/58. He was given 500 milliliters (ml) of fluids. A head computed tomography (CT) scan showed chronic brain infarctions. His blood urea nitrogen (BUN)/creatinine (Cr was) 79/2.6. His hemoglobin was 12.1 grams per deciliter (g/dl). His lactate was 1.5 millimoles per liter (mmol/L).
On subsequent assessment, his BUN was stable at 75.8 but his creatinine rose to 3.0 milligrams per deciliter (mg/dl) despite fluid. His creatinine clearance had decreased to 22 milliliters per minute (ml/min). At issue is the medical necessity of an inpatient hospital admission.

The requested health service/treatment of inpatient admission is medically necessary for this patient. In an LVAD patient with renal insufficiency (CKD) and hypotension, hyponatremia, inpatient admission provides prompt treatment. The combination of renal insufficiency (CKD) and hypotension, hyponatremia in a patient with advanced heart failure with an LVAD is not safely treated in a lower level of care. Monitoring is difficult, not widely available for the LVAD and blood pressure (BP) measurement requires a doppler. Overhydration may lead to right ventricular failure and morbidity.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: papillary thyroid carcinoma
Treatment: home health care: Personal Care Aide Services: 63 Hours Per Week, Consumer Direct, 1 Client. 
The insurer denied Personal Care Aide Services: 63 Hours Per Week, Consumer Direct, 1 Client. 
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for papillary thyroid carcinoma. The patient and her care team requested Personal Care Aide Services: 63 Hours Per Week, Consumer Direct, 1 Client. The patient provided a letter of support on her own behalf. The letter states that she has an aggressive form of cancer and is undergoing radiation treatments. She has required tube hydration due to her salivary gland issues. She uses a wheelchair and cane and reports she still requires assistance. She was recently in a car accident and will be having surgery on her elbow. She reports she needs assistance with meal preparation, transfers, dressing, bathing, transportation, and medication management.

The Personal Care Aide Services: 63 Hours Per Week, Consumer Direct, 1 Client is medically necessary for this patient.
The patient requires assistance with all personal care tasks. She is not able to transfer, ambulate, or toilet without assistance. The requested increase would allow her 9 hours per day of consumer directed aide. This would be a reasonable amount to allow her to complete all of her personal care tasks for the day. She can distribute her consumer directed hours as needed to ensure adequate coverage of all of her needs. The requested increase is medically necessary and reasonable for the patient.
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 including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, and overbite, ectopic eruption and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 26 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 13 points by internal reviewers.

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 does not claim an automatic qualifying condition and completes the second portion of the index. arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 13 points on the HLD index (2 overjet, 2 overbite, 6 ectopic eruption, 3 labiolingual spread) which is below the threshold of 26 points to support 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. 

Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

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.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
Asked to review the case of a gentleman that presented to the hospital complaining of abdominal pain, nausea vomiting and syncope with head trauma.  The patient had presented to the emergency department (ED) one day earlier with abdominal pain and was diagnosed with small bowel obstruction. He left against medical advice. He subsequently was standing at the bank and became lightheaded and lost consciousness, hitting his head.  He subsequently developed nausea and vomiting. Past medical history was significant for peptic ulcer disease and remote duodenal ulcer perforation, hypertension, and prostate cancer.  On arrival to the hospital the patient was bradycardic with a pulse of 44.  Blood Pressure was stable (156/90).  On physical exam the patient was noted to have abdominal tenderness in the epigastric region.  12 lead electrocardiogram (EKG) was significant for sinus bradycardia.  Intervals were normal and no abnormal ST or T wave signals were noted. Serum blood testing revealed no significant abnormality.  The patient was admitted for additional testing and treatment. Head computed tomography (CT) revealed no abnormality.  Telemetry demonstrated sinus bradycardia.  Echocardiogram showed a preserved left ventricular ejection fraction (LVEF) without significant valvular abnormalities.  The patient was treated with IV fluid and discharged following several days of observation. 

This patient presented to the hospital with syncope, head trauma and abdominal pain.  EKG demonstrated sinus bradycardia at a rate of 44. His diagnostic work up pointed to a cardiac etiology for syncope.  In addition, he had nausea and vomiting and had a second viable etiology for syncope (volume depletion) that required acute treatment.  Although patients presenting to the hospital with syncope can often be risk stratified and rapidly discharged from the ED, those with cardiac syncope are at high risk of future events that result in increased morbidity and even mortality.  (Reference 1,2)  Admission to the hospital for work up with subsequent close follow up by a cardiologist was medically necessary.

Based on the above, the insurer's denial must be reversed. 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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion. 
Treatment: braces. 
The insurer denied braces. 
The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion. She has maxillary and mandibular crowing. She is treatment planned for 24-30 months of braces to correct her malocclusion. 

Braces are not medically necessary for this patient. 
The patient does not meet the criteria for automatic qualification for orthodontics. It is not possible to calculate an accurate HLD (Handicapping Labiolingual Deviation) score on this patient with the supplied radiograph since the ruler is present but as previously stated, this patient does not have a 9-millimeter (mm) overjet. 
Discounting the HLD score, there is still no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear. There are functional problems that may occur in dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal, but her overjet would not affect oral health-related quality of life unless it was greater than 6 mm. If her teeth were aligned, it would provide an aesthetic improvement, but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Taltz Injectable 80MG/ML (milligrams per milliliter).
The insurer denied: Taltz Injectable 80MG/ML (milligrams per milliliter).
The denial is upheld.

The patient is an adult male with psoriasis. He has been treated with topical steroids, methotrexate, Enbrel, Humira, Tremfya, and Skyrizi. The provider is requesting Taltz (ixekizumab). The health plan requires a trial and failure of Cosentyx (secukinumab).

The proposed treatment is not medically necessary.

While Taltz is an approved and effective medication for psoriasis, Cosentyx has a similar mechanism of action and is also widely used. The 2020 American Academy of Dermatology-National Psoriasis Foundation (AAD-NPF) joint clinical guidelines for the use of biologics for the treatment of psoriasis only recommend switching biologics if there is a clinical need and the new agent may have better efficacy, safety, and/or tolerability. A 2019 meta-analysis (7) concluded that interleukin (IL)-17, interleukin-12/23, and interleukin-23 inhibitors had high efficacy in the 
achievement of Psoriasis Area and Severity Index (PASI) 75, Psoriasis Area and Severity Index 100, and Static Physician Global Assessment (sPGA) 0/1 or Investigator's Global Assessment (IGA) 0/1 or Physician Global Assessment (PGA) 0/1 in moderate to severe plaque psoriasis after 12 or 16 weeks of treatment. Interleukin-17 inhibitors showed superior efficacy. Therefore, Cosentyx would also be an appropriate therapy, and Taltz is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Computed tomography (CT), thorax diagnostic; with contrast material (s) (71260). 
The health plan denied the computed tomography (CT), thorax diagnostic; with contrast material (s) (71260). 
The health plan's determination is upheld. 

The patient's provider requested a Computed Tomography (CT) scan of the thorax for the diagnosis of non-cardiac chest pain. There was no mention of chest pain in the history of present illness (HPI) section of the note, but the assessment noted "non-cardiac chest pain" as a diagnosis. The note stated, "Given his ongoing non-cardiac intermittent chest pains" and was followed by an order for a CT scan of the chest with IV (intravenous) contrast and without oral contrast. Previous notes from a visit were provided as well. They described "random stabbing pains all over...left sided chest pain." The note also stated the patient had heartburn intermittently for the past year, but it had increased over the month prior. An electrocardiogram (EKG/ECG) was performed which was normal. Laboratory work was requested as well.

The requested Computed Tomography (CT) of the chest/thorax has not been demonstrated to be medically necessary for this patient. 

The patient is documented as having chest pain. He had a normal ECG test. There was no chest x-ray done. Office visit notes do not discuss the differential diagnosis or what the provider was hoping to rule in / rule out with a CT of the chest. The health plan is correct that typically a chest x-ray would be the first imaging test performed. They are also correct that gastrointestinal, cardiac, and respiratory causes should be considered before advanced imaging. Although a CT scan images these structures, it will not be able to rule in or rule out the majority of diagnoses that can cause intermittent pain. Therefore, the requested CT scan of the chest has not been demonstrated to be medically necessary for the patient. The patient should continue to work with his healthcare provider in determining the next steps in the workup for his condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Ozempic 1/0.75 (3) Pen Injector
The insurer denied: Ozempic 1/0.75 (3) Pen Injector
The denial is upheld.

The patient is an adult female. She has a past medical history of obesity and polycystic ovary syndrome (PCOS) treated with metformin and phentermine currently. The patient had a 
good response to Qsymia in the past; however, she was taking phentermine only now. She lost 12 pounds while using Saxenda samples; however, it was not covered by insurance. She was taking Ozempic (semaglutide) and lost 20 pounds. Ozempic coverage was denied due to lack of supporting documentation confirming type 2 diabetes diagnosis. Her reported HbA1c (glycated hemoglobin) is 5.1 from seven months ago. The request is for Ozempic due to significant weight loss while taking Ozempic.

The treatment with Ozempic is not medically necessary. 

The patient does not have type 2 diabetes. Ozempic was prescribed off-label for the sole purpose of weight management. Ozempic has not been studied for weight management, unlike Wegovy. Therefore, the proposed treatment is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Migraine (G43.711). 
Treatment: Formulary exception for Dihydroergotamine Spray. 
The insurer denied: Formulary exception for Dihydroergotamine Spray. 
The denial is overturned. 

The patient is an adult female with migraines. She is currently on Botox and Vyepti. Her provider wishes to prescribe DHE (dihydroergotamine) nasal spray. The patient takes naratriptan/sumatriptan and Reyvow/Ubrelvy as needed. The request was previously denied coverage by the health plan, as they noted that the patient has not tried 3 formulary alternatives. An appeal letter indicates that she has failed all of these medications. 

The health plan should cover the Formulary exception for Dihydroergotamine Spray. 

The patient has tried more than 3 formulary alternatives and meets the formulary requirements. DHE (dihydroergotamine) is available in IV (intravenous) and intranasal forms. She has already tried the IV (intravenous) form. DHE (dihydroergotamine) has a long history of use, and data shows that it is safe and effective. For these reasons, the health plan should cover the formulary exception for DHE (dihydroergotamine) nasal spray.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
inpatient hospital

diagnosis: abdominal pain
Treatment: inpatient stay

The insurer denied an inpatient stay. The health plan's determination is upheld. 

This patient is a man who presented with the complaint of severe abdominal pain and nausea of 1-day duration. Vital signs at the time of presentation included a heart rate of 90/minute and blood pressure of 154/96. Comorbid health conditions included a history of pancreatitis, hypertension, hyperlipidemia, and diabetes. He had epigastric tenderness and distention on examination. Lab data identified normal liver enzymes and bilirubin with normal amylase and lipase. The white blood cell (WBC) count was elevated at 12.4. A computed tomography (CT) scan showed dilated small bowel with a transition point in the left hemiabdomen and a pancreatic pseudocyst.

Inpatient hospital admission was not medically necessary for this patient. This patient presented with abdominal pain. He was clinically and hemodynamically stable. His evaluation with examination, lab data, computed tomography (CT) scan, and magnetic resonance cholangiopancreatography (MRCP) identified a pancreatic pseudocyst. Gastroenterology consultation was obtained and the patient underwent endoscopic ultrasound guided pseudocyst drainage.

The patient was provided intravenous (IV) fluid and follow up lab assessment. He remained clinically stable during the period of monitoring. This patient's clinical needs could have been satisfied at a lower level of care. This level of care would have provided for clinical assessment, treatment, and monitoring as was performed.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Left small saphenous vein and gastrocnemius vein thrombi
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a history of hypertension (HTN) and hyperlipidemia (HL) who was sent to the emergency department (ED) after the patient reported developing severe left lower extremity pain and swelling one day after starting Eliquis. The patient had been diagnosed with left small saphenous vein and gastrocnemius vein thrombi and was started on Eliquis.
A repeat venous duplex exam of the left lower extremity demonstrated new, acute clots in the left soleal vein and left posterior calf varicose vein and acute clots in the left gastrocnemius vein and left small saphenous vein. Vascular surgery was consulted and the patient was diagnosed with a left lower extremity deep vein thrombosis with propagation, and was admitted to the hospital and started on a heparin drip and serial neurovascular exams and pain control.
The issue for review is whether inpatient admission was medically necessary.

The requested health service/treatment of inpatient stay was medically necessary for this patient.
The patient was diagnosed with a left lower extremity DVT (deep vein thrombosis) as an outpatient and failed initial therapy with anticoagulation. The patient required admission for treatment that required further work up of the patient's DVT.
He was admitted to the hospital and started on a heparin drip and had serial neurovascular exams and pain control. Hematology/oncology was consulted and the patient was diagnosed with an unprovoked left lower extremity (LLE) deep vein thrombosis (DVT). They recommended continuing the patient on therapeutic low molecular weight heparin (LMWH) and warfarin, and a computed tomography (CT) scan of the chest, abdomen and pelvis to evaluated for an occult malignancy. They recommended outpatient follow up in 2 months.
The patient improved clinically, and was therapeutic on his anticoagulation. A computed tomography (CT) scan of the chest, abdomen and pelvis demonstrated mild lung emphysematous changes and was negative for malignancy. The patient was stable for discharge to home and was discharged. The inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion. 
Treatment: D8080 Braces, D8670 Monthly Visit. 

The insurer denied: D8080 Braces, D8670 Monthly Visit. 
The denial is upheld. 

The patient is a teenage male with unknown case history. The health plan denied coverage of the requested braces due to a handicapping index score of 22. The denial is being appealed. 

The D8080 Braces, D8670 Monthly Visit are not medically necessary. 

Determining whether a patient needs orthodontic treatment requires the inclusion of quality photographs. In this case, no photographs were supplied to show the patient's dentition. Without the photographs, the medical necessity of the requested braces and monthly visits cannot be confirmed.