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

Diagnosis: Malocclusion
 
Treatment: D8080-Braces

The insurer denied coverage for D8080-Braces. The denial is upheld. 

This patient is a male with malocclusion. The provider states that impinging overbite with severe soft tissue damage was not considered. In order to assess the severity of the patient's malocclusion a Handicapping Labio-Lingual Deviation (HLD) Index was utilized. Criterion for approval of braces is met in two ways; either by having one of the listed automatic qualifiers or by achieving a score of 26 or more.

The patient does not meet the medical necessity criteria. The provider noted automatic qualifying criteria of "Deep impinging overbite with severe soft tissue damage," but no evidence of this is present in the clinical photos submitted. 

The patient notes no pain or handicapping conditions that are a result of his occlusion. No medical conditions are noted in medical history that would support medical necessity. The patient's clinical presentation as demonstrated through clinical photos and radiographs does not warrant coverage under automatically qualifying condition. The patient's HLD score was 18 which is below the required 26.

Based on the above, the medical necessity for the requested code D8080- Braces (comprehensive orthodontic treatment of the adolescent dentition) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Premenstrual tension syndrome
 
Treatment: lab tests CPT 83090 (homocysteine) and CPT 81291 (methylenetetrahydrofolate reductase)

The insurer denied coverage for lab tests CPT 83090 (homocysteine) and CPT 81291 (methylenetetrahydrofolate reductase). The denial is upheld. 

This patient is a female with a history of headaches, migraines, kidney stone, hypertension, depression, anxiety and environmental allergies. The patient initially presented with reports of premenstrual symptoms, abnormal periods, nausea, headache and fatigue.  The patient had cold hands and feet, muscle aches, neck spasms, anxiety, difficulty concentrating and poor memory. The patient also reported reflux symptoms and canker sores.  Based on the office visit note the patient's assessments were premenstrual tension syndrome and R53.83- other fatigue; the etiology was suspected to be multifactorial.  Based on these assessments, multiple labs, including homocysteine level and methylenetetrahydrofolate reductase (MTHFR) mutation detection were ordered.  The lab tests were performed and the results revealed C-reactive protein (CRP) of 15.29, free thyroxine of 1.15, thyroperoxidase antibody of 89.55, erythrocyte sedimentation rate (ESR) of 27, homocysteine level of 9; MTHFR mutation detection was negative.

According to the literature review, the MTHFR screening is not indicated based on the presenting symptoms. Moreover, even if abnormalities are found, studies have shown that due to the lack of evidence on the risk of clotting and the lack of evidence on the benefits of administering anticoagulation, positive testing does not provide sufficient support to alter and impact treatment and management. The literature evidence for testing homocysteine levels and mutational analysis for the responsible gene, methylene tetrahydrofolate reductase (MTHFR), are not supported.  This is because although elevated levels of homocysteine can be found in patients with thrombosis, the causal role of having elevated homocysteine level in the blood in thrombosis is unclear.  In addition, studies do not support that lowering homocysteine levels with supplemental treatments, such as folic acid, pyridoxine, and vitamin B12, reduce the rate of venous thromboembolism (VTE) in patients with elevated homocysteine level in the blood (i.e., hyperhomocysteinemia). Finally, no symptoms indicative of a thrombotic issue are noted in this patient.
Due to the lack of literature evidence to support the utility of these requested lab tests in the management of this patient's care, CPT 83090 (homocysteine) and CPT 81291 (methylenetetrahydrofolate reductase) were not medically necessary to treat this patient's medical condition. 
The health plan acted reasonably with sound medical judgment and in the best interest of the patient. 
The carrier's denial of coverage for lab tests CPT 83090 (homocysteine) and CPT 81291 (methylenetetrahydrofolate reductase) performed is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Inflammatory Bowel Disease 

Treatment: Fecal Calprotectin

The insurer denied the Fecal Calprotectin. The denial was reversed.  

This is a young male patient who was experiencing episodes of nausea and vomiting, associated with poor eating. It was reported that he was having rectal bleeding. A series of test were performed which included stool for ova and parasites, Celiac antibody, and stool for Calprotectin all of which had negative results. 

Clinical and Experimental Gastroenterology, 2016; 9: 27-29 has an article titled "Fecal Calprotectin in IBD."  The conclusions were that Fecal Calprotectin has adequate sensitivity and specificity in identifying patients who have IBD rather than functional disease.  It has been determined to be useful to assess the disease activity and response to treatment in Inflammatory Bowel Disease.

Inflammatory Bowel Disease, 2014; 20: 1407-1415 has an article titled "Meta-analysis: Fecal Calprotectin for Assessment of IBD Activity."  There were 13 studies examined in the final analysis.  The conclusion was that Fecal Calprotectin is a reliable marker for assessing IBD activity.

This patient was having ongoing nausea, vomiting and rectal bleeding.  There was a concern that he had IBD.  Fecal Calprotectin has been shown to be a good way to differentiate between IBD and functional disease.  The scientific literature shows that it results in improved health outcomes.  The Food and Drug Administration (FDA) has cleared calprotectin as a marker intended for differentiating Irritable Bowel Syndrome from Inflammatory Bowel Disease (IBD).  The patient is a good candidate since one would not want to have to perform a colonoscopy on a young male.  Fecal Calprotectin is the best available treatment since it is non-invasive.  This test is likely to be more beneficial than any standard treatment/procedures for this patient since it makes IBD unlikely and hopefully avoids the need for a colonoscopy.  The denial is reversed. 

The carrier's denial of coverage for Fecal Calprotectin to screen for IBD should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient substance abuse treatment

The proposed treatment, inpatient substance abuse treatment, was not medically necessary for this patient.

The patient in this case was using heroin on a continuous daily basis together with intermittent use of cannabis. The patient presented as and cooperative and motivated to receive detoxification treatment in the absence of severe symptoms of opioid withdrawal. He had recently received detoxification treatment with no mention of whether he had relapsed. Mental status examination was free of severe symptoms, and the patient was noted to deny suicidal ideation or aggressive impulses at the time of admission. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have required inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical presentation was not serious enough to warrant inpatient level treatment or 24-hour monitoring. Moreover, the patient did not present with severe psychosocial stressors that would have posed a problem if detoxification treatment was provided in a less restrictive treatment setting at a lower level of care. Thus, the detoxification treatment (and referral/treatment for/with rehabilitation services) could have been effectively provided at a lower level of care, as the health plan asserts. 

Medical necessity is not met in this case for the time interval under review, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, as well as the clinically appropriate application of NY State OASAS LOCADTR 3.0 Guidelines.

The substance use disorder detoxification services and withdrawal management could have been safely and effectively provided at a lower level of care in this case scenario. Thus, the requested service of substance use disorder inpatient admission for detoxification and other medical services is not reasonable in this case scenario. The patient's presentation and clinical features of substance use disorder did not warrant the intensity of inpatient level services or inpatient level structure or 24-hour monitoring in keeping with New York State Level of Care for Alcohol and Drug Treatment Referral Guidelines (NY State OASAS LOCADTR 3.0 Criteria), referenced below.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for dementia, anxiety, heart disease and chronic lower back pain secondary to spinal stenosis. She has a recent diagnosis of cancer of unknown origin. Her medical problems are associated with weight loss fatigue and ambulatory dysfunction. The patient's physical exam notes that she is wheelchair bound and does not ambulate. Her current medications include Sinemet, Depakote, Aricept, Namenda and Seroquel.

Personal care service hours split shift 24 hours a week are being requested. The services were denied based upon medical necessity stating the following: There is no medical need for frequent nighttime changing of incontinence products. You do not have any decubitus ulcers. You use incontinence products to manage urinary incontinence. Regulation state that the personal care assistant services for safety supervision alone, such as may be clinically necessary for someone with cognitive dysfunction. Personal care assistant hours for companion care or for safety supervision without the need for activity of daily living tasks is not required to be covered under the benefits of your plan. It is noted that Consumer Directed Personal Care Assistance level II 24 hours per day (live in) 7 days per week (Monday through Sunday) were approved by the plan.
The health plan's determination is upheld.
This patient is a female with multiple medical problems most notably ambulatory dysfunction and dementia. There is notation that the patient is wheelchair bound.
The Uniform Assessment System (UAS) State of New York noted that the patient required personal care assistant services for almost all services including activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). The report also noted that the patient has frequent urinary incontinence but no bowel incontinence. Undergarments including pull-ups are used for continence during the day and also during nocturnal hours. No noted decubitus ulcers or other skin breakdown is noted. There is no noted medical documentation stating that the patient needed frequent turning in the nocturnal hours. There is no noted nighttime log necessitating frequent turning or other assistance in the middle of the night. In order for split shift to be considered medically necessary in contrast to a 24 hour live-in aide, there needs to be documentation in regards to the aide not being able to get adequate downtime / rest of at least 5 hours a night. This is not noted.
Medical records note that the patient has dementia of Alzheimer's type.  Patients with dementia of Alzheimer's type frequently have sleep disorders including sun downing and other nocturnal sleeping pattern problems.  It is reasonable to expect that this patient has problems sleeping at night and is awake at times. There is a notation from the patient's granddaughter stating that the aides are not sleeping at night; however, this does not create medical necessity for personal care assistant hours in the middle of the night.   There is no noted medical necessity for care hours in the middle the night.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and monthly visits
The Braces and Monthly visits are medically necessary.

The patient's upper right canine is way out of its proper position. It is too far towards the patient's lip. The upper left canine is in crossbite, meaning it is inside of the lower tooth underneath it. This is backwards from what it should be. The patient has a Class II malocclusion, meaning his lower jaw is retruded, with a reduced airway. All these issues absolutely need to be corrected with orthodontic treatment so that the patient's teeth mesh properly during the chewing cycle (which they are not doing now). There is a high probability that if not corrected, some of his teeth will fracture due to excessive forces on the out-of-position teeth. The patient also has a higher probability of TMJ (temporomandibular joint) problems in the future, as well as a higher chance of developing obstructive sleep apnea. Orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Positive BRCA gene mutation 
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is reversed. 

This patient is a female with a past medical history of major depression and family history of breast cancer and malignant neoplasm of the ovary, who was diagnosed with a positive BRCA gene mutation. She was admitted and underwent bilateral mastectomies with reconstruction.

According to the State of New York Law "Section 2803-O Hospital care for mastectomy, lumpectomy, and lymph node dissection patients:"  "Hospital care for mastectomy, lumpectomy, and lymph node dissection patients. 1. When a general hospital provides mastectomy surgery, lymph node dissection or a lumpectomy, inpatient care shall be offered for a period as determined by the attending physician in consultation with the patient to be medically appropriate."  This patient underwent mastectomy surgery. Her attending physician, in consultation with the patient, recommended hospitalization. 

Per NY State law, the hospitalization was medically appropriate. The health plan did not act reasonably and with sound medical judgment.

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sepsis
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.    

This is a female patient with a history of rheumatoid arthritis, partial thyroidectomy, and Hashimoto's Thyroiditis. She presented to the emergency department(ED) with a fever of 104F and headaches for the past three days. The patient was evaluated for Sepsis. She was consulted by Infectious Disease, Rheumatology and Hematology. She underwent a lumbar puncture and pan cultures which were negative for acute meningitis. Intravenous (IV) broad spectrum antibiotics were administered. She was tested for Lyme and Legionella which were both negative. An initial chest x-ray was performed which was negative for infiltrates and a repeat chest x-ray revealed some congestion which was suggestive of fluid overload. A computer tomography (CT) of the abdomen and chest were done; the chest revealed some nodule changes and the abdomen showed some hepatosplenomegaly. The patient was medically stable and discharged home.

This patient was admitted with Fever of Unknown Origin (FUO) with isolated thrombocytopenia possibly related to sepsis.  Emergent hospitalization was appropriate for this patient. The patient still needed hospital stay beyond 3 days of admission, but if a transfer could be arranged to an in-network hospital then, the patient was medically stable to undertake such a transfer.

As per the Case management notes 2 days after admission - CM gets call from Oscar that patient should be transferred to another hospital "in a few days" since needs in network.  They were given a list of in network hospitals. The next Case management note is dated three days later  - the doctor was made aware that Oscar was not covering the stay as of 2 days after admission date and that the patient needed to be transferred to an in network hospital. There is no indication in the CM note that they attempted to contact any of the in network hospitals to arrange for the transfer. 

In view of the CM notes and the lack documentation of inability to transfer the patient to an in network hospital, the denial of the inpatient admission is upheld. The health plan did act reasonably.

The health plan did act reasonably.

The insurer's denial of coverage for the inpatient admission should be upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history (PMH) of peptic ulcer disease (PUD), asthma, sleeve gastrectomy, obstructive sleep apnea (OSA), hyperlipidemia (HLPD), transient ischemic attack (TIA) and pre-diabetes who was admitted with complaints of (c/o) worsening epigastric abdominal pain associated with nausea and bright red blood per rectum (BRBPR). Vital signs were notable for normal blood pressure. The physical exam was notable for no apparent distress (NAD), abdominal tenderness, and the rectal exam was negative for blood/melena. Lab work was notable for a normal hemoglobin and normal lactate. A computed tomography (CT) scan of the abdomen/pelvis was without acute findings, An ultrasound (US) of the abdomen was without acute findings. The patient was diagnosed with PUD and treated with intravenous (IV) fluids, anti-emetics, a proton pump inhibitor (PPI) and pain control. The patient was deemed stable for outpatient gastroenterology (GI) evaluation and discharged in stable condition. The health plan's determination is upheld.
This patient presented to the ED with c/o abdominal pain associated with BRBPR. The patient was hemodynamically stable, had a stable hemoglobin, did not have persistent orthostasis, there was no evidence of active bleeding in the ED (such as frequent episodes of hematemesis, melena, BRBPR), coagulopathy, known esophageal varices, transfusion requirement, or age greater than (>) 65. The patient's Rockall score was 0, suggesting a low-risk upper gastrointestinal (UGI) bleed. In addition, this patient's Glasgow-Blatchford Bleeding Score was 0, indicating a low-risk GI bleed. Overall, this patient received close clinical and biochemical monitoring and was deemed stable enough to complete the work-up as an outpatient, which could have been safely performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal - Back pain
Surgical Services (All)

The patient is a male with a history of low back pain, high blood pressure and non-insulin dependent diabetes. He is unable to take anti-inflammatory medications. His complaints are low back and bilateral leg pain. He is unable to walk more than 5 to 10 minutes without feeling weakness in his lower extremities. His physical examination noted limited range of motion and forward leaning posture as well as paraspinal muscle spasm. He had a wide based tandem gait.

He has undergone medial branch blocks, lumbar epidural steroid injections since for more than five years and ongoing, and physical therapy. Medications included hydrocodone and gabapentin. The patient's diagnoses included other spondylosis with radiculopathy lumbar region, low back pain, other intervertebral disc degeneration lumbar region and spinal stenosis lumbar region with neurogenic claudication. 

The health plan has denied his request for an interspinous spacer procedure as not medically necessary. 

The health plan's determination is overturned. 

The patient suffers from lumbar stenosis and has failed conservative treatment for six months. He was physically limited in standing and walking and had relief in a forward flexed position. His surgeon felt he would do better with this procedure over a standard open decompression. The procedure is safe and effective for his diagnosis and should be considered medically necessary.

In this case, the interspinous spacer procedure (ISS) device is approved by the Food and Drug Administration (FDA)FDA, has five years with Level one study results that show it is safe, effective and comparable to standard decompression.

Approved indications for use include skeletally mature patients suffering from pain, numbness and/or cramping in the legs (intermittent neurogenic claudication) secondary to diagnosis of moderate degenerative lumbar spinal stenosis with or without grade 1 spondylolisthesis, confirmed by x-ray, magnetic resonance imaging and/or computed tomography, evidence of thickened ligamentum flavum, narrowed lateral recess, and/or central canal or foraminal narrowing, those who have relief with forward flexion of symptoms of leg/buttock/groin pain, numbness, and/or cramping with or without back pain and those who have undergone at least six months of nonoperative treatment. 

Pragmatic experience with stand-alone IPD using the Superion spacer in the real-world, clinical practice environment confirms the success achieved with this treatment in the controlled clinical trial setting. These registry findings further support the continued clinical adoption of this beneficial treatment in patients considering minimally invasive options to manage neurogenic claudication symptoms due to LSS.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Small fiber neuropathy
Issue under review: IVIG

Determination:
The health plan should not cover the IVIG.

The patient is an adult male with small fiber neuropathy. 

There are no high-quality clinical trials or standard of care guidelines supporting that IVIG improves outcomes for persons with small fiber neuropathy. This is not a standard of care treatment for this patient's condition.

The use of IVIG in this clinical context is not likely to be more beneficial than any standard treatment or treatments for the insured's condition.

There is no high quality, prospective, controlled, randomized trials to support that IVIG is effective treatment for small fiber neuropathy.