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

Diagnosis: Mild to Moderate Arthritis

Treatment: Hyaluronan injection for knee pain (procedure code J7324)

The insurer denied coverage for Hyaluronan injection for knee pain (procedure code J7324).

The denial is upheld.

This patient presented to the Orthopedic Surgeon's office with complaints of knee pain. The physical examination was positive for patellofemoral crepitus. An x-ray of the knees revealed mild to moderate arthritis. The physician recommended treatment with physical therapy (PT) and Orthovisc injections. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis (OA) if all other courses failed prior to surgery. 

The recommendations for use of Viscosupplementation have changed. 

A review of the Clinical Practice Guideline by American Association of Orthopedic Surgeons (AAOS) cites:

The OA knee treatment CPG (clinical practice guidelines) contains one significant recommendation change from the CPG, and this is with regard to the issue of viscosupplementation. The OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA)(HA) injections that was largely the motivating factor for the expedited update of the clinical practice guidelines (CPG).

The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, May 2013.)

The Orthopedic group reports "strongly do not recommend use"

There has been no change to this Guideline. 

Additional references and expert opinion do not support benefit. (see below)

A meta analysis was completed of multiple references. This is a high level evidence based criteria which does not support use. 

Based on the above, the medical necessity for the Hyaluronan injection for knee pain (procedure code J7324) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a female with a history of chronic systolic heart failure due to nonischemic cardiomyopathy, cardiac sarcoidosis, implantable cardioverter defibrillator (ICD), chronic kidney disease stage 4, pericardial effusion status post window, aortic stenosis (AS) status post Transcatheter aortic valve replacement (TAVR), breast cancer treated with chemotherapy, diabetes mellitus type 2, hyperlipidemia, anemia, hypertension, obstructive sleep apnea. Records show that the patient presented to the emergency department (ED) for evaluation of worsening shortness of breath, paroxysmal nocturnal dyspnea (PND), orthopnea, and weight gain found to be volume overloaded due to acute on chronic systolic heart failure. Chest x-ray (CXR) showed pulmonary edema. The patient was admitted under inpatient level of care for evaluation and treatment of acute on chronic systolic heart failure. She underwent echocardiogram showing decline in left ventricular ejection fraction (LVEF) from 35% to 20%, moderate mitral regurgitation (MR), and moderate pericardial effusion adjacent to the right atrium but no tamponade. Cardiology service was consulted for evaluation and management. Computed tomography (CT) of the chest showed no new findings. After adequate intravenous (IV) diuresis, the patient was discharged home. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is overturned. 

Given the patient's presentation of acute on chronic systolic heart failure with associated significant volume overload, persistent symptoms beyond the observation level of care time frame, inpatient level of care was medically appropriate and necessary for optimal outcomes and patient safety. 

Given the patient's significant degree of volume overload requiring intravenous (IV) diuresis beyond the observation level of care time period, persistent symptoms of shortness of breath and orthopnea and in the context of worsened LV systolic function, inpatient level of care was medically necessary, appropriate and in the best interest for the safety of this patient. Inpatient level of care in this case is supported by peer reviewed medical literature and expert consensus guidelines on the evaluation and management of acute heart failure (1-3).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain
Treatment: Intracept Procedure

The health plan denied the requested procedure as not medically necessary. 
The health plan's determination is upheld.

This is a male patient. His diagnosis is intervertebral disc degeneration, lumbar region. The patient is noted to have a history of chronic low back pain (CLBP) due to degenerative disc disease with Modic changes and the treating provider requested intraosseous ablation (Intracept procedure).

The patient was seen regarding chronic back pain and bilateral leg pain. It was noted the patient complains of "zap" in his feet with weight-bearing and has reduced activity. It was noted the patient would be starting physical therapy. He tried physical therapy several years ago and has tried medications including over-the-counter (OTC) and prescription non-steroidal anti-inflammatory drugs (NSAIDs). He has had multiple lumbar epidural injections. It was noted the pain radiates. On physical examination there was diminished lumbar range of motion with pain at extremes. There was positive Kemp's and positive facet loading bilaterally. Sensation was intact and reflexes were normal. It was noted they would proceed with another lumbar epidural injection as well as obtain authorization for an L4 - L5 and L5 - S1 Intracept procedure.
At issue is whether the proposed health service of the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

I uphold, in whole, the health plan's determination regarding the proposed health service.

No, there is no evidence to support the proposed health service or treatment of the Intracept procedure as likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve ablation). However, the patient is noted to have radicular symptoms into the lower extremities and there are multiple other findings on MRI that would be considered likely pain generators, including multilevel annular tears and nerve root impingement. This procedure remains experimental and investigational as there is a lack of high-quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. There is a lack of high-grade evidence and large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure. The requested procedure is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain
Treatment: Intracept Procedure

The health plan denied the requested procedure as not medically necessary. 
The health plan's determination is overturned

This patient is a male who has a long-standing history of low back pain. His current pain is localized in the midline lower back with no radiating pain to the buttocks/legs. His pain is worse with exercise, walking, going from sitting to standing position and with prolonged sitting. He had tried pain medications, physical therapy (PT) and epidural injection, but none of these treatments provided adequate pain relief. The physical exam revealed motor strength 5/5 in the upper and lower extremities, decreased range of motion (ROM) in the thoracic and lumbar spine, straight leg raise (SLR) produced back pain only. A lumbar magnetic resonance imaging (MRI) showed annular tears at (lumbar-sacral) L3-4, L4-5 and L5-S1, no significant central and foraminal stenosis, Modic changes at L4-5 and L5-S1 level. This patient was recommended to have the Intracept procedure for his persistent low back pain.
The issue is whether the proposed health service or treatment of the Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination regarding the proposed health service treatment is overturned, in whole.

The proposed health service is medically necessary. The patient has failed extensive treatments including epidural injections, physical therapy, and pain medications. Other potential treatment options are long-term use of medications (non-steroidal anti-inflammatory drugs (NSAIDs), opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the Intracept procedure is medically necessary as the appropriate next step intervention.
The Intracept system was designed to treat low back pain from the vertebral body by ablating basivertebral nerves. There are multiple clinical trials demonstrating the efficacy of this intervention in the treatment of vertebrogenic pain. This patient has persistent back pain consistent with vertebrogenic pain from his L4-5 and L5-S1 degenerative endplate changes.
From reviewing the medical records and current clinical studies, this patient has persistent symptoms consistent with vertebrogenic pain. In addition, an MRI revealed a finding of Modic changes at L4-5 and L5-S1 levels of his lumbar spine. The Intracept procedure is a medically necessary and appropriate intervention for this patient's persistent back pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic low back pain
Treatment: Intracept Procedure

The health plan denied the requested procedure as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a history of chronic low back pain. A magnetic resonance imaging (MRI) of the lumbar spine revealed multilevel degenerative changes, disc bulging and annular tears at (lumbar-sacral) L4-5 L5-S1. It was noted that he had pain for ten years. He was treated with two lumbar epidural steroid injections. Physical therapy was scheduled to begin. A recommendation was made for an Intracept procedure.
At issue is whether the requested Intracept procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination regarding the proposed health service is upheld, in whole.

No. The proposed health service or treatment Intracept procedure would not be likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. The limitation of the studies performed include unavailable long-term comparative data, lack of sham controls and short duration of follow-up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder/Autistic Disorder
Treatment: Speech Therapy
The health plan denied the requested speech therapy visits.
The health plan's determination is upheld.

This female patient has a diagnosis of autism, with receptive/expressive communication deficits.

Short-term and long-term goals are documented, but no indication of progress made towards these goals is provided.

At issue is the medical necessity of the requested outpatient speech therapy (ST) visits.

I uphold, in full, the health plan's determination of medical necessity.

The requested speech therapy health service is not medically necessary for this patient. No indication of progress towards goals and no medical information with an indication that the patient has capacity to progress towards the goals listed are documented in the clinical information submitted.

The patient's therapy progress notes documentation do not support the medical necessity for standards of practice for ST (speech therapy). ST is medically necessary when there is documentation that it is improving a patient's current condition, or preventing or slowing further deterioration of the patient's condition, or to help a person keep, learn or improve skills and functioning for daily living to maintain the patient's current condition AND all of the following elements of the plan are documented in the health care record: the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition, the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider, and the services including amount, frequency, and duration are reasonable under accepted standards of practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with history of asthma, DM (diabetes mellitus), HTN (hypertension), and HLD (hyperlipidemia). She presented to the ER (emergency room) with wheezing and SOB (shortness of breath).

The patient was found to have asthma exacerbation. The patient was treated with oral steroids, nebulizations, IV (intravenous) magnesium and oxygen in the ER (emergency room) without much improvement in the wheezing. The patient was admitted to acute in hospitalization and was treated with oral steroids, and nebulizations.

This admission was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed, since the patient has had multiple admission to the hospital in the last year with ICU (intensive care unit) level of stay.

No, the Inpatient admission was not medically necessary.
The patient had mild asthma exacerbation. The patient's breathing was improved with ER (emergency room) care. The patient was admitted for mild wheezing due to asthma exacerbation. The patient was treated with oral prednisone and nebulizations. The patient was not in any distress. The patient was able to speak in full sentences. The patient was tolerating oral diet. The patient's oxygen level was above 90% (percent) on RA (room air). The patient could have been safely and effectively be treated at a lower level of care. The Inpatient admission was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever And Painful Urination.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He was admitted for an E. coli (Escherichia coli) pyelonephritis. The patient's vitals were as follows: Temperature 99.7, pulse 97, blood pressure 112/73. CT (computed tomography) imaging demonstrated a segmental pyelonephritis. The WBC (white blood cell) count was 17,000. IV (intravenous) antibiotics were started.

On day two, IV (intravenous) antibiotics were continued.

On day three, the patient's WBC (white blood cell) count was 7900. He was afebrile. He received IV (intravenous) antibiotics.

On day four, the patient was discharged home.

No, the Inpatient admission was not medically necessary.
The treatment of a presumptive uncomplicated pyelonephritis/UTI (urinary tract infection) with IV (intravenous) antibiotics did not require an acute inpatient level of care. The patient did not have complicating features such as obstruction, abscess or immunosuppressed status. IV (intravenous) antibiotics can be administered at an observation level of care in an afebrile and hemodynamically stable patient. There were no compelling reasons to support an acute inpatient level of care, as he was medically stable throughout the hospital stay.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
An observation level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Impinging Overbite

Treatment D8080 braces

The insurer denied coverage for D8080 braces.

The denial is upheld.

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 deep impinging overbite, among other 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 to support orthodontic necessity. 

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, a 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. This reviewer concurs with the HLD index with a total of 15 points (5 points overjet, 7 points overbite, 3 points labiolingual spread).

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.  This is confirmed by several studies referenced below. 

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 medical/dental necessity of orthodontic care.

The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for D8080 braces is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Nausea/vomiting
Treatment: Inpatient stay 
The insurer denied the inpatient stay. The health plan's determination is overturned in part (3 day stay was medically necessary).

The patient is a woman with a history of alcoholic cirrhosis who presented with 2 days of nausea and vomiting. She had a history of recent liver transplantation. The patient was evaluated by the transplant team and was admitted to the hospital. The admitting condition was transplant rejection versus (vs) medication induced nausea and vomiting. The patient was noted to have worsening abdominal distention due to ascites. She had had prior paracentesis with evacuation of 8.6 liters of fluid. Abdominal ultrasound showed a normally perfused transplanted liver and ascites.

An inpatient level of care was medically necessary for 3 days. Continued inpatient care was not medically necessary after 3 days. This patient required an acute assessment of her liver transplant, assessment of ongoing immunosuppression and management of hypertension. The complexity of her condition in the setting of recent liver transplant and the reasonable expectation that her care would span a period of at least 48-hours supported the medical necessity of inpatient admission. She required the coordinated care of multiple medical/surgical services and adjustment of her ongoing immunosuppressive drug regimen.

However, as of day 3 the patient was tolerating a diet, there was no description of significant ongoing nausea or vomiting, liver function was normal based on lab data and the management of her headache could have reasonably been performed with a lower level of care in the outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld.

This is a patient who presented to the emergency room with complaints of a 4-day history of right index finger swelling and redness, that had failed to improve on outpatient antimicrobials. 

The patient had no signs of sepsis, hemodynamic alteration, or abnormal labs. In the emergency department (ED), he had no fever, and his vital signs were stable. Nevertheless, he was admitted for intravenous (IV) antibiotics and but the rationale for that is not adequately justified or documented in the ED or Peds (Pediatric) admission notes. Given the localized nature of the fingertip infection, he could safely have been treated and observed as an outpatient on oral antibiotics to cover both bacterial (group A Strep and Staph aureus) and herpetic whitlow infections, after receiving 1 dose of IV antibiotics (Stevens et al). There is a good examination of the extremities documented in the pediatric history and physical, which states normal range of motion, cellulitis with swelling and redness of the right distal index finger 1 centimeter in diameter on the dorsal surface with a whitish collection seen under the skin, tender and fluctuant. The magnetic resonance imaging (MRI) and surgical consultation for incision and drainage (I & D) could have been done as an outpatient. Moreover, it is documented that he had two previous similar infections at this same site in the past two to three years, which is strongly suggestive of herpetic whitlow, which does not need to be treated with intravenous acyclovir (Schiffer & Corey, Mandell textbook). MRI ultimately showed no evidence of osteomyelitis.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.