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


Diagnosis: Migraines.

Treatment: Procedure codes 64716, 64732, 21137, 64771, 64787, and 64722, surgery to treat chronic migraines.

The insurer denied coverage for procedure codes 64716, 64732, 21137, 64771, 64787, and 64722, surgery to treat chronic migraines.

The denial is upheld.

The patient is a female who was hit in the head with a ball and has chronic migraines. The physician noted that the patient was hit on the back of the head a year ago playing volleyball in high school and has had significant headaches since that time. That was her second concussion and she had neck pain and nausea after that; she has neck pain and pain that radiates from her face and near the ears. She has pain in different directions and also from the back of her head. She has not improved with medical therapy, and she is "desperate to do whatever she can to make things better." On exam she is well appearing and breathing comfortably, and he noted "given the many different places involved at this point she may not ultimately be a great candidate for migraine or headache surgery." The doctor noted that she had injection "in bilateral upper eyebrows and preauricular regions," after which her headaches went away. BMI (body mass index) was 24.  

American Society of Plastic Surgeons has a policy statement that reads, "based on a comprehensive literature search and review of a large body of peer-reviewed scientific evidence, peripheral nerve surgery for refractory chronic migraine headache is safe and effective in the treatment of patients with a suspected peripherally generated centrally conducted migraine headache etiology. Although some data suggest that decompression of the nerves provides some benefit, overall, the history presented in the records, with mechanism of injury being "hit in the back of the head during a volleyball game," and less than one day improvement after injection of the nerve roots, all suggest that surgical intervention is not necessary. Anthem Medical Policy SURG.00096 (Surgical and Ablative Treatments for Chronic Headaches) states, "surgical treatment for chronic headaches is considered investigational." 

The records do not establish that the planned procedure, for decompression of the supraorbital nerves, supratrochlear nerve, and preauricular nerve is likely to be more beneficial than any other existing standard health service.    

The carrier's denial of procedure codes 64716, 64732, 21137, 64771, 64787, and 64722, surgery to treat chronic migraines should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld


Diagnosis: Migraines

Treatment is procedure codes 64716, 64732, 21137, 64771, 64787, and 64722, surgery to treat chronic migraines.

The insurer denied coverage for procedure codes 64716, 64732, 21137, 64771, 64787, and 64722, surgery to treat chronic migraines.

The denial is upheld.

This case involves a female who was complaining of migraines. The documentation indicated she was hit in the back of the neck approximately a year prior playing volleyball in high school and has had significant headaches since that time. She has had a prior concussion and indicated she has had nausea and vomiting in addition to neck pain. She has been treated by neurology as well as psychology and put on epilepsy medication in an attempt to help her symptoms however nothing is worked. She did undergo injections and headache symptoms did dissipate for some time. Is recommended she keep track of her headaches and may or may not be a great candidate for a migraine headache surgery. She stated she did have improvement with local anesthetic blocks of the supraorbital region and auriculotemporal nerves bilaterally. Her headache did go away until the following morning when she woke up. She was wanting to proceed with surgery. The documentation indicated she was booked for surgery and recommended to undergo preoperative clearances. The surgical codes provided included a neuroplasty and/or transposition of cranial nerve with foraminotomies/osteotomy of frontal bone, release of zygomaticotemporal branch and or auriculotemporal branch, transection/avulsion of cranial nerve, implantation of nerve in the ends into muscle.

There is no scientific evidence to support the requested procedure.

Given that there is no scientific evidence to support the requested procedure, the patient is not a candidate.  

Given that there is no scientific evidence to support the requested procedure, the requested codes are not a treatment for migraines.

Given that there is no scientific evidence to support the requested procedure, there are inherent risks to the requested procedure.

Given that there is no scientific evidence to support the requested procedure, it is not likely to be more beneficial than any other existing standard health service.

The carrier's denial of procedure codes 64716, 64732, 21137, 64771, 64787, and 64722, surgery to treat chronic migraines should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld


Diagnosis: Migraines.

Treatment: Procedure codes 64716, 64732, 21137, 64771, 64787, and 64722, surgery to treat chronic migraines.

The insurer denied coverage for procedure codes 64716, 64732, 21137, 64771, 64787, and 64722, surgery to treat chronic migraines.

The denial is overturned.

According to the documentation submitted, this is a female with a history of migraines after being hit in the head by a ball. She presented to the Plastic Surgeon's office for a follow up visit for migraines. She has failed medical therapy to treat migraines. The physician recommended nerve decompression surgery to treat migraines. 

Peripheral nerve trigger point decompression for migraine headaches is not experimental. A systematic review of the surgical management of migraine headaches concluded: "Peripheral nerve decompression surgery is highly effective in reducing migraine headache frequency and migraine headache intensity. However, not all patients benefit from the surgical procedure, with a small subset showing no improvement."  Another systemic literature review concluded: "Nerve decompression surgery is an effective way of treating headaches in a specific population of patients with neuralgia. Although a meta-analysis of the current data was not possible, the extracranial decompression of peripheral head and neck sensory nerves has a high success rate."  

The patient has failed medical management and multiple studies support the efficacy of surgical intervention for patients with medically refractory and debilitating migraine headaches. Migraine headache surgery is safe with few risks and the potential for enormous clinical benefit. The proposed headache trigger point surgery is likely to be more beneficial than standard medical therapies, all of which have thus far failed to improve the patient's clinical condition.

The carrier's denial of procedure codes 64716, 64732, 21137, 64771, 64787, and 64722, surgery to treat chronic migraines should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical Incompetence

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a female who presented to labor and delivery requesting admission for antenatal monitoring and possible pessary placement because of a history of short cervix. The patient has a history of incompetent cervix S/P (status post) 2 failed cerclage procedures. She was maintained on vaginal progesterone. She was seen by maternal fetal medicine. Pessary placement was discussed, and the patient was informed that the data does not report an improvement in outcome with pessary placement. She was fitted with a pessary. She was discharged home.

It is unclear why this patient was admitted. According to the submitted information, she was admitted because of concern about her short cervix but nothing was done in the hospital except for fitting her with a pessary. Note that a pessary fitting does not require hospital admission, as it could be done easily as an outpatient. Note that fetal monitoring was not necessary, as the fetus was previable. The patient was already on vaginal progesterone, she had failed twice placement of a cerclage, and there was nothing that needed to be done at this time. While the effectiveness of the pessary is questionable, as mentioned above, this could have been done as an outpatient without the need for admission.

According to MCG (Milliman Care Guidelines), admission is indicated for one or more of the following:

1) Condition requiring premature delivery 2) Fetal distress or demise 3) Preterm pre-labor rupture of membranes 4) Significant maternal disease 5) Vaginal bleeding 6) Complications of tocolytic treatment 7) Continued fetal monitoring that require inpatient care 8) Tocolytic therapy needed that requires inpatient care 9) Inability to stop preterm labor.

This patient did not have any of these conditions. Based on the above, admission to the hospital was not medically necessary. This is in accordance with standard of care and Milliman guidelines.

The health care plan acted reasonably, with sound medical judgment, and 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.  

The patient is a male with a two-week history of intermittent diarrhea and several-day history of vomiting who presented to the emergency department (ED) for evaluation. They had recently returned home from a trip to Europe, but there were no known ill contacts. Vital signs included temperature 37.3, respiratory rate 26, heart rate 136. Examination was unremarkable except for diaper rash. Intravenous (IV) access was unsuccessful despite multiple attempts, so he was treated with intramuscular (IM) Zofran. He was given an oral challenge which he tolerated. Laboratory studies were significant for elevated chloride (113), metabolic acidosis (carbon dioxide [CO2] 14), and leukocytosis with white blood cell (WBC) count 19.2. He improved, with diarrhea only following milk ingestion. He began taking more regular foods and had no vomiting. Repeat labs revealed resolution of hyperchloremia, improved CO2, unremarkable urinalysis, and negative pending blood culture. Gastrointestinal (GI) polymerase chain reaction (PCR) panel was positive for enteropathogenic Escherichia (E). coli (EPEC), Enteroaggregative Escherichia coli (EAEC), Norovirus, and Sapovirus, necessitating only supportive care. He was deemed stable for discharge home.

This patient could have been safely managed at a lower level of care.
Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of 5 years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications. Hospitalization may be necessary for those that do not respond to oral hydration and anti-emetic treatment, as well as those with severe dehydration.
This patient presented to the ED with two-week of intermittent diarrhea and new-onset vomiting. He was found to have laboratory indicators of dehydration (hyperchloremic metabolic acidosis) on evaluation but had an unremarkable physical examination except for tachycardia. He was able to tolerate an oral challenge in the ED following Zofran administration. However, because of the laboratory abnormalities and the prolonged course of the illness, he was admitted to the hospital. While it was reasonable to monitor him for ongoing ability to tolerate liquids and keep up with diarrhea losses, he was overall hemodynamically stable without impending hypovolemic shock or other significant sequelae of infectious diarrhea. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Onychomycosis. 
Treatment: Formulary exception for Jublia. 

The insurer denied the Formulary exception for Jublia. 
The denial is overturned. 

The patient is a male with onychomycosis, treated with Jublia.  The patient has a liver condition, and therefore systemic anti-fungals have been avoided. 

The provider is requesting Jublia.  The health plan prefers a trial and failure to preferred alternatives terbinafine and itraconazole. 

Yes, the health plan should cover the Formulary exception for Jublia.
After review of the evidence based medical literature for onychomycosis, there are no strict requirements for Itraconazole or other systemic anti-fungals before topical anti-fungals. 

The meta-analysis referenced attempted to compare data among the systemic anti-fungals and found superiority of oral Lamisil over other systemic anti-fungals, but did not compare the systemic agents to topical agents.  The topical agents were compared to placebo and showed similar efficacy to systemics. The analysis concluded that because treatments are seldom directly compared in randomized controlled trials, more comparative studies are needed before firm guidelines can be established. 

The comparative analysis showed that "Efinaconazole potency against many common onychomycosis organisms was similar to or greater than those of antifungal drugs currently used in onychomycosis, including amorolfine, ciclopirox, itraconazole, and terbinafine." 

Therefore, there is no support in the current medical literature for a trial of Itraconzole before Jublia solution.  Jublia is a new topical agent with far greater safety profile, and efficacy comparable to systemic Lamisill and Itraconazole. 

The formulary agents would have adverse effects for the patient and should be avoided in patients with abnormal liver function.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Primary focal hyperhidrosis

Treatment: Botox to treat primary focal hyperhidrosis, axilla

The insurer denied coverage for Botox.

The denial is upheld.

The patient is a female with hyperhidrosis. The requested medication is Botox injection.  

Based on the submitted documentation, Botox is not medically necessary. There is no documentation provided that the patient has failed traditional therapies for hyperhidrosis which are known to improve the condition. Treatment with topical therapies such as Aluminum chloride (Drysol) as well as oral therapies such as glycopyrrolate are known to improve the symptoms of hyperhidrosis and are within the standard of care for therapy and are associated with a limited side effect profile. One such example is the conventional treatment oxybutynin, which has been shown to be effective for hyperhidrosis. Wolosker, et al writes in "A randomized placebo-controlled trial of oxybutynin for the initial treatment of palmar and axillary hyperhidrosis" that "Treatment of palmar and axillary hyperhidrosis with oxybutynin is a good initial alternative for treatment given that it presents good results and improves quality of life." (5)

The conventional agents are appropriate agents for the treatment of the patient's hyperhidrosis. The conventional medications should be tried and failed prior to initiating Botox. After review of the documentation provided, there is no documentation provided that would justify the patient requiring treatment with Botox prior to the conventional alternatives such as oxybutynin.  

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

The insurer's denial of coverage for Botox to treat primary focal hyperhidrosis, axilla is upheld. Medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin Disorders - Psoriasis.
Treatment: Pharmacy/Prescription Drugs - Taltz.
The health plan denied Taltz for this patient because he did not meet the formulary exception for this medication. 
The reviewer has upheld in whole the health plan's determination.

The patient has psoriasis. Body surface area affected is 30 percent (%). He has tried and failed phototherapy and clobetasol. It is noted that Skyrizi and Cosentyx were both tried and "drug was not effective" according to the submitted documentation. The prescriber is a dermatologist. The medication under review is Taltz 80 milligrams per milliliter (mg/ml) auto injector.

The formulary drugs, methotrexate, cyclosporine, acitretin, Humira, Otezla, Stelara, Tremfya, Enbrel and Cimzia, would not be ineffective. The formulary drugs would be as effective as the non-formulary drug, Taltz. The formulary drugs would not have adverse effects.

According to the American Academy of Dermatology Psoriasis Guidelines and medical literature, the preferred medicines Humira and Stelara covered by the patient's insurance plan are effective treatments for the management of psoriasis (1, 2). Within the peer-reviewed literature, according to Burness, et al, "well-designed randomized clinical trials demonstrated that adalimumab 40 milligrams (mg) every other week (eow) effectively reduced the signs and symptoms of psoriasis and improved dermatology-specific and general measures of health-related quality of life, with these benefits sustained during long-term treatment" (3). Langley, et al writes, "Treatment with ustekinumab for up to 5 years was safe and effective" (4).

The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents are appropriate agents for the treatment of the patient's psoriasis. The formulary medications should be tried and failed prior to initiating Taltz.

It is noted that the patient has failed clobetasol. However, there is no documentation provided that would justify the patient requiring treatment with Taltz prior to the formulary alternatives such as Humira or Stelara. There is no proof or documentation provided the patient has tried these preferred drugs and had an adverse effect or proof that these formulary tried drugs did not work for the patient.

It is noted that Skyrizi and Cosentyx were both tried. However, there is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the other preferred therapies such as Stelara and Humira, which are effective according to the dermatology evidence-based literature for the treatment of psoriasis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting. 
Treatment: Inpatient Stay. 

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

The patient is a female with a history of polysubstance use disorder who presented to the emergency room (ER) with complaints of nausea, vomiting, diarrhea and difficulty sleeping for 4 days. She stated she had stopped using crack and heroin 7 days prior and expressed desire to pursue sobriety. She had been on a rehab program in the past and also had previous admissions for opioid overdose. She had also been on Suboxone and Methadone in the past.

The inpatient level of care was not medically necessary.
The review of records showed that the patient presented to the ER with a request for treatment as she had been trying to quit drugs. She had stable vital signs, was not altered, had no neurologic deficits on exam, and had no history of seizures. She had complained of vomiting and diarrhea, but her labs did not indicate Acute Kidney Injury and she received IV fluids as well as anti-emetics. Thereafter, she did not have protracted vomiting and was not described as dehydrated.
As such, her symptoms of withdrawal could have been managed at a lower level of care and the Inpatient Hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion. 
Treatment: Comprehensive Orthodontic Treatment. 

The insurer denied coverage for comprehensive orthodontic treatment

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. 

Upon review of the submitted documentation, (study models were not provided for review), 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 the use of an orthodontic Index, the Handicapping Labia-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 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 of the insurer with a total of 10 points (4 points overjet, 4 points overbites, 2 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 insurer's denial of coverage for the comprehensive orthodontic treatment is upheld. Medical Necessity is not substantiated.