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



Diagnosis: alopecia areata

Treatment: Xeljanz 5 milligram (mg) Tablet (procedure code J8499)

The insurer denied coverage for Xeljanz 5 milligram (mg) Tablet (procedure code J8499)

The denial is overturned.

The patient is a child with a history of severe alopecia areata with significant scalp hair loss.  The patient has failed therapy with topical, intralesional, and oral steroids. The requested medication is Xeljanz.  

The patient has extensive disease involvement of alopecia which necessitates systemic therapy.  Limited systemic options are available for a young child.  The use of light therapy and topical therapy would likely not be sufficient to appropriately treat the patient's severe disease.  While Food and Drug Administration (FDA) approved systemic therapies are available, none of them are approved in young children.  Xeljanz at the low dose which appears to be the intended dosing regimen may represent a viable treatment option.  In this clinical situation Xeljanz is an appropriate treatment option and may represent the best available option for treatment of the patient's alopecia areata.   The patient's parents have documented that they are aware of possible side effects and wish to proceed with Xeljanz therapy.  

The use of Xeljanz is likely to be more beneficial compared to other standard treatments and procedures without significant added risks.  

The denial is reversed and the use of Xeljanz is appropriate for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment.

In summary, the denial of Xeljanz 5 milligram (mg) Tablet (procedure code J8499) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Total ankle replacement surgery
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult male patient that was admitted to the hospital. This was for an elective total ankle replacement. He had a history of chronic opioid use. On the day of admission, the patient underwent: left total ankle replacement with the INBONE total ankle; left calcaneal osteotomy, medializing translation; left intraoperative C-arm of the ankle less than one hour by operative surgeon; and left bone marrow aspirate from the iliac crest. The patient was discharged on day number (#) 5.

The requested health service was not medically necessary.

The medical records were significant for the patient having a history of chronic opioid use. The facts were that he had undergone several orthopedic procedures in the past and required morphine sulfate immediate release (MSIR) on a continual basis. The medical records showed that as of 
post-operative day 1 (POD #1), the patient's patient-controlled analgesia was discontinued, and he returned to taking his morphine sulfate immediate-release. The pain management consults showed ongoing use of oral medication and satisfactory pain response. The patient underwent a complex ankle reconstruction including osteotomies and bone grafting (with his ankle replacement). The medical records showed that surgery was almost four hours. There was limited blood loss. A drain was not used. The post-surgical reports showed no complications. The vital signs were stable. There was no bleeding, no neurologic deficits, and no problem with his wound. He was able to tolerate physical therapy. He did not have a medical condition to require additional consultation nor imaging. The discharge summary did not provide a reason for the ongoing acute level hospitalization. The denial language was appropriate and consistent with the clinical presentation. Therefore, the requested health service was not medically necessary.
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 Deviation (HLD) index attaining 27 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 15 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 Labio-Lingual 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 27 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 15 points on the HLD index (6 overjet, 3 overbite, 3 ectopic emption, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labio-Lingual 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.

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: Upheld

Diagnosis: Jaw fracture. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a male with a history of ethanol (EtOH) use disorder, hypertension (HTN), and WPW (Wolff-Parkinson-White). He presented with bilateral subcondylar mandibular fractures and R (right) parasymphyseal fractures sustained from a motor vehicle accident. He reported pain to the jaw bilaterally, with inability to close bite. He also had lacerations to sides of tongue from biting. A computed tomography (CT) of facial bones demonstrated bilateral mandibular condylar traumatic fractures and fractured comminuted symphysis of the mandible with subcutaneous air dissecting through the soft tissues in the prevertebral space. 

Inpatient hospital admission was not medically necessary. 
According to the Milliman Care Guidelines, 27th Edition, "General Admission Criteria", the patient did not meet criteria for an inpatient admission. The patient had pain following the surgery but was hemodynamically stable. His pain was controlled with analgesics. He did not have any significant physiologic or surgical complications following the procedure. He could have been managed at a lower level of care. This patient was medically stable and needed only additional analgesic medication and a short period of post-anesthesia monitoring of his airway. He could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck/back pain, breast hypertrophy
Treatment: Breast reduction
The insurer denied the breast reduction.
The health plan's determination is upheld. 

The patient is a female who had macromastia with neck and back pain, intertrigo and kyphosis resistant to non-surgical therapy. Her surgeon performed bilateral breast reduction. The surgeon removed 718 grams from the right breast and 779 grams from the left breast. 

The breast reduction is not medically necessary.

The records contain only hospital notes. Preoperative office consult notes should be provided that better document the indications for surgery. According to the plastic surgeon's operative note, this patient complained of neck and back pain due to her large breasts. These are the typical complaints of women who suffer from macromastia. Photos, however, are not provided for review. A work-up for other possible causes of her symptoms is not documented, and she has not seen a musculoskeletal specialist. The records do not include any PCP (primary care provider) notes that document attempts at medical treatment for chronic musculoskeletal pain such as chiropractic care, physical therapy, analgesics, or support bras. Confirmatory evidence of symptoms, such as a history of conservative therapy, photographic evidence of severe breast hypertrophy, or a history of frequent primary care physician visits for musculoskeletal symptoms is necessary to support the history provided by the plastic surgeon. Other than the history of symptoms provided by the patient to her plastic surgeon, the records do not provide any documentation that supports a need for a reduction mammoplasty.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Weakness, Lightheadedness, Elevated Blood Pressure.
Treatment:  Inpatient Hospital Stay.

The insurer denied inpatient hospital stay. The determination is upheld.

This is a female patient with a past medical history (PMH) of alcohol abuse, hypertension (HTN), peripartum cardiomyopathy, generalized anxiety disorder (GAD), bipolar disorder (d/o), and paranoid schizophrenia who was admitted with complaints of (c/o) subacute weakness, lightheadedness, and headaches after running out of her hydrochlorothiazide (HCTZ) one month prior to presentation. Vital signs were notable for blood pressure (BP) 178/109. The physical exam was notable for well-appearing, no apparent distress (NAD), no focal deficits, normal respiratory effort. Lab work was notable for negative troponin. Imaging studies, a chest x-ray (CXR) showed no acute pathology, transthoracic echocardiogram (TTE) showed no wall motion abnormalities and normal ventricular function, and renal ultrasound (US) showed no significant findings. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) with new T-wave inversion (TWI) in volt (V) 1, and V2, thought secondary to left ventricular hypertrophy (LVH). The patient was diagnosed with HTN and treated with acute coronary syndrome (ACS) ruled out (r/o), BP medication management, occupational therapy (OT), and intravenous fluids (IVF). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The admission was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o subacute weakness, lightheadedness, and headaches after running out of her HCTZ one month prior to presentation and was found to have significant BP elevation. The patient did not have any evidence of end-organ damage as there was no alteration of consciousness, neurologic deficits, encephalopathy, cerebrovascular accident (CVA), intracerebral hemorrhage (ICH), retinal hemorrhage/papilledema, acute coronary syndrome (ACS), aortic dissection, acute heart failure, or severe acute kidney injury. There was a mild creatinine increase not associated with significant electrolyte abnormalities that responded to intravenous fluids (IVF). The patient was treated with medication management and responded appropriately to the medication with a reduction in BP. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain. 
Treatment: Pain injection in the spine (64483 x 1, 64484 x 1). 
The insurer denied pain injection in the spine (64483 x 1, 64484 x 1). 
The determination is upheld. 

This is a patient who is diagnosed with back pain. Records show that a request for additional pain management injections was previously denied. 
There is a letter of appeal stating that the patient is currently under this provider's care for the treatment of severe back pain. The patient has tried and failed a course of conservative care including 6 weeks of provider directed physical therapy in the past 3 months along with home exercises and oral pain medications including non-steroidal anti-inflammatory drugs (NSAIDs) for 3 weeks and activity modification for 6 weeks. The pain is affecting the patient's ability to perform activities of daily living. They are requesting to proceed with epidural steroid injection. 
There is a letter of appeal stating that the patient experienced 50 percent (%) relief from his right-sided procedure and would like to proceed with left-sided injections. 
A progress note shows that the patient returned status post the most recent transforaminal epidural steroid injection a few weeks prior reporting 50% improvement in symptoms. The patient was pleased with the results and returned for follow-up today. Current medication includes aspirin, celecoxib and Tylenol PM. There was no physical examination performed. It was noted he would follow up for his left side in the coming months to treat his low back and radicular pain. At issue is the medical necessity of pain injection in the spine. 
The requested health service/treatment of pain injection in spine is not medically necessary for this patient. 
In this case, there are no objective findings on examination of radiculopathy such as altered motor strength, sensation, or reflexes in a specific dermatomal/myotomal distribution. There were no corroborative imaging studies included for review. The single progress notes submitted contained very limited information and there was an appeal stating the patient had 50% relief from his right-sided procedure several months ago and would like to proceed with left-sided injections. However, absent any objective evidence of radiculopathy, the requested injections are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Eustachian tube (ET) dysfunction 
Treatment: Balloon Dilation of the Eustachian Tubes 
The insurer denied Balloon Dilation of the Eustachian Tubes. 
The health plan's determination is upheld.

The patient is a female with eustachian tube dysfunction. Medical management included nasal steroids. Ear exam revealed mildly retracted ear drums. Hearing test was normal. Tympanogram on right was type C; on left it was type A. Balloon eustachian tube dilatation was carried out and is the topic of this review.

The Balloon Dilation of the Eustachian Tubes (BDET) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Balloon eustachian tube dilatation has not been studied against the placement of ear tubes for the treatment of eustachian tube dysfunction.
Although balloon dilatation of the Eustachian tube provides exciting research for chronic eustachian tube dysfunction, the literature does not support long term effectiveness. The current literature is based on non-controlled case series with poor standardization. Recent 12 month studies showed a 50-60% (percent) improvement rate in symptoms and tympanogram data. (see Poe and Anand), yet these studies are prone to bias as there were few patients left in the control arm. Although the procedure is safe, there is no strong, high quality evidence that this procedure is effective. A recent systemic review concluded, "Due to the limited and poor quality evidence it is inappropriate to make conclusions on the effectiveness of any intervention; the evidence base is insufficient to guide recommendations for a trial of any particular intervention. Consensus on diagnostic criteria for Eustachian tube dysfunction is required to inform inclusion criteria of future trials."
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Eustachian tube (ET) dysfunction 
Treatment: Balloon Dilation of the Eustachian Tubes 
The insurer denied Balloon Dilation of the Eustachian Tubes. 
The health plan's determination is overturned. 

The patient is a female with Eustachian tube (ET) dysfunction for 2 years. Symptoms included tinnitus, ear irritation, and chronic ear pain. Other symptoms included increased pressure during travel. Prior treatment with nasal steroids and other medical therapies had failed to provide relief.

The Eustachian tube dilation is likely to be more beneficial than the standard treatment. The patient had received treatment for the mucosal disease with nasal steroids and failed. Evidence that severe complications had occurred were present - history of tympanic membrane rupture. Wind instrument musicians are uniquely vulnerable to ET (Eustachian tub) related symptoms with the constant blowing. In addition, an ear tube (tympanostomy) can disrupt hearing, making it difficult for musicians to appreciate certain notes. ET dilation would be the most appropriate choice for this patient. Lastly, the patient actually received significant benefit in the ear pressure/fullness following the ET dilation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Eustachian tube (ET) dysfunction 
Treatment: Balloon Dilation of the Eustachian Tubes 
The insurer denied Balloon Dilation of the Eustachian Tubes. 
The health plan's determination is overturned. 

The patient is a female who has been followed in the office for eustachian tube dysfunction for 2 years with tinnitus and chronic ear pain. The patient has gotten no relief from steroids and other attempted failed medical therapies. She has had many years of chronic middle ear effusions, middle ear infections, significant pressure and pain and pressure with elevation changes and travel. There is an appeal letter from the patient noting that she gets excruciating pain and bleeding in her ears of as well as a perforated eardrum and that she has to travel as a musician. 

Balloon Dilation of the Eustachian Tubes is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The records clearly note this patient has intractable eustachian tube dysfunction. There are significant confirming medical records. They note she is receiving maximal medical treatment and has not improved. They note that she travels very frequently as a musician and experiences pain bleeding and perforations. They note she has been followed for 2 years but has persistent ear congestion, pressure, pain and tinnitus. She herself notes that since the procedure she has repeatedly flown and been pain free and normal. She has an audiogram showing abnormal results and tympanograms and nasal endoscopy was done.
Balloon dilation of the eustachian tube when done in appropriate patients has been found to be efficacious, durable and medically appropriate. The literature supports its efficacy, durability, results and patient satisfaction. It is worth noting that patients who require eustachian balloon dilation have been plagued with ear problems, can have reduced hearing, recurrent infections and very significant quality of life issues. These patients often have no alternatives other than having persistent ear infections and ear problems for years. The treatment is being done regularly by many ENT (Ears/Nose/Throat) physicians and is appropriate and standard of care for appropriate patients.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation
The insurer denied Intraosseous Basivertebral Nerve Ablation
The health plan's determination is upheld. 

The patient is a female with chronic low back pain that began over 6 months ago. Prior treatments have included heat, ice, or back injections, medications, and physical therapy. The pain ranges from 7-10 out of 10. The pain impacts activities of daily living. Magnetic resonance imaging (MRI) lumbar spine demonstrated Modic type I changes at disc spaces L (lumbar) 5 and S (sacral)1.

The Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The patient has complaints of low back pain. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. An Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the Intraosseous Basivertebral Nerve Ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: back pain
Treatment: Intraosseous Basivertebral Nerve Ablation
The insurer denied Intraosseous Basivertebral Nerve Ablation
The health plan's determination is upheld. 

The patient is a female with diagnoses that include Low Back Pain; Cervical Spondylosis, Cervical Radiculitis, Lumbar Radiculitis, Vertebrogenic Pain. Records provided indicate that the patient was previously recommended to undergo the Intracept procedure.
The provider states the patient has a history of chronic back pain that began greater than six months ago. The patient has tried heat, ice, lumbar epidural steroid injections, medication management, physical therapy, radiofrequency ablations and trigger point injections. 

Intraosseous Basivertebral Nerve Ablation Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The 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 recommended the Intracept System (intra-osseous basivertebral nerve ablation). 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.
Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required."