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

Diagnosis: Malocclusion.
Treatment: Full braces and monthly brace adjustment visit.
The insurer denied coverage for full braces and monthly brace adjustment visit.
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 identified several clinical findings including mandibular prognathism and anterior crossbite and has recommended orthodontics. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required medical necessity requirements. The patient's mother is appealing the decision.

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 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 provide adequate documentation to calculate the score. The documentation provided is insufficient and inadequate to approve care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

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 full braces and monthly brace adjustment visits is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis and mastoiditis.
Treatment: Inpatient admission.

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

This is the case of a female child with a history of Down's Syndrome, atrial septal defect (ASD), gastroesophageal reflux disease (GERD), and hypothyroidism. She presented with pain and swelling of an ear for one day. There was no discharge or hearing loss. There was a one-week history of runny nose and dry cough, and a small paronychia of the right first distal phalange. No fever. The emergency department (ED) flowsheet documents vital signs of heart rate 122, 94 at different times, temperature max 101.

Labs revealed white blood cell (WBC) count of 9000, with 80% neutrophils as would be expected from an acute infection, but C-reactive protein (CRP) was only moderately elevated at 7.9.

On examination her right pinna was tender to palpation, with swelling and red skin, and skin overlying the mastoid was also red, but she was well-appearing. However, no protrusion of the ear is mentioned. The attending physician noted redness, swelling, tenderness to palpation and slight proptosis to top of left ear helix, and redness and tenderness extending over mastoid area. The middle ear was normal.
 
The medical decision making section states "concern for serious outcome if not closely monitored due to perichondritis rapidly progressing over the past 24 hours, with potential for the risk of progressing to chondritis and ear deformity." However, the physical exam does not suggest perichondritis. Perichondritis is not usually an acute condition and is a complication of either ongoing otitis external or penetrating trauma and would manifest with exquisite tenderness.

The appeal states that the admission was medically necessary for cellulitis and mastoiditis. The cellulitis was mild, and there was no evidence of mastoiditis, or hemodynamic instability or sepsis. Pediatrician notes that she could have sustained a bug bite while at the beach resulting in mild cellulitis of the pinna. In the ED course, it is clearly stated there is no computed tomography (CT) evidence of mastoid or middle ear effusion.

Her exam also was not consistent with mastoiditis, as there was no protrusion of the pinna. (Wald, 2002) In the ED plan, it was noted that based on CT results they would admit if positive or send home with oral meds if negative. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: D8080 Braces. 

The insurer denied coverage for D8080 Braces. 

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite and posterior crossbite. The orthodontist has completed the Handicapping Labio- Lingual Deviation (HLD) index attaining 26 total points. 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 attaining only 10 points on the HLD index by internal reviewers. The orthodontist is appealing the decision on behalf of the patient. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, and HLD index is utilized. 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 completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which meets 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. 

D8080 braces is considered medically necessary for this patient. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 Braces services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Gastrointestinal bleeding.
Treatment: Inpatient hospital admission.

The insurer denied coverage for Inpatient hospital admission.  The denial is overturned.

The patient had cardiac disease requiring stents and a lower extremity open thrombectomy and stent placement. He was seen in his physician's office and found to be hypotensive with systolic pressures in the 70s. He was complaining of dizziness. He was anticoagulated with both Eliquis and Plavix. In the emergency room (ER) he had a blood pressure of 78/48 which improved after intravenous (IV) hydration. The electrocardiogram (EKG) showed a tachycardia with premature ventricular contractions (PVCs). The hemoglobin had dropped to 7.3. The stool occult blood was positive. The Eliquis was placed on hold and a heparin infusion was given. Prior to a blood transfusion he was orthostatic. He underwent endoscopic testing. 

Clinical indications for admission for Lower Gastrointestinal Bleeding (Milliman Care Guidelines (MCG) M-182) include hemodynamic instability, ongoing active bleeding, and having a coagulopathy that is not quickly reversible such as irreversible anticoagulation therapy. This patient had hypotension and remained with orthostatic changes. In view of the large drop in hemoglobin, there was a concern that he had active bleeding. He was also on two long-acting anticoagulation agents with both Eliquis and Plavix. This met MCG criteria for admission for gastrointestinal bleeding. 

This patient required continued anticoagulation and was having symptomatic anemia with hypotension and gastrointestinal bleeding. He met the MCG criteria for admission for Lower Gastrointestinal Bleeding. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for the continued inpatient stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient had a history of a bowel obstruction and presented with abdominal pain, nausea, and vomiting. She was hemodynamically stable. There was no abdominal rebound or guarding. There was no leukocytosis. A computed tomography (CT) scan showed mild narrowing at the duodenal jejunal junction. The anterior abdominal wall had a fluid collection. She was also found to have a gallstone without acute cholecystitis. No acute surgical interventions were advised. A repeat X-ray showed no signs of obstruction. 

Milliman Care Guidelines (MCG) clinical indications for admission for Undiagnosed Abdominal Pain (MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had a previous history of intestinal obstruction but at this time she was not obstructed. Intravenous (IV) hydration, antiemetics, and proton pump inhibitor (PPI) therapy could have been given with observation status. No surgical interventions were required during this admission. An upper gastrointestinal (GI) endoscopy could have been performed on an outpatient basis. She had mild narrowing at the duodenal jejunal junction, but it did not require any acute interventions. She did not meet MCG criteria for admission for Undiagnosed Abdominal Pain. 

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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is overturned. 

This patient has a history of congestive heart failure (CHF), hypertension, and substance abuse. The patient was on Methadone and presented to the hospital with complaints of abdominal pain for 3 weeks and chest pain and shortness of breath (SOB) for 1 month. The patient also complained of some burning micturition. The patient's home medications included Lasix and Entresto. The ejection fraction was 30 percent (%). He presented with a CHF (congestive heart failure) exacerbation and was noted to have elevated jugular venous distention (JVD). The lung exam revealed crackles and pedal edema was also noted. 

His B-type natriuretic peptide (BNP) was 1812 and then 3700. His Troponin was 0.06. The Blood urea nitrogen (BUN) and Creatinine (Cr) were elevated at admission. An acute kidney injury (AKI) was noted as Cr was 1.4 from a baseline of 0.9.  A chest x-ray revealed a pulmonary edema pattern. 

The patient was admitted for decompensated CHF. He was started on intravenous (IV) Lasix 40 milligrams (mg) twice daily (BID), Entresto was held due to the AKI. Subsequently Lasix was increased to 80 mg IV BID. The patient was also treated with Spironolactone. Acute Coronary Syndrome was ruled out. The patient's Cr increased to 1.8 and fluids were adjusted. This patient was also treated with Bactrim for a possible urinary tract infection (UTI).

This patient had presented with acute decompensated CHF. He needed acute hospitalization for treatment with IV Lasix. His intake and output were monitored strictly. In addition, other medications and fluids had to be adjusted due to his AKI which had become worse after hospitalization.  Admission and length of stay was appropriate. The patient decided to sign out against medical advice (AMA). 

The health plan did not act 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 overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain

Treatment: basivertebral nerve ablation, procedure code 64628

The insurer denied coverage for basivertebral nerve ablation, procedure code 64628

The denial is upheld 

This patient has chronic low back pain.  He has tried Chiropractic, Acupuncture, Heat, Ice, Physical therapy, transcutaneous electrical nerve stimulation (TENS), Home Exercise, and Epidural Steroid injections (ESI).  He takes non-steroidal anti inflammatory drugs (NSAIDs) and Tylenol for pain. The progress notes state that he has Modic changes at lumbar (L)4-L5 and at L5-sacral (S)1. The imaging reports notes multiple herniated discs. The request is for radiofrequency (RF) ablation of the Basivertebral nerves (BVN) at L4, L5 and S1.	

The publications to date have been company sponsored and had methodology flaws. There is no published data on long term complication rates. There are other evidence-based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain (CLBP) who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline while favorable pointed out the limitations of the current literature:

-  Industry funding is a potential source of study bias for the available data reviewed.
-  Limited number of studies.
-  Short-term follow up for the majority of studied patients.
-  Unknown effect on the primary degenerative process

This procedure is not likely to be more beneficial than the standard of care.

In summary, the denial of intraosseous basivertebral nerve ablation, procedure code 64628 and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lower back pain

Treatment: basivertebral nerve ablation, procedure code 64628

The insurer denied coverage for basivertebral nerve ablation, procedure code 64628

The denial is upheld 

This is an adult with a history of lower back pain. He reported symptoms for several years.  The patient presented to the Pain Management physician's office for a follow up for lower back pain. There were Modic changes at lumbar (L)4, L5, and sacral (S)1. The patient tried physical therapy (PT) and injections with 50 percent (%) relief for a few months. The patient tried ice, heat, and medications with minimal relief. The treating physician recommended the Intracept procedure to treat lower back pain. 

The Pain Management literature reports it may be beneficial. References submitted reported a 65% improvement at one year. The Orthopedic and Neurosurgical literature do not recognize this treatment as a standard. There are no recommendations made by this practice group. 

Food and Drug Administration (FDA) approval has been granted for marketing. The FDA has not provided any information about efficacy or standard of care. 

No pain generator has been defined for the patient's pain. His imaging studies showed a disc herniation. He had received epidural steroid injections (ESI) with 50% improvement. He has disc disease to L4-5 and L5 - S1. He has stenosis and facet arthrosis. It is unclear where his pain is originating from. Based upon his clinical presentation and course it is extremity unlikely that the source is vertebrogenic. He has degenerative disease with stenosis to several levels. It may be of benefit to manage his herniation. His condition is more than likely degenerative. 

The procedure is invasive. There have been case reports of instrument breakage, infection and retroperitoneal hematoma. 

The requested services are not likely to be more beneficial than any of the standard treatments for this patient. 

The procedure is not mainstay nor current accepted treatment by the practicing medical community. The procedure is essentially a thermoablation performed within the vertebral body. 

There are several level 1 studies showing the benefit of this procedure up to 2 years after treatment compared to controls. However, all of these studies were either funded by the manufacturer and/or authored by consultants from the manufacturer. No high-quality study exists that does not have a significant conflict of interest with the manufacturer. 

In summary, the denial of intraosseous basivertebral nerve ablation, procedure code 64628 and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy 2.4mg (milligrams) /0.75 ml (milliliter) Pen Injector
The insurer denied coverage for Wegovy 2.4mg/0.75 ml Pen Injector
The denial is overturned.

 
The patient has been on Wegovy over one year and has lost 60 pounds. His current weight is 171 with a Body Mass Index (BMI) of 24. 7. He has undergone behavior and diet modifications. His cholesterol level has improved. His physician is recommending continuing the Wegovy in order to prevent a relapse of the obesity. He has provided a position statement from the World Obesity Federation stating that obesity is a chronic relapsing condition. 

The physician has provided a reference from JAMA 2021 ;325(14):1414-1425 titled "Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults with Overweight or Obesity." 803 participants in this study were randomized to either continue Semaglutide or to take a placebo after 20 weeks of semaglutide treatment. Those who continued the treatment with semaglutide had ongoing weight loss, a better lipid profile, improved glucose metabolism, better blood pressure control, and physical functioning scores. The group who took the placebo regained their weight. The article states that the result of this study emphasizes the chronicity of obesity and the need for treatments that can maintain and maximize weight loss. 

This patient has had a good effect with weight loss from the Wegovy. His physician is concerned that he requires continued Wegovy in order not to gain the weight back. The study from the JAMA article supports the use of continued Wegovy and documents that the group that continued with the Wegovy were in better health than the group that stopped it. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Wegovy 2.4mg/0.75 (milligram per milliliter) Pen Injector services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple sclerosis
Treatment: Inpatient admission to a skilled nursing facility (SNF)
The insurer denied coverage for inpatient admission to a skilled nursing facility (SNF)
The denial is upheld.

This patient has a history of multiple sclerosis, atrial fibrillation and lymphedema. She was sent from a Skilled nursing facility (SNF) to the hospital emergency department for evaluation and treatment of urosepsis. Under review is the medical necessity for a continued inpatient admission to a SNF.

This was not appropriate for the SNF subacute rehabilitation level 1 care for the time period under review. The patient received acute rehabilitation for five weeks and transferred to the SNF for subacute rehabilitation. She was admitted to the hospital for intravenous (IV) antibiotic treatment of urosepsis. This physician would agree that the patient's functional progress would have been negatively affected due to urosepsis. However, she received several months of combined acute and subacute rehabilitation, with only limited functional improvement.  Unfortunately, she remained essentially at the maximal assistance level for activities of daily living and functional mobility. For the time period under review, her care would have been primarily custodial and more appropriate for long term care. In addition, there were no specific acute medical or complicated nursing issues to support a SNF admission.

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 a continued inpatient admission at a skilled nursing facility (SNF) is not substantiated.