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

Diagnosis: lower abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient is a teenager with a history of tubo-ovarian abscess (TOA) who presented to the emergency department with complaints of lower abdominal pain of 3 days' duration. The patient was afebrile with stable vital signs. Evaluation was consistent with a urinary tract infection, menstruation, Chlamydia infection and possible ruptured cyst of the right ovary. The patient was seen by Gynecology. The patient had possible pelvic inflammatory disease (PID). A repeat hematocrit to rule out a bleeding hemorrhagic cyst was recommended. The patient was treated with antibiotics prior to discharge home.

Most females with pelvic inflammatory disease (PID) can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include:

1) Severe clinical illness (for example (e.g.), fever greater than or equal to (>=) 38.5 degrees Celsius (Celsius) [101Fahrenheit], nausea and vomiting)
2)  Complicated PID with pelvic abscess (including tubo-ovarian abscess)
3)  Possible need for invasive diagnostic evaluation for alternate etiology (e.g., appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess
4)  Inability to take oral medications
5)  Pregnancy
6)  Lack of response or tolerance to oral medications
7)  Concern for nonadherence to therapy

The patient presented with severe abdominal pain and stable vital signs. The patient was afebrile. The patient was diagnosed with a chlamydia infection, a urinary tract infection, dysmenorrhea and possible ruptured ovarian cyst. A drop in hematocrit was reported. The patient was started on antibiotics. There was no evidence that the patient fulfilled any of the above criteria. Note that on examination and while the patient tested positive for Chlamydia, there was no evidence of PID (no cervical motion tenderness).

Patients with ruptured ovarian cysts can usually be managed as outpatients as long as they are hemodynamically stable without a significant drop in hematocrit. Oral analgesia is given as needed. Nonhemorrhagic cyst fluid is usually resorbed within 24 hours and symptoms typically resolve within a few days. Follicular and corpus luteum cysts account for most of these cases.

It was noted that the ultrasound showed a small amount of fluid and serial hematocrits did not show any evidence of hemorrhage.

A urinary tract infection does not require hospital admission. In summary, this patient was stable and could have been managed at the observation level of care. Once the provider ascertained that there was no evidence of hemorrhage, the patient 's pain and infections could have been managed as an outpatient. 

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

Diagnosis: Dental malocclusion

Treatment: braces and monthly visits

The insurer denied coverage for braces and monthly visits.

The denial is overturned.


Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radio graph, 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 anterior crossbite among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth (#25) when clinical attachment loss and recession of the gingival margin are present. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant 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 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 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic 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 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 braces and monthly visits services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis. 
Treatment: Full hospital admission (hospital-at-home). 
The insurer denied the full hospital admission (hospital-at-home). 
The health plan's determination is upheld. 

This case involves a man with a peripheral neuropathy history of a right foot wound who presented to the hospital with a recurrence of the foot wound. The patient reported a black spot on the foot's plantar surface and was concerned about necrotic skin. Associated symptoms included pain with weight-bearing. He denied fevers, chills, shortness of breath, or other constitutional symptoms. Vital signs on evaluation included a temperature of 100 degrees Fahrenheit, blood pressure of 108/57, and heart rate of 93. Examination showed normal cardiopulmonary exam. The right lower extremity was edematous and tender to palpation, with a necrotic quarter-size lesion of the fifth metatarsal. Dorsalis pedis pulses were preserved.

The inpatient hospital admission was not medically necessary. The documentation describes uncomplicated cellulitis with a blood blister, which was lanced and drained. Podiatry cleared the patient for discharge within the first two days of presentation. Imaging studies showed no evidence of deep-seed infection, abscess, or osteomyelitis. There is no documentation suggesting a failure of outpatient treatment with antibiotic therapy. There were no resistant microorganisms identified on cultures. The patient remained hemodynamically stable and afebrile, without hemodynamic compromise or evidence of severe sepsis. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient admission.

The insurer denied: Inpatient admission.  The denial is upheld.

The patient is an adult male. He presented with chest pain, and he was hospitalized. His past medical history includes diabetes, hypertension, hyperlipidemia, sleep apnea, obesity, and subclinical coronary artery disease (CAD) identified by coronary computed tomography (CT). He presented to the emergency department for evaluation of acute, severe chest pain. The patient's vitals were stable. There were no acute electrocardiogram changes or troponin elevation documented. Chest X-ray revealed cardiomegaly. Treatment included aspirin, beta-blocker, statin, and anti-hypertensives. Cardiology was consulted and recommended cardiac catheterization with intent to re-vascularize. The study showed patent coronary arteries, and he was treated medically. The patient was discharged home with follow-up with cardiology, his primary care, physician, and gastroenterology. The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, including the MCG (Milliman Care Guidelines) guidelines for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom, or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care that the patient received for acute chest pain, including urgent cardiac catheterization like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male who presented to the ED (emergency department). The patient reported that he was eating ice cream and a potato, and it felt like it got stuck and he developed pain across his chest.
The patient was brought by Emergency Medical Services (EMS). The patient had a tracheostomy on 2L (liters) O2 (oxygen), without dyspnea.

The Inpatient Hospital Admission was medically necessary for this patient.
The patient presented with chest pain, which had some atypical features. The patient does have multiple coronary risk factors. The patient had a mildly elevated troponin. It was reasonable to place the patient for observation on telemetry and follow his course and troponin.
However, the inpatient level of care was not medically necessary. The patient was stable, his vitals were normal and physical examination was unremarkable. The patient was free of chest pain. The patient had chronic respiratory insufficiency, with tracheostomy. However, there were no exacerbation of his respiratory failure. There was suggestion of congestive heart failure (CHF) on his chest x-ray (CXR), but the patient was stable, with comfortable breathing. He was administered intravenous (IV) Lasix, but clinically was stable even before Lasix.
His troponin was stable and the patient did not undergo any additional studies and was discharged back to Skilled Nursing Facility (SNF) the same day. Therefore, the inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Kidney failure.
Treatment:  Continued stay at a skilled nursing facility (SNF).

The insurer denied coverage for continued stay at a skilled nursing facility (SNF).  The denial is upheld.

This is a patient with chronic medical problems including kidney failure.  The patient was admitted to an acute hospital and started on emergent dialysis.  The patient was transferred to a skilled nursing facility (SNF) upon discharge from the hospital.  Under review is the medical necessity for continued stay at a SNF.

The submitted SNF records do not support that the patient continued to be an appropriate candidate for the SNF level of care during the time period under review (1, 2, 3).  The therapy notes document a level of functional ability appropriate for transfer to a lower level of care.  According to the physical therapy (PT) note, the patient required only stand by assistance for bed mobility, transfers and ambulation.  A similar level of functional independence was documented by the occupational therapist.  Subsequent treatment for the time period under review could have been safely provided at a lower level of care (e.g., long term care or home care with visiting wound care nursing/therapy services).  The patient was subsequently discharged home with their spouse. There were also no other specific acute medical or complicated nursing issues that warranted continued SNF level of care for the time period under review.  

From a physical medicine and rehabilitation perspective, continued stay at a skilled nursing facility (SNF) was not  medically necessary.

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 stay at a skilled nursing facility (SNF) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain
Treatment: Facet Joint Injections (Code: 64490, 64491, 64492, each x[times]1)
The insurer denied: Facet Joint Injections (Code: 64490, 64491, 64492, each x1)
The denial is upheld.

The patient is an adult female with a history of intractable neck pain, left worse than right, 9/10 on a pain scale. The pain has not been controlled with more than 3 months of physical therapy, activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), and over the counter painkillers. The pain is interfering with the patient's ability to perform activities of daily living. The physical examination is significant for pain with palpation of C4-7 facet joints and positive facet loading. The request is for coverage of CPT codes 64490, 64491, and 64492, each x1, for medial branch blocks at left C4-C7. This was denied as "Your imaging studies cannot show findings that suggest other causes of pain (such as severe spinal disc disease or severe spinal canal narrowing)." Magnetic resonance image (MRI) of the cervical spine was performed showing cervical joint hypertrophy as well as disc bulges.

The requested health service was not medically necessary.

At the time the medical branch block was performed, diagnostic imaging had not been performed. As such other pathologies of pain around the facet joint including but not limited to "extra ossicles, traumatic dislocation, osteoarthritis, synovial cyst, axial spondyloarthritis, rheumatoid arthritis, calcium pyrophosphate deposition disease, septic arthritis, and malignant and benign neoplasms" could not be excluded. "Imaging is the mainstay to detect and characterize these diseases." As such the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bilateral flank and abdominal pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.


This is an adult who presented to emergency department (ED) complaining of severe, bilateral flank pain and abdominal pain. He was diagnosed previously with a left ureteral stone which he assumed had passed. The patient had elevated Creatinine of 1.77 (Acute Kidney Injury), left hydronephrosis with stone seen in left distal ureter. The patient was given intravenous (IV) fluids, IV analgesic and was admitted. He was taken to the operating room (OR) later that day for cystoscopy, left ureteroscopy, laser lithotripsy, and stent placement. The patient tolerated the procedure well without complications and was stable for discharge home with improved labs and clinical status, and with outpatient follow-up. 

Per Milliman Care Guidelines (MCG) Health (27th  Edition): Renal Colic + Kidney Stones, the patient fails to meet clinical indications for admission to in patient care; Urologic Surgery or Procedure, the patient meets the discharge parameters within 24 hours post operatively. As per the guidelines, this procedure is performed in an ambulatory surgery setting. 

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: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (CPT 64628 and 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (CPT 64628 and 64629)
The denial is upheld.

The patient is an adult male with low back pain that began several years ago. Past treatments include acupuncture, chiropractor, epidural steroid injections, medial branch blocks, 
lumbar radiofrequency ablation, physical therapy, Motrin, and Tylenol. His pain ranges from 6/10 to 10/10. Magnetic resonance imaging (MRI) of the lumbar spine shows degenerative changes with moderate central canal and bilateral lateral recess stenosis at L4-5 with diffuse disc bulge and facet arthrosis at this level. The request for L3-S1 Intracept was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested health service.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the procedure. In this clinical case, the magnetic resonance imaging findings do not support the use of Intracept. This patient does not have Modic changes on magnetic resonance imaging according to the radiologist report. This patient does have other causes of low back pain that have not been excluded on magnetic resonance imaging as likely causes of pain. As such, the health plan 
should not cover the requested health service.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (CPT 64628 and 64629)
The insurer denied: Intraosseous Basivertebral Nerve Ablation (CPT 64628 and 64629)
The denial is upheld.

The patient is an adult male. He has chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, medial branch blocks/ radiofrequency ablation, epidural steroid injections, and chiropractic care. The patient has failed medications, including non-steroidal anti-inflammatory drugs (NSAIDs). Magnetic 
resonance imaging (MRI) does not show Modic changes according to the radiologist's written report. The physical exam does not reveal any neurological injury.

The health plan should not cover the requested health service.

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is no likely to be more beneficial than standard treatments. The patient is an adult male. He has chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, medial branch blocks/ radiofrequency ablation, epidural steroid injections, and chiropractic care. The patient has failed medications, including non-steroidal anti-inflammatory drugs (NSAIDs). Magnetic resonance imaging (MRI) does not show Modic changes according to the radiologist's written report. The physical exam does not reveal any neurological injury. The requested Intracept procedure should be employed after all conventional and evidence-proven alternatives have failed. However, in this case, the patient has not failed or attempted sacroiliac joint injections, which are common causes of axial low back pain. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternative sacroiliac injections do show favorable outcomes in the literature and have lower risk and morbidity, the requested Intracept procedure is not considered medically appropriate.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Sotyktu
The insurer denied Sotyktu.
The determination is upheld.

The patient is a male with psoriasis. He has tried and failed Humira and Otezla. He has also tried Cosentyx. The medication under review is Sotyktu. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Sotyktu, or would have adverse effects.

The formulary drugs, Skyrizi, Stelara, Taltz, and Tremfya will not be ineffective and have not been ineffective. The formulary drugs would be as effective as the non-formulary drug, Sotyktu. The formulary drugs would not have adverse effects.
According to the American Academy of Dermatology Psoriasis Guidelines and medical literature, the preferred medicines such as Skyrizi are effective treatments for the management of psoriasis (1-3).
Gu et al writes in "Risankizumab is a humanized immunoglobulin (Ig)G monoclonal antibody that binds to the p19 subunit of Interleukin (IL)-23 and inhibits its interaction with the IL-23 receptor. Clinical trials showed that risankizumab was significantly more effective than ustekinumab. Risankizumab was well tolerated" (2). Reddy et al writes in "As the number of biologic agents used to treat psoriasis expands, newer medications provide promise of enhanced efficacy. In phase III trials conducted thus far, risankizumab has proven to be both efficacious and safe in the treatment of plaque psoriasis. By specifically targeting the IL-23p19 subunit and thereby blocking the T helper 17 (Th-17)/IL-23 pathway, risankizumab, when compared to other more non-specific agents, may have a lesser impact on normal immune function. The head-to-head phase III clinical trials discussed in this review have demonstrated that risankizumab is superior to ustekinumab and adalimumab in efficacy, including time to visible clinical improvement, and comparable in its safety profile." (3). The evidence-based literature is consistent. The preferred agents are appropriate agents for the treatment of the patient's psoriasis. The formulary medications should be tried and failed prior to approving Sotyktu.
There is no documentation provided that would justify the patient requiring treatment with Sotyktu prior to the formulary alternatives such as Skyrizi.