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

Reviewer #2:

Diagnosis: Low back pain

Treatment: Intracept procedure

The insurer denied coverage for Intracept procedure

The denial is upheld 

This patient has chronic low back pain. He has had Physical therapy, Acupuncture, and Chiropractic therapy. His magnetic resonance imaging (MRI) shows Modic changes at lumbar (L)3 and L4.  Also noted on the MRI is L3-L4 disc bulge which causes mild to moderate foraminal stenosis on the right with impingement of the L3 nerve root. As well as Moderate Left foraminal stenosis contacting the Left L3 root.  There is no surgical consultation in the documents reviewed.  The request is for radiofrequency (RF) ablation of the Basivertebral nerves(BVN) at L3 and L4.

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 (3) 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 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 (4) 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 Intracept Procedure for intraosseous ablation of basivertebral nerve, codes 64628 Thermal destruction of intraosseous basivertebral nerve 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

Reviewer 1

Diagnosis: Low back pain

Treatment: Intracept procedure

The insurer denied coverage for Intracept procedure

The denial is upheld 

This is a patient with chronic back pain.  Prior treatment included physical therapy, acupuncture, chiropractic, home exercise, lumbar medial branch blocks and analgesic medications.  Currently under review is the medical necessity for requested Intracept Procedure for intraosseous ablation of basivertebral nerve, codes 64628 Thermal destruction of intraosseous basivertebral nerve.

Patients who are amenable to this (Intracept procedure; intraosseous basivertebral nerve ablation) procedure have non-radiating (axial) pain.  In this particular case the patient has well documented degenerative spine changes that may not be amenable to the requested procedure.  Of particular concern is the lumbar spine magnetic resonance imaging (MRI) scan. There is evidence of "mild to moderate right foraminal stenosis with impingement on the right lumbar (L) 3 nerve root."  There is also "Moderate left foraminal stenosis, with contact of the left nerve root at the exit zone of the neural foramina."  The medical literature does not support the medical efficacy of the requested Intracept procedure in this case; particularly in the context of the lumbar MRI finding, demonstrating bilateral nerve root impingement.

Intracept Procedure for intraosseous ablation of basivertebral nerve, codes 64628 Thermal destruction of intraosseous basivertebral nerve does have final approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for Intracept Procedure for intraosseous ablation of basivertebral nerve, codes 64628 Thermal destruction of intraosseous basivertebral nerve.

Intracept Procedure for intraosseous ablation of basivertebral nerve, codes 64628 Thermal destruction of intraosseous basivertebral nerve is not the best available treatment at this time.

Thermal destruction of intraosseous basivertebral nerve; compared to non -spinal interventional treatment can result in  infection, hemorrhage and nerve damage.  

The requested Intracept Procedure for intraosseous ablation of basivertebral nerve, codes 64628 Thermal destruction of intraosseous basivertebral nerve is not likely to be more beneficial than any of the standard treatments/procedures for this particular patient.

In summary, the denial of Intracept Procedure for intraosseous ablation of basivertebral nerve, codes 64628 Thermal destruction of intraosseous basivertebral nerve 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: ataxia
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a young girl who presented with ataxia. She was admitted 2 weeks previously for fever and dehydration, and had just been home for 3 days when she seemed 'off balance'. She had decreased oral intake and was sent home from school because she appeared ill. She went to her doctor's office and then developed emesis and 10/10 abdominal pain. She was also complaining of pain in her thighs.
In the emergency department, she was noted to have dry mucous membranes with peeling skin on her fingers and swelling on her right anterior neck. 

Inpatient Hospital Stay was medically necessary for this patient.
This is a young girl who presented with decreased oral intake, vomiting, and ataxia following a hospitalization for dehydration. She had abnormal lab values with elevated white blood count and inflammatory markers, and had an abnormal physical examination with dry mucous membranes, adenopathy, and peeling skin. The diagnoses being considered have potentially serious complications and require prompt evaluation and potential treatment. Therefore, she required an inpatient hospital admission for treatment with intravenous fluids to maintain her hydration status, parenteral antibiotics while cultures were pending, specialist consultation, and close monitoring with additional treatment as needed.
Children with dehydration require hospitalization for intravenous fluids if they are unable to tolerate oral fluids. In addition, patients who are considered to have potential serious diagnoses such as serious bacterial infection, Guillan-Barre or Kawasaki Disease require hospitalization during evaluation to ensure immediate initiation of therapy as needed in order to prevent potentially serious morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: weakness/fever
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is a case of a female admitted for the diagnosis of fever, weakness and general malaise. The patient presented with a chief complaint of a fever. She was seen on an outpatient basis and evaluated for COVID. Flu and respiratory syncytial virus (RSV) workup were negative. She was treated with doxycycline without relief. 

The patient in this case was admitted for fever, but no source was identified. She did not have sepsis, acute coronary syndrome, carbon monoxide poisoning or adrenal insufficiency. She was not diagnosed with vasculitis or malignancy. There was no bacteremia of fungemia. She did not have any localizing symptoms such as chest pain, palpitations, shortness of breath, nausea, vomiting, diarrhea, dysuria, hematuria, melena, hematochezia or sick contact exposure. She did not have any recent travel to further complicate exposure possibilities. She did not have systemic rheumatic disease such as systemic lupus erythematosus or polymyalgia rheumatica. She was treated initially on outpatient basis with doxycycline but then was continued on this medication in the hospital with the addition of vancomycin.

Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Severe Persistent Asthma.
Treatment: Formulary exception for Dulera.

The insurer denied: Formulary exception for Dulera.  The denial is upheld.

The patient is an adult female with moderate persistent asthma, who is being treated with Dulera. The patient has tried and failed Advair, as well as Breo. Dulera was denied due to a lack of medical necessity since patient has not tried Symbicort. This denial is being appealed.

The health plan should not cover the proposed formulary exception for Dulera.

This patient with moderate persistent asthma is being treated with Dulera. The patient has tried and failed Advair, as well as Breo. The patient has not tried and failed or has contraindication to Symbicort. Thus, the Dulera is denied. The clinical documentation reports that the patient has been on Dulera for years; however, the patient has not been using the proper dose of the Dulera and continues to have uncontrolled asthma. There is lack of peer reviewed evidence-based literature that supports the use of Dulera over Symbicort in the management of asthma. Thus, the continued use of Dulera is not medically necessary. The formulary drug would not be ineffective for this patient. The formulary drug would be as effective as the requested non-formulary drug and would not have adverse effects for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Insertion and adjustment of braces.
The insurer denied insertion and adjustment of braces.
The determination is overturned.

The patient is a female with buccal (reverse) crossbite on tooth 13. She presents with a skeletal Class II malocclusion with severe maxillary and mandibular crowding. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion, but treatment was denied due to a lack of medical necessity. At issue is the medical necessity of insertion and adjustment of braces.

Because tooth 13 is in buccal crossbite, it has no antagonist. As a result, it is extremely likely that this tooth will overerupt. Once this overeruption occurs, it is very difficult to treat. (1) Buccal crossbite (also known as scissor-bite in the literature) can also negatively affect mandibular growth and should be treated as early as possible to eliminate the potential growth disturbance. (2)
If left untreated. the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For these reasons, the requested treatment is medically necessary.
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 has a history of diverticulosis and irritable bowel syndrome (IBS) and presented with abdominal pain and rectal bleeding. The patient was afebrile and the vital signs were stable. There were no peritoneal signs. The white blood cell (WBC) count was 10.34. A computed tomography (CT) scan was read as mild, acute, non-complicated diverticulitis without a fluid collection. Intravenous (IV) antibiotics, IV fluids and pain medications were given. The patient's symptoms improved. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-150 for Acute Diverticulitis. Clinical indications for admission include hemodynamic instability, peritoneal signs, persistent gross bleeding with a falling hematocrit, and a significant abnormality on imaging studies. This abnormality can be a fistula, obstruction, or a frank perforation. The patient did not have these complications. The patient also did not need a drainage procedure, have bacteremia, severe vomiting, or an inability to maintain oral hydration after observation care. 

This patient had uncomplicated diverticulitis. There was no abscess, perforation, or need for a drainage procedure. Antibiotics and pain medications could have been given with observation care. The patient did not meet MCG criteria for admission for Acute Diverticulitis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission 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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.

Treatment: D8080 braces and D8670 monthly visits x 12.

The insurer denied coverage for D8080 braces and D8670 monthly visits x 12.

The denial is overturned.

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 Deviations (HLD) index as required stating the patient exhibits the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet this required handicapping malocclusion medical necessity requirement on the HLD index attaining a score of 15 points on review by internal reviewers. Nylah Kydd is appealing on behalf of the patient.

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess the 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 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 is met and supports 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 needs is a valid approach. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. 

As this is an accepted methodology, it has been determined to represent an appropriate approach for assessing orthodontic needs. 

Based on the above, the insurer's denial must be reversed. 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 and D8670 monthly visit x 12 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic obstructive pulmonary disease (COPD)
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is a case of a male admitted for diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation and sepsis. The patient presented with symptoms of wheezing for a couple days prior to admission. The patient was noted to be a poor historian. Vital signs demonstrated blood pressure 108/60, pulse 78, temperature 36.1C, respiratory rate 19 and O2 (oxygen) saturation 97%. Physical exam showed no acute distress or altered mental status. 

The inpatient hospital admission was not medically necessary.
The patient in this case was admitted for what was thought to be a COPD exacerbation and sepsis. The patient ultimately had evaluation with cultures, and x-ray imaging but source of infection was not identified. Antibiotics were able to be discontinued. He was wheezing and thought to have COPD exacerbation. There was no altered mental status, or peripheral edema. There was no increased oxygen requirement, respiratory distress, pneumonia, arrhythmia, heart failure, or diabetes. Serum creatinine was 1.5 and it was not known if this was acute kidney injury versus chronic kidney disease. However, if his creatinine was normal at baseline this would still be a mild acute kidney injury which would not usually require hospitalization. His blood pressure in the emergency room was 90/59 but there was no persistent hypotension. He would have reasonable home support with the group home where he was established.
Although the patient required services in the hospital setting the monitoring, diagnostic testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip Fracture
Treatment: Medical equipment rental (E0261 x (times) 3, E0185 x 1), semi- electric hospital bed
The insurer denied coverage for medical equipment rental (E0261 x 3, E0185 x 1), semi- electric hospital bed.
The denial is upheld. 

The insurer has denied coverage for medical equipment rental (E0261 x (times) 3, E0185 x 1), semi- electric hospital bed, as not medically necessary. In a Final Adverse Determination letter, they stated that medical records do not show that the patient needs frequent and immediate changes in body position. Medical records do not show that the patient needs a special traction device that can only be attached to a hospital bed. The requested bed is denied based on criteria from New York State Medicaid Guidelines using the guideline Durable Medical Equipment, Orthotics, Prosthetics, and Supplies - Procedure Codes and Coverage Guidelines. 

This is a patient with chronic medical problems including dementia, glaucoma and osteoarthritis.  The patient underwent a left hip fracture surgical repair; the daughter declined post-surgical rehabilitation in a facility.  The daughter brought the patient home (lives with daughter and son-in-law), where the patient has a live-in aide.  The patient's treating nurse practitioner requested an electric hospital bed, which is currently under review.    

There is no documentation that the patient requires frequent change in position, head of the bed elevated more than 30 degrees, or a need for traction equipment that cannot be attached to a standard bed.  In addition, the requested hospital bed is not specifically needed for preventing contractures, avoiding respiratory infections or decreasing the risk of pressure ulcers.  The recommended physical therapy will instruct the patient and aide regarding proper bed positioning and transfer technique when transferring on/off a standard bed. 

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 medical equipment rental (E0261 x (times) 3, E0185 x 1), semi- electric hospital bed is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ectopic pregnancy
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld. 

The patient was referred to the emergency room (ER) and was diagnosed with a right unruptured ectopic pregnancy.  She  underwent an uncomplicated laparoscopic right salpingectomy. Blood loss was 100 cubic centimeters (cc). She was discharged the next day.

The patient presented with a diagnosis of ectopic pregnancy and underwent a laparoscopy. The procedure was uncomplicated. The surgical management of an ectopic pregnancy is an outpatient procedure. The surgery most commonly involves a laparoscopic procedure which is an ambulatory surgery. According to Milliman Care Guidelines (MCG), Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for: Older patients (> 65); Conversion to abdominal procedures; Surgical complications; Comorbidities.
This patient did not have any of these criteria. She is young and healthy. Her procedure was uncomplicated. There was no evidence of any injury to other organs. There is no medical reason given for admission nor was admission 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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol withdrawal. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient is an adult male with a past medical history of alcohol abuse, alcohol withdrawal, and withdrawal seizures. He was a patient in the detoxification unit. The patient had a witnessed seizure on that date. When the patient woke up, he was disoriented. He had bitten his tongue. The patient was admitted to the intensive care unit of the hospital. He was found to have lactic acidosis. Treatment consisted of intravenous fluids and intravenous Ativan. The following day, the patient had resolution of his acidosis. He was moved to a general medical unit. On day #3, the patient was found to be orthostatic. He was given additional intravenous fluids. Ongoing withdrawal symptoms were managed with oral medication. The patient was cleared to return to his detoxification program on day #6. The patient's health plan has denied coverage for this inpatient admission on the grounds that Milliman criteria for inpatient care have not been met. The hospital has appealed this denial. 

The proposed treatment of inpatient admission was medically necessary. 

Milliman Clinical Guideline ORG:M-595 (Substance Related Disorders) states that appropriate reasons to admit a patient with alcohol withdrawal to the hospital under inpatient status include: 
"Severe alcohol withdrawal not manageable at a lower level of care as indicated by 1) marked signs of withdrawal including heart rate greater than 120 beats per minute, and 2) signs of withdrawal that require inpatient care." 

This patient had multiple signs of severe alcohol withdrawal on admission including tachycardia with a heart rate of 126 beats per minute. Other signs of severe withdrawal requiring inpatient care include withdrawal seizure, altered mental status, and lactic acidosis. For these reasons, Milliman criteria for inpatient care have been met. The proposed treatment is medically necessary.