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

Diagnosis: Class II malocclusion
Treatment: Braces and Monthly Visit
The insurer denied: Braces and Monthly Visit
The denial is overturned.

This patient is a teenage male. The request is for orthodontic benefits with monthly visits. The patient has a Class II canine malocclusion with severe upper and lower jaw crowding. Also, he has a deep bite. The prior denial was due to a handicapping index score of 20 points.

The requested health service is medically necessary.

The patient's upper left permanent canine (tooth #11) is "blocked out" of its proper position. This means that it cannot erupt into the correct position due other teeth being in its way. This is not allowing this canine to touch the lower canine. Without these two teeth touching properly, there can be no "canine guidance." This means that instead of the lower canine on the left side gliding along the inside of the upper left canine and allowing the posterior teeth on that side to "disarticulate" (separate) during the chewing cycle, these teeth will bang into each other traumatically. Over time teeth will fracture and/or loosen due to this imbalance and incorrect position of the upper canine. Orthodontic treatment is needed to correct this problem. This case has medical necessity. The monthly visits are needed to make sure the treatment progresses properly.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria
Treatment: Genital surgery
The insurer denied genital surgery.
The determination is overturned in whole. 

This is a male to female transgender who desires vaginoplasty. She transitioned and has been on hormone therapy. Her mental health professionals have written letters of support for gender transition genital surgery. She had facial feminization surgery. Vaginoplasty is planned.
At issue is the medical necessity of the genital surgery.

The requested health service/treatment of genital surgery is medically necessary for this patient.
Per the mental health professional letters, she has well documented gender dysphoria and transitioned. She can consent for treatment and is beyond the age of majority in the United States. Mental health issues are well controlled per letters from her mental health professionals. She has been on hormone therapy and has lived as a female. She had facial feminization surgery, and she continues follow-up with her mental health professionals.
Therefore, the requested health service/treatment of genital surgery is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis. 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This patient is an adult female who presented to the hospital with flank pain, fever, and dysuria. The patient had been treated for a urinary tract infection (UTI). The patient was admitted to the hospital, and was given intravenous antibiotics, and intravenous and oral hydration. The patient did have an outpatient course of oral Clindamycin prior to admission. The request for the inpatient hospital admission was denied. This request is under appeal. 

The requested health service of an Inpatient Hospital Admission is not considered medically necessary. 

Based on available data for this patient, there was no documentation of hemodynamic instability, acute renal failure, bilateral obstruction, a single kidney obstruction, a transplanted kidney with obstruction, severe pain requiring acute inpatient management, vomiting that was severe or persistent, a urinary tract infection, nor was there the need for intravenous hydration support, despite this patient already receiving care at a lower level. Based on available data, none of these criteria were met, as there was no documentation that a stone removal procedure was needed, nor did it require an inpatient admission. Therefore, the requested inpatient level of care is not recommended. The requested inpatient level of care is considered to have been provided primarily for the convenience of the patient, and/or the practitioner. The requested health service would not be considered the least intensive, nor the most appropriate alternative among diagnostics. Therefore, the requested health service is not considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary tract infection
Treatment: Inpatient stay
The insurer denied the inpatient stay.
the health plan's determination is overturned. 

The patient is a female without significant past medical history who presented with right flank pain, urinary frequency and urgency for 2 days. She also noted right sided back pain, weakness and fatigue. She was febrile in the emergency room to 102.5o (degrees)F (Fahrenheit). Her heart rate was 91, her blood pressure was 141/78, her respiratory rate was 18 and she was not hypoxic. On exam, she was not in any acute distress and she did not have costovertebral angle tenderness. Her labs showed a white blood cell count (WBC) of 19.2, a creatinine of 0.92, a. hemoglobin of 14.1, and a lactate of 2.1. A urinalysis showed trace leukocyte esterase, negative nitrite, 0-5 WBCs, 0-2 red blood cell (RBC) and no bacteria. 

The inpatient hospital admission was medically necessary based on the documentation provided. The patient presented with a febrile illness and symptoms concerning for a urinary tract infection. She was hemodynamically stable but had leukocytosis and an elevated lactate on preventions. Despite intravenous (IV) antibiotic therapy her clinical condition worsened with continued, higher fevers, tachycardia and further increase of her lactate level. It was appropriate to admit her to an inpatient level of service as she was likely to require prolonged IV antibiotics and close monitoring of her febrile illness. Management at a lower level of care would not have been appropriate or safe for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: low back pain

Treatment: procedure (intraosseous basivertebral nerve ablation) (procedure code 64628)

The insurer denied coverage for procedure (intraosseous basivertebral nerve ablation) (procedure code 64628)

The denial is upheld

Reviewer #1:

This is a patient with a history chronic low back pain for many years. As noted, the pain radiates to the buttocks. The patient has tried multiple conservative modalities including heat, ice, over-the-counter medication, chiropractic adjustments and home-based exercise. The patient has also undergone various injections with only short pain relief. The patient's pain is limiting their activities of daily living (ADLs). Magnetic resonance imaging (MRI) shows evidence of mixed Modic type II endplate changes at L (lumbar) 5, S (sacral) 1. The doctor recommends treatment with basivertebral nerve (BVN) ablation with the Intracept device. The note concluded "possible vertebrogenic source of pain, lumbar spondylosis and lumbar herniated disc. Similar diagnoses are listed in another note.

In assessing whether intraosseous basivertebral nerve ablation using the Intracept device is considered more beneficial for this patient than standard treatments or procedures, it is important to know that the publications in peer-reviewed literature to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. 

The requested treatment is not likely to be more beneficial than other evidence-based treatments. 

There is no evidence in the medical record of additional evidence-based non-surgical treatment such as a trial of physical therapy, cognitive behavioral therapy, or proven first line medications such as tricyclic antidepressants (TCAs) or gabapentinoids.  

Any invasive procedure has risk of bleeding, infection, nerve injury or retained foreign body compared to non-invasive treatments.

In summary, the supporting publications to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. The Intracept procedure is unlikely to be more beneficial than standard treatments/procedures for this patient. Additional evidence-based non-invasive treatment such as physical therapy and proven non-opioid medications should be attempted prior to any invasive procedure. The denial is upheld.

In summary, the denial of a procedure (intraosseous basivertebral nerve ablation) (procedure code 64628) on a date yet to be determined (TBD) 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: Upheld

Diagnosis: Low hemoglobin
Treatment: Inpatient Hospital Admission:
The insurer denied: Inpatient Hospital Admission:
The denial is upheld.

The patient is a teenage female with review for medical necessity of inpatient stay. This was a one-day hospital stay previously approved at observation level of care for a teenage female who presented to the emergency department for evaluation of a low hemoglobin of 5.6 due to chronic illness.

The requested health service was not medically necessary.

The patient in this case is a teenage female who presented to the emergency department for evaluation of low hemoglobin of 5.6 due to chronic illness. The patient was sent from the clinic. There were no associated symptoms. The patient has a history of protein calorie malnutrition and Crohn's disease and is being treated with Simponi every other week, topical tacrolimus, and methotrexate. On examination, the patient was in no acute distress. She was hemodynamically stable with only mild tachycardia 103 and normal blood pressure. Laboratory testing revealed white blood cell count of 6.8 and hemoglobin of 5.7. No coagulopathy was noted. The patient received a blood transfusion. After the transfusion, hemoglobin was 7.5. There was no hemodynamic instability or fevers noted, and the patient was discharged home. In this case, the requested service of inpatient admission would not be considered medically necessary. The patient was hemodynamically stable, did not require any invasive hemodynamic monitoring, no mechanical ventilation, no oxygen supplementation, and there is no orthostasis or any active bleeding. A blood transfusion is an ambulatory procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain, fever, and dysuria
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is an adult female who underwent a Cesarean section. She presented to the emergency department (ED) with complaints of abdominal pain, fever, and dysuria. Evaluation in the ED showed that the patient had felt pain in the right lower quadrant of her abdomen for about seven days and fever for the past three days. The patient's vital signs were temperature 101.3 degrees Fahrenheit, pulse 114, respirations 18, blood pressure 85/71, and pulse oxidation 96% (percent). Evaluation showed tenderness and drainage at the incision site. Lab results showed white blood cell count 15 thousand, neutrophils 84%, and influenza B positive. Chest X-ray had suggestion of right base atelectasis/infiltrate. A computed tomography (CT) scan of the abdomen and pelvis showed abnormal enlargement/thickening of ventral pelvic muscular space of Retzius concerning for phlegmonous change and/or hematoma. The patient was treated with intravenous (IV) fluids and IV Zosyn. The patient was evaluated by obstetrics/gynecology (OB/GYN) consult who did not advise any acute gynecology/surgical intervention. The patient was also seen by infectious disease consult and advised continuation of IV Zosyn and recommended addition of vancomycin and gynecology re-evaluation for consideration of possible pelvic phlegmon/abscess. The patient was admitted to inpatient hospital care and continued on IV antibiotics with gradual improvement. The patient was stabilized and discharged home on day number (#) 4.

The requested health service was medically necessary.

The requested inpatient hospital admission was medically appropriate.

The patient presented with fever, signs of possible wound infection, and concern for possible pelvic infection (an abscess based on results of CT scan). The patient was also hypotensive on admission, and it was medically appropriate to treat with IV fluids and antibiotics. Based on the clinical evaluation, there was concern for sepsis, wound infection, and possible pelvic abscess. The patient needed treatment with IV antibiotics and fluids and also required follow-up to ensure that the patient was responding to treatment and to definitively exclude the possibility of pelvic abscess - wound infection that may require further surgical intervention if it did not respond to the IV antibiotic course. Close inpatient follow-up was appropriate for this patient to ensure continued improvement and response to the treatment and to initiate additional treatment/measures if the clinical response did not happen. This could not be achieved at a lower level of care, and so medical inpatient admission was appropriate for this patient's clinical presentation.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention deficit hyperactivity disorder
Treatment: Mydayis
The insurer denied Mydayis
The health plan's determination is overturned. 

This case involves a female student diagnosed with attention deficit hyperactivity disorder (ADHD)-combined type. She is prescribed Mydayis (dextroamphetamine-amphetamine mixed salts, 24-hour extended release) together with a 10-20 milligrams (mg) Adderall booster. 

A formulary exception is indicated for this patient. In this case scenario, the formulary drugs will be or have been ineffective due to a shorter duration of effect as opposed to the non-formulary drug, Mydayis, and the formulary alternatives would not be as effective as the non-formulary drug in view of the unique pharmacokinetics and pharmacologic characteristics demonstrated in the clinical trials with Mydayis.
As asserted in the appeal, the requested non-formulary drug would be more effective than all other covered formulary drugs on any tier. The exception request for the benefit of Mydayis 24-hour oral capsule for the treatment of attention deficit hyperactivity disorder (ADHD) should be approved as a coverage exception in this case. In this regard, the patient has been tried on several formulary alternatives with the same outcome with a short duration of effect. The Mydayis offers the long delayed-release coverage deemed to be appropriate and necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: Home health care
The insurer denied Personal Care Aide (PCA) Services: Level 2 Live-In per Diem - 7 Days per Week
The health plan's determination is overturned. 

This is a female patient with a history of Progressive Supranuclear Palsy (PSP), Parkinson's disease, anxiety, Graves' disease, and a history of cancer. She lives with her elderly partner in a 2- bedroom apartment. Her son lives an hour away. 

Personal Care Aid (PCA) services level 2 live-in per diem, 7 days per week is medically necessary.
There is documentation in the recent Uniform Assessment System (UAS) of the patient requiring at least maximal assistance with tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs. A tasking tool should not have been used to calculate the hours of care given the patient's need for assistance with unscheduled and unpredictable care needs. There is documentation from the patient's Neurologist of the medical necessity of increased PCA services. The patient lives with her partner who is not able to provide informal support due to his own health status. Per NYCRR (New York Codes Rules and Regulations) 505.14, it cannot be assumed that the informal support person can provide all needed care outside of the approved PCA hours as informal supports must be voluntary. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: obesity
Treatment: Saxenda
The insurer denied Saxenda.
The health plan's determination is upheld. 

This is a case review for a female being prescribed Saxenda for the treatment of morbid obesity due to excess calories.
Office visit notes from the prescribing physician were provided for review. The patient has a body mass index (BMI) of 36 and was interested in medications to help with weight loss. The patient had tried 6 months of diet and lifestyle changes with an exercise plan and did not have any success with sustained weight loss. The physician prescribed tirzepatide during that office visit.

Saxenda is not clinically appropriate for the patient's condition,
Saxenda is Food and Drug Administration (FDA) approved for the treatment of obesity in adults. The patient does have a BMI of 36 which qualifies for a diagnosis of obesity. However, there were no physician letters provided as part of this appeal. The office visit note which was provided recommended prescribing tirzepatide, not the requested medication Saxenda. There is insufficient documentation regarding the necessity of treatment with Saxenda based on the provided documentation. Therefore, its use is not clinically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: braces, monthly visits, and retainer.
The insurer denied braces, monthly visits, and a retainer.
The determination is upheld.

The patient is a male with a Class I occlusion. He has a 7-millimeter (mm) overbite and 2 mm overjet. He has moderate maxillary and mandibular crowing. He is in the late mixed dentition stage of dental development with one remaining primary tooth. The second molars are still far from the eruption. The patient's treatment planned for orthodontics to correct his malocclusion. At issue is the medical necessity of braces, monthly visits, and retainer.

There is no medical reason to correct the patient's malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the mandibular teeth or palatal soft tissue damage from their current position. There are functional problems that can occur in dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) The patient has a slightly excessive overjet, but this amount of overjet does not negatively affect oral health-related quality of life. (3) If his teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

 
Diagnosis: Possible Vitamin D Deficiency

Treatment: Vitamin D Level Testing

The insurer denied coverage for vitamin D level testing

The denial is upheld. 

The member is a patient who was evaluated by their physician for routine physical exam and vitamin D level was requested. The medical records provided did not show that the member had a condition which would benefit from Vitamin D testing such as osteoporosis or osteopenia. There was no documentation of conditions which would increase risk for vitamin D deficiency and bone fracture such as malnutrition, alcoholism or use of systemic steroids.

The United States Preventive Services Task Force guidelines, a nationally recognized standard, did not recommend routine screening as a preventive health measure.

There is no evidence-based literature to support routine screening of vitamin D level and this request is not medically necessary.

As explained above, the request for vitamin D testing is not medically necessary per standard of care.

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 vitamin D level testing is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Facet Joint Injections 
The insurer denied Facet Joint Injections 
The health plan's determination is overturned. 

This is a female who has chronic lower back pain. Her pain is localized in the lower back, right greater than left. Pain level is 8/10. Her pain is debilitating despite prior treatments including physical therapy (PT), chiropractic manipulation, and pain medications. Physical exam (PE) shows tenderness to palpation (TTP) in the lumbar paraspinal regions and positive facet-loading test.

This is a female who has chronic lower back pain. Her pain is localized in the lower back, right greater than left. Pain level is 8/10. Her pain is debilitating despite prior treatments including physical therapy (PT), chiropractic manipulation, and pain medications. Physical exam (PE) shows tenderness to palpation (TTP) in the lumbar paraspinal regions and positive facet-loading test.

Facet Joint Injections (64493 x 1, 64494 x 1, 64495 x 1) are medically necessary for this patient.
This patient has persistent back pain despite extensive conservation treatments. Her pain is consistent with lumbar facet arthropathy based on history and physical exam (PE). Her pain is debilitating despite extensive prior treatments including PT, chiropractic manipulation, and pain medications. Given this clinical scenario, facet joint injections are the next step intervention. The lumbar facet joint received innervation from the same level and the level above. It is medically necessary to block 3 levels (CPT 64493 x 1, 64494 x 1, 64495 x 1) to achieve optimal pain relief.