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

Diagnosis: Other - Cardiac Catheterization
Treatment: Inpatient Hospital Stay
The health plan denied: Inpatient Hospital stay
The determination is: Upheld

This male patient presented to the emergency department (ED) complaining of two weeks of intermittent exertional chest pain and dyspnea. His medical history was remarkable for coronary artery disease, percutaneous coronary intervention, hypertension, and cigarette smoking. He admitted to noncompliance with his prescribed medical regimen. In the ED, his blood pressure was 156/90 millimeters of mercury (mmHg) with a heart rate of 90 beats per minute (bpm). His room air oxygen saturation was 96 percent (%). An electrocardiogram showed sinus rhythm with right bundle branch block. There were no acute changes. His serum troponin level was normal and remained normal when re-measured. The patient was treated with aspirin and was admitted to the hospital to rule out acute coronary syndrome. The next day his troponin level remained normal. Myocardial perfusion imaging suggested inferior ischemia. Cardiac catheterization showed multivessel disease including a 50-60% distal left main stenosis. An echocardiogram showed a left ventricular ejection fraction of 25-30%. The patient's pharmacologic regimen was adjusted, and the plan was to transfer him to another institution for coronary artery bypass graft surgery. After three days he was still waiting for transfer. It was decided to discharge him with plans for outpatient evaluation by the cardiothoracic surgeon after nine days. A LifeVest wearable cardioverter defibrillator was prescribed.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is upheld in whole.
Based on the documentation provided, an inpatient level of care was not medically necessary.
This man, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, further evaluation was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under an alternate level of care. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the 2021 Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion 

Treatment: D8080 braces

The insurer denied coverage for D8080 braces

The denial is upheld

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. 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 the Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used which utilize 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 overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that these automatically qualifying conditions are not met and do not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not 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. This is confirmed by several referenced studies (1, 2, 3). 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 D8080 braces is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Humerus Fracture, Intractable Pain.
Treatment: Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.
The health plan's determination is overturned.

The patient is a female with a medical history notable for anxiety. The patient was hospitalized for management of a humeral fracture and intractable pain.
The patient suffered a fracture of the left humerus 3 days prior to presentation. She was evaluated by an orthopedist at that time, who recommended non-operative management and had a brace placed on the upper arm. The patient presented to the emergency department due to intractable pain despite using Percocet. She was admitted under observation status and an orthopedic consultation was requested. She required escalation of intravenous pain management. She was given the option of operative management and ultimately decided to proceed with open reduction and internal fixation. She was discharged the next day in stable condition.

The hospital argues that the patient required an inpatient hospital admission. They state that the physician assistant signed an admission order with an attestation that this was medically necessary due to uncontrolled pain requiring multiple titrations of intravenous (IV) medications as well as impending surgery.
The health plan argues that inpatient hospitalization was not necessary. They state that the patient remained stable throughout her stay; she did not have a life or limb threatening injury; there was no evidence of new bone infection; there were no multiple fractures with severe soft tissue injuries.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment and in the best interest of the patient.

The requested health service/treatment of the inpatient hospital admission was medically necessary for this patient. The patient presented to the hospital with intractable pain and failed conservative treatment of her fracture. She required ongoing titration of pain medication and ultimately surgery to correct the issue. According to the Milliman Care Guidelines (MCG) guidelines for musculoskeletal disease (26th edition), clinical indications for inpatient care include severe pain requiring acute inpatient management. The patient failed outpatient care and was not able to be stabilized under an initial period of observation care. Therefore, ongoing care in the inpatient setting was medically necessary and appropriate.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain
Treatment: 6 Additional Physical Therapy Visits
The insurer denied: 6 Additional Physical Therapy Visits
The denial is upheld.

The records indicate that the patient is an adult male with a history of back pain interfering with his activities. He underwent physical therapy for 6 visits, which included performing and training in exercises. His symptoms improved then subsequently recurred. Comorbidities include anxiety and depression. The health plan denied coverage of the service under review, indicating that the patient has a home exercise program and should be able to complete his recovery with home exercises. The reason for appeal is that the patient's symptoms have recurred after his therapy finished. More physical therapy has been prescribed.

The continued physical therapy is not medically necessary.

There is no medical necessity of additional physical therapy for this patient based on the available clinical records, standard of care, and current medical literature. The management of persistent mechanical/benign low back pain revolves around advice and education, including reassurance and encouragement to stay active/continue with usual activities (Foster NE, et al., 2018; Bagley C, et al., 2019; Berry JA, et al., 2019). Exercise and physical activity have low risk for adverse effects and are generally encouraged in the setting of these types of chronic pains (Chou R, et al., 2017; Geneen LJ, et al., 2017; Oliveira CB, et al., 2018). When there are impairments or complicating factors that preclude independent pursuit of exercise and modalities, or if appropriate independent measures have failed, formal rehabilitation can be a consideration. The general aim of formal rehabilitation is to initiate a program to address and manage symptoms and functional impairments, with goals that can include reduction of pain, reduction of impairment/disability, and improvement of quality of life (Urits I, et al., 2019).

Formal rehabilitative interventions are rendered, in conjunction with education, towards a goal of self-management, independent exercise and remaining active. The benefit of prolonged formal rehabilitation such as physical therapy, however, is not established in the medical literature for these conditions (Bagley C, et al., 2019; Berry JA, et al., 2019).
The records in this case show that the patient has already undergone therapy, which has included training in an exercise program. He has no impairments that would preclude an independent exercise and modality program to manage his ongoing symptoms. No marginal improvement in outcomes or clinical course would be expected with the additional formal physical therapy in question over an independent program. The proposed additional therapy in question is not supported by the medical literature and is not medically necessary. The health plan appropriately denied coverage of the requested service given that the service is not necessary for treatment of this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Systemic lupus erythematosus and glaucoma
Treatment: Consumer directed personal assistance services - 84 hours a week
The insurer denied coverage for consumer directed personal assistance services - 84 hours a week
The denial is upheld

This is an adult with chronic medical problems including systemic lupus erythematosus and glaucoma. She lives with her spouse. The insurer approved 35 consumer directed personal assistance services (CDPAS) hours/week and the patient is requesting 84 CDPAS hours/week.

The most recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Modified independent." She reportedly requires maximal to total dependence for completing most Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires extensive assistance for bathing, personal hygiene, dressing, locomotion, ambulation (uses a cane) and toilet transfer/use. She requires limited assistance for eating and bed mobility. The patient is occasionally incontinent of bladder and continent of bowel. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested CDPAS 84 hours/week. The patient may benefit from monitoring for safety; particularly due to her reported joint pain and decreased mobility. However, CDPAS for companion care or safety supervision without the direct provision of activities of daily living (ADL) task assistance is not a covered service. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved CDPAS 35 hours/week, shared household responsibilities with the other adult living in the home, personal emergency response service (PERS) and informal care from family.

From a physical medicine and rehabilitation perspective, the requested 84 CDPAS hours per week are 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 consumer directed personal assistance services - 84 hours a week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left testicular pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult male. He presented to the hospital ED (emergency department) with complaint of left testicular pain. Comorbid health conditions included obesity, hypertension, thoracic aortic aneurysm, and daily smoking. The records indicate that the patient was evaluated with CT (computed tomography) scan and surgical consultation. The CT (computed 
tomography) showed a small fat-containing left inguinal hernia. He was mildly tender over the left inguinal area. Lab data was normal. He was monitored overnight. Vital signs were consistently normal during the period of monitoring. The initial surgical plan was for laparoscopic/robotic repair of the left inguinal hernia during this hospital presentation. However, due to shortage in operating room availability, it was decided to provide pain medications and plan for a schedule outpatient procedure. He was able to tolerate a diet and oral analgesia as of day #2.
He was discharged from the hospital on day #2. The submitted material includes the health plan denial letter. This letter notes that the patient presented to the hospital to undergo a scheduled inguinal hernia repair procedure. This letter references MCG (Milliman Care Guidelines) and notes that admission to the 
hospital was not medically necessary. The hospital appeal letter notes that the patient presented to the ED (emergency department) with acute onset of left testicular pain and was diagnosed with a fat-containing left inguinal hernia. Surgical consultation was obtained, and the patient was cleared for discharge with surgical follow up to arrange for the outpatient repair of the left inguinal hernia.

The Inpatient Hospital Admission was not medically necessary.

The medical records indicate that this patient presented to the ED (emergency department) with a symptomatic left inguinal hernia. He was clinically stable at the time of presentation and remained so during the period of monitoring. While surgical repair of the left inguinal hernia was initially considered to be performed during this hospital presentation, due to lack of operating room availability, it was decided to defer the operative repair of the left inguinal hernia as an outpatient procedure. The patient had consistently normal vital signs, was able to tolerate a diet and oral pain medications. He did not require an emergent operation. An inpatient level of care was not medically necessary.
The records support that the care and treatment provided to this patient did not require an inpatient level of care. A lower level of care would have permitted surgical evaluation, monitoring, and follow up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other - Malocclusion.
Treatment: Braces and monthly visits.
The health plan denied: Braces and monthly visits.
The determination is: Overturned.

The patient is a male with dental issues. He presents with a skeletal Class III malocclusion. He has maxillary and mandibular spacing. Teeth 7 and 10 are in anterior crossbite. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion.
At issue is the medical necessity of braces and monthly visits.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of braces and monthly visits is medically necessary for this patient. This patient presents with an anterior crossbite, crowding, and a skeletal jaw imbalance. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects[1,2,3]. These problems are much more time consuming and costly to correct than the patient's existing orthodontic problem.
Teeth 7 and 10 are at high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time[4], which will make treating this occlusion at a later time more difficult. Further movement of teeth 23 or 26 will likely lead to the need for future for periodontal grafting on these teeth. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Intracept
The health plan denied: Intracept
The determination is: Overturned

The patient is a male with more than 10 years of chronic low back pain. His physical exam was notable for lumbar muscle tenderness to palpation, limited lumbar range of motion (ROM), and no neurologic deficits. Prior treatments included activity modification, discogram (Lumbar 5/Sacral 1 [L5/S1] with 50% relief), heat, ice, home exercise program, Aleve, physical therapy (PT), muscle relaxers, meloxicam, oral steroids, narcotics, medial branch block (MBB) of bilateral Lumbar 4 (L4) and Lumbar 5 (L5) (50% pain relief), epidural steroid injection (ESI), and trigger point injections. Lumbar x-rays demonstrated mild degenerative changes at L4/5 and L5/S1. Lumbar magnetic resonance imaging (MRI) demonstrated modic changes at L5 and S1 (based on clinical notes, not mentioned in the radiology report). The patient's pain limits his activities of daily living (ADL). He was diagnosed with vertebrogenic pain, and he was recommended L5 and S1 Intracept procedure.
At issue is the medical necessity of the requested health service/treatment of Intracept procedure.
The health plan's determination of medical necessity is overturned in whole.
, the requested health service/treatment of Intracept procedure is medically necessary for this patient.
This procedure is a low risk, potentially high reward benefit. Medical literature studies involving the Intracept procedure suggest it is a safe and effective procedure. It is Food and Drug Administration (FDA) approved. It has been deemed safe and at least as effective as other treatments available. It has supporting evidence in peer-reviewed journals. It is supported by international spine organizations such as the International Society for the Advancement of Spine Surgery (ISASS). Given this, current medical literature does support the Intracept procedure.
As per the provided references, the Intracept Procedure is neither experimental nor investigational. According to ISASS Guidelines[3]:
"Intraosseous ablation of the basivertebral nerve is a relatively new minimally invasive treatment for the relief of chronic low back pain (CLBP) that is diagnosed using well-established clinical and magnetic resonance (MR) imaging findings. The procedure is supported by Level I evidence including 2 randomized controlled trials (RCT) demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies. These results were seen in a patient population that is one of the most expensive and difficult to provide care for and in this era of rising healthcare costs and increasing need for therapies to reduce the use of opioids, basivertebral nerve (BVN) ablation may provide a treatment option to fill the gap in the treatment paradigm for patients that fail non-surgical treatment."
Therefore, the Intracept procedure is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain, Headaches
Treatment: Diagnostic or therapeutic injection (62321)
The insurer denied: Diagnostic or therapeutic injection (62321)
The denial is upheld.

The patient is an adult male with history of neck pain associated with headaches, with no numbness or tingling or radiating pain to the upper extremities with pain average eight out of ten (8/10) and affecting functionality. Magnetic resonance image (MRI) of the cervical spine showed multilevel degenerative spondylosis most prominent at C5/C6 (cervical five/cervical six). The patient has tried conservative measures including physical therapy, chiropractic manipulation, supervised home exercise program, Percocet, et cetera. The treating physician requested C7-T1 (cervical seven to thoracic one) interlaminar epidural steroid injections (CPT Code 62321). Prior authorization was denied by the health plan because of a lack of a four-week trial of treatment and a lack of radicular symptoms.

The proposed C7-T1 ((cervical seven to thoracic one) interlaminar epidural steroid injection is not medically necessary.

The patient has not met the general standard criteria for cervical radiculopathy for which the procedure is intended to treat because his pain has no radiating pattern with no numbness or tingling in the upper extremities. Therefore, there is no clinical basis for this procedure to treat neck pain associated with headaches that has no radicular component to it.