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

Diagnosis: Chronic low back pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure.
The denial is upheld.

The patient is a male with a history of chronic low back pain. His pain has not responded to epidural medial branch blocks, RFA (radiofrequency ablation), Epidural steroid injections, physical therapy (PT), and pain medication. He has done physical therapy and has seen a chiropractor. He has tried various medications. Physical exam reveals extension based pain and pain on facet loading maneuvers. An Intracept procedure has been recommended.

No, the health plan should not cover the Intracept procedure.
The requested Intracept procedure is not likely to be more beneficial than standard treatments.

The patient is a male with a history of chronic low back pain. His pain has not responded to epidural medial branch blocks, RFA (radiofrequency ablation), Epidural steroid injections, physical therapy (PT), and pain medication. He has done physical therapy and has seen a chiropractor.

The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It is typically used in patients with significant Modic type I or type II vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. Alternatives, such as spinal fusion, do not have good long-term results in the literature for axial low back pain without instability. Spinal fusion is a very invasive procedure with high morbidity and poor outcomes, compared to the Intracept procedure. In fact, most recent articles show less than 50 percent improvement for the treatment of chronic low back pain with spinal fusion.

However, this patient has not failed common treatments for axial low back pain, such as sacroiliac (SI) joint interventions, which are common causes of axial low back pain. In addition the patient has severe spinal stenosis at multiple levels. Spinal stenosis can cause axial low back pain and is a common cause of low back pain that typically does respond well to operative management, such as laminectomy and decompression. Chronic opiates are not without risk, and can lead to addiction and overdose. Therefore, while the Intracept procedure is a reasonable option, it should be employed after all conventional and evidence-proven alternatives have failed. Given that multiple proven and effective less invasive options have not been failed, the requested Intracept procedure is not medically appropriate.

No, the Intracept procedure is not more beneficial.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alopecia areata

Treatment: Xeljanz XR

The insurer is denied coverage for Xeljanz XR

The denial is overturned. 

This female patient has a history of seborrheic dermatitis of the scalp and with alopecia areata that affects 50% of her scalp and facial hair.

The patient is currently stable with her current regimen.  It would be medically inappropriate to deny coverage for a therapy shown in studies to improve the patient's condition following successful therapy having failed numerous topical and oral alternatives.  As a result, the denial is reversed and the use of xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment.

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

The carrier's denial of coverage for Xeljanz XR is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse. 
Treatment: Partial Hospitalization Substance Use Treatment.

The insurer denied Partial Hospitalization Substance Use Treatment. The health plan's determination is upheld. 

The patient is a female who was admitted to partial hospital program (PHP) substance use disorder treatment to address a relapse with use of opioid and cocaine substances of abuse. The patient had relapsed while receiving medication assisted treatment with Suboxone and other outpatient level services. Upon discovering her relapse, she was referred by the probation officer for PHP level treatment with 5 day per week and 6 hours per day programming together with sober community living and peer supported recovery groups.

Partial Hospitalization Substance Use Treatment is not medically necessary for this patient.

The patient presented with substance use disorders with use of opioids and cocaine while participating in an outpatient treatment program and while on probationary status. She was referred by the probation office for PHP treatment and readily engaged in treatment with continued use of Suboxone and medications to address the mood and anxiety disorder including prn medication for insomnia. During the time interval under review, the patient was noted to be in no apparent distress with improved functioning and active participation in treatment including positive interactions with staff and peers. There were no remaining treatment issues or biomedical or co-occurring psychiatric issues that would have warranted continued PHP level of care.

The patient could have been effectively managed with lower-level services, and the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a man with a history of hypertension, hyperlipidemia, diabetes and known coronary artery disease (CAD). The patient had a percutaneous coronary intervention (PCI). He presented for PCI of a chronic total occlusion (CTO) of the right coronary artery (RCA). A Promus drug-eluting stent was implanted in the RCA. The patient was admitted and observed. The patient had PCI on the left anterior descending (LAD) and intermediate ramus with imaging guidance with intravascular ultrasound (IVUS) and optical coherence tomography (OCT). The patient was discharged.

The inpatient admission was not medically necessary.

The patient had elective PCI on two separate procedures. Each intervention required monitoring afterward. For the first procedure, the patient did require monitoring for several hours after the intervention. Thus, in the absence of a second procedure the patient could have been observed after intervention and be discharged later the same day or early the next morning, i.e. (that is) less than 24 hours of admission. In view of the fact that the interventions were divided into 2 procedures, the same sequence was required to occur, i.e. observation for greater than 24 hours but in principle less than 48 hours. It has been well described in multiple studies that same day discharge of elective interventions is feasible and safe. As such, both procedures could have been performed and the patient monitored at a lower level of care. An inpatient admission was not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease.
Treatment:  Stelara SQ 90 mg every 4 weeks.
The insurer denied Stelara SQ 90 mg every 4 weeks.
The determination is overturned.

The patient has Crohn's disease. She failed mesalamine. She has been on Stelara 90 milligrams (mg) every 8 weeks, with significant improvement. She has required corticosteroids. An ultrasound of the bowel showed moderate active and chronic inflammation in the terminal ileum. The dose was escalated to 90 mg every 4 weeks. The medical necessity for Stelara 90 mg every 4 weeks for the treatment of Crohn's disease.
The request for Stelara 90 mg every 4 weeks is medically necessary in this case.
Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease. Guidelines for the treatment of Crohn's disease recommend the use of Stelara. In this case, the patient had initial improvement, followed by symptoms and objective evidence of active disease. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response. One study showed that dose escalation was required and approximately half of patients, and successful in 61.1% of dose escalation attempts. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted. Additionally, the American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should...have their medication dose adjusted in order to attempt to optimize therapy" . In this case, the patient has failed Stelara every 8 weeks, with active disease symptoms and finding of active disease on imaging; continuation of dosing every 8 weeks or discontinuation of Stelara (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with moderate to severe disease.
For all of these reasons, the use of Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.
Treatment: Inpatient stay.

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

This case involves a female who presented to the hospital due to having 2 seizure episodes while at school.  The documentation indicated she was initially seen in the emergency department and discharged; however, after discharge she had an additional episode of a generalized tonic-clonic seizure.  She has been maintained on Keppra.  She has also undergone a prior electroencephalogram (EEG), which has been normal.  The physical examination revealed a blood pressure of 97/60 with pulse of 104.  Oxygen saturation was 99% (percent).  The physical exam revealed no significant findings.  There were no focal deficits, and she was alert and oriented.  It was recommended she undergo laboratory diagnostic studies.  Laboratory studies did not reveal any significant abnormalities.  She was recommended to undergo diagnostic studies to include an EEG.  The patient was admitted for further testing and observation.  She did undergo an additional EEG, which was noted to be abnormal.  She did not have any further seizures however did complain of one episode of vomiting after dinner.  The following day she was observed where it was noted she was stable.  It was recommended she be discharged with instruction to follow-up.

The physical examination revealed no significant findings with no focal deficits.  The patient was recommended to undergo diagnostic studies including an EEG.  The guidelines indicate that in order to be medically necessary there should be documentation that the patient has status epilepticus or a recurrent seizure in the emergency department or observation care.  The records did not support that the patient had either one of the above.  The patient would have been appropriate for observation care.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Crossbite.
Treatment: D8080 braces and D8670 monthly visit x 12.

The insurer is denied coverage for D8080 braces and D8670 monthly visit x 12.  The denial is upheld. 

This female patient has a history of skeletal class I, vertical growth pattern, permanent dentation, class II canines, moderate maxillary crowding, moderate mandibular crowding, deep bite, moderately excessive overjet, impacted third molars and anterior crossbite with gingival attachment loss.

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD (Handicapping Labio-Lingual Deviation) index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist 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 condition criterion is not met, as there is no evidence of gingival attachment loss or gingival recession and therefore does 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. This reviewer concurs with the HLD index of the insurer attaining 21 points (5 overjet, 3 overbite, 10 anterior crowding, 3 labiolingual spread).

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 studies.

Each of the 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.

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

The carrier's denial of coverage for D8080 braces and D8670 monthly visit x 12 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: D8080 Braces and D8670 Monthly Visit.

The insurer denied the D8080 Braces and D8670 Monthly Visit.  The denial is overturned.

The patient is a female. The request is for orthodontic benefits. The health plan denied coverage due to no "auto qualifiers" and a handicapping index of only 19.

Yes, the braces and monthly visits are medically necessary.

Both of the patient's lower canines, 22 and 27, are in crossbite with the upper lateral incisors. There is also gingival recession on the canines. These are two "automatic qualifiers" for orthodontic benefits. Both the lower canines are anterior teeth, and when they are in crossbite (i.e., reverse bite) with gum recession, the auto qualifier clause rules.

Therefore, given the above, the braces and monthly visits are medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. Please see the rationale, above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status.

Treatment: Inpatient hospital admission.

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

This female patient has a history of diabetes, hypertension, hyperlipidemia, hypothyroidism, bipolar disorder, and schizoaffective disorder.

The MCG (Milliman Criteria Guidelines) for Psychiatric Disorder: Common Complications and Conclusions reports that one meets criteria for hospitalization if one is a danger to self or others and not manageable at a lower level of care, if they have severe behavioral health issues such as hallucinations, or if a less restrictive level of care is not considered feasible until acute intervention is done. This was the case with this patient, as she was considered a danger to self with severe psychiatric symptoms, including altered mental status and paranoid delusions, as she thought her husband threw her off the chair when her husband reported that the patient was banging her head on the chair.  She had altered mental status changes and drowsiness as well as disorientation to time and place and paranoid delusional thinking.  She was considered in need of 24-hour hospital treatment, as she could not care for her basic needs due to these symptoms and was considered a danger to self as a result.  The medical records reported that she was not at her baseline.  Notes on day after admission reported that she still had altered mental status and drowsiness and still had poor functioning and inability to care for basic needs, so she still required 24-hour hospital treatment.  Notes on date of discharge reported that she no longer had altered mental status and that it resolved and that she was at her baseline symptoms and functioning. 

The medical records supported that she required 24-hour hospital treatment due to her severe psychiatric symptoms, including altered mental status and delusional thinking. 

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

The carrier's denial of coverage for inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Encounter for crown on tooth #2 
Treatment: D2750 White Glass with High Gold Content Crown, Tooth #2 
The insurer denied the D2750 White Glass with High Gold Content Crown, Tooth #2. 
The denial is overturned. 

The patient is a female. The request is for dental benefits for a crown to be placed on tooth # (number) 2. There is no provider clinical summary noted.  

The health plan denied the claim because the initial x-ray shows a crown or a large restoration already on the tooth. The patient is appealing the decision because she states that she does not have a crown on that tooth. 

Yes, the proposed treatment of a crown on tooth #2 is medically necessary. 

The initial x-ray submitted shows an existing crown/restoration on tooth #2. There is no
narrative as to the condition of that restoration or crown. The initial x-rays do not show any defect present on tooth #2. However, upon further review of multiple x-ray images that were submitted, there is an x-ray that reveals that tooth #2 (an endodontically treated tooth-- root canal tooth) does not exhibit a crown. A tooth that has a root canal means that the nerves and blood supply have been removed from the tooth; the tooth becomes brittle over time and can become prone to fracture and eventual tooth loss. Standard care for such a tooth is crown placement to protect and restore the tooth's function. Based on this fact, a white glass with high gold content crown on tooth #2 is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgement, or in the best interest of the patient. 

A replacement crown is necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impinging Overbite.

Treatment D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visit.

The insurer denied coverage for D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visit.

The denial is upheld.

This is a teenaged patient with no documented history. She presented to the Orthodontist's office for an evaluation. X-rays and pictures were taken.

The provider states that the patient automatically qualifies as there is a deep bite. However, in order to qualify with a deep bite, there must be documentation that the lower incisors are destroying the soft tissue of the palate. The photographs do not show that there is damage to the palatal tissues. The criteria for a deep bite are not met. 

The patient's Handicapping Labio-Lingual Score (HLD) is 21. To qualify for braces a score of 26 is required, the guidelines for braces and monthly visits are not met.

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for the D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visit is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision-dry eyes. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Xiidra. 
The denial is overturned. 

The patient is female with diagnosis of dry eye disease and meibomian gland dysfunction. The patient failed artificial tears for treatment of the dry eyes and is recommended to use Xiidra for the treatment of dry eyes. The patient has 3+ superficial punctate keratopathy of the left eye. The subject under review is the medical necessity for Xiidra. 

The requested Xiidra is medically necessary for this patient. 

Xiidra is a medication to help treat the signs and symptoms of dry eyes. Xiidra has been studied in more than 1000 patients with dry eye in 4 separate, 12-week clinical studies. In some patients at 12 weeks, Xiidra was shown to reduce dry eye symptoms in all 4 studies and Inferior fluorescein Corneal Staining score in 3 of 4 studies.
The patient does demonstrate a history of meibomian gland dysfunction with superficial punctate keratitis and dry eye disease as well as symptoms of dry eyes. Artificial tears were attempted but the patient failed treatment. Xiidra would be appropriate to use in this patient to further attempt the relief of the dry eye.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: TIA (transient ischemic attack). 
Treatment: Inpatient stay. 
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This case involves a female with a history of transient ischemic attacks, and a history of supraventricular tachycardia (SVT) ablation, who transient ischemic attacks presented to the hospital with a left-sided headache and left facial numbness with tingling. Blood pressure at home measured 150/100. She denies a history of hypertension. She was instructed to come to the emergency department (ED) by her family doctor to be assessed. Vital signs on admission included a normal temperature, heart rate of 93, respirations of 18, and blood pressure 134/87. The patient's body mass index (BMI) is 34. The patient was admitted to the hospital with possible transient ischemic attack (TIA). 

The inpatient hospital admission is not medically necessary. Per the Milliman criteria for headache, there are no clinical indications for inpatient admission. The patient did not have persistent severe headaches, despite observation care. The presenting symptom was primarily numbness to the face. There was no alteration of mental status, dehydration, severe electrolyte derangements. There is no evidence of intracranial thrombosis, large vessel occlusion, or stroke. There are no clinical or radiologic findings of vasculitis. The patient was appropriately evaluated for a TIA work-up and safely released home. A lower level of care was appropriate.