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

Diagnosis: Chronic Sinusitis.

Treatment: Outpatient surgery, current procedure terminology (CPT) codes 30520, 30140(50), 31255(50), 31267(50), 31288(50), 31276(50), and 61782.

The insurer denied coverage for outpatient surgery, current procedure terminology (CPT) codes 30520, 30140(50), 31255(50), 31267(50), 31288(50), 31276(50), and 61782.

The denial is overturned.

According to the medical records, the patient presented with chronic sinusitis. The member has a longstanding history of chronic nasal complaints. The patient's symptoms include congestion. Medical management has been trialed in addition to allergy immunotherapy. The imaging demonstrated sinus disease. The recommendation was made for sinus surgery given persistent infections and complaints.

Outpatient surgery, current procedure terminology (CPT) codes 30520, 30140(50), 31255(50), 31267(50), 31288(50), 31276(50), and 61782 is considered medically necessary for this patient. The member has failed medical therapy. The imaging demonstrated chronic sinus disease since medical management. The literature supports these procedures in similar cases.

"Functional endoscopic sinus surgery can be considered for patients who fail medical management. In more complicated cases, it can serve as an adjunct to medical management. The goal of this surgery is to relieve obstructions, restore drainage and mucociliary clearance, and to ventilate the sinuses" (Kwon, E., & O'Rourke, M. C. 2023).

"One of the most common reasons for clinical visits in the United States is sinusitis, also known as rhinosinusitis. It is also one of the top reasons that antibiotics are prescribed. Over one year, there were up to 73 million restricted-activity days related to sinusitis and total direct medical costs of almost 2.4 billion, not including surgery or radiographic imaging. In addition, up to 14.7 percent of individuals surveyed in the National Health Interview Survey reported having had sinusitis the preceding year" (Battisti, A. S., et al. 2023). 

According to Karakurt, S. E., et al. (2021), "In Group A, mean postoperative minimal cross-sectional area (MCA) and nasal volume (NV) values and Nasal Obstruction Symptom Evaluation (NOSE) scores were significantly greater compared to those obtained in the preoperative period. Similarly, Group B showed significantly greater mean postoperative MCA, NV, and NOSE score values compared to the preoperative period. In Groups A and B, the mean postoperative total nasal resistance (TNR) value was significantly lower in comparison to the preoperative period. The differences in mean preoperative and postoperative MCA, NV, TNR, and NOSE scores were significantly greater in Group B versus Group A."

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 outpatient surgery, current procedure terminology (CPT) codes 30520, 30140(50), 31255(50), 31267(50), 31288(50), 31276(50), and 61782 is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Below Knee Amputation
Treatment: Prosthetic parts (shock reducing pylon and a vacuum suspension)
The insurer denied Prosthetic parts (shock reducing pylon and a vacuum suspension).
The determination is overturned.

This is a female patient with a pertinent past medical history significant for diabetes mellitus type II and vascular disease who underwent a left transtibial amputation secondary to diabetes and vascular disease. The post-operative course was complicated by infection. The patient was previously functionally independent without device prior to amputation and would like to return to their prior level of function. At issue is whether the proposed shock reducing pylon and vacuum suspension are likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Both the proposed vacuum suspension and shank foot system with vertical loading pylon are likely to be more beneficial than any standard treatment of treatments for the insured's condition. Both prosthetic components are appropriate for this specific patient.
The patient is described as a K3 ambulator. Documentation noted the postoperative course complicated by infection. Vacuum suspension reduces axial limb-socket movement which decreases risk of skin irritation, breakdown and infection, something the patient has already had during the post-operative course. It also manages daily residual limb fluid volume changes which also improves stability. In addition, the patient is a first-time prosthetic user. Vacuum suspension provides better proprioception and socket stability decreasing the patient's risk of falls which could result in catastrophic injury.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Below Knee Amputation
Treatment: Prosthetic parts (shock reducing pylon and a vacuum suspension)
The insurer denied Prosthetic parts (shock reducing pylon and a vacuum suspension).
The determination is overturned.

This is a female patient with a below knee amputation who has had a denial of prosthetic parts by the health plan. The request was for a shock reducing pylon and vacuum suspension system. This is an appeal of the denial. At issue is whether the proposed health service or treatment prosthetic parts (shock reducing pylon and a vacuum suspension) likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Shock reducing pylons reduce the magnitude of the force transmitted up through the knee and hip on the BKA side. They provide increased efficiency of gait and increased comfort. The vacuum suspension system is more beneficial than standard treatment. Evidence shows reduced pistoning and reduced volume fluctuation of the residual stump. This reduces sheer forces and a loose socket which contribute to poor fitting and skin breakdown. A shank foot system with vertical loading pylon reduces impact forces while ambulating which allows for increased activity and increased energy efficiency.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Below Knee Amputation
Treatment: Prosthetic parts (shock reducing pylon and a vacuum suspension)
The insurer denied Prosthetic parts (shock reducing pylon and a vacuum suspension).
The determination is upheld.

The patient is a female with a left below the knee transtibial amputation, diabetes, hypertension, and vascular disease. Her postoperative course was complicated by an infection treated with oral antibiotics. She underwent rehabilitation and then was discharged home. She is treated with Lyrica for phantom pain, with minimal relief. The provider stated that her strength was 5/5. The left residual limb was well healed. There was full range of motion with no contractures. Sensation was intact and reflexes were symmetric. At issue is whether the proposed health service or treatment Prosthetic parts (shock reducing pylon and a vacuum suspension) is unlikely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment Prosthetic parts (shock reducing pylon and a vacuum suspension) is unlikely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has a left below the knee transtibial amputation. Her provider stated that her strength was 5/5. The left residual limb was well healed. There was full range of motion with no contractures. Sensation was intact and reflexes were symmetric. The proposed health service or treatment Prosthetic parts (shock reducing pylon and a vacuum suspension) is not the standard treatment for patients with left below the knee amputation. There are no well-designed well conducted studies published in peer-reviewed journals to support prosthetic parts (shock reducing pylon and a vacuum suspension), demonstrate that the prosthetic parts (shock reducing pylon and a vacuum suspension) affect health outcomes, or show that prosthetic parts (shock reducing pylon and a vacuum suspension) are equally or more effective than conventional therapies. There are many standard treatments for the diagnosis of left below the knee amputation including a conventional left below the knee prosthesis. The use of prosthetic parts (shock reducing pylon and a vacuum suspension) is not supported by the peer-reviewed medical literature and is not considered the standard of care in United States at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and vomiting
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult obese female with history of asthma and gastroparesis who presented with history of abdominal pain and vomiting. On presentation to the emergency department (ED) 
it was noted that the patient was not ill appearing, toxic appearing or diaphoretic. She had abdominal and flank pain. Her vitals at 13:01 demonstrated pulse of 109, blood pressure (BP) 136/89, 100 percent oxygen saturation, and afebrile. Vital signs at 1602 demonstrated a pulse of 62 and blood pressure of 156/107 and thereafter, the patient's her blood pressure and pulse were normal at 119/89 and pulse of 65 prior to admission at 20:05. Labs revealed a white blood cell count of 16.1 and creatinine of 0.9. The patient received intravenous fluids, intravenous morphine and Toradol for her pain as well as Zofran for nausea and vomiting and was noted to vomit in the emergency department. The patient was given one dose of Rocephin. A computed tomography (CT) scan was obtained that demonstrated a 5 millimeter ureteral calculus with hydronephrosis and perinephric fluid. The patient was admitted due to poorly controlled pain in the emergency department and emesis in the emergency department. The admission note indicates the patient was ill appearing with left costovertebral angle (CVA) tenderness and abdominal tenderness. The patient remained afebrile and hemodynamically stable inpatient. Urology consult recommended urinalysis, culture, nothing by mouth (NPO) after midnight and plan for stent placement the next day. The patient underwent cystoscopy, retrograde study, stent placement and was discharged later.

The requested health service was not medically necessary.

The patient was noted to initially be tachycardic and hypertensive in the emergency department but prior to admission her pulse was normal as was her blood pressure. Her renal function was normal. She had a normal contralateral kidney. Her management plan included stent placement the following day which is an ambulatory procedure and thus discharge to home the following day was anticipated. She did not require continuous pain management (i.e. patient controlled analgesic [PCA]), intravenous hydration beyond 24 hours or management of persistent nausea and vomiting (greater than 24 hours). The patient was afebrile, hemodynamically stable and did not exhibit signs/symptoms of sepsis. The records do not report a high level of suspicion of an infected obstructing stone. StatPearls' renal colic, reference below, notes that indications for hospital admission include a significant renal stone in a solitary kidney, severe kidney injury, an infected renal stone, intractable pain or nausea, urinary extravasation, or hypercalcemic crisis (2). 
The patient was noted have intractable pain and thus needed hospital care, but she could have been managed at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Upheld

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

This is a female diagnosed with obesity. According to the records she has hypertension (HTN), pre-diabetes, hyperinsulinemia, and metabolic syndrome with low high-density lipoprotein (HDL) cholesterol. She was started on Mounjaro and despite not ever being at the most effective and highest dose of 15 mg; her weight decreased to 302 lbs (pounds). Since she has been off Mounjaro (expiration of the saving card); her weight has already increased to 318 lbs. She is unable to tolerate more than 500 milligrams (mg) of metformin ER (extended release).

Mounjaro is not medically necessary.
Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for treating adults with type 2 diabetes. It is a GLP-1 (Glucagon-like peptide-1) and GIP (gastric inhibitory polypeptide) receptor agonist. Tirzepetide in the form of Zepbound is FDA-approved for obesity. Name brand Mounjaro is no longer used for the treatment of obesity. The patient is diagnosed with obesity.
The request does not meet the standard of care and is, therefore, not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: decayed or fractured tooth

Treatment: Procedure D2740 - Porcelain Crown tooth # 30

The insurer denied coverage for Procedure D2740 - Porcelain Crown tooth # 30

The denial is upheld 


Upon review of the documentation provided which includes copies of periapical and bitewing radiographs and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist Dr. Christopher Armento recommended full coverage crown for #30 due to tooth fracture and failing restoration. The insurer has denied this service stating the there is no clinical/radiographic evidence, such as traumatic injury or decay, nor is there documentation to indicate cracked tooth syndrome, to support the necessity of this service.  The service does not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is a copy of periapical and bitewing radiographs. There does not appear to be any radiographic evidence of caries nor is there evidence of significant coronal loss of tooth structure. The radiographs do not substantiate the requested dental services as enumerated above. There are no dental treatment records provided and no evidence of cracked tooth syndrome. Therefore the crown is deemed 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 Procedure D2740 - Porcelain Crown tooth # 30 for service date 8/2/23 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Remicade 600mg (milligrams)
The insurer denied: Remicade 600mg (milligrams)
The denial is overturned.

The patient is an adult female with Crohn's disease who has used Remicade. When switched to a biosimilar, she had a full body eruption or a psoriasiform rash. She was consulted by dermatology, and it is stated that there were not any negative issues with Remicade. The joint decision was made to place the patient back on Remicade.

The requested Remicade is medically necessary.

Although literature supports the safety and efficacy of switching from an originator (i.e. Remicade) to a biosimilar agent (i.e. Avsola or Inflectra), this patient attempted to switch to Inflectra and developed a rash. For this reason, there is medical necessity to stay on the previously tolerated Remicade.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia, Sepsis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient admitted to the hospital for a fever and shortness of breath. Examination revealed a mildly ill-appearing patient, with scattered crackles bilaterally on lung exam. An x-ray was concerning for a right lower lobe pneumonia.
The patient was diagnosed with sepsis secondary to pneumonia, treated with 30 milliliters per kilogram (mL/kg) intravenous (IV) fluid bolus, and started on IV Rocephin and azithromycin empirically.
The medical team assessed the patient and found him distressed and diaphoretic, with persistent tachycardia. They also documented wheezes and respiratory distress.
Pulmonary medicine assessed the patient the next day, and noted that the patient was started on bi-level positive airway pressure (BiPAP) to ease the work of breathing. The patient was not tolerating the BiPAP therapy and was placed on Airvo at 40 liters (L).
The patient was transferred to the intensive care unit. Hemodialysis was initiated by nephrology.
Dialysis was continued for fluid removal as the patient continued to have profound hypoxemia on the ventilator. He still required Levophed and vasopressin during hemodialysis.There was no additional gastrointestinal bleeding.
The patient's oxygenation and ventilation status continued to deteriorate, failing prone ventilation. Extracorporeal membrane oxygenation (ECMO) consultation was requested at another hospital; the patient was accepted and transferred.
At issue is the medical necessity of an inpatient level of care.
The inpatient admission was medically necessary. The patient required an inpatient level of care at an ICU level. The patient was admitted to the hospital with septic shock secondary to Legionella pneumonia. The patient could not be successfully ventilated despite extraordinary measures to treat the pulmonary infiltrates with pronated ventilation, corticosteroids, and broad-spectrum antibiotics. The patient required vasopressors. He developed acute renal failure secondary to acute tubular necrosis (ATN), requiring progression to hemodialysis. The patient was critically ill throughout the hospital stay, and his condition could not be managed at any other level than the ICU level of care. The patient was appropriately transferred for last resort treatment to undergo ECMO at a tertiary care center.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dental malocclusion

Treatment: braces, monthly visits, and a retainer

The insurer denied coverage for braces, monthly visits, and a retainer

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crossbite among other findings. The orthodontist has completed the Handicapping Labia-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth (#[number]22) when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 18 points by internal review is when 26 points or greater is needed to approve braces. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labia-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 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 met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for braces, monthly visits, and a retainer is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain; hip pain
Treatment: Spine Surgery
The insurer denied: Spine Surgery
The denial is upheld.

The patient is an adult female with a history of severe spinal stenosis at L4-5 (with spondylolisthesis) and to a lesser degree at L3-4. There is severe lateral recess narrowing as well as neuroforaminal stenosis. The patient underwent chiropractic care, physical therapy, medications, and epidural steroid injections. A minimally invasive lumbar decompression/percutaneous laminectomy was recommended.

The health plan should not cover the requested health service.

The patient is an adult female with a history of severe spinal stenosis at L4-5 (with spondylolisthesis) and to a lesser degree at L3-4. There is severe lateral recess narrowing as well as neuroforaminal stenosis. The patient underwent chiropractic care, physical therapy, medications, and epidural steroid injections. A minimally invasive lumbar decompression/percutaneous laminectomy was recommended.
Minimally invasive lumbar decompression (MILD) is a fluoroscopically guided minimally invasive laminectomy that targets debulking of the ligamentum flavum in order to relieve symptoms of neurogenic claudication caused by spinal stenosis. However, this patient has severe spinal stenosis secondary to degenerative changes, severe facet arthropathy, and 
spondylolisthesis. She has severe lateral recess narrowing and severe neuroforaminal stenosis. Unfortunately, with the exception of the debulking of the ligamentum flavum, the remainder of the factors contributing to the spinal stenosis will be unchanged, specifically the neuroforaminal stenosis and facet arthropathy, likely to result in little improvement. As such, the requested percutaneous laminectomy/laminotomy is not medically appropriate.