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

Diagnosis: Back Pain
Treatment: Pain Injections
The insurer denied the pain injections.
The health plan's determination is overturned.

The patient is a male who had complaints of low back pain. Electrodiagnostic studies that were performed demonstrated chronic bilateral lumbar vertebrae (L) 5 and sacral vertebrae (S) 1 lumbosacral radiculopathy. The magnetic resonance imaging (MRI) of his lumbar spine reported an L3-4 disc herniation, along with other degenerative changes. 

The patient presented for an office visit with low back pain. His pain was radiating towards both legs and the pain was rated 8 out of 10. It is noted that the patient has had multiple sessions of physical therapy (PT). It is noted that the patient had epidural steroid injections performed. The patient's medications include Neurontin. The physical examination of his lumbar spine showed decreased range of motion and weakness in the muscles innervated by the L5 and S1 nerves. There is a plan for a left L4-5 and L5-S1 transforaminal epidural injection.

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

The patient indicated epidural injection performed resulted in 20 months decreased pain with 50% (percent) improvement and increased ability to participate in activities of daily living and PT. The provider is requesting a left L4-5 and L5-S1 transforaminal epidural steroid injection. It is noted that the patient has had prior similar epidural injections. There is documentation of efficacy at least 50% from prior epidural steroid injection (ESI) and increase in function. Therefore, the request is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Pain Injections
The insurer denied the pain injections.
The health plan's determination is upheld.

The patient is a male who had complaints of low back pain. Electrodiagnostic studies that were performed demonstrated chronic bilateral lumbar vertebrae (L)5 and sacral vertebrae (S)1 lumbosacral radiculopathy. The magnetic resonance imaging (MRI) of his lumbar spine reported an L3-4 disc herniation, along with other degenerative changes. 
The patient presented for an office visit with low back pain. His pain was radiating towards both legs and the pain was rated 8 out of 10. It is noted that the patient has had multiple sessions of physical therapy. It is noted that the patient had epidural steroid injections performed in February 2021. The patient's medications include Neurontin. The physical examination of his lumbar spine showed decreased range of motion and weakness in the muscles innervated by the L5 and S1 nerves. There is a plan for a left L4-5 and L5-S1 transforaminal epidural injection.

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

The provider is requesting a left L4-5 and L5-S1 transforaminal epidural steroid injection. It is noted that the patient has had prior similar epidural injections in 2021. There is no documentation of at least 50 percent (%) relief of the patient's functional improvement for at least 2 months from the prior injections to consider this repeat treatment. The requested health service and treatment of pain injections is not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces
The insurer denied Braces.
The determination is upheld.

This is a patient with Class II malocclusion, mild maxillary spacing and mild mandibular crowding, moderate overjet and moderate overbite. The issue for review is the medical necessity of braces.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score an 11 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and the treatment would not be considered medically necessary. According to the standard of care, the requested health service/treatment for braces is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible.  

Per the clinical documentation, this patient presented to the emergency department (ED) with chest pain. There was associated nausea. Vital signs in the ED were within normal limits. Pain had resolved upon arrival to the ED. Due to the chest pain, a computed tomography (CT) angiograph of the chest was performed and was negative. Troponins were negative. An abdominal ultrasound indicated cholelithiasis. Alanine transaminase (ALT) and aspartate aminotransferase (AST) were slightly elevated at 73 and 175, respectively. The white blood cell count was normal at 5.5. The patient was planned for a laparoscopic cholecystectomy, but it was cancelled when the ALT and AST increased to 455 and 420, respectively. Gastroenterology was consulted and a magnetic resonance cholangio pancreatography (MRCP) was performed that demonstrated cholelithiasis without choledocholithiasis. The pain remained controlled and liver function tests decreased. The patient was discharged for outpatient cholecystectomy. Per Milliman Care Guidelines (MCG) criteria, admission is indicated when common bile duct obstruction is indicated via imaging, there is acute cholangitis, or acute cholecystitis. The patient did not meet criteria for inpatient admission. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible.  

Per the clinical documentation, this patient presented to the emergency department (ED) with chest pain. There was associated nausea. Vital signs in the ED were within normal limits. Pain had resolved upon arrival to the ED. Due to the chest pain, a computed tomography (CT) angiograph of the chest was performed and was negative. Troponins were negative. An abdominal ultrasound indicated cholelithiasis. Alanine transaminase (ALT) and aspartate aminotransferase (AST) were slightly elevated at 73 and 175, respectively. The white blood cell count was normal at 5.5. The patient was planned for a laparoscopic cholecystectomy, but it was cancelled when the ALT and AST increased to 455 and 420, respectively. Gastroenterology was consulted and a magnetic resonance cholangio pancreatography (MRCP) was performed on that demonstrated cholelithiasis without choledocholithiasis. The pain remained controlled and liver function tests decreased. The patient was discharged for outpatient cholecystectomy. The patient did not meet criteria for inpatient admission. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Cholecystitis/Inflammation of the Gallbladder
Treatment: Inpatient Hospital

Diagnosis:  Digestive System/Gastrointestinal/Cholecystitis/Inflammation of the Gallbbladder
Treatment: Inpatient Hospital Admission

The patient is a previously healthy man who presented with complaints of abdominal pain, nausea, and vomiting of 2-days duration. Vital signs were normal at the time of presentation. He was tender in the epigastrium and right upper quadrant. The white blood cell count (WBC) count was elevated at 16.7 and liver enzymes were elevated with a normal bilirubin. Ultrasound showed gallstones in the gallbladder, a wall thickness of 2.5 millimeters, and pericholecystic fluid consistent with acute calculus cholecystitis. A computed tomography (CT) scan showed findings of acute cholecystitis. He was started on intravenous (IV) antibiotics. The surgical history and physical states that the patient had cholecystitis for which antibiotics and follow up lab studies were ordered. The WBC count normalized to 9.1, but the serum bilirubin was up to 4.2 The patient was evaluated with a magnetic resonance cholangiopancreatography (MRCP) that showed gallstones and cholecystitis, but no common duct stones. 
The next day, the WBC count was 6.5, the bilirubin was down to 1.7 and transaminases were still elevated. He was discharged from the hospital  with continued oral antibiotics and with instructions for outpatient surgical follow up in one week to arrange for a laparoscopic cholecystectomy.
At issue is the medical necessity for the inpatient hospital admission.

The health plan's determination of medical necessity is overturned, in whole.

In this case, the patient presented with cholelithiasis/cholecystitis. His evaluation included lab and imaging data that identified elevated serum transaminases with normal bilirubin. However, the bilirubin value increased to 4.2 and necessitated further diagnostic imaging with an MRCP. Cholecystectomy was reasonably deferred to the outpatient setting following completion of as course of IV antibiotics and oral antibiotics. The patient was stable for discharge from the hospital with arrangements for outpatient surgical follow up. In this case, the above noted Milliman Care Guideline criteria did exist to warrant an inpatient level of care. The patient's presenting condition at the hospital, lab data and his clinical course did justify an inpatient level of care. The care provided could not have appropriately been rendered at an alternate level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: gastroesophageal reflux disease

Treatment: Linx Reflux Management System and one bed day - 43284 - laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of augmentation device (i.e., magnetic band), including cruroplasty when performed

The insurer denied coverage for Linx Reflux Management System

The denial is overturned

The patient has a history of chronic gastroesophageal reflux disease (GERD) and has had increased symptoms. An endoscopy showed esophagitis. He has been on proton pump inhibitor (PPI) therapy. Both manometry and pH (potential for hydrogen) impedance studies were done. The testing showed significant upright and supine acid reflux with likely correlation to belching. Dietary and lifestyle changes were made. His physician has discussed with him the options of doing the LINX procedure or a fundoplication. 

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the Linx Reflux Management System in March 2017. With regards to safety, the conclusion was that long-term followup supports the Food and Drug Administration (FDA) conclusion that the device is safe. With regards to efficacy there were several conclusions. The LINX implant results in pH normalization, improved quality of life, and cessation of regular PPI use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating GERD symptoms and dysphagia are similar following LINX. The long term followup data demonstrates that the LINX Reflux Management System is effective in the management of GERD.

The scientific peer-reviewed literature supports the use of the LINX system as resulting in improvements in health outcomes. The procedure has FDA approval. The patient is a good candidate for the procedure because he has long standing reflux and has remained symptomatic on PPI therapy.There are several procedures available for the treatment of GERD, but the LINX system has been shown to be safe and effective. The LINX Reflux Management System has been shown to be beneficial in patients with chronic reflux symptoms who have not responded adequately to PPI therapy. The denial is overturned.

In summary, the denial of  LINX Reflux Management System (LINX) and one bed day - 43284 - laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of augmentation device (i.e., magnetic band), including cruroplasty when performed and coverage for the requested service should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: D8080 braces.
The insurer denied coverage for D8080 braces.
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. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index Report as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth 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 12 points by internal reviewers when 26 points are required for approval.

Upon review of the submitted documentation 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 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 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.

Overturn denial as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

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 D8080 braces is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adolescent male teen that presented to the emergency department for evaluation of his left leg wound. He had injured his left shin, punctured by a tree branch five days prior with imbedded wood. He was seen the same day in the emergency department where the wood was removed, and the wound was cleaned and dressed. He was prescribed doxycycline. He subsequently developed redness, swelling, purulent discharge, and some difficulty with ambulation. He was using bacitracin since the injury. The patient's vital signs included temperature 36.8, heart rate 96, blood pressure 109/63, and respiratory rate 20. His examination was significant for no acute distress, no muscle or joint tenderness, three wounds on the anterior left lower leg with purulent drainage from two wounds, and non-focal neurologic exam. Laboratory evaluation was significant for white blood cell (WBC) count 5.0 thousand (K), 55.2%(percent) neutrophils, and unremarkable metabolic panel. The 
patient was admitted for treatment of cellulitis and failed outpatient treatment. The patient's computed tomography (CT) scan was negative for abscess but revealed suspected residual foreign body. He was treated with parenteral antibiotics, cefazolin (Ancef). Surgery was consulted and the retained wood splinter was removed at the bedside. No other surgical intervention was deemed medically necessary. The patient remained stable, with adequate pain control, decreased swelling and erythema, tolerating a regular diet for age. He was discharged the next day to complete a course of enteral antibiotics.

The acute inpatient admission was not medically necessary.

Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. 
The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as well as age and immune status of the patient. This male teen presented with signs and symptoms consistent with wound cellulitis despite outpatient antibiotic therapy. While it was reasonable and appropriate to monitor the patient in the hospital for response to parenteral antibiotic therapy, he was overall hemodynamically stable with no evidence of impending sepsis or serious wound complications. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis 

Treatment: Taltz 

The insurer denied coverage for Taltz 

The denial is upheld

The patient is an adult with a diagnosis of psoriasis and psoriatic arthritis. The patient has failed numerous topical agents as well as biologics and systemic therapies, including methotrexate, Cosentyx, and Stelara. The request is for Taltz in combination with Otezla. 

Based on the submitted documentation, the patient has failed numerous systemic agents for treatment of psoriasis and psoriatic arthritis. The documentation would support the use of Taltz to treat the existing psoriasis and psoriatic arthritis. However, there are no randomized controlled data to suggest the necessity of continued Otezla use while taking Taltz. 

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 Taltz in addition to Otezla is not substantiated.