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

Diagnosis: Low Back Pain
Treatment: Spine Procedure (22899) and C9752 Destruction Of Intraosseous Basivertebral Nerve, First Two Vertebral Bodies Including Imaging Guidance
The insurer denied the Spine Procedure (22899) and C9752 Destruction Of Intraosseous Basivertebral Nerve, First Two Vertebral Bodies Including Imaging Guidance.
The denial is upheld.

The patient is a male with low back pain.  He had a basketball injury years ago.  He has had multiple bouts of PT (physical therapy) and facet blocks, which provided short-term relief.  He can stand for about 45 minutes.  He denies any numbness or tingling.  His pain is exacerbated by prolonged standing or jumping.  His physical exam reveals mild back tenderness in lumbosacral spine with percussion.

The patient's MRI (magnetic resonance imaging) lumbar spine shows L5 (fifth lumbar spine vertebra)-S1 (first sacral vertebra) disc desiccation with type I and type II modic changes.  There is also fluid in the facets consistent with facet degeneration.

The patient's provider recommends L5 (fifth lumbar spine vertebra) and S1 (first sacral vertebra) Intracept procedure.

No, the health plan should not cover the requested health service.

This patient has chronic low back pain with tenderness in the lumbar spine and temporary relief with facet injections.  His pain is worse with standing and not with flexion at the waist or with sitting.  Therefore, the patient is not evidenced to have discogenic pain.  Since he had relief with facet blocks even temporarily, the facets are a likely source of his pain, and then the Intracept may not provide any benefit.  There was not a thorough physical examination of the spine documented that supports discogenic related pain.

The Intracept procedure has been shown to be safe and effective treatment in properly selected patients, but this patient is not evidenced to be an ideal candidate, based on the information provided.

Since the patient had temporary relief with facet blocks, facet ablation may provide more relief.  Also, the patient is not evidenced to have symptoms consistent with discogenic pain, so the Intracept may not be helpful.  In addition, more conservative treatments can always be attempted with minimal risk to the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, left knee

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned.

This is a female with a history of arthritis of the left knee. She presented to the hospital for a left anterior cruciate ligament (ACL) repair. The procedure was performed without complications. The patient was admitted to Orthopedics for postoperative care. Pain was well controlled, and the patient was able to void. The patient had a nerve block and could not move her foot or feel sensation. The plan was to continue with pain control, administer 325 milligrams (mg) of oral (PO) aspirin twice a day (BID), encourage use of an incentive spirometer, monitor motor and sensation, and follow physical therapy (PT) recommendations. The patient's condition improved, and she was discharged. 

The records show the patient underwent a complex orthopedic procedure consisting of a medial compartment arthroplasty and revision ACL (not a primary ACL). The time in the operating room was greater than 6 hours. Her tourniquet time was close to three hours. 

Her post-surgical course was complicated by loss of feeling to the extremity. She was unable to move it and was also in a knee immobilizer. The PT records showed she could be mobilized less than 4 steps with rolling walker. Taking into consideration her elevated body mass index (BMI), she was unlikely to be independent and required additional acute PT services. Discharge to home would not be an appropriate option at that time. 

In conclusion based upon the extent, duration of surgery and post-surgical course, admission and length of stay were appropriate. 

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

The hospital admission is considered medically necessary for this patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vasovagal Syncope

Treatment: hospital admission

The insurer denied coverage for hospital admission

The denial is upheld.

The patient presented to the hospital with no past medical history.  The patient had an episode of syncope without tonic-clonic activity.  The patient's father reported that the patient came out of the bathroom and collapsed, and he was noted to be shaking.  The patient was unconscious on arrival at the emergency room.  The teeth were clenched and there was a mild, diffuse, tremulous stenosis noted.  The pupils were 3 mm (millimeters) and reactive to light.  The chest x-ray was normal.  The electrocardiogram (EKG) was normal.  The computed tomography (CT) of the head revealed an incidental benign finding of a Mega-cisterna magna.  There were no acute intracranial abnormalities.  The patient was treated with 2 mg (milligrams) of Ativan with subsequent improvement in his condition.  The patient became more calm, less tremulous, and was able to answer questions and follow commands.  The patient was admitted, and was evaluated by neurology, who recommended consideration of a video encephalogram and an magnetic resonance imaging (MRI) of the brain. The patient was discharged home in stable condition.  The patient had a negative work-up for a seizure disorder and brain structural abnormalities.  The discharge diagnosis was mental status change suspected to be attributed to vasovagal syncope.  

According to the guidelines provided by the Milliman, this acuity of this case is considered to have required observation as the patient had a seizure. Upon arrival, the patient was not considered to be in status epilepticus. No events concerning for seizures were noted during the stay. Precautionary testing with EKG and CT were performed without abnormality outside of a benign mega cisterna magna. No other interventions were necessary. The patient was described as interactive and was able to be discharged. The patient did not require an escalated level of care.

The current literature indicates a patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new focal neurologic deficits, altered mental status that is severe persistent or there is evidence of hemodynamic instability. Within the documentation it was noted the patient presented with a seizure but had no recurrence during the period of observation. However, the submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The documentation detailed the patient was back at his baseline and was discharged. The requested inpatient admission would not be the most appropriate level of care.

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 hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis
Treatment: Durable Medial Equipment (high frequency chest wall oscillation -E0483RR)
The insurer denied the Durable Medial Equipment (high frequency chest wall oscillation -E0483RR)
The denial is overturned

The patient is a male with Parkinson's disease, obstructive sleep apnea, bronchiectesis with chronic cough and recurrent aspirations. He was prescribed high frequency chest wall oscillation. The patient has tried and failed manual chest physiotherapy as well as flutter valve to improve cough.

Yes, the requested high frequency chest wall oscillation is medically necessary.
The patient patient has bronchiectesis with poor phlegm clearance. Patient has tried and failed, chest physiotherapy, and PEP (positive expiratory pressure) device. The use of vest airway clearance therapy is medically necessary in this patient despite not meeting the health plan's coverage criteria.

Bronchiectesis has similar mechanism of action as cystic fibrosis induced bronchiectesis. The patient has tried and failed multiple therapies to improve pulmonary secretions. The HFCWO (high-frequency chest wall oscillation) technique provides an improvement both in pulmonary function and quality of life related parameters in patients with chronic hypersecretive disease. Since those patients need daily airway clearance, this treatment should be included among the principal options in chest physiotherapy.  The use of vest therapy will reduce the decline in pulmonary function by improving secretion clearance. This will lead to improved quality of life, fewer doctor's visits and fewer hospitalizations.

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

Diagnosis: Malocclusion. 
Treatment: Full braces (code D8080) and monthly brace adjustment visits (code D8670). 

The insurer denied coverage for full braces (code D8080) and monthly brace adjustment visits (code D8670). 

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due excessive overjet and skeletal Class II deficiency. The orthodontist has completed the Handicapping Labio-lingual index (HLD) index as required stating the patient exhibits the automatically 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 to support orthodontic necessity. 

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, a Handicapping Labiolingual 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 overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties and deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition is met and supports comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

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

The insurer's denial of coverage for full braces (code D8080) and monthly brace adjustment visits (code D8670) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid Arthritis
Treatment: Tofacitinib Extended Release (Xeljanz XR)
The insurer denied Tofacitinib Extended Release (Xeljanz XR).
The health plan's determination is upheld. 

The patient is a male with rheumatoid arthritis (RA). The issue in this case is Xeljanz XR (Tofacitinib Extended Release) is being denied by the health plan, as the patient has not tried the optimal dose of methotrexate (MTX) = 20 milligrams (mg) a week. The patient is currently on MTX 15 mg weekly, but has not received full benefit per a letter from the patient's provider. The patient has already tried and failed Plaquenil.

Tofacitinib Extended Release (Xeljanz XR) is not medically necessary for this patient. There is no medical reason the patient cannot try the optimal dose of methotrexate (MTX).

The standard of care is to optimize MTX at this point. It's a reasonable next step in management to increase MTX to 20 mg weekly. If the patient does not respond to this dose, it would be appropriate to add Xeljanz.

A study published in Trans Am Clin Climatol Assoc in 2013 concluded that "MTX therapy has been a major advance in the treatment of rheumatoid arthritis and is now the cornerstone of therapy." Another article in Autoimmun Rev in 2014 concluded that "this review first analyses data supporting the evolution of MTX towards the role of 'anchor drug' for RA in the pre-biologic era." Moreover, according to UpToDate, "we prefer MTX over alternative nonbiologic disease modifying anti-rheumatic drugs (DMARDs) and b-DMARDs in such patients for several reasons. MTX typically serves as the 'anchor' drug for the most commonly used DMARD combinations. Randomized head-to-head trials have found that MTX has a faster onset of action, comparable or greater efficacy, better long-term tolerance, and results in improved survival compared with other conventional nonbiologic DMARD monotherapy."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Disease, Right Leg.

Treatment magnetic resonance imaging (MRI) of the leg.

The insurer denied coverage for magnetic resonance imaging (MRI) of the leg.

The denial is overturned.

The patient has metastatic rectal cancer now suspected to have disease in the right femur. A positron emission tomography-computed tomography (PET/CT) showed worsening disease. The patient was complaining of pain to femur. The request is to perform magnetic resonance imaging (MRI) of femur.

MRI remains the preferred imaging modality for evaluation of bone metastasis. An MRI is more sensitive than CT to detect metastases, allows better delineation of the extent of tumor, and is particularly useful for patients with spine metastases to evaluate the extent of medullary and extraspinal disease. MRI may distinguish benign from malignant compression fractures. MRI demonstrates greater accuracy than CT or bone scan and comparable accuracy to FDG (fluoro-deoxy-glucose)-PET/CT in diagnosis of skeletal metastases. On a per-lesion basis, the sensitivity and specificity of MRI, FDG-PET/CT, CT, and bone scan are 91 and 96 percent, 94 and 97 percent, 75 and 94 percent, and 77 and 83 percent, respectively. To specifically evaluate the spine for metastases, MRI is the most accurate modality. Therefore, the request for MRI of the leg is medically necessary for this patient.

Jayarangaiah, A., Kemp, A.K., and Kariyanna, P.T., "In the detection of bone metastasis, MRI demonstrates a sensitivity of 95% (percent) and specificity 90%. MRI is also more advantageous than a bone scan as it can detect marrow involvement before the development of osteoblastic lesions. It can be used with women who are pregnant and used to detect spinal cord compression. Bone metastases manifest as low T1 (longitudinal relaxation time) signal and high intensity on the T2 (transverse relaxation time on MRI) sequence. Whole-body MRI requires 40 to 45 minutes to perform and involves short-tau inversion recovery (STIR) and/or T1-weighted sequences."                                                         

The health care plan act did not reasonably and with sound medical judgment and in the best interest of the patient.   The magnetic resonance imaging (MRI) of the leg is medically necessary for this patient.

The insurer's denial of coverage for magnetic resonance imaging (MRI) of the leg overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: gastroenteritis.

Treatment: hospital admission

The insurer is denied coverage for hospital admission

The denial is upheld. 

This female patient has a history of bipolar disorder.

Milliman Care Guidelines (MCG) Clinical indications for admission for Gastroenteritis (MCG M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, severe abdominal pain, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had a gastroenteritis. IV (intravenous) hydration, PPI (proton pump inhibitors) therapy, and antiemetics could have been given with observation status. The Cipro and Flagyl could have been given orally as an outpatient. She responded to treatment and was then able to have her diet advanced. She did not meet MCG criteria for admission for Gastroenteritis.

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 hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient presented with abdominal and flank pain. She reported losing 10 pounds of weight. She was afebrile and the vital signs were stable. The abdominal exam was benign. There was no leukocytosis. A previous outpatient computed axial tomography (CAT) scan was negative for acute findings. She had a mildly elevated eosinophil count. Stool testing was done for parasites. There was a plan to do outpatient endoscopic testing.

Clinical indications for admission under Milliman Care Guidelines (MCG) Undiagnosed Abdominal Pain M-05 include hemodynamic instability, severe pain not responding to analgesics, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient required a workup for abdominal pains and weight loss. The testing for a parasite could have been done as an outpatient. There were no peritoneal signs or need for a surgical intervention. She did not meet MCG criteria for admission for Undiagnosed Abdominal Pain. The health care plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: respiratory complications

Treatment: second home ventilator

The insurer is denied coverage for second home ventilator

The denial is overturned. 

This female patient has a history of chronic respiratory failure and tracheostomy and ventilator dependent secondary to rapid-onset obesity with hypothalamic dysfunction, hypoventilation and autonomic dysregulation disease.

In this patient there were significant abnormal apneic episodes of 25 seconds in the polysomnography (PSG) tracheostomy cap trial. This clearly indicates that patient is dependent on the assisted ventilation all the time and particularly sleep time. The patient has significant autonomic deficits and hence the compensatory mechanism after hypopnea nor apnea is not discernible clinically hence patient needs EtCO2 (end tidal carbon dioxide) and SpO2 (oxygen saturation) to monitor the respiration and ventilation. Patient needs a uninterrupted ventilatory support and a second trilogy ventilator is essential for sustenance of life. Even if there is back up battery for the first ventilator, if the first ventilator breaks down, the patient needs a functional second ventilator to back up respiratory function, ready within minutes. The durable medical equipment (DME) company will or may take hours to days to rectify the malfunction. Due to the risk of mortality and morbidity in absence of adequate ventilator back up, the second ventilator is essential. Hence denial is reversed.

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 second home ventilator is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: severe aortic stenosis, coronary artery disease, hypertension and cognitive impairment
Treatment: Increase Home Care /Personal Care HHC Level 2 Per 15 minutes To 24 Hour(s) Per Day (live in)
The insurer denied the Increase Home Care /Personal Care HHC Level 2 Per 15 minutes To 24 Hour(s) Per Day (live in)
The denial is overturned.

The patient is a male with a history of severe aortic stenosis, coronary artery disease, hypertension and cognitive impairment. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 24 hours/day live in Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the increase in personal care services to 24 hours/day live in is medically necessary.
The patient is a male with a history of severe aortic stenosis, coronary artery disease, hypertension and cognitive impairment. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).

Although an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that the currently approved plan of 56 hours/week Personal Assistance Services is sufficient to meet the patient's current needs; the patient's advocates relate this reduced schedule leaves him home alone, completely unassisted for at least numerous hours/day. This is problematic, as he requires increased assistance with all ADLs (activities of daily living) including toileting, wiping himself after a bowel movement, personal hygiene, showering and dressing. Furthermore, the beneficiary awakens frequently at night and needs to use the restroom on average 2-3x/night. He requires his meals to be prepared and set up along with ordinary housework and shopping completed for him.

Hence, provision of 24 hours/day live in Personal Care Services can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment of 24 hours/day Personal Care Services is deemed medically necessary.

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