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

Diagnosis: Dilated Cardiomyopathy
Treatment: LifeVest
The insurer denied LifeVest.
The determination is overturned.

The patient is a male with a past medical history significant for systolic heart failure due to dilated cardiomyopathy with severely reduced left ventricular ejection fraction (LVEF) 13 percent (%), coronavirus disease (COVID) infection, hypertension who was prescribed a wearable cardioverter defibrillator (WCD/ LifeVest). The patient wore the WCD until it was discontinued after improvement of the patient's cardiac function to 37%. At issue is whether the proposed health service or treatment LifeVest is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes, the LifeVest (WCD) was more beneficial than any other standard treatments. The current body of published medical literature on the use of the WCD demonstrates that this device is both safe and highly effective at terminating potentially life-threatening ventricular arrhythmias.
Finally, according to the 2017 American Heart Association (AHA)American College of Cardiology (ACC) / Heart Rhythm Society (HRS) guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death, the WCD is reasonable for patients, not ineligible for ICD, at high risk of sudden death due to life-threatening ventricular arrhythmias with LVEF 35% or less during the 90 day period after initial diagnosis of heart failure while monitoring for recovery of cardiac function during optimization of medical therapy (3). For these reasons, the WCD is beneficial in this case for protection against ventricular arrhythmias while allowing time for myocardial recovery during optimization of medical therapy prior to ICD implantation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Dilated Cardiomyopathy
Treatment: LifeVest
The insurer denied LifeVest.
The determination is overturned.

This is a male patient who was admitted to the hospital with acute decompensated heart failure. An echocardiogram showed severe global left ventricular systolic dysfunction with a left ventricular ejection fraction (LVEF) of 13 percent (%). The patient had recently had coronavirus disease 2019 (COVID-19) and his cardiomyopathy was thought to be post-viral in etiology. Guideline directed medical therapy for heart failure was prescribed. At the time of hospital discharge, a LifeVest wearable cardioverter defibrillator (WCD) was prescribed. Outpatient cardiac catheterization showed normal coronary arteries. An echocardiogram showed an LVEF of 37%. The LifeVest was discontinued. The LifeVest is under review.
The proposed health service or treatment LifeVest was likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient presented with decompensated heart failure due to newly diagnosed nonischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 13%. He was started on guideline directed medical therapy for heart failure. Depressed left ventricular systolic function is a risk factor for, and powerful predictor of, sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients, such as this man, with nonischemic cardiomyopathy and left ventricular ejection fractions of 35% or less. However, due to the possibility that left ventricular function may improve with time and/or treatment, it is recommended that device implantation be delayed for at least 90 days following the initial diagnosis of nonischemic cardiomyopathy and initiation of therapy. If, after 90 days of optimal medical therapy, the LVEF remains less than or equal to 35%, ICD implantation is then recommended. However, subset analyses of patients from the large multi-center randomized DEFINITE [Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation] trial evaluating the use of ICDs in nonischemic cardiomyopathy for the primary prevention of sudden cardiac death have shown that even patients with recently diagnosed cardiomyopathy are at risk for serious ventricular arrhythmias.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Dilated Cardiomyopathy
Treatment: LifeVest
The insurer denied LifeVest.
The determination is upheld.

The patient is a male who was hospitalized with acute decompensated heart failure. He was diagnosed with nonischemic cardiomyopathy, severe global left ventricular (LV) dysfunction, with an ejection fraction (EF) of 13 percent (%). This was suspected to be post viral, as he had a recent coronavirus disease (COVID) infection. He was treated with torsemide, metoprolol extended release (XL), Entresto, Spironolactone, and empagliflozin. A Life Vest wearable defibrillator was prescribed. The LifeVest is under review.
The proposed health service, a LifeVest wearable cardioverter -defibrillator, is not likely to be more beneficial than standard medical treatment for this patient. The patient presented with a newly diagnosed nonischemic cardiomyopathy. Based on standard guidelines, including the American College of Cardiology (ACC) and American Heart Association (AHA) science advisory (references below) the wearable defibrillator is considered a class IIB indication for patients with newly diagnosed nonischemic cardiomyopathy. A IIB indication means that there is some divergence of opinion but the weight of evidence is not in favor of the treatment. The patient did not have an explant of an implantable cardioverter defibrillator (ICD) due to infection, condition which temporarily delayed ICD implant, such as infection, (he did not have an indication for ICD placement, as he had newly diagnosed cardiomyopathy without a trial of guideline-directed medical therapy), and was not on a cardiac transplant waiting list.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Braces and monthly visits x 12. 
The insurer denied coverage for braces and monthly visits x 12. 
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 mandibular protrusion and an open bite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 37 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining only 20 points on the HLD index by internal reviewers. 

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 Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual 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 completes the second portion of the index arriving at 37 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care. 

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 braces and monthly visits x 12 is substantiated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Class III Malocclusion
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a Class III malocclusion. Double jaw surgery was performed. The patient has a history of obesity, has a cardiac arrhythmia and hypertension. The inpatient admission denied based on Milliman Care Guidelines (MCG) guidelines. The patient was admitted for airway monitoring and pain control. At issue is the medical necessity of inpatient admission.
The hospital admission was not medically necessary. The patient had no adverse events and no medical problems that would require an admission. On postoperative day 1, the patient was voiding, ambulating, afebrile and tolerating his diet. Care could have been provided at a lower level, such as overnight at observation status. An admission would only have been necessary for a medical problem or postoperative problem.
 In the United States, it has been reported that between 46 percent (%) and 84% of patients go home the same day of surgery after an orthognathic procedure. It is rare for an orthognathic surgery patient stay to extend beyond the first postoperative day following a 3.5-hour bimaxillary surgery. This is also consistent with Milliman Care Guidelines (MCG) guidelines. According to the MCG guidelines, this is considered an outpatient surgery. An admission is indicated for a head and neck surgery procedure if one of the General Admission Criteria are met. The patient was having a head and neck procedure but there is no documentation of a significant medical problem or any of the above problems.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Adrenal Mass.
Treatment: Inpatient Hospital Stay.

The insurer denied inpatient hospital stay. The determination is overturned.

This patient is a male who was admitted to the hospital. He had been diagnosed with an incidentally found, enlarging, 4.4-centimeter (cm) left adrenal mass suspicious of pheochromocytoma (elevated normetanephrine). The patient had comorbid health conditions of Crohn's disease and prior subtotal colectomy. The patient underwent a laparoscopic left adrenalectomy. Following surgery, he received parenteral analgesia, and his vital signs were monitored hourly (per the submitted flow sheets). He was advanced to a diet. The patient was clinically stable. The vital signs showed hemodynamic parameters of pulse and blood pressure. He was tolerating a diet and was considered to be clear for discharge.

At issue is the medical necessity of an inpatient stay.

This patient had a biochemically active left-sided adrenal mass (Pheochromocytoma). These lesions produce and release vasoactive substances that can result in profound and acute hypertensive episodes. The surgical treatment of these patients requires coordinated treatment between the surgeon and anesthesiologist with intensive hemodynamic monitoring. In this case, the operation was performed without adverse incident. The patient was monitored appropriately in the postoperative period with frequent vital sign assessments. Vital signs were monitored hourly (per the submitted flow sheets).

With resection of the adrenal lesion, there can be reactive hypotension. This patient did manifest mild post-surgical hypotension. The intensity of service with hourly vital sign assessment and follow-up and the recognized risks associated with adrenal surgery for pheochromocytoma support the medical necessity of inpatient admission for this patient. A lower level of care with overnight monitoring would not have been appropriate in this circumstance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: pyelonephritis

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is an adult male who presented for back pain-constant, non-radiating and also complained of new onset general malaise, hematuria, urinaryfrequency. Patient was afebrile in emergency department (ED), stable vitals, (HR = 52) urinalysis positive for blood, leukocytes, mild wheezing on exam white blood cell count 19,000. Computed tomography scan showed asymmetric kidney enhancement, concerning for pyelonephritis, non-obstructing stone. Patient was given intravenous fluids (IVF), Levaquin, dexamethasone in the emergency department and was admitted. The patient was noted to improve on IVF, intravenous antibiotics, and nebulizer treatments. He was stable for discharge with outpatient follow up. The insurer has denied coverage for the full hospital admission as not medically necessary, they noted the lack of a serious medical condition. The appeal on behalf of the hospital is noted and read in detail. 

Per Milliman Care Guidelines (MCG) Health (27th Edition) for urinary tract infection; the patient fails to meet indications for admission to inpatient care. These include hemodynamic instability severe or persistent altered mental status, ureteral obstruction, renal or perinephric abscess...acute kidney injury (AKI), pyonephrosis, etc. Also, the patient was noted to have negative urine culture from emergency department evaluation.

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 full Hospital Admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion 

Treatment: Braces, monthly visits, and retainer

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

The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, ectopic eruption, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 35 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 23 points by internal reviewers. The patient's family is appealing the decision.

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, 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 Labio-Lingual 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.

ln this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 35 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 23 points on the HLD index (5 overjet, 4 overbite, 10 anterior crowding, 4 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

Regarding the validity of the Handicapping Labio-Lingual Deviation 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 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 braces, monthly visits, and retainer is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8020 Braces
The insurer denied D8020 braces.
The denial is overturned.

The patient is a school aged female. The request is for orthodontic benefits. She has a Class I malocclusion with maxillary and mandibular spacing. Also, she has a deep bite. The health plan's prior denial of the request was due to the patient not having a "hard time with her bite" and also not having a "poor biting position." The denial is being appealed.

The requested braces are medically necessary.

The patient has two "automatic qualifiers" for benefits. She has an impacted anterior permanent tooth not needing extraction (tooth number 11), and she has a deep, impinging overbite with trauma to her palatal tissue. This patient has medical necessity, and orthodontic treatment is needed to correct her malocclusion. Therefore, the requested braces are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy 0.25 milligrams (mg) Injections

The insurer denied coverage for Wegovy 0.25mg Injections. The denial is overturned.

This patient is an adult female diagnosed with obesity. This request is for Wegovy. She states that diet and exercise have always been part of her day. Her leg can only take so much pounding from exercise; it swells every night. As reported, she tried and failed in diet and exercise. Her Body Mass Index (BMI) was 30.21. She has hyperlipidemia, obstructive sleep apnea (OSA), and Hashimoto's thyroiditis. Two months prior to this review, her weight was 176 pounds (lbs.), and her BMI was 30.21.  Fifteen months prior to this review, her weight was 164 lbs.; her height was 64 inches ("), and her BMI calculated was 28.1. Twenty-nine months prior to this review, her weight was 151 lbs.; her height was 64", and her BMI calculated was 28.1.

Semaglutide is a glucagon-like peptide 1 receptor (GLP1R) agonist [1] that is approved by the Food and Drug Administration (FDA) in the treatment of type II diabetes and obesity [2-4]. Recent studies published in major peer-reviewed medical journals have shown the safety and efficacy of semaglutide for the treatment of obesity [5-7]. This medication in the form of Wegovy is now available for treating obesity. The standard of care based on multiple societal guidelines [8-13] requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia. 

The patient has a BMI of 30.1 and participates in lifestyle modifications, such as diet and exercise. 

The request does meet the standard of care and is, therefore, medically necessary. 

The denial is, therefore, overturned.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, and in the patient's best interest. 

The medical necessity for Wegovy 0.25mg Injections is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polycythemia Vera (PV).
Treatment: Genetic Testing - Targeted Genomic Sequence Analysis Panel (code 81455).

The insurer denied coverage for genetic testing - targeted genomic sequence analysis panel (code 81455).  The denial is upheld.

The patient has a diagnosis of polycythemia vera (PV). The attending provider (AP) has performed next-generation sequencing (NGS) testing with Foundation One testing. The patient had already tested negative for Myeloproliferative neoplasms (MPNs). The patient's polycythemia is secondary; on subsequent testing, the patient's hemoglobin was normal.

Genetic testing - targeted genomic sequence analysis panel (code 81455) is not considered medically necessary for this patient. There is no role for evaluation with a Foundation One panel in a patient with normal hemoglobin of 17 and prior elevated hemoglobin, who previously had negative testing for MPNs.

"Since then, there have been numerous advances in the identification of unique biomarkers associated with some myeloid neoplasms and acute leukemias, largely derived from gene expression analysis and next-generation sequencing that can significantly improve the diagnostic criteria as well as the prognostic relevance of entities currently included in the World Health Organization (WHO) classification and that also suggest new entities that should be added." (Arber et al., 2016).

"The classic Philadelphia chromosome-negative myeloproliferative neoplasms (MPN) consist of myelofibrosis, polycythemia vera, and essential thrombocythemia and are a heterogeneous group of clonal blood disorders characterized by an overproduction of blood cells." (Gerds et al., 2022).

"Risk-adapted therapy: The main goal of therapy in both PV and ET is to prevent thrombohemorrhagic complications. All patients with PV require phlebotomy to keep hematocrit below 45% and once-daily or twice-daily aspirin (81 milligrams [mg]), in the absence of contraindications. Very low risk essential thrombocytopenia (ET) might not require therapy while aspirin therapy is advised for low risk disease. Cytoreductive therapy is recommended for high-risk ET and PV, but it is not mandatory for intermediate-risk ET. First-line drug of choice for cytoreductive therapy, in both ET and PV, is hydroxyurea and second-line drugs of choice are interferon- and busulfan. We do not recommend treatment with ruxolutinib in PV, unless in the presence of severe and protracted pruritus or marked splenomegaly that is not responding to the aforementioned drugs." (Tefferi & Barbui, 2020). 

Medical records provided for review did not support the targeted genomic sequence analysis panel (code 81455).  

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. 

The medical necessity for genetic testing - targeted genomic sequence analysis panel (code 81455) is not substantiated.