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

Diagnosis: Traumatic brain injury.
Treatment: Continued stay long term acute care hospital (LTACH).
The insurer denied: Continued stay long term acute care hospital (LTACH).
The denial is upheld.

This adult female has a history of traumatic brain injury. She underwent hemicraniectomy, cranioplasty, and EVD (external ventricular drain) placement for hydrocephalus.

The patient was found to have exposed mesh on the scalp wound and underwent I&D (incision and drainage) in early April.

The patient was admitted to LTACH (long-term acute care hospital) 5 days later. As of 7 days post-admission, the patient's vital signs were stable, and she was afebrile. She had normal oxygenation with 35% FiO2 (fractional-inspired oxygen concentration). Oxygen was being weaned with a plan for decannulation. She had a tracheostomy and PEG (percutaneous endoscopic gastrostomy) in place. She was on oral antibiotics. She was receiving wound care for a sacral wound, left hip wound, left ear wound, right scalp wound, and right thigh wound. She had upper and lower extremity fractures, and her level of functioning was total assistance.

During her stay, the patient continued to receive supportive care. Antibiotics were completed and she was decannulated. Attempts for transfer to inpatient rehabilitation were unsuccessful. Her husband declined SNF (skilled nursing facility) and home health.

This review is for the medical necessity of Continued Stay (LTACH).

The Continued Stay at LTACH (long-term acute care hospital) was not medically necessary.

An LTAC (long-term acute care) level of care is indicated for individuals that require direct physician interventions, complex and extensive nursing, and rehabilitation participation in skilled rehabilitation services 5 days a week. This patient has a history of traumatic brain injury with hemicraniectomy, cranioplasty, EVD (external ventricular drain) placement, and I&D (incision and drainage) of the scalp wound. She was admitted to an LTAC (long-term acute care) level of care. During the period from 7 days post-admission, she was hemodynamically stable. She was undergoing oxygen weaning and she was decannulated. She had a PEG (percutaneous endoscopic gastrostomy). She was receiving oral antibiotics that were completed. She had pressure wounds that did not require complicated wound care. She had contractures and required total assistance. The continued LTAC (long-term acute care) level of care was not medically necessary, because the patient no longer required complex and extensive nursing or direct physician intervention. Per the appeal statement, "acute rehabilitation was recommended as the appropriate level of care, but the health plan declined to authorize this level and denied ongoing LTACH [long-term acute care hospital] care." The continued LTACH (long-term acute care hospital) stay was not medically necessary. The patient was stable for treatment at an SNF (skilled nursing facility) level of care or home with a home health level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary open angle glaucoma

Treatment: Laser eye surgery (Trabeculoplasty), CPT code 65855

The insurer denied coverage for laser eye surgery (Trabeculoplasty), CPT code 65855.

The denial is overturned.

The patient is a female with primary open angle glaucoma. Her best-corrected visual acuities were 20/20 in both eyes (OU). Exam showed cup-to-disc ratios of 0.55 OU. Diagnosis of primary open angle glaucoma was noted. Drops versus selective laser trabeculoplasty (SLT) was discussed, and the patient opted for drops. Her visual acuities were 20/20 OU. Intraocular pressures (IOP) were 18 millimeters of mercury (mmHg) in right eye (OD) and 16 mmHg in left eye (OS). The patient was noted to be non-complaint with drops and failed to use them as directed. IOP was elevated off drops. Drops versus SLT was discussed and patient opted for SLT. The patient underwent SLT OU. The visual acuities were 20/20 OU. IOP were 13 OD and 14 OS. The patient noted to have good pressures after SLT.

The appeal request form noted that the patient was non-compliant with drops and IOP remained high, so SLT was necessary. 

The patient was non-compliant with glaucoma drops and IOP were high without drops. Thus, the SLT procedure is medically necessary for the patient to prevent vision loss from glaucoma. In addition, SLT as a first-line treatment before drops has been shown to be beneficial in lowering intraocular pressures.

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

The insurer's denial of coverage for laser eye surgery (Trabeculoplasty), CPT code 65855 is overturned. Medical necessity is 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 and tracings, 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 to excessive overjet. The orthodontist completed the Handicapping Labio-Lingual Deviation (HLD) index as required asserting the patient exhibits the automatically qualifying condition of overjet greater than 9 mm (millimeter) with incompetent lips or reverse overjet greater that 3.5 mm with reported masticatory/speech difficulties to support orthodontic necessity. 

Upon review of the submitted documentation, (study models were not provided for review), 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 HLD. 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 9 mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition is not met and does not support comprehensive orthodontic care using this criterion. This reviewer concurs with the findings of the insurer reviewer attaining a score of 17 points on the HLD index (8 overjet, 4 overbite, 3 ectopic eruption and 2 labiolingual spread). 

Regarding the validity of the HLD 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 peer reviewed studies referenced below. Each of these 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 acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the braces, monthly visits, and retainer is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: braces and monthly visits

The insurer denied coverage for braces and monthly visits

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, 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 to excessive overjet. The orthodontist completed the Handicapping Labio-Lingual Deviation (HLD) index as required asserting the patient exhibits the automatically qualifying condition of overjet greater than 9 mm (millimeter) with incompetent lips or reverse overjet greater that 3.5 mm with reported masticatory/speech difficulties to support orthodontic necessity. 

Upon review of the submitted documentation, (study models were not provided for review), 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 HLD. 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. This reviewer finds that this automatically qualifying condition is not met and does not support comprehensive orthodontic care using this criterion. This reviewer concurs with the findings of the insurer reviewer attaining a score of 17 points on the HLD index (8 overjet, 4 overbite, 3 ectopic eruption and 2 labiolingual spread).

Regarding the validity of the HLD 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 peer reviewed studies referenced below. Each of these 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 acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the braces and monthly visits is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back/neck pain.
Treatment: Nerve treatment in spine (Intracept Procedure).
The insurer denied: Nerve treatment in spine (Intracept Procedure).
The denial is: Upheld.

The patient is a female with neck pain and low back pain. The patient's diagnoses include vertebrogenic low back pain. The pain is described as aching and dull, and there is radiation down the right arm. Magnetic resonance imaging (MRI) of the cervical spine showed cervical (C)5-6 stenosis. MRI of the lumbar spine demonstrates degenerative disc disease at lumbar (L)3-sacral (S)1 with significant L5-S1 herniation. It is noted patient has tried 6 months of conservative treatment. There is a request for Intracept procedure targeted to the low back.

The proposed health service or treatment nerve treatment is not likely to be more beneficial than any standard treatment or treatments for the patient's condition. The patient has complaints of low back pain.

There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended. Despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as a treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered to be the standard of care.

Given the above, the proposed health service or treatment Nerve treatment is not likely to be more beneficial than any standard treatment or treatments for patient's back pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back/neck pain.
Treatment: Nerve treatment in spine (Intracept Procedure).
The insurer denied: Nerve treatment in spine (Intracept Procedure).
The denial is: Upheld.

The patient is a female with complaints of (c/o) neck pain. Her pain is achy and dull with radiation to her right arm. Her cervical spinal magnetic resonance imaging (MRI) showed severe cervical (C)5/6 stenosis. Her lumbar spine showed degenerative disc disease (DDD) at lumbar (L)3-sacral (S)1, L3/4 disc herniation and moderate to severe stenosis at L4/5 and L5/S1. The physical exam (PE) was unremarkable for except facet joint tenderness at L4/5 and L5/S1 levels. This patient was recommended for L4, L5, S1 basivertebral nerve ablation (Intracept Procedure).
The issue under review is whether the Intracept procedure is likely to be more beneficial for this patient than any standard treatment.

The Intracept system was designed to treat low back pain from vertebral body by ablating basivertebral nerves. Review of the available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. Her lumbar MRI revealed multilevel DDD, L3/4 disc herniation, facet joint arthropathy, and moderate to severe spinal stenosis.
Truumees's study supported the efficacy of Intracept procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge, spinal stenosis and facet arthrosis were excluded. 1
Given this patient's medical history, MRI reading, and the current clinical evidence, she is not an appropriate candidate for the Intracept procedure.
The proposed Intracept Procedure is unlikely to be more beneficial than any standard treatment for this patient's back pain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Saxenda
The health plan denied Saxenda.
The health plan's determination is overturned.

The patient is a male with obesity with a body mass index (BMI) of 64 and a weight of 530 pounds (lbs). He has been prescribed Saxenda, and the request for Saxenda is under review. The prior request was denied as the patient has not been in a comprehensive weight management program for the previous three months, and the patient is also taking Topamax. At issue is the medical necessity for Saxenda. 

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

The treatment with Saxenda for obesity is medically necessary for this patient. The prior request was denied as the patient has not been in a comprehensive weight management program for the previous three months, and the patient is also taking Topamax. This patient has a very elevated body mass index greater than 60. He has tried and failed lifestyle changes with dietary adjustment and dietician appointments. Given his very elevated body mass index, it is not medically reasonable that this patient will be able to achieve a body mass index below 30 with a comprehensive weight management program without the use of weight loss medications. In addition, this patient has been followed in a weight loss clinic for years. The patient is on phentermine, which will be discontinued at the time he starts Saxenda. He is on Topamax, which was clarified to be for migraines and not for weight loss. Therefore, he will be on Saxenda as monotherapy. This patient has already experienced multiple weight-related co-morbidities, including hypertension, obstructive sleep apnea, and fatty liver disease. Without Saxenda, this patient will be at increased risk of future weight-related co-morbidities, including type 2 diabetes. Therefore, the requested Saxenda is medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes
Treatment: Afrezza
The insurer denied Afrezza.
The health plan's determination is upheld. 

This is a male diagnosed with T2DM (type II diabetes mellitus). This request is for Afrezza. The provider states since inclusion of Afrezza his HGB (hemoglobin) A1C levels have decreased dramatically; prior to Afrezza his HGB A1C was 9.6% (percent). His most two recent HGB A1C were 5.3 and 5.6. During hospitalization, he was placed on Lantus and Lispro which his BG (blood glucose) average went up to 216 and his diabetes was not well controlled despite being in a 24 hour/day care setting. He has been maintained on long-acting insulin, Trulicity, Metformin, Actos, Cycloset (had no effect), and Farxiga (caused his creatinine to be high). 

A formulary exception is not indicated in this case.

Afrezza is Food and Drug Administration (FDA) approved for treatment of diabetes. It has been shown to be beneficial in patients with diabetes. Studies have demonstrated the safety and efficacy of the medication and treatment of diabetes. There are no studies showing superiority of Afrezza over injectable insulin. However, in this case, the patient has tried and failed injectable insulin in the form of Humalog. The patient has not tried NovoLog or Fiasp. Although NovoLog and Humalog are similar, Fiasp has a faster onset of action. The patient can try Fiasp and it is not expected to be ineffective or less effective or have adverse effects.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: Procedure 64628 and 64629: Intraosseous Basivertebral Ablation. 
The insurer denied: Procedure 64628 and 64629: Intraosseous Basivertebral Ablation. 
The denial is upheld. 

The patient is an adult female with low back pain. The patient has obtained relief with caudal epidural steroid injections for several weeks. She has tried physical therapy and a 
transcutaneous electrical nerve stimulation (TENS) unit with minimal relief. Celebrex 200 milligrams twice daily does help the severity of her pain. Zanaflex provided no relief. Other treatments tried included bilateral lumbar vertebrae four (L4) - lumbar vertebrae five (L5) transforaminal epidural steroid injection (TFESI), Tylenol, Robaxin, and Tramadol. Magnetic resonance image (MRI) of the lumbar spine shows scoliosis, multilevel degenerative disc disease, a developmentally narrow spinal canal, facet arthropathy, and disc bulges with moderate spinal stenosis at lumbar vertebrae four (L4) - lumbar vertebrae five (L5). Request for Intracept was denied as there is no proof or not enough proof that it improves health and therefore it is investigational. 

The health plan should not cover the proposed treatment. 

Review of the literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such, the Intracept procedure is considered unproven/experimental/investigational.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain. 
Treatment: Procedure 64628 and 64629: Intraosseous Basivertebral Ablation. 
The insurer denied: Procedure 64628 and 64629: Intraosseous Basivertebral Ablation. 
The denial is upheld. 

The patient is an adult female. Per the appeals letter: The patient has a history of chronic low back pain due to degenerative disc disease that has resulted in development of vertebral genic pain identified by degenerative endplate changes Modic on magnetic resonance image. The patient has had greater than six months of pain and failed greater than six months of treatment. Previous treatments include medial branch block, medication, radiofrequency ablation, sacroiliac joint injection and physical therapy. The patient has tried medications. The patient presented with a history of low back pain. The patient had several weeks of relief from the caudal steroid injection. The patient has seen multiple rheumatologists to evaluate her arthritis. The patient has been in physical therapy use of a transcutaneous electrical nerve stimulation unit with minimal relief. Previous treatments included medial lumbar radiofrequency ablation, injection, sacroiliac joint injection, caudal epidural steroid injection. Diagnosis includes vertebral genic low back pain, lumbar spondylosis, spinal stenosis lumbar region and lumbar degenerative disc disease. 

The health plan should not cover the proposed treatment. 

Based on the provided documentation, the requested procedure is not recommended at this time. 

The patient has a history of continued low back pain despite other treatments. Magnetic resonance image (MRI) did not demonstrate any documentation of the patient having Modic type changes. There were degenerative changes noted but no evidence of Modic type change that would support the requested procedure.