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

Diagnosis: Respiratory Failure
Treatment: 168 hours per week, two thousand one hundred and eighty-four (2,184) units of private duty nursing (PDN, T1000) services

The insurer denied coverage for 168 hours per week, two thousand one hundred and eighty-four (2,184) units of private duty nursing (PDN, T1000) services.
The denial is modified.

This is a child with a history of Prader-Willi syndrome, global delay, respiratory arrest, respiratory failure, encephalopathy, prediabetes, polyphagia, mild pulmonary hypertension, right ventricular systolic dysfunction, obstructive sleep apnea and obesity. Per the detailed letter of medical necessity, the patient was hospitalized for respiratory failure, cardiac arrest and infection. A tracheostomy was placed. The patient is stable on humidified oxygen via trach collar, requires continuous oxygen monitoring, chest physiotherapy twice daily, deep tracheal suctioning 4-6 x (times) a day, oral suctioning as needed, nebulizer treatments, mildly thick liquids orally and regular solids with constant supervision. He is risk of respiratory arrest and death if his artificial airway has a mucous plug. He has developed airway obstruction multiple times throughout this hospitalization and requires someone awake and alert to intervene in an airway trach emergency.

The patient has been hospitalized for now resolved tracheitis. He is stable but unable to be discharged home without PDN in place. He requires continuous humidified supplemental oxygen overnight, nebulizer treatments every 4 hours and as needed, frequent suctioning and urgent tracheostomy changes by trained providers or caregivers when he develops a mucous plug. The mother is the primary caregiver and works full time. Without overnight PDN, the patient will have to be institutionalized.

As per the available document, patient was noted to have maintained baseline requirements and patient needs oxygen flow at night and no need for BiPAP (bilevel positive airway pressure). There is no documentation how much he desaturates at night and how much respiratory decompensation he has periodically. However, for the nocturnal monitoring, approve 12 hours per night for 7 days a week PDN coverage. The daytime custodial care and medication administration can be done by caregiver. Hence denying 168 hours per week PDN but approving 84 hours per week PDN. 

Based on the above, the medical necessity for the 168 hours per week, two thousand one hundred and eighty-four (2,184) units of private duty nursing (PDN, T1000) services is not substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: gastrointestinal hemorrhage

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is overturned. 

This male patient has a history of hypertension who presented to the Emergency Department (ED) with a complaint of bloody diarrhea. The patient reported 2 to 3 episodes of loose and hard stools with dark red blood. The patient also endorsed shortness of breath with exertion when climbing stairs. Laboratory results were notable for anemia (hemoglobin 7.2). The patient was transfused with packed red blood cells. The patient was admitted to Medicine for gastrointestinal hemorrhage. During the hospital course, the patient received proton pump inhibitors (PPI) and intravenous (IV) hydration. Occult stool testing returned positive for blood. Gastrointestinal polymerase chain reaction (PCR) showed Enteroaggregative Escherichia coli. Gastroenterology was consulted and recommended hematology evaluation for macrocytic anemia, and outpatient colonoscopy. The patient was discharged home on with Gastroenterology, Hematology, and Primary Care Provider (PCP) follow-up.

MCG guideline M-182 lists indications for admission for lower gastrointestinal bleeding. Having anemia along with exertional dyspnea is an indication for admission. MCG Guideline M-170 lists indications for admission for Gastroenteritis. A suspected severe infection such as bloody diarrhea is an indication for admission. The patient had a severe anemia resulting in dyspnea on exertion. He also had an infectious colitis causing bloody diarrhea. He met the indications for admission for both lower gastrointestinal bleeding and gastroenteritis. 

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 the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic low back pain.

Treatment: Intracept procedure for intraosseous ablation of the basivertebral nerve to treat back pain.

The insurer denied coverage for the Intracept procedure for intraosseous ablation of the basivertebral nerve to treat back pain. 

The denial is upheld. 

This is a female patient who has a history of chronic low back pain and radiculopathy to the bilateral posterior thighs that has been resistant to ongoing medication and physical therapy. Her exams are negative for any neurological deficits and positive for antalgic gait. She also complained of right hip pain with instability and was referred to an Orthopedist. Her electromyography (EMG) shows left L5 and bilateral S1 radiculopathy of a chronic nature. A lumbar magnetic resonance imaging (MRI) showed multilevel degenerative changes in the lumbar vertebrae level L1 through L4, a right paracentral herniated disc at L1-2 causing mild central canal stenosis, L3-4 mild central stenosis,
 L4-5 with mild central stenosis and Modic type I endplate changes, and Modic type II changes of the endplates, mild central stenosis and mild bilateral foraminal stenosis at L5-S1. The recommendation was for the Intracept procedure.

The Intracept Procedure is not medically necessary. The Intracept procedure is not appropriate for this patient as it is not a generally accepted treatment for low back pain at this time. The procedure is currently undergoing a larger clinical trial (1). Although there has been benefit noted in 2 level I studies and it is clinically supported by the International Society for the Advancement of Spine Surgery (ISASS), there continues to be a question of limitations that they state, "Industry funding is a potential source of study bias for the available data reviewed; Limited number of studies; Short-term follow-up for the majority of studied patients; Unknown effect on the primary degenerative process" (2).

The role of radiofrequency ablation for low back pain is summarized by Up to Date as follows: "We suggest not using radiofrequency denervation for the management of chronic low back pain. The available data are inconsistent and suggest that, compared with placebo, radiofrequency denervation may modestly reduce pain in the short-term; however, there does not appear to be clear long-term benefit. When added to a treatment regimen that includes a regular exercise program and psychologic support, radiofrequency denervation provides little additional benefit."

The insurance company acted reasonably and with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the Intracept procedure for intraosseous ablation of the basivertebral nerve to treat back pain is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: GERD
Treatment: EsophyX Transoral Incisionless Fundoplication 
The insurer denied the EsophyX Transoral Incisionless Fundoplication. The health plan's determination is upheld. 

This patient is a woman (body mass index (BMI) 20) who sought surgical evaluation for the symptoms of gastroesophageal reflux disease (GERD) (regurgitation, belching, heartburn). The records state that she has been treated with Proton-pump inhibitors (PPI) (Esomeprazole and Dexilant) in addition to Pepcid with only partial clinical response. She also reports side-effects related to use of anti-acid medications. There is no reported dysphagia. The treating surgeon has proposed the Transoral Incisionless Fundoplication (TIF) procedure as treatment of chronic GERD and as an alternative to traditional surgical fundoplication.

Considering the submitted documentation, the published literature, and the clinical details of this case, there is not sufficient evidence to demonstrate that the requested TIF procedure is indicated for this patient.
Indications for the TIF procedure per the device manufacturer and published data include: adult over 18 years old, experiences chronic symptomatic gastroesophageal reflux disease (GERD), requires and responds to pharmaceutical therapy, has a hiatal hernia less than or equal to 2 centimeter (cm) in size, has a Body Mass Index (BMI) less than 35.
Contraindications to TIF include: A bleeding disorder, chronic uncontrollable cough, stricture, severe esophagitis, esophageal diverticulae, an obstruction, a paraesophageal hernia, limited neck mobility, osteophytes of the spine, esophageal varices, esophageal infections or fungal disease, or esophageal stenosis, has any kind of normal or abnormal esophageal anatomy which would prohibit insertion of the EsophyX device, is unable adhere to the post-operative diet recommended for appropriate healing, is under 18 years old, aberrant esophageal function, has a hiatal hernia greater than 2-cm in size, has a BMI greater than 35.
While transoral incisionless fundoplication (TIF) is considered to be safe and effective, the submitted records in this case do not support the definitive diagnosis of surgically amenable GERD or the medical necessity of TIF. The submitted records do not include documentation of the prerequisite clinical evaluation to include an assessment of esophageal function as would be obtained with either esophageal fluoroscopy or motility testing. Nor do the records confirm that there is pathologic esophageal acid exposure with an objective pH study performed while off acid suppressing medications. This data is required to establish the diagnosis of surgically-amenable GERD and preserved esophageal motility. Without this data to confirm the diagnosis of GERD and rule out alternative diagnoses, the proposed treatment (TIF) is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (skeletal Class I, vertical growth pattern, maxillary and mandibular crowding, deep bite, and anterior crossbite with gingival attachment loss).
Treatment: D8080 Braces and D8670 Monthly Visit x 11.
The insurer denied coverage for D8080 Braces and D8670 Monthly Visit x 11.
The denial is overturned. 

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, vertical growth pattern, maxillary and mandibular crowding, deep bite, and anterior crossbite with gingival attachment loss. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index 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, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements. 

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, an HLD index is utilized. This index provides 6 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 the insurer and the plan criteria to justify orthodontic care.

D8080 braces and D8670 monthly visit x 11 is considered medically necessary for this patient.

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 D8080 Braces and D8670 Monthly Visit x 11 should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing teeth.
Treatment: D6010 Implant Placement [Tooth #s 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 26, 27, 28, 29, 30, 31]. 

The insurer denied D6010 Implant Placement [Tooth #s 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 26, 27, 28, 29, 30, 31].  The health plan's determination is upheld. 

The patient is a male who presents for evaluation and treatment of missing teeth # (number) 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 26, 27, 28, 29, 20, 31. Provided for review are letters of denial, full mouth panoramic radiographic images from an unknown date, a single page of claim forms, a single clinical note, and a letter from the provider rewording in narrative form.

The requested D6010 Implant Placement [Tooth #s 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 18, 19, 20, 21, 22, 23, 26, 27, 28, 29, 30, 31] is not medically necessary for this patient.

There is no diagnosis given nor any rationale for why any teeth in the patient's mouth require extraction nor why dental implants are the only treatment option. The notes declare that the patient has experience wearing a current partial denture, but they do not express if this is in the maxilla or mandible, and the panoramic radiograph shows that there are no guide planes, no rest preps or any other dental adjustments that would be made for a partial denture, indicating that the patient either does not have one or has not had a proper prosthesis ever fabricated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right knee pain.
Treatment: Right Knee Arthroscopic Surgery.

The insurer denied the Right Knee Arthroscopic Surgery.  The denial is overturned.

The patient is a male with right knee pain. The duration was approximately five months. He believes he twisted his knee. He reported pain medially and could not run as prior. He notes pain with squatting. The physical examination was significant for medial knee pain and positive McMurray test.

An MRI (magnetic resonance imaging) showed a tear to the posterior horn of meniscus. Recommendations were made for arthroscopic surgery.

Yes, the Right Knee Surgery was medically necessary.

The records show evidence of an acute meniscal tear sustained secondary to squatting. The patient reported ongoing subjective complaints secondary to his injury. He was functionally limited and had problems. He could not squat, twist nor run. He was found to have physical findings consistent with meniscal pathology. His imaging studies and intra operative findings were consistent for an acute meniscal tear to require surgical intervention. The nature of the tear (ie flap, moving in and out of joint) caused a mechanical derangement. The pathology would not likely improve with PT (physical therapy), brace, activity restriction or injection.

The standard of practice would be to perform arthroscopic surgery.

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

The health plan used criteria that were limited. It did not include other activities which caused pain. It included painful locking, clicking, catching or popping during weight bearing actives. There should be inclusion for painful squatting and twisting. This usually occurs with meniscal tears. There was consistency of subjective complaint, objective finding and imaging studies for the diagnosis. All other criteria were fulfilled. These factors should be taken into consideration as a surgical indication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia. 
Treatment: Surgical placement of implant body to tooth 30 and 31 and a crown to tooth 14. 

The insurer denied coverage for surgical placement of implant body to tooth 30 and 31 and a crown to tooth 14.  The denial is upheld. 

Based on review of the submitted documentation, which includes copy of panoramic radiograph and dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation, treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas as enumerated above as well as a crown on #14. The dentist is requesting implants over removable partial dentures presumably due to patient's reported dysphagia and nausea. The insurer has denied the aforementioned services, stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants. The insurer states that the medical records received do not demonstrate such condition; therefore, the endosteal implants and related services are considered not medically necessary, are considered elective; therefore, no benefit is available. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. In regard to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. Further, the documentation provided does not support, justify, or substantiate the requested treatment. 

Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary. There is no objective information documented to substantiate the need for crown on tooth #14. 

An appropriate alternative standard of care treatment would be conventional removable dentures, and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment, this renders the endosteal implants and associated services not medically necessary. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the surgical placement of implant body to tooth 30 and 31 and a crown to tooth 14 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left sided weakness

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned. 

This male patient has a history of asthma, alcohol abuse, mandibular fracture, seizures, and traumatic brain injury (TBI).

The patient presented to the emergency department (ED) for left hand weakness and headache.  He reportedly developed the headache and weakness following a seizure.  He appeared to be intoxicated and demonstrated generalized weakness.  His past medical history was significant for alcohol abuse, seizures, and traumatic brain injury.  He was evaluated by Neurology, who noted concern for cerebrovascular accident (CVA) given left arm/leg weakness and left sided facial droop.  On exam, he was also lethargic.  He was admitted to inpatient level of care for concern for possible stroke, altered mental status and alcohol abuse disorder.

Given that the patient had persistent focal neurological deficits with altered mental status concerning for possible CVA vs Todd's paralysis following seizure, inpatient admission was medically necessary.

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

The carrier's denial of coverage for inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Familial Hypercholesterolemia
Treatment: Formulary exception for Livalo 1 mg TABLET, Pre-service
The insurer denied the Formulary exception for Livalo 1 mg TABLET, Pre-service.
The denial is upheld.

The patient is a male with a history of familial hyperlipidemia, asymptomatic coronary disease with elevated coronary calcium score of 291. He had previously had side effects with Lipitor (atorvastatin) and Crestor (rosuvastatin). He tolerated Zetia 10 mg (milligrams) (ezetimibe), but his LDL (low density lipoprotein) was still above goal. He was given samples of Livalo 1 mg with good control of LDL. Use of Livalo is being requested. There is no history of trial or failure of other formulary statins.

No, the health plan should not cover the formulary exception for Livalo.

There is no history of trial or failure of other formulary statins. There is no evidence that a formulary statin, such as Pravastatin, Simvastatin, Lovastatin would be ineffective or have an adverse effect in this patient. The patient had prior adverse reaction (back pain) with the use of two formulary medications (atorvastatin and rosuvastatin). There is no documented trial of any other formulary medications in this case.

Therefore, given the above, the health plan should not cover the formulary exception for Livalo.