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

Diagnosis: Malocclusion

Treatment: D8080

The insurer denied coverage for D8080

The denial is upheld 

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 to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 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 6 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 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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labio-Lingual 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 D8080 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 epigastric and right upper quadrant (RUQ) pains. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The sonogram did not show gallstones. The common bile duct (CBD) was 6 millimeters (mm). The liver enzymes were elevated. The international normalized ratio (INR) was normal. There was no leukocytosis. A magnetic resonance cholangiopancreatography (MRCP) was negative for duct obstruction. A computed tomography (CT) scan showed mild inflammatory colitis. It was determined that the patient was stable for an outpatient workup. 

Clinical indications for admission for Undiagnosed Abdominal Pain (Milliman Care Guidelines [MCG] M-05) include hemodynamic instability, peritoneal signs, bowel perforation or obstruction, an inability to maintain oral hydration after observation care, and bacteremia. The patient did not have these conditions. 

Clinical indications for admission for Liver Disease (MCG M-570) include having acute liver failure as manifested by an INR over 1.5 and encephalopathy, infected ascites, hepatorenal syndrome, and an acute exacerbation of cirrhosis. The patient did not have these conditions. 

This patient required a workup for abdominal pain and elevated liver enzymes. The patient was not in acute liver failure. No surgical interventions were needed. The hepatitis serologies and imaging studies could have been done with observation status. The patient did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Liver Disease. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

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 the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Middle Cerebral Artery Stroke. 
Treatment: Skilled Nursing Facility. 
The insurer denied Skilled Nursing Facility. 
The determination is upheld. 

The patient is a female who suffered a right middle cerebral artery stroke. She was admitted from an acute hospital to acute inpatient rehabilitation. She was then admitted to a Skilled Nursing Facility (subacute rehabilitation). At issue is the medical necessity of Concurrent Stay in an Inpatient Sub-Acute Rehabilitation (Skilled Nursing Level 2) Facility.
At the time of transfer, the patient made minimal functional progress. For example, therapy noted minimal assistance (MINA) for oral hygiene, maximal assistance (MAXA) upper body dressing (UBD), dependent lower body dressing (LBD) and toileting. Despite nearly 4 more weeks of skilled therapy, the patient failed to make enough functional progress to support the need for skilled therapy. At the time of the subacute rehabilitation admission, the patient was noted to require MAXA self-feeding and was dependent for hygiene/grooming, toileting, upper body dressing and lower body dressing. The patient also was noted to be dependent for bed mobility, transfers and gait. The patient remained dependent for bed mobility, transfers and ambulation. The patient had improved from MAXA to MINA for self-feeding and dependent to moderate assistance (MODA) for hygiene/grooming but remained dependent for toileting, upper body dressing and lower body dressing. 
In addition, due to a lack of skilled therapy need there was also no support for continued skilled nursing need. The patient was tolerating an oral diet. Her antibiotic regimen (for treatment of urinary tract infection) had been changed to 2 more days of by mouth (PO) medication. She does not have a suprapubic catheter, tracheostomy, management of oxygen administration or skilled wound care needs. 
For all of these reasons, it was appropriate for this patient to continue therapy services at a lower level of care such as with home health or outpatient in the community. 
The patient does not have supported skilled therapy needs. She is not making functional progress that supports that only a skilled therapist can provide successful management. Additionally, she does not have complex medical needs that support inpatient stay. Lastly, she does not have any skilled nursing needs. The patient is tolerating an oral diet.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Nucala. 
The insurer denied coverage for Nucala. 
The denial is upheld. 
 
This is an adult with a history of hypertension, diabetes mellitus, obstructive sleep apnea and asthma. The patient was a fire fighter by occupation. The patient's diagnosis was exercise / environmental-induced asthma. The patient was admitted recently with complaints of fever, chills and shortness of breath, and was diagnosed with Klebsiella Sepsis. Computed tomography (CT) scans of the chest did not reveal any parenchymal disease. The patient's main symptoms were cough with sputum production for about 5 years. Imaging never revealed any pulmonary pathology. There was no obstruction on pulmonary function tests. Spirometry had revealed forced vital capacity (FVC) 3.98, 58% (percent); forced expiratory volume (FEV1) 3.12, 55% (percent); ratio 0.8, restrictive pattern. Eosinophils were 450. The patient was prescribed continuous positive airway pressure (CPAP) but was documented as not very compliant. Medications included Symbicort, Singulair, Spiriva and bronchodilators as needed (PRN) for asthma. There was also some question of whether the patient took their inhalers as prescribed. The patient was prescribed Nucala (Mepolizumab) by their physician. The patient was reported to have felt much better with that medication. Continuation of Nucala is requested. 

Dupixent (Dupilumab) and Fasenra (benralizumab) are other biologics that are indicated for patients with eosinophilic asthma, such as this patient. They are all equally effective in treating the kind of asthma this patient has. Their side effect profile is similar, as is their efficacy in this subclass of patients. 

There is no documentation that these drugs were tried and found to be ineffective. 

There is no indication to support that Nucala would be more effective in this patient compared with the alternatives on the preferred formulary list. 

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication. 

The formulary drugs are not expected to be ineffective. 

The non-formulary drug is not expected to be more effective than the formulary alternatives. 

The carrier's denial of a request for a Formulary Exception for Nucala to treat unspecified asthma, uncomplicated is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: teeth decay
Treatment: Dental Work (Cavities Fixed/Teeth Removed) at the Hospital
The insurer denied Dental Work (Cavities Fixed/Teeth Removed) at the Hospital.
The health plan's determination is overturned. 

The patient is a male who presents for the treatment of multiple teeth with decay. Provided for review are copies of dental radiographs, letters of appeal and denial, a treatment plan, and health plan language.

Dental Work (Cavities Fixed/Teeth Removed) at the Hospital is medically necessary for this patient.
Based on the provided documentation the patient has generalized anxiety, behavior disorder, is young and requires extensive amounts of dental treatment that cannot be done under local anesthesia nor moderate sedation as the patient will undergo undue stress and may be a danger to himself and others and will not be compliant to allow for Dental work. Thus, the patient requires general anesthesia making the requested services medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty breathing
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a female infant born full term who presented to the emergency department (ED) with increased work of breathing. She was well until four to five days prior to presentation when she developed congestion, a cough, sneezing, and intermittent difficulty breathing. She had known respiratory syncytial virus (RSV) contact with her brother. She had been seen in the ED two days prior, improved with nebulized normal saline, and was discharged with instructions for returning. The mother was treating with nebulized saline and suctioning with some improvement. The baby continued to have copious secretions, but was able to breast feed with some difficulty due to congestion. The examination was significant for non-toxic appearance, moist mucous membranes, accessory muscle usage, nasal flaring, no grunting, decreased breath sounds, expiratory wheezing, no rashes, and non-focal neurologic exam.
Treatment started on the bronchiolitis pathway with nebulized normal saline, suctioning and a trial of albuterol. She improved transiently with these treatments. Testing returned positive for RSV. She continued to require frequent suctioning with increased congestion and worsening respiratory difficulties. She was admitted for airway clearance and observation. Admission orders included supplemental oxygen to maintain saturations 90% or greater with consideration for high flow nasal cannula, assess need for intravenous (IV) fluids and/or nasogastric tube feedings, suctioning as needed. She remained hemodynamically stable, afebrile, with no need for supplemental oxygen. At issue is the medical necessity of an inpatient admission.
The patient did not require acute inpatient admission.
This female infant with a known RSV infection presented with congestion and increased work of breathing. She was afebrile, with no supplemental oxygen requirement, but was having some difficulty feeding due to congestion. While it was reasonable to monitor her overnight for need for supplemental oxygen and ability to tolerate feedings, she was overall hemodynamically stable with no evidence of significant dehydration or impending respiratory failure. She did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain.
Treatment: Intracept Procedure (64628).

The insurer denied: Intracept Procedure (64628).  The denial is upheld.

The patient is an adult male with low back pain that began more than three years ago. Past treatments include L (lumbar) 4-5 lumbar laminectomy/discectomy, radiofrequency ablation, trigger point injections, Celebrex, and Norco. The pain affects the patient's ability to perform activities of daily living (ADLs). Magnetic resonance imaging (MRI) of the lumbar spine shows postoperative changes with enhancing granulation tissue at L4-5, facet arthropathy at L4-S1, and Modic grade 1 marrow edema at left L4-5. The request for L4, L5 Intracept was denied coverage by the health plan as not medically necessary.

The requested Intracept procedure is not medically necessary.

Review of 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 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 requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male who was admitted for diagnosis of acute kidney injury. The patient presented with chief complaint of difficulty ambulating and weakness in the legs for four days. Vital signs demonstrated temperature at 98.5F, pulse 89, respiratory rate 18, blood pressure 143/97 and O2 (oxygen) saturation 96%. Physical exam showed the patient lying comfortably in the bed with five out of five strength in all extremities. Creatinine was 1.5 with baseline 1.1. Bilirubin was 1.7. Chest x-ray was clear. A computed tomography (CT) of the head did not show any acute findings. The patient was treated with intravenous fluids and the source of acute kidney injury was thought to be Pre-renal. 

The inpatient hospital admission was not medically necessary. 
The patient in this case was admitted for weakness and acute kidney injury which was thought to be pre-renal. The stage of acute kidney injury for this patient would fall in a mild range with stage one as the creatinine was less than 1.9 times the baseline. There was no obstruction or intrinsic kidney diseases such as vasculitis or necrosis. He was simply treated with intravenous fluids. The patient then felt well enough to sign out against medical advice.
Although the patient required services in the hospital setting, the monitoring, diagnostics testing and therapeutic interventions could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Short bowel syndrome

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

The toddler presented to the emergency room (ER). The patient has a complex medical history with short bowel syndrome with only 15 centimeter (cm) of small bowel (normal at this age would be 300-400 cm). The patient has gastrostomy (G) tube for small enteral feeds. The patient relies on most of fluids, nutrition, vitamins, and minerals using intravenous (IV) feeding and total parenteral nutrition (TPN). TPN is administered through a large IV inserted surgically under general anesthesia called a central line. The patient came to the ER because the central line was not functioning properly. Glucose fell to 38. The patient stayed in the ER until being formally admitted. During the ER visit, the doctors tried to correct the line using tissue plasminogen activator (tPA) but this failed, so the patient was admitted for the placement of a new central line. The child was discharged after the central line was placed.

The patient is being worked up for an intestinal transplant since there is no chance that the 15 cm will adapt well enough to support his hydration, nutrition and growth with enteral feeds.

A small infant cannot remain with no fluids for many hours before becoming dehydrated, especially with short bowel, because there was also diarrhea. At one time glucose fell to 38. While waiting to place the central line, a peripheral IV must be maintained to prevent low glucose and dehydration. Such a peripheral IV cannot be maintained in the outpatient setting. The patient needed a new central line and this was placed under general anesthesia, then discharged. This is standard of care and essential care for such a fragile patient. This cannot be handled as an outpatient since the patient needs constant IV fluids for hydration. The surgical replacement was done in a very short time from when the decision to place a new line was made. This patient must have a functioning central line in order to survive because of  short bowel syndrome.  The central line allows the infusion of TPN so that fluids and calories are provided. 

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain
Treatment: Lumbar or sacral injection, code 64483 for future date of service (DOS)
The insurer denied coverage for lumbar or sacral injection, code 64483 for future DOS.
The denial is upheld.

This patient has low back pain and radicular symptoms. The patient has tried Celebrex, Tizanidine, Mobic, Ibuprofen, and Tylenol. The patient has done a home exercise program. The patient had L (lumbar) 5-S (sacral) 1 interlaminar epidural steroid injection at L5-S1. This provided the patient with 100% (percent) pain relief, but only for one week. The request is for bilateral L5 transforaminal epidural steroid injection.

The health plan has the following criteria for repeat epidural steroid injection: there has been 50% or greater relief of radicular pain for two or more weeks duration. One of the following additional criteria must also be met: increase in the level of function/physical activity, reduction in the use of pain medication and/or additional medical services such as physical therapy/chiropractic care. Advanced diagnostic imaging within 24 months is required for cervical/thoracic interlaminar and transforaminal epidural steroid injection.

The American Society of Interventional Pain Physicians (ASIPP) has suggested this is the standard of care with respect to frequency of Epidural Steroid injections:

"2 procedures in the diagnostic or initial phase with 4 and 6 weeks apart after first and second procedures per spinal region, followed by 4 epidural injections per spinal region in a rolling year, initiated with a third procedure. If the patient's condition includes an acute lumbar herniated nucleus pulposus, then the patient should wait no longer than 2 weeks for the first epidural steroid injection and no longer than 2 weeks for a second and or third epidural steroid injection, if indicated. Additionally, to provide a second epidural after 3 months of sustained 50% pain relief is not supported by the literature. An overwhelming evidence in the literature shows the first 2 procedures providing 5.69  8.23 weeks in 1,510 patients assessed and the second procedure providing 10.02  12.57 weeks assessed in 1,402 patients (40-52). In addition, multiple other studies also shows 6 weeks of relief rather than 3 months of relief is typical." [1]

In this case, the period of pain relief was only one week. There is no recent magnetic resonance imaging (MRI) report submitted for review. Therefore, the request for a second epidural steroid injection is deemed not medically reasonable and necessary. 

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

The medical necessity for a lumbar or sacral injection, code 64483 for future date of service (DOS) is not substantiated.