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

Diagnosis: Alcohol withdrawal.
Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.  The denial is overturned.

This male patient reportedly was admitted to this inpatient hospital due to alcohol withdrawal symptoms including hand tremors, tongue fasciculations, increased heart rate of 104, elevated blood pressure of 170/100, nausea, vomiting, loose stools, and body shakiness. He had a CIWA (clinical institute withdrawal assessment) of 8. He reportedly fell at the bar that day and had head trauma reported. He reportedly was drinking alcohol heavily for years and also using cocaine. He reportedly had rhabdomyolysis with elevated CK (creatinine kinase). He reportedly had hypertension. He reportedly was given Valium for detoxification but then refused more Valium, so Librium was ordered but he refused further benzodiazepines stating that he had intolerance to them. He reportedly continued with withdrawal symptoms until his discharge date.
     
The APA (American Psychology Association) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence, patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification are candidates for inpatient detoxification treatment. As well as patients who currently abuse other substances and have heavy use or tolerance putting one at high risk for complicated withdrawal. It also states that patients with past complicated or life-threatening withdrawal symptoms including withdrawal seizures or delirium tremens need an inpatient hospital treatment for the management of withdrawal. Patients with comorbid medical conditions that complicate the management of withdrawal are also candidates for inpatient detoxification. He reportedly did not want to take benzodiazepines due to intolerance, so he was observed, given IV (intravenous) hydration, Pepcid, Zofran, a MVI (multivitamin intravenous) infusion, and thiamine. He was considered at risk for more complicated and life-threatening withdrawal, so he required hospital treatment until he no longer reported withdrawal symptoms. Hospital notes report that he refused Ativan and thiamine and still had withdrawal. He also was at risk for medical complications due to his comorbid heavy alcohol and cocaine use. He did require 24-hour medical hospital treatment for alcohol detoxification and medical treatment. It was considered unsafe for him to be treated for detoxification in a less restrictive level of care. It also unsafe for him to be treated medically outside of a hospital setting due to his medical issues. 
 
The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 
 
The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Varicose veins.
Treatment: Medical procedure 37785LT x 4.

The insurer denied coverage for medical procedure 37785LT x 4.  The denial is overturned.

This case involves a female with history of recurrent varicose veins in the lower extremities, who is being recommended for outpatient procedure code 37785LT x 4. The patient was status post left ablation and sclerotherapy and reported that her left leg remained extremely painful with associated swelling. Her occupation required standing for prolonged periods of time for which she was experiencing significant discomfort, which interfered with her job responsibilities. The patient wore compression stockings without significant relief and was interested in further venous intervention. The lower extremity venous Doppler ultrasound noted that the saphenofemoral junction vein measured 11 millimeters (mm), greater saphenous vein proximal thigh measures 3 mm, and greater saphenous vein mid-thigh vein measures 3 mm. There was evidence of left anterior saphenous vein reflux and deep venous reflux in the common femoral vein. The patient received a notice of adverse determination stating that criteria was not met for sclerotherapy plus ligation of the saphenofemoral junction, because the role of these services remained uncertain.  

The medical procedure 37785 LT x4 does not need to have final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for the medical procedure. The procedure is one of the best available treatments for this patient at this time. The adverse risks are not increased over standard treatment/services.

The requested services are likely to be more beneficial than any of the standard treatment/procedures for the patient.

Literature notes that sclerotherapy is a common treatment for patients who have continued symptoms associated with varicose veins that failed to respond to nonoperative measures to include the use of compression stockings. Records noted that the patient works on her feet for up to 8 hours a day, was not getting much time to sit and elevate her legs while at work, although she was able to elevate them at home. She wore the compression stockings for several years without relief, and the symptoms were beginning to interfere with job duties. Based upon the provided information noted on physical examination, subjective complaints, and the venous Doppler ultrasound, the proposed service is reasonable and within the standard of care for the patient's condition. This treatment is likely to be more beneficial than any of the standard treatment procedures for the patient given that additional nonoperative care will not likely resolve her symptoms. The risks are not substantially increased.

The carrier's denial of medical procedure 37785LT x 4 should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Occlusion; crowding
Treatment:  D8080 Braces, D8670 Monthly Visits, D8680 Orthodontic Retention
The insurer denied the  D8080 Braces, D8670 Monthly Visits, D8680 Orthodontic Retention.
The denial is upheld.

The patient is a girl with permanent dentition.  Her gum tissue is very inflamed. The upper right canine is blocked out of eruption.

The patient's Mother reports her daughter's 'teeth are very crooked because the teeth are growing out very high up in her gums, and the new teeth are pushing out the already grown out teeth.'

The patient's dentist noted the patient has Class II occlusion and moderate upper and lower crowding.  Recommended treatment plan: comprehensive orthodontics, extraction of #5, 12, 21, 28, full braces, and upper and lower retainers.

No, the requested comprehensive orthodontics (D8080, D8670, D8680) is not considered medically necessary for this patient.

In order for the patient to qualify for braces, there needs to be medical evidence of a condition that causes significant impairment and therefore establishes medical necessity or a Handicapping Labio-Lingual Deviation Index score of 26 or higher. There was no medical evidence provided that the patient has any impairment due to the position of her teeth. Thus, the requested braces are not needed to address eating, speech, breathing difficulties or to prevent permanent damage to the teeth or to the bones or soft tissues of the mouth. In addition, the patient's HLD (Handicapping Labio-Lingual Deviation) Index score was calculated by this reviewer to be 22, which does not qualify her for braces.

Given all of the above, the requested braces are not medically necessary.

Yes, the medical records and accompanying information are sufficient.
The health plan made their decision based on the New York State Medicaid Program requirements. Their decision was based on the HLD (Handicapping Labio-Lingual Deviation) Index score and lack of medical evidence to establish a medical reason that braces would be necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spine Disorder.
Treatment: Pain Management (epidural steroid injection; 01 Unit).

The insurer denied the Pain Management (epidural steroid injection; 01 Unit).  The denial is overturned.

The patient is a female with history of chronic neck pain affecting her quality of life and ADLs (activities of daily living).

The request is for a repeat C7-T1 (seventh cervical spine vertebra-first thoracic spine vertebra) Interlaminar Epidural steroid injection. The same procedure was last performed with 85% relief.

The patient has failed conservative measures including physical therapy, NSAIDs (nonsteroidal anti-inflammatory drugs), valium, and activity modifications.

MRI (magnetic resonance imaging) cervical spine showed herniated disc at C3/C4 (third cervical spine vertebra-fourth cervical spine vertebra), C4/C5 (fourth cervical spine vertebra/fifth cervical spine vertebra), C5/C6 (fifth cervical spine vertebra/sixth cervical spine vertebra) and C6/C7 (sixth cervical spine vertebra/seventh cervical spine vertebra).

Yes, the requested epidural steroid injection is medically necessary.

The repeat C7-T1 (seventh cervical spine vertebra-first thoracic spine vertebra) Interlaminar epidural steroid injection is medically necessary, as it is the standard treatment for cervical radiculopathy, as in this case.

The health plan's reason for denial was because there is a need for the patient to show at least 50% improvement in a prior injection at the same level and an interval of at least 10 weeks before the next one. In this instance, the first injection was with 85% relief and a request for a repeat injection was made approximately three months later. This is an interval period of about 13-14 weeks (more than health plan's required 10 weeks).

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

The requested spinal procedure is medically necessary and it is likely to be more beneficial than any standard treatments for cervical radiculopathy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems 
Treatment: Nerve treatment on bicuspid tooth # (number) 4
The insurer denied nerve treatment on bicuspid tooth #4. 
The denial is upheld.

The patient is a female who presented to the office of her dental provider for evaluation and treatment of tooth # (number) 4. Included for review are previous letters of appeal and denial, a narrative from the patient, a single radiographic image, and one page of American Dental Association (ADA) claim forms. In question is the medical necessity of the planned treatment of root canal therapy for tooth #4.

The health plan's determination of medical necessity is upheld.

There is nothing in the documentation by the dental provider to indicate any pulpal pathology, any diagnosis of any pulpal pathology, nor any other dental rationale for the requested treatment. The radiographic documentation does not support the presence of any decay or loss of tooth structure in proximity to the nerve nor necessitating any root canal therapy. Hence, as there is no support for the treatment, there is not support for any medical necessity and the service of nerve treatment on bicuspid tooth #4 is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems.
Treatment: Inpatient Hospital.
The health plan denied the Inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This case involves a patient with diabetes and migraines who presented to the hospital with two days of high blood pressure. The patient complained of 10/10 frontal headaches for two days with photosensitivity and nausea. She described the headache as worse than her typical migraines. At baseline, she is on Topamax for migraine headaches. She is not on any antihypertensive medications.
Vital signs in the emergency department (ED) included a temperature of 98.6, heart rate of 70, respiration 16, and blood pressure of 152/111.
On exam, she was alert, with no acute distress or cyanosis. The cardiopulmonary exam is unremarkable. There were no neurologic deficits.
Laboratory data showed a normal renal function, and sodium of 133. White blood cell count was 13.8, and hemoglobin 14.1. Urinalysis showed six white blood cells and some urine casts, but otherwise unremarkable.
Head computed tomography (CT) scan showed no intracranial pathology except for chronic lacunar infarcts in the caudate nucleus. There is no evidence of acute stroke.
The medical team documented malignant hypertension as the principal admitting diagnosis and a migraine headache. The next day, the patient was reassessed, and the vital signs showed a blood pressure of 134/77 and a heart rate of 92. The exam was fairly unremarkable. Repeat labs show normal electrolytes, renal function, and normal complete blood count (CBC).
She was seen by neurology and had a normal neurologic exam. The neurologist recommended a brain magnetic resonance imaging (MRI) study; however, the patient refused, and it was deferred to the outpatient setting where she could get an open MRI and have a follow-up appointment. They also documented the patient has been under many psychosocial stressors, possibly contributing to the symptoms. The patient was released safely home in stable condition.

No. The requested health service of an inpatient admission is not medically necessary for this patient. 

The patient has known migraines and has elevated diastolic blood pressures on admission to the hospital. The admitting team documents that the patient was recently taken off propranolol in favor of Topamax to treat her migraine headaches. The propranolol was likely to control the patient's blood pressure, and she had rebound hypertension with the discontinuation. She was admitted for treatment of migraine and hypertension. Head CT showed no acute stroke. The patient had no focal neurologic deficits. She is described as awake, alert, and oriented times (x)3, with no signs of encephalopathy. There were no other concurrent end-organ damage signs on laboratory work-up or imaging. The blood pressure stabilized with the initiation of an antihypertensive regimen, and she was released safely home. Lower level of care services are appropriate for this type of presentation based on the provided documentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services (All). 
The insurer denied EGD (diagnostic esophagogastroduodenoscopy). 
The denial is upheld in whole. 

The patient was a female. She presented with esophageal reflux and was assessed to have esophageal reflux; she was not on any medication. She presented again with heartburn and was assessed to have esophageal reflux; she was not on any medication. Esophagogastroduodenoscopy (EGD) with biopsies and snare cautery polypectomy for the indication of epigastric pain and gastroesophageal reflux disease (GERD) showed normal esophagus, chronic superficial gastritis, multiple gastric fundic gland polyps, and duodenitis; the recommendation was omeprazole 20 milligrams (mg) daily, office follow-up, and possible referral for endoscopic ultrasound. Biopsies showed fundic gland polyps, mild chronic gastritis, and lack of Helicobacter pylori.
At issue is the medical necessity of EGD (diagnostic esophagogastroduodenoscopy).

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

The requested health service/treatment of EGD (diagnostic esophagogastroduodenoscopy) is not medically necessary for this patient.
Clinical guidelines, including the American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease, and guidelines for dyspepsia, recommend endoscopy for investigation of upper gastrointestinal symptoms when those symptoms are refractory to proton pump inhibitor taken properly for 4-8 weeks without response. [1-4] The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. [3] Current medical literature continues to support these recommendations. [5-8] In this case, there is no documented proton pump inhibitor therapy for at least 4 weeks before the endoscopy. No other guideline-supported indication for esophagogastroduodenoscopy is documented. For these reasons, coverage for esophagogastroduodenoscopy was not supported in this case.
Therefore, the health service/treatment of EGD (diagnostic esophagogastroduodenoscopy) is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular dementia, osteoarthritis, complete incontinence, weakness, dizziness, fatigue, and an unsteady gait

Treatment: Personal care aide (PCA) services Level 2 of live-in per diem 24 hours, 7 days per week

The insurer denied coverage for personal care aide (PCA) services Level 2 of live-in per diem 24 hours, 7 days per week

The denial is overturned

This is a with multiple medical problems including vascular dementia, coronary artery disease and stroke.  She is oriented to person only. She lives downstairs from her son who is involved with her care. According to her treating medical providers, the patient has had multiple falling episodes with subdural hematomas that required surgical evacuation. The insurer approved PCA level 2; 10 hours/day- 7 days/week for a total of 70 hours/week. Under review is the request for PCA level 2 services: live in per diem 24 hours, 7 days/week.

According to the Uniform Assessment System (UAS) report, the patient's cognitive skills are "moderately impaired." She is only oriented to person and is not self-directing. The patient requires maximal assistance for activities daily living including dressing, hygiene and bathing. She requires maximal assistance for toilet transfers/use and is bowel/bladder incontinent. She requires maximal assistance for ambulation. Her ADL (activities of daily living) status and overall self-sufficiency have declined and deteriorated, respectively over the prior 90 days. The combination of the patient's progressive functional decline with recent falls necessitating hospitalization for surgical evacuation of subdural hematomas, dementia as well as maximal assistance for activities of daily living and mobility, support the requested increase PCA level 2 services: live in per diem 24 hours, 7 days/week, in order to allow her to continue living safely at home.  
The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. 

From a physical medicine and rehabilitation perspective, (PCA) level 2 services: live in per diem 24 hours, 7 days/week is medically necessary.

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

The insurer's denial of coverage for Patient Care Aide (PCA) Services Level 2: live-in per diem 24 hours, 7 day(s) per week is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: intraosseous nerve ablation
The insurer denied intraosseous nerve ablation
The determination is upheld.

The patient has low back and leg pain with prior lumbar (L) 4-5 interspinous spacer placement for spinal stenosis under review for basivertebral ablation. Magnetic resonance imaging (MRI) of the L spine shows ongoing L5-sacral (S)1 severe foraminal stenosis.
At issue is whether intraosseous nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No, as no long-term studies have shown clinical safety and efficacy in this patient cohort. Becker et al noted "Ablation of the basivertebral nerve (BVN) for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period." But this study did not identify patients with prior L4-5 implants nor with ongoing L5-S1 stenosis that can be causing the patient pain.
Intraosseous nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Qulipta. 
The denial is upheld. 

The patient is a female diagnosed with migraine. Treatment with Qulipta is the subject of this review. The drug was denied because the member has not tried and failed available formulary alternatives such as Aimovig, Ajovy, Emgality, propranolol, timolol, valproic acid, venlafaxine, and lamotrigine. The provider appealed the determination.
There is no documentation that the member has tried and failed any of the following formulary drugs: Aimovig, Ajovy, Emgality, propranolol, timolol, valproic acid, venlafaxine, and lamotrigine. The physician indicates that the member has tried and failed topiramate, verapamil, and indomethacin for prevention of migraine. Of these, only topiramate is generally considered to be an effective migraine prevention agent. The physician notes that the patient may instead have a trigeminal autonomic cephalgia. 

The health plan's determination is upheld. 

Qulipta has not been compared head to head with the formulary agents of Aimovig, Ajovy, Emgality, propranolol, timolol, valproic acid, venlafaxine, and lamotrigine. As such, there are no data to show that Qulipta will be more or less effective than these alternatives. 
However, drugs such as Ajovy, Aimovig, and Emgality are Food and Drug Administration (FDA) approved for prevention of episodic and chronic migraine. Literature shows that use of these medications results in a statistically significant decrease in migraine frequency. The member does not have an absolute medical contraindication to the use of these drugs or any of the formulary alternatives. Similar to Qulipta, Ajovy, Aimovig, and Emgality modulate the Calcitonin Gene-Related Peptide (CGRP) pathway and usually do not have any clinically significant side effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Hypertension/High Blood Pressure
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a past medical history of hypertension (HTN), diabetes mellitus type 2 (DM2), end stage renal disease (ESRD), and a prior cerebrovascular accident (CVA) who was admitted with complaints of fatigue and vomiting after missing a session of dialysis. Vital signs were notable for a blood pressure (BP) of 229/137 millimeters of mercury (mmHg). A physical exam was notable for the patient being in no apparent distress. Lab work was remarkable for a creatinine of 13.4. The patient was diagnosed with hypertensive urgency and was treated with Labetalol and Hydralazine and hemodialysis. The patient was discharged in stable condition.
What is at issue is the medical necessity for the inpatient level of care.

The requested health service/treatment of an inpatient stay was not medically necessary for this patient. This patient presented to the emergency department (ED) with complaints of fatigue and vomiting and was found to have a significant blood pressure elevation. He did not have any evidence of new end-organ damage, as there was no alteration of consciousness, neurologic deficits, encephalopathy, CVA, intracerebral hemorrhage (ICH), retinal hemorrhage/papilledema, acute coronary syndrome (ACS), aortic dissection, or acute heart failure. The patient was treated in the ED with intravenous (IV) anti-hypertensives and received hemodialysis after his missed session with good symptomatic results and responded appropriately to the treatments with a reduction in blood pressure. Overall, this patient could have been safely treated at an alternate level of care.