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

Diagnosis: Chronic pain, diabetes, heart disease
Treatment: Increase Home Care/Personal Care HHC Level II per 15 Minutes to 56 Hours per Week
The insurer denied the Increase Home Care/Personal Care HHC Level II per 15 Minutes to 56 Hours per Week.  The denial has been upheld.

The proposed treatment is not medically necessary. 

The female has medical conditions that include chronic pain, asthma, anemia, diabetes, heart disease, hypertension, gastroesophageal reflux disease (GERD), and lumbago.  The denial of an increase in home care/personal care to 56 hours per week is being appealed.  The health plan approved 20 hours per week.

Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with meal preparation, and housework; maximal assistance stairs and shopping; extensive assistance with phone use, bathing, and lower body dressing; limited assistance with personal hygiene, bathing, upper body dressing, and toileting; supervision with managing medications and walking; and independent with bed mobility and eating. Compared to Uniform Assessment System evaluation completed previously, the patient has declined with meal preparation, housework, and bathing.  She has bladder incontinence.  

An appeal statement shows the patient has suffered recent injures and needs more physical assistance, is unable to walk long distances, and is unable to push a wheelchair due to shoulder pain.

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

This patient has multiple chronic conditions.  The denial of an increase in home care/personal care to 56 hours per week is being appealed.  The health plan approved 20 hours per week.  Comparison of Uniform Assessment System (UAS) evaluations shows the patient's functioning has deteriorated to now require total dependence with meal preparation and housework, and extensive assistance with bathing.  Otherwise, her level of functioning has remained stable.  Appeal letters note the patient requires more assistance after injuries.  However, the information provided does not support that the patient's functional status has deteriorated to require an increase in home care hours.  Home care is not indicated for supervision or when no tasks are being performed.  The approved home care of 20 hours per week is appropriate to meet this patient's needs for assistance with activities of daily living.  The proposed home care of 56 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission
The health plan denied: Inpatient hospital admission
The determination is: Overturned

This male presented to the emergency department (ED) complaining of chest pain. His medical history was remarkable for coronary artery disease, percutaneous coronary interventions, diabetes, and hypertension. A week prior he had a cardiac stress test that suggested ischemia. In the ED, his blood pressure was 163/93 millimeters of mercury (mmHg) with a heart rate of 64 beats per minute. His electrocardiogram was normal. His serum troponin I level was 0.01. The patient was treated with aspirin and oral and topical nitroglycerin. He was admitted to the hospital. Cardiac catheterization showed 80 percent (%) stenoses in the mid and distal right coronary artery that were treated with stents. That evening he had an episode of chest pain that resolved with nitroglycerin. There were no associated electrocardiographic changes. His serum troponin I level was 0.06. The next day, his troponin I level was 0.19 and then increased to 0.21. An echocardiogram showed a normal left ventricular ejection fraction; there was apical and inferior hypokinesis that was similar to his previous study. Transdermal nitroglycerin was prescribed. The following day, the patient complained of burning chest pain that resolved with pantoprazole; he had no chest pain with ambulation. He developed headache with the nitroglycerin, which was discontinued. Ranolazine was prescribed. He was discharged on hospital day 3.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient hospital admission was medically necessary for this patient.
This patient presented with chest pain and underwent percutaneous coronary intervention (PCI) with two stents placed in his right coronary artery. Post-procedure, he developed chest pain and had a 20-fold increase in his serum troponin level. While asymptomatic troponin elevation is common after PCI, and there remains debate regarding its significance, this man's rising level in the face of recurrent chest pain raised concern regarding the possibility of ongoing myocardial ischemia. He required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient admission.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

Diagnosis: Gastroesophageal reflux disease (GERD)

Treatment: laparoscopic esophageal sphincter augmentation

The insurer denied coverage for laparoscopic esophageal sphincter augmentation

The denial is upheld

This is an adult patient with a history of GERD. The patient presented with persistent reflux. Symptoms are not controlled despite the use of famotidine. An Esophagogastroduodenoscopy (EGD)  demonstrated severe esophagitis at the gastroesophageal junction. Pathology was consistent with Barrett's esophagus. A pH study demonstrated abnormal reflux events and an elevated DeMeester score of 209.8 off medication. An upper gastrointestinal (GI) study demonstrated a small sliding hiatal hernia with a nonobstructive ring. LINX was designed for those who have chronic GERD despite medical therapy. The procedure should be performed in those with normal esophageal motility, a Body Mass Index (BMI) <35, no previous foregut surgery, and no or a small <3 centimeters (cm) hiatal hernia. LINX is not intended for use in patients with allergies to metals. It is also not intended for patients with defibrillators, pacemakers, or metallic implants. Contraindications of LINX implantation include a history of dysphagia, previous upper abdominal surgery, previous anti-reflux procedures, large sliding hiatal hernias, or those with Barrett's esophagus. [4-6] 
Per provided clinical documentation, LINX is contraindicated due to the history of Barrett's esophagus. 
Peer reviewed literature does not support a result of improvement in health outcomes with the requested procedure for patients with Barrett's esophagus. 

The requested procedure does have final regulatory approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for the requested procedure.  

It is not the best available treatment for this patient at this time.

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are substantially increased over standard treatments.
In summary, the denial of laparoscopic esophageal sphincter augmentation surgery and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #1:

Diagnosis: Gastroesophageal reflux disease (GERD)

Treatment: laparoscopic esophageal sphincter augmentation

The insurer denied coverage for laparoscopic esophageal sphincter augmentation

The denial is overturned

The patient was complaining of severe reflux. He had been treated with both famotidine and pantoprazole twice a day. He was found to have a small hiatus hernia on the upper gastrointestinal (GI) series. An endoscopy showed a small area of Barrett's esophagus. Esophageal potential hydrogen (pH) testing was done and the DeMeester score was 209.8. His physician has advised doing the LINX sphincter augmentation procedure. 

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the Linx Reflux Management System in March 2017. With regards to safety, the conclusion was that long-term follow up supports the Food and Drug Administration (FDA) conclusion that the device is safe. With regards to efficacy there were several conclusions. The LINX implant results in pH normalization, improved quality of life, and cessation of regular proton pump inhibitor (PPI) use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating gastroesophageal reflux disease (GERD) symptoms and dysphagia are similar following LINX. The long term follow up data demonstrates that the LINX Reflux Management System is effective in the management of GERD. 

The Annals of Surgery 2019 Aug 270(2):302-308 has an article titled "Objective Evidence of Reflux Control After Magnetic Sphincter Augmentation: One Year Results from a Post Approval Study." The conclusion was that both safety and effectiveness of magnetic sphincter augmentation has been demonstrated outside of an investigational setting to further confirm the procedure as treatment for GERD. 

The scientific literature supports the use of the LINX system as a treatment for GERD. The 2019 study in the Annals of Surgery confirms the long-term safety and efficacy of the procedure. 

The LINX system has been approved by the FDA. 
The patient is a good candidate for the procedure since he has chronic GERD with a high DeMeester score and has had continued symptoms on long term PPI therapy. 

There are multiple options for treating GERD, but the LINX system has been shown to be both effective and safe.

In summary, the denial of laparoscopic esophageal sphincter augmentation surgery and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: visual changes
Treatment: Inpatient stay
The insurer denied an inpatient stay. The health plan's determination is upheld. 

The patient is a female with past medical history of asthma, diabetes mellitus type 2, hypertension, congenital septal defect status post-repair, morbid obesity, and thrombophilia who presented to the emergency department with complaints of visual change and slurred speech. Documentation from the emergency room provider noted the patient had blurry vision, headache, and aphasia for approximately 1 (one) hour prior to presenting to the emergency room. 

Inpatient Hospital Services were not medically necessary for this patient.
The patient presented with resolved neurologic symptoms with no focal deficits on physical examination and no acute findings on CT (computed tomography) head. The patient's blood pressure was markedly elevated at the time of presentation to the emergency room but had improved within 1 (one) hour and nicardipine drip was discontinued with blood pressure at the time of admission noted to be 138/64. The patient did not have persistent severe elevation of her blood pressure and did not have recurrent or persistent neurologic deficits. The patient did not require urgent consultation or procedure. The patient's MRI (magnetic resonance imaging) brain performed within 24 hours of admission failed to demonstrate any acute changes.
The admission history and physical did not document medical necessity of inpatient hospital stay. The patient's severity of illness and intensity of care at the time of admission was not medically necessary at inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain

Treatment: diagnostic or therapeutic agent (procedure codes 64490, 64491, and 64492)

The insurer denied coverage for diagnostic or therapeutic agent (procedure codes 64490, 64491, and 64492)

The denial is upheld

 
According to the documentation provided, this is an adult who was seen in pain clinic with complaint of chronic and debilitating 8/10 neck pain right greater than left, sharp and achy with radiation to the bilateral upper extremities including the shoulder and scapula. The pain was not controlled with more than 3 months of physical therapy, acupuncture, chiropractic manipulation, and home exercise program with ice, rest and stretching, as well as failing 3 months of non-steroidal anti-inflammatory drugs (NSAIDs), Tylenol and aspirin. The pain interfered with his ability to perform his regular activities of daily living including self-care. Physical exam findings included moderate to severe pain on palpation of cervical (C)4, C5, C6 and C7 facet joints, right side worse than left side, with positive facet loading and pain on extremes of motion of the cervical spine. Xray in the past had shown multilevel degenerative changes. His doctor recommended medial branch blocks (MBB) for pain control. No additional cervical neck imaging was performed prior to performing the MBBs. Prior x-ray mentioned, no radiology report included in documents. The health plan has denied payment for the MBBs stating that there must be imaging studies that do not suggest any other obvious cause of pain.

Based on the documentation provided, this patient meets the Centers for Medicare and Medicaid (CMS) recommended criteria for diagnostic facet joint injections. However, despite any clinical red flags it is still medically reasonable and necessary to obtain imaging prior to performing cervical nerve blocks to rule out other sources of pain. There are no official radiology reports provided indicating that this was done prior to the MBBs. 

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 diagnostic or therapeutic agent (procedure codes 64490, 64491, and 64492) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper respiratory infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is the second emergency department (ED) visit for this child with fever and hives and now upper respiratory infection (URI) (runny nose, cough, congestion) symptoms. The patient is not irritable as per family. The patient's mother reports that the patient is drinking as per usual, and that Motrin and Tylenol do control the fevers. The reason for evaluation appears to be worsening of the patient's hives, now spreading to the arms from the chest. Viral panel sent but only includes Flu and COVID testing. There was cardiac echo performed and the provider notes acknowledge that low suspicion of Kawasaki (KS) or atypical KS. The patient was admitted for fever and viral exanthem, but no further viral etiology was assessed. 

The algorithm includes a critical need for a cardiac echo. It also includes (in kids over 6 months of age) c-reactive protein (CRP)> 3, erythrocyte sedimentation (ESR)> 40 and 3 supplemental abnormal lab tests needed to make the diagnosis. These include:

-anemia for age; platelet count >450,000 after day 7 of fever; albumin <3.0; Elevated alanine aminotransferase (ALT); white blood cell count (WBC)> 15,000; >10 WBC on urinalysis.

On review the urinalysis (UA) had no WBC present, despite being a very concentrated UA, specific gravity 1.024. The initial complete blood count (CBC) had a WBC count of 7.5, there was no anemia (HCT at 34.3), ALT was 16 (normal) and albumin was 4.9 (normal for age). CRP was 3.0 and ESR was 62.

Of all of these labs, only 1 met criteria for atypical KS; an elevated ESR. All other labs were within normal range and did not meet criteria for atypical KS. 

In summary, this admission does not meet criteria for a diagnosis or suspicion of atypical KS. No other ethology for the URI symptoms was performed and the child was treated with medications that can be administered orally and as an outpatient. Criteria for admission were not met.

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces

The insurer denied coverage for D8080 braces.

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 anterior crossbite among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of cross bite 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 as the clinical circumstance does not meet the requirements of the HLD index attaining 18 points by internal reviewers when 26 points are required for approval. The provider is appealing on behalf of the patient.

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 the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual 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
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 insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual 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 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 D8080 braces is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Upper and lower arch crowding; Deep impinging
overbite
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is overturned.

This patient is an adolescent female who has crowding on upper and lower arches, and a deep impinging overbite. The request for orthodontic treatment with monthly visits is under review. 
Prior denial was due to a score of 24 on the Handicapping Labio-Lingual Deviations index scale. 

The requested health service of D8080 Braces, D8670 Monthly Visit, is considered medically necessary. 

The patient has a deep, impinging overbite with palatal tissue trauma, as well as an anterior tooth (#7 [number seven]) in cross bite with attachment loss and gingival recession. Both of these 
conditions are automatic qualifiers for treatment. This case has medical necessity, and orthodontic treatment is needed to correct the above-mentioned issues.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell disease. 
Treatment: Inpatient hospital stay. 
The insurer denied the inpatient hospital stay. 
The health plan's determination is overturned. 

This is a female with sickle cell anemia who presented to the emergency room with lower limb pain and low back pain consistent with an uncomplicated sickle cell crisis. The patient received intravenous (IV) fluids, incentive spirometry, IV narcotics, and supportive care. 

The inpatient hospital admission was medically necessary. 
The patient was admitted with acute vaso-occlusive crisis. The authors of UpToDate state "...The gold standard for assessment of pain is the individual's (or family's) report; no combination of clinical and laboratory findings exists to determine (or confirm) whether an individual with sickle cell disease (SCD) is in pain...". This patient was managed in this fashion with additional supportive care as needed. Further, attention is to be paid to hydration status, venous thromboembolism (VTE) prophylaxis, and potential adverse effects of opioids. The management of this patient was consistent with national guidelines including parenteral opioids and intravenous (IV) fluids. The care provided could not have been provided at a lower level of care and the patient was promptly discharged after resolution of the episode.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intraosseous basivertebral nerve ablation
The insurer denied Intraosseous basivertebral nerve ablation.
The determination is overturned.

This is a female patient with a history of chronic low back pain for more than 6 months. Magnetic resonance imaging (MRI) revealed Modic changes in the lumbar (L) 3- sacral (S) 1 vertebral bodies. She has been treated with activity modification, physical therapy, home exercises, and multiple medications. The treating provider recommended the Intracept procedure and this is under review.

The proposed health service or treatment of Intraosseous basivertebral 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.
Intracept is a minimally invasive procedure that targets the basivertebral nerve (BVN) for the relief of chronic vertebrogenic low back pain. A review of available up-to-date publications utilizing BVN ablation in the treatment of vertebral pain suggests that there is quality evidence that this is an effective intervention for reduction of disability and improvement in function, at short- and long-term follow-up, in addition to evidence that BVN radiofrequency ablation (RFA) is superior to conservative care for pain reduction, at least at 3-month follow-up. Also there is a highly clinical and statistically significant treatment effect of BVN ablation for vertebral pain with clinically meaningful benefits in pain reduction, functional improvements, opioid dose reduction, and improved quality of life. There were no reported device-related patient deaths or serious adverse events (AEs) based on the available literature. BVN ablation is a safe, well-tolerated and clinically beneficial intervention for vertebral pain, when proper patient selection and surgical/procedural techniques are applied.