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

Diagnosis: Trauma/ Injuries 
Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.
The denial is upheld. 

This is a female patient with a past medical history of cervical spine surgery who presented to the Emergency Department (ED) via Emergency Medical Services (EMS) due to trauma. Her blood pressure was 117/65, heart rate was 105, and respirations were 18. The patient complained of a headache. Her pain was rated 8/10. The patient stated she was punched several times in the face and head and her head was slammed into a car. She noted she was dragged on concrete. She complained of headache and dizziness, bruising, and abrasions on the left side of the face, neck, and left arm. The patient was calm and cooperative. She denied drug or alcohol use. She moved all extremities with equal strength. There was no active bleeding. Her respirations were even and unlabored. Her skin was within normal limits and was dry. The patient had tenderness throughout the cervical spine and left cervical paraspinal region upon examination. The grip strength and sensation were intact. There was point tenderness to palpation over the left upper chest wall. The patient was alert and followed commands. The patient had ecchymosis and swelling to the left cheek. She was evaluated by the emergency room doctor and the trauma resident. The patient's urine human chorionic gonadotropin (HCG) was positive in the ED. The patient was unaware she was pregnant.  The patient was admitted to the trauma service for pain management. The patient was stabilized and discharged on day 2 of admission.

Milliman Care Guidelines indicate that a hospital admission for trauma is indicated for patients with multiple significant traumas requiring inpatient care for non-operative care of a significant injury or when they meet the general admission criteria. The patient did require parenteral pain medication (non-narcotic and narcotic), intravenous (IV) fluids, and IV nausea medications, etcetera. Intractable pain is a diagnosis that may result in an admission to the Hospital. The patient was very appropriately worked up, including but not limited to the history and physical exam, blood work, X-rays and Computed Tomography (CT) scans. In this case, the documentation indicated that the ED physician and the trauma resident felt the patient could go home and the patient asked to be admitted after a thorough workup. The records did not support that she was unstable. After a review of all of the records presented, and her clinical picture, the patient would have been appropriate for an observation status and did not require a full admission. 

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atherosclerotic heart disease of native coronary artery
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld. 

This is a male patient with a history of unstable angina, asthma, diabetes mellitus, non-ST segment elevation myocardial infarction (NSTEMI), and multi-vessel disease who presented to the hospital for an elective cardiac catheterization. The patient underwent a cardiac catheterization revealing left anterior descending (LAD) coronary artery, right coronary artery (RCA), first diagonal (D1) artery and first oblique marginal (OM1) artery disease.  A percutaneous intervention was done and drug eluting stents were placed.  Post procedure, the patient was placed on bedrest, admitted to the Cardiology floor for atherosclerotic heart disease of native coronary artery, and monitored. The patient's was discharged on day 2 of admission once hemodynamically stable.

This patient presented for elective percutaneous revascularization. He underwent an uncomplicated procedure and was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between low risk patients that are discharged on the same day as compared to patients admitted to the hospital. Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. In conclusion, this patient could have been treated at a lower level of care. 

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

The carrier's denial of coverage for the inpatient admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits. The denial is upheld in whole.

The patient is a male with Skeletal Class I occlusion. There is mild mandibular crowding. There is mild overjet and mild overbite. The subject to be determined is the medical necessity for braces and monthly visits.

The health plan's determination is upheld in whole.

The requested treatment of braces and monthly visits are not medically necessary for this patient. The patient has no crowding in the maxillary arch and only mild crowding in the mandibular arch. The patient also merely has mild overjet and a mild overbite. The occlusion is in Class I with good posterior occlusion. Overall, the patient's malocclusion is very mild and thus treatment with braces and monthly visits is deemed not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (overjet, class I malocclusion, vertical growth pattern, maxillary crowding and mandibular crowding, excessive overjet, ectopic eruption). 

Treatment: D8080 braces and D8670 monthly visit x 12. 

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12. 

The denial is upheld. 

This is a male patient who presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, class I malocclusion, vertical growth pattern, maxillary crowding and mandibular crowding, excessive overjet, ectopic eruption and has recommended treatment. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 26 total points to support orthodontic care. 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. 

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, the HLD index is utilized. 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care.  In this case the HLD index states that if both ectopic eruption and anterior crowding are noted, then the more severe of the two conditions is to be scored, not both. This reviewer concurs with the index completed by the insurer attaining a total of 24 points on the HLD index (6 overjet, 5 overbite, 10 anterior crowding, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. 

The clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval. The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

D8080 braces and D8670 monthly visit x 12 is not considered medically necessary for this patient. 

The carrier's denial of coverage for D8080 braces and D8670 monthly visit x 12 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal class I, vertical growth pattern, class II canines, maxillary and mandibular crowding, and anterior crossbite (mandibular right canine and maxillary right lateral incisor). 
Treatment: D8080 braces and D8670 monthly visits x 12.
The insurer denied coverage for D8080 braces and D8670 monthly visits x 12. The denial is upheld. 

This is a male patient who was evaluated for orthodontic treatment. The orthodontist recommended comprehensive orthodontics due to skeletal class I, vertical growth pattern, class II canines, maxillary and mandibular crowding, and anterior crossbite (mandibular right canine and maxillary right lateral incisor). The orthodontist has completed the patient's Handicapping Labio-Lingual Deviation (HLD) index 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 to support orthodontic necessity. 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 on the HLD index. 

Upon review of the submitted documentation, 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, the HLD index is used. 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 not met as there is no evidence of gingival attachment loss or gingival recession and therefore 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. This reviewer concurs with the patient's HLD index of the insurer attaining 7 points (i.e., 3 overjet, 2 overbite, 2 labio-lingual spread).

The coverage for D8080 braces and D8670 monthly visits x 12 is not considered medically necessary for this patient.  

The health plan acted 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 visits x 12 should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral breast pain

Treatment: Bilateral simple mastectomy

The insurer denied coverage for bilateral simple mastectomy.

The denial is overturned. 

This is a female patient with a history of bilateral breast pain and fibromyalgia. She has a family history of breast cancer. She is thought to have fibrocystic disease causing mastodynia, but the patient's medical records do not document an endocrinology work-up and treatment. She has no evidence of breast cancer; mammogram, ductogram, cytology and magnetic resonance imaging (MRI) are normal.  

The patient has an International Breast Intervention Study (IBIS) (Tyrer-Cuzick model) lifetime risk assessment of breast cancer of 23.1%. Per Milliman Care Guidelines (MCG), mastectomy is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for bilateral simple mastectomy is overturned. The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Low back and leg pain; L3-4 spinal surgery.
Treatment:  Intraoperative neurophysiological monitoring during spinal surgery (95941x3 and 95851-26).

The insurer denied the Intraoperative neurophysiological monitoring during spinal surgery (95941x3 and 95851-26).  The denial is upheld.

The patient is a male with history of lumbar fusion.  Intraoperative monitoring (IOM) was performed during the surgery, and there were no changes noted throughout the procedure.

No, the health plan should not cover the proposed treatment. 

The patient had degenerative changes of the lumbar spine and underwent a lumbar fusion.  The patient did not have any diagnosis that would support the use of IOM (intraoperative monitoring) intraoperatively, such as fracture or other unstable injury which can cause nerve or spinal cord injury without the surgeon's knowledge.  In this case, the patient had degenerative changes, and the patient had surgery in which the relevant neural structures could be directly visualized; as such, there is no clear indication in the literature that IOM (intraoperative monitoring) will provide any additional benefit or prevent any risk.  Good care and surgical technique can avoid injuries to the nerves and spine but IOM (intraoperative monitoring) does not provide any additional benefit and would not be considered medically appropriate.  The use of IOM (intraoperative monitoring) and all CPT (current procedural terminology) codes are not medically indicated.

While intraoperative monitoring (IOM) can be medically indicated for certain patients with the above diagnoses, in this situation, the patient did not have any finding that would support intraoperative monitoring (IOM), and it would not be considered medically indicated or standard of care in this setting.  Standard treatment is to perform this surgery without the use of intraoperative monitoring (IOM) and utilize good care and surgical technique to avoid injury to the neural structures.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Low back and leg pain; L3-4 spinal surgery.
Treatment:  Intraoperative neurophysiological monitoring during spinal surgery (95941x3 and 95851-26).

The insurer denied the Intraoperative neurophysiological monitoring during spinal surgery (95941x3 and 95851-26).  The denial is upheld.

The patient is a male, who underwent spinal surgery.  Neuromonitoring was used during surgery, specifically somatosensory evoked potentials, spontaneous electromyography and motor evoked potentials.  Codes 95938 and 95939 were processed and reimbursed, but codes 95941 and 95861 were denied.

No, the health plan should not cover the proposed treatment.  

The use of remote monitoring by another physician does not provide any additional benefit to the neuromonitoring process.  The surgeon is capable of interpreting the feedback and monitoring results.  Also, the additional monitoring of the extremities (needle myography) is bundled with the other monitoring codes and not separately reimbursable.  The proper codes were billed and paid.  

There is no additional safety provided by a remote physician monitoring when the surgeon can interpret the same information within the operating room.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Low back and leg pain; L3-4 spinal surgery.
Treatment:  Intraoperative neurophysiological monitoring during spinal surgery (95941x3 and 95851-26).

The insurer denied the Intraoperative neurophysiological monitoring during spinal surgery (95941x3 and 95851-26).  The denial is overturned.

The patient is a male with right-sided low back and leg pain, who underwent an L3-4 laminectomy and fusion.

Appeal documentation included the operative report and intraoperative monitoring report.  Per the records, payment for neuromonitoring services for a L3-4 laminectomy and fusion was denied, stating that intraoperative evoked potentials have 'no proven value' in surgery below the level of the spinal cord.  Also, it was stated that intraoperative electromyography (EMG) is investigational because there is 'insufficient evidence that...provides useful information to the surgeon'.

Yes, the health plan should cover neuromonitoring services for this procedure.  

Yes, the requested health service or procedure is likely to be more beneficial than any standard treatment(s) for the insured's condition or disease.

The health plan should cover neuromonitoring services for this procedure.  The use of intraoperative electromyography (EMG) is a well-established and widely used method for helping to ensure that hardware is placed accurately, avoiding nerve root damage as well as repeat surgeries to revise hardware.  The medical records provided with the case are sufficient to answer this question.  The requested health service is likely to be more beneficial than not using intraoperative monitoring during this procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Idiopathic Short Stature.
Treatment:  Nutropin AQ Inj. (Injection) Nuspin 5.

The insurer denied Nutropin AQ Inj. Nuspin 5.  The determination is overturned.

The patient had a fall-off in height from the third to less than (<) 3rd percentile.  Current height standard deviation score (SDS) is -2.94.  Body mass index (BMI) is at the 51st percentile.  Her father has osteogenesis imperfecta (OI), and she has been screened for the genetic mutation associated with OI and is negative.  Growth velocity is 4 to 4.7 centimeters(cm) /year.  She had a normal response to provocative growth hormone (GH) testing, normal thyroid function tests, and chemistry profile. Testing failed to reveal a cause of short stature.  GH is being requested for the treatment of idiopathic short stature.  At issue is the medical necessity of Nutropin.

Nutropin is medically necessary.  Although the patient does not have biochemical evidence of classic GH deficiency, she is short enough to meet Food and Drug Administration (FDA) criteria for treatment of idiopathic short stature, as her height is more than 2.25 SDs below the mean for age and gender and more than 2 SDs below her genetic target height percentile.  She has a slow growth velocity, and all other causes of short stature have been ruled out.  The optimal time to intervene to improve her height potential is prior to pubertal progression.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces and Monthly Visits.
The insurer denied the Braces and Monthly Visits.
The determination is upheld.

The patient has a skeletal Class I occlusion, mild maxillary spacing and mild mandibular crowding, mild overjet and moderate overbite. At issue is the medical necessity for braces and 12 monthly visits.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 11 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeter (mm) or greater and underbite 3.5 millimeter (mm) or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary.
Thus, braces and 12 monthly visits are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/musculoskeletal. 
Treatment: Home health care. 
The insurer denied increase in PCA hours to 45.5 hours per week. 
The denial is overturned. 

The patient is a female with past medical history of DM type 2, osteoarthritis, rheumatoid arthritis, osteoporosis, anxiety, coronary artery disease, hearing loss, urinary incontinence, anemia, fatigue, and dizziness who had been assigned Personal Care Assistance (PCA) services 3.5 hours/day, 7 days/week to total 24.5 hours/week based on assessment tool performed. At this assessment, the patient was assessed at total assistance with tasks of ordinary housework and managing finances while extensive assistance with tasks of meal preparation and shopping. The patient was assessed at limited assistance with tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use. There was a request to increase PCA hours.

The health plan's determination is overturned in whole.

The requested increase in hours is medically necessary for this patient. The patient had decline in her chronic medical conditions as documented by her medical providers with recommended increase in PCA hours. The insurer incorrectly stated the patient did not have a change in assistance needs between the assessments. The patient had an increase in assistance needs with tasks of meal preparation, managing medication, phone use, stairs, shopping, transportation, bathing, dressing lower body, transfer toilet, toilet use, and bed mobility. Furthermore, the patient had telephonic assessment which could have underestimated her care needs. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of activity of daily living (ADLs) and Instrumental activities of daily living (IADLs). The patient does not have informal helper outside of the requested increase in PCA hours. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastric cancer

Treatment: Opdivo for the treatment of gastric cancer

The insurer denied coverage for Opdivo for the treatment of gastric cancer.

The denial is upheld. 

This is a female patient with stage II gastric cancer on curative therapy with FLOT [fluorouracil, leucovorin, oxaliplatin and docetaxel]. The patient's attending provider (AP) has requested the add-on of Opdivo (nivolumab) to chemotherapy.

There is no current evidence to support the use of Opdivo in conjunction with chemotherapy in the adjuvant/neoadjuvant setting of gastric cancer. At this time, the National Comprehensive Cancer Network (NCCN) does not support the use of Opdivo with chemotherapy to treat gastric cancer. While the preliminary report of the studies cited by the treating provider (Moehler, M. et al. 2020) support the use of nivolumab with chemotherapy in the metastatic setting, this is not applicable to the non-metastatic setting. It should also be noted that the chemotherapy regimen used in these studies differed from the one planned for this patient. In addition, as this patient has stage II non metastatic disease, results of these trials are not applicable to her clinical situation. Therefore, the health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.      

There is no evidence to support the use of Opdivo in the adjuvant treatment of gastric cancer at this time. Therefore, Opdivo for the treatment of gastric cancer is not considered medically necessary for this patient. The health plan acted reasonably with sound medical judgment in the best interest of the patient.                                                      

Based on the above, the medical necessity for Opdivo for the treatment of gastric cancer is not substantiated. The insurer's denial is upheld.