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

Diagnosis: Lumbar superior endplate compression fracture
Treatment: Pain injection (62323 x 1) - Epidural steroid injection
The insurer denied coverage for Pain injection (62323 x 1) - Epidural steroid injection.
The denial is upheld.

The patient had magnetic resonance imaging (MRI) performed which showed mild acute/subacute right sided lumbar (L) 4 superior endplate compression fracture, and bilateral L5 spondylolysis with slight L5-sacral (S) 1 anterolisthesis. There was no evidence of spinal stenosis or neural compression. Per the office visit note, the patient had received multiple treatments and therapies to help alleviate the back pain with no sustainable relief. The physician recommended a lumbar interlaminar steroid injection at the level of L3-4 to help with the patient's pain. The patient did not receive a kyphoplasty or intra-thecal therapy.  

An Epidural steroid injection is not evidence-based therapy in the presence of a vertebral body fracture. Kerezoudis et al (1) conducted a systematic review on the effect of epidural steroids on Bone Mineral density:

A total of 7,233 patients (eight studies) with a mean age ranging between 49 and 74 years and an average follow-up between six and 60 months were studied. Steroids that were used included triamcinolone, dexamethasone, and methylprednisolone (MP), with a mean number of injections ranging from one to 14.7 and an average cumulative dose in MP equivalents between 80 and 8,130milligrams (mg). Epidural steroids were associated with significantly decreased bone mineral density (BMD) in four out of six included studies, and with increased risk of vertebral fracture in one out of two included studies. Significant reductions in BMD were associated with a cumulative MP dose of 200mg over a one-year period and 400mg over three years.  Each Epidural steroid injection increases the risk of further vertebral fractures. There are other evidence based therapies available to this patient.

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

The insurer's denial of coverage for a pain injection (62323 x 1) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity. 
Treatment: Saxenda. 

The insurer denied the Saxenda. 
The denial is overturned. 

The patient is a female diagnosed with Obesity. This request is for Saxenda. As reported, she has HTN (hypertension); HLD (hyperlipidemia); Pre-diabetes; aortic aneurysm. She has failed to achieve and/or maintain clinically significant weight loss with lifestyle modifications alone and currently has class 1 obesity. As per provider; she is not a candidate for phentermine and Qysmia due to aortic aneurysm. As per visit note; she is on metformin XR (extended release) 1000 mg (milligrams); metformin IR (immediate release) 500 mg (milligrams) daily; Saxenda 3 mg (milligrams) daily (change to Ozempic 1 mg [milligrams] weekly). 

Yes, the requested Saxenda is medically necessary. 

Saxenda is a GLP1 (glucagon-like peptide 1) agonist that is used in the treatment of obesity [1-4]. The standard of care is to use the medication most compatible with the patient's condition and other medications. The patient has obesity and meets the FDA (United States Food and Drug Administration) label. The patient has prediabetes, which makes GLP-1 (glucagon-like peptide 1) receptor agonists superior to other medications for the treatment of obesity. The request is consistent with generally accepted standards of medical practice. The request is therefore medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Coronary Artery Disease (CAD)
Treatment: Home Health Care
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: Total of 132 Hours per Week [12 Hours per Day, 4 Days per Week / 12 Hours per Day, 4 Days per Week (Split-Shift), and 12 Hours per Day, 3 Days per Week]. 

The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease (CAD), hypertension, congestive heart failure (CHF), dementia, bipolar disorder, osteoarthritis, hypothyroidism, and urinary incontinence who had been assigned CDPAP (Consumer Directed Personal Assistance Program) services based on assessment performed via telephone assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, managing medication, and shopping. With tasks of phone use, stairs, transportation, bathing, dressing lower body, and toilet use, the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and eating. The patient was assessed as independent with task of bed mobility. 

Consumer Directed Personal Assistance Program (CDPAP) Services: Total of 132 Hours per Week [12 Hours per Day, 4 Days per Week / 12 Hours per Day, 4 Days per Week (Split-Shift), and 12 Hours per Day, 3 Days per Week] are medically necessary for this patient.
The patient's primary care physician (PCP) and son had noted decline in patient's functional and cognitive status. The PCP specifically noted the patient's vision issues prevented her from completing activities of daily living (ADL) and Instrumental activities of daily living (IADL) independently. The patient was documented to require at least extensive assistance with all ADLs and IADLs. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in personal care assistance (PCA) services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs.
Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Consumer Directed Personal Assistance Program (CDPAP) Services: Total of 132 Hours per Week [12 Hours per Day, 4 Days per Week / 12 Hours per Day, 4 Days per Week (Split-Shift), and 12 Hours per Day, 3 Days per Week] are medically necessary for this patient. 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: Liposarcoma of the right calf status post resection
Treatment: Intensity-modulated radiation therapy (IMRT).
The insurer denied the IMRT.
The determination is upheld.

This is a female with history of type pT2N0 myxoid/round cell high grade liposarcoma of the right calf status post resection. She has been recommended to proceed with a course of postoperative radiotherapy with a curative intent.

At issue is the medical necessity for the requested intensity-modulated radiation therapy (IMRT).

I uphold, in whole, the health plan's determination of medical necessity.

No, IMRT is not medically necessary for this patient. 

IMRT is not proven to yield superior clinical outcomes for all patients with extremity sarcoma. The provider has not shown that IMRT is medically necessary in the patient's setting. The treating provider has not supplied a Three Dimensional Conformal Radiation (3DCRT)/IMRT plan comparison to show that 3DCRT is unable to provide adequate safety/precision. The patient has not received prior radiation to the same area in the past which would necessitate the use of IMRT in the patient's situation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, dementia, arthritis, diabetes, and recurrent falls.
Treatment: Increase Home Care/Personal Care, Home Health Care (HHC) Level II per 15 Minutes to 84 Hours per Week.
The insurer denied: Increase Home Care/Personal Care, Home Health Care (HHC) Level II per 15 Minutes to 84 Hours per Week.
The denial is overturned.

This patient is an elderly female with dementia and recent fall resulting in fracture of the coccyx. She is appealing the denial of an increase in home care/personal care to 84 hours per week. The health plan approved 59 hours per week. The Uniform Assessment System (UAS) evaluation completed recently shows minimally impaired cognition and functional status: total dependence with housework, managing finances, and shopping; maximal assistance with meal preparation, managing medications, bathing, and lower body dressing; extensive assistance with phone use, stairs, transportation, personal hygiene, upper body dressing, walking, locomotion, and toileting; and limited assistance with bed mobility and eating. She is incontinent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation completed six months earlier, there has been a decline with managing medications, stairs, shopping, and bed mobility. A letter from a provider notes the patient has a history of hypertension, dementia, arthritis, 
diabetes, and recurrent falls. She is home bound. She requires an increase in aid to 84 hours per week.

The proposed treatment is medically necessary.

This patient has multiple chronic conditions. She is appealing the denial of an increase in home care/personal care to 84 hours per week. The health plan approved 59 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows the patient requires assistance with all activities of daily living. She is incontinent of bowel and bladder. Compared to Uniform Assessment System (UAS) evaluation completed six months earlier, there has been a decline with managing medications, stairs, shopping, and bed mobility. The records and appeal statement supports the request for increase in personal care hours. The information provided shows that this patient has significant limitations in functioning. There has been some progression in her impairments between Uniform Assessment System (UAS) evaluations. Based on this patient's need for assistance with all activities of daily living (ADLs), the approved personal care of 59 hours per week is insufficient to meet this member's needs for assistance with activities of daily living (ADLs). The proposed increase personal care services to 84 hours per week is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Lower back pain
Treatment: Oxycontin
The insurer denied coverage for Oxycontin.
The denial is overturned.
 
This patient has chronic low back pain and peripheral vascular disease. According to a letter from the physician, he has tried and failed Nucynta and Hydromorphone. He is currently taking Xtampza. He has been taking Oxycontin with good effect. There is no evidence of diversion or abuse documented.

He is already on the Oxycontin and has not had an adverse reaction. He has met the formulary requirements of trying 3 alternatives.

The letter from the physician outlines the adverse reactions the patient has had from the formulary alternatives.

There is no superiority of one opiate over another. Rather, this patient has received good effect from the prescribed medication and therefore should continue on it.

Clinical practice guidelines (1) support the use of opiate medication. The long-term goal is to taper, but he is stable on this regime and has naloxone as recommended by the Surgeon General (2).

The formulary drugs are expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Oxycontin (oxycodone ER) is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung disease (refractory mycobacterium avium 
complex - MAC)
Treatment: Arikayce
The insurer denied: Arikayce
The denial is overturned.

The patient is an adult female with bronchiectasis due to multi-drug resistant mycobacterium avium complex (MAC) who is prescribed Arikayce. The infection is resistant to azithromycin, ethambutol, and rifampin. She is currently on intravenous therapy with Recarbrio. The intravenous therapy is being transitioned to oral Arikayce and Omadacycline. This request is denied due to lack of medical necessity. This denial is being appealed.

The proposed treatment is medically necessary.

This patient with bronchiectasis due to multi-drug resistant mycobacterium avium complex (MAC) is prescribed Arikayce. The infection is resistant to azithromycin, ethambutol, and rifampin. She is currently on intravenous therapy with Recarbrio. The intravenous therapy is being transitioned to Arikayce and Omadacycline. 
Inhaled Arikayce therapy is an effective and feasible therapy for difficult-to-treat nontuberculous mycobacteria (NTM) lung disease. In a most recent clinical trial, the addition of Arikayce to guideline-based therapy (GBT) for treatment-refractory mycobacterium avium complex lung disease achieved significantly greater culture conversion by month six than guideline based therapy alone, with comparable rates of serious adverse events. (1,2) This is due to better penetration of the medication into the nontuberculous mycobacteria biofilm and enhances amikacin uptake into macrophages. (3) Based on available data, the Arikayce has shown to be effective in well-conducted clinical trials to treat difficult to treat nontuberculous mycobacteria infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Dental services, CT scan maxillofacial area, consultation on x-ray exam made elsewhere, intraoral periapical and limited oral evaluation 
The insurer denied dental services, CT scan maxillofacial area, consultation on x-ray exam made elsewhere, intraoral periapical and limited oral evaluation.
The determination is overturned.

This is a patient who underwent a computed tomography (CT) scan and periapical x-ray for dental issues. At issue is the medical necessity of the dental services CT scan maxillofacial area, consultation on x-ray exam made elsewhere, intraoral periapical and limited oral evaluation.

The requested health service/treatment is medically necessary for this patient. The evaluation and periapical radiograph are needed to evaluate the area and plan treatment. Regarding the computed tomography (CT) scan and consultation regarding the computed tomography (CT) scan, further information was needed. There were no consultation notes regarding a discussion with the patient regarding an implant nor a radiograph to evaluate whether an implant would be appropriate. When tooth number (#) 18 is removed, normally a bone graft is performed to preserve the ridge for an implant. A radiograph would be able to determine at this time if there was sufficient bone for an implant. The Panorex radiograph could determine where the inferior alveolar nerve was located and a computed tomography (CT) scan would not be needed unless more information than can be provided by a Panorex radiograph is needed.
Additional information was requested, received and reviewed. A computed tomography (CT) scan would be needed after the removal of tooth #18 and after healing of the socket or bone graft to determine the amount of the bone available for an implant and the location of the inferior alveolar nerve.
The American Academy of Oral and Maxillofacial Radiology recommends that cross-sectional imaging be used for the assessment of all dental implant sites and that cone-beam computed tomography (CBCT) is the imaging method of choice for gaining this information. This document will be periodically revised to reflect new evidence. Therefore, the requested services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rib Fractures and Leak in the Lung 
(pneumothorax)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female without any past medical history who had fall at home after developing dizziness and loss of consciousness. The patient was found to have left pneumothorax in the ER (emergency room). The patient had chest tube placed in the ER (emergency room). The patient was admitted to hospital for the management of pneumothorax and chest tube management.
The health plan denied coverage of the inpatient admission on the basis of medical necessity. This denial is being appealed.

The Inpatient Hospital Admission was medically necessary.

The patient had loss of consciousness, which led to fall with left-sided broken ribs as well as large pneumothorax. The patient needed an intervention, chest tube placement, which is beyond observation care time frame. Given the patient's signs and symptoms due to left pneumothorax needing chest tube placement, the patient's treatment course would not have been expected to be safe and effective at a lower level of care. The treatment provided in this patient was reasonably expected to be provided at an acute inpatient level of care. The acute in hospital level of care is considered standard of clinical practice in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hysterectomy.
Treatment: Full Hospital Admission.
The insurer denied: Full Hospital Admission.
The denial is: Upheld.

This patient is a female who presented for surgical management of post-menopausal bleeding and expected undergo total hysterectomy and bilateral salpingo-oophorectomy secondary to postmenopausal bleeding and breast cancer. The patient has no active complaints and had been nothing by mouth since midnight. She denied fever, chills, cough, shortness of breath, chest pain, myalgias, fatigue, sick contacts, calf pain and an endometrial biopsy was noted to be normal. The transvaginal ultrasound noted the uterus to measure 8.1 x 5 x 5.5 centimeters (cm) with an average volume of 114 milliliter (mL). Endometrial echo measured 28.3 millimeters (mm) which was thickened and heterogeneous. There were no fibroids or masses seen. The ovaries were not visualized. There was trace fluid within the cul-de-sac. The patient was taken to the operating room where she underwent a total endoscopic hysterectomy, bilateral salpingo-oophorectomy. 

The patient was seen and examined at bedside and was doing well with no active complaints. Pain was well-controlled, and she denied headache, nausea, vomiting and palpitations. There was pain. This is from her visit bedside, and she was using this. She denied flatus or bowel movement. The patient was noted to have a difficult blood draw and was unable to have her blood drawn at that time. Vital signs were stable, and she was afebrile. The exam was benign, and the incisions were clean, dry and intact with Dermabond in place. Urine output was 400 cubic centimeters (cc) clear urine over 4 hours, and this was adequate. The patient was planned for transfer to the surgical floor at that time. She was maintained on Ancef 2 grams every (q) 8 hours. Percocet orally was used for pain. Postoperatively, the patient restarted Eliquis and was maintained or oral pain medication. She progressed normally and had passage of flatus and a bowel movement. She was stable and discharged home with follow-up in the outpatient setting in 1-2 weeks.

The full hospital admission is not medically necessary for this patient based upon review of the Milliman Care Guidelines (MCG) Guidelines (Hysterectomy, Laparoscopic - MCG Health 25th Edition) appropriate to the review of this case and care. Based on a review of this case, the patient underwent a laparoscopic hysterectomy with bilateral salpingoophrectomy and cystoscopy for the diagnosis of post-menopausal bleeding. The patient was noted to have an uncomplicated procedure with minimal blood loss during the procedure. The patient had a stable hemoglobin and hematocrit and required no transfusion. Vital signs were noted to be stable. She was ambulatory and on oral medications and diet. Thus, this patient met all of the discharge criteria for home care after surgery recovery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 braces

The insurer denied coverage for D8080 braces

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 on the HLD index. 

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, the use of an orthodontic Index, the HLD 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 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. 

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.

D8080 braces is not considered medically necessary for this patient. 

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 braces is not substantiated.