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

Back Pain
Surgical Services

The patient is a female diagnosed with lumbar intervertebral disc displacement, lumbar radiculopathy, and lumbar intervertebral disc degeneration. Progress notes provided show the patient with a history of low back and lower extremity pain with associated numbness and tingling down the back of both legs. It was noted she has undergone a formal consultation and was not determined to be a surgical candidate. She has had several interventions without significant relief. She is currently using baclofen and Cymbalta without side effects. She has tried physical therapy and chiropractic treatment. She complained of pain rated at 5 out of 10. Examination findings showed limited lumbar range of motion with pain. She has well-preserved strength in the bilateral lower extremities, sensation was intact, and she had normal muscle tone throughout without any spasticity or rigidity. She was recommended for a spinal cord stimulator trial.
Records provided indicate the patient was recommended for a two level thoracic spinal cord stimulator trial for the patient for treatment of complaints of low back pain and lower extremity pain with associated numbness and tingling down the back of both legs. It was stated the patient has failed to improve after undergoing several conservative therapies including injections, medication management and surgical consultations. Records provided show that the spinal cord stimulator trial was denied by the health plan as not medically necessary.
The subject under review is the medical necessity of the spinal cord stimulator.

The health plan's determination is upheld.

No, the requested spinal cord stimulator trial is not medically necessary for this patient. The patient is diagnosed with lumbar intervertebral disc displacement, lumbar radiculopathy, and lumbar intervertebral disc degeneration. The patient has chronic low back pain and radicular symptoms, though neurological examination was noted to be unremarkable. It was noted the patient has failed multiple conservative treatments and was deemed not a surgical candidate. However, the patient does not have a diagnosis/condition that would be supported for use of a spinal cord stimulator. This treatment is only supported for certain conditions including complex regional pain syndrome, failed back surgery syndrome, or critical limb ischemia. There is no evidence supporting spinal cord stimulation for the treatment of chronic low back pain or radicular symptoms and no evidence that this treatment would be effective. Medical necessity is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Worsened depressive symptoms

Treatment: Inpatient mental health treatment

The insurer denied coverage for inpatient mental health treatment. The denial was upheld.

This patient is a female who was admitted to this inpatient mental health treatment in this hospital due to worsened depressive symptoms including a suicidal plan to jump in front of a train. She had depressed mood, low energy, feelings of hopelessness, tearfulness, poor activities of daily living (ADL's), neurovegetative symptoms, and had a past overdose as well as past self-injurious behavior such as cutting self. She was in treatment at a partial hospital program. She had a diagnosis of Bipolar II Disorder. She was prescribed and required medication changes including being discharged with Lamotrigine and Quetiapine. She improved and was discharged.

The insurer denied coverage for continued inpatient mental health treatment in this hospital as not medically necessary treatment.

This reviewer agrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital, as not medically necessary treatment; as the chart notes provided did not report enough specific evidence to support that she only required acute inpatient hospital treatment, or that she could not be treated in a less restrictive level of care. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with aggression, homicidal or suicidal intent, plan, or behavior, psychotic symptoms, or severe agitation are candidates for inpatient hospitalization.

In this case this patient had initially presented with suicidal ideation and plan to jump in front of a train and had severe depressive symptoms including feelings of hopelessness but the chart notes as of a specified date reported that she denied suicidal ideation, plan, or intent. As of that date there were no reports of manic episodes, aggression, disruptive behavior, paranoid delusions, hallucinations, disorganized speech or thought process, suicidal or homicidal ideation, plan, or intent, or severe agitation. There were no reports of acute medical instability of severe withdrawal requiring hospital treatment.
As a result, the determination is to uphold the previous decision and deny coverage for continued inpatient mental health treatment in this hospital. It appeared that the health plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for continued Inpatient Psychiatric services is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Lupus flare versus atypical preeclampsia

Treatment: inpatient hospital admission

The insurer denied coverage inpatient hospital admission. The denial was modified.

This patient is a female who presented at 31.5 weeks gestation; with a 3 day history of bilateral lower leg swelling and headache with blurred vision not relieved by Tylenol. The patient has a past medical history of Systemic Lupus (SLE) and seizures in 2 previous pregnancies. Preeclampsia was ruled out based on lack of elevated blood pressure and lack of proteinuria and normal laboratory evaluation. There were concerns about possible deep vein thrombosis (DVT). The patient was admitted for observation, management of her headache and for Doppler studies. Her vital signs were stable. There was no evidence of SLE flare-up. The patient was seen by Maternal Fetal Medicine, Rheumatology and Neurology. Neurology was concerned about seizures and recommended oral magnesium. The Rheumatology team did not feel that this was an SLE flare-up. Her symptoms improved and she was discharged.

The patient presented with complaints of headaches and leg swelling. Her blood pressure was not elevated. There was no vaginal bleeding, no uterine contractions and no ruptured membranes. There was no evidence of fetal compromise. Preeclampsia refers to the new onset of hypertension and proteinuria or hypertension and significant end-organ dysfunction with or without proteinuria after 20 weeks of gestation in a previously normotensive woman. So, based on this patient's presentation, she did not have preeclampsia. Because of her history of prior seizures, admission for close observation and neurology consult were medically necessary and so was the need to rule out deep vein thrombosis (DVT). However, as of a specified date, the patient was stable. Neurology recommended oral magnesium, preeclampsia and DVT had been ruled out, the patient was stable and she could have been discharged home and followed up as an outpatient. It is unclear why she was kept in the hospital for 2 additional days. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient with regard to the admission. The inpatient hospital admission from the dates specified is medically necessary for this patient. However, continuous admission from other specified dates was not medically necessary.  

The determination is modified. Based on the above, the medical necessity for the inpatient hospital admission from specified dates is not substantiated. Inpatient hospital admission from other specified dates is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic obstructive pulmonary disease (COPD) exacerbation

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male with history of chronic obstructive pulmonary disease (COPD), hypertension (HTN), diabetes mellitus (DM) who presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) and wheezing. The patient also complained of intermittent chest pain and right lower extremity (RLE) swelling x 3 days. The patient was just discharged from another hospital where he was going to be admitted but they discharged him. There was no history of fever. The patient also has history of underlying malignancy - Prostate Cancer.

The vital signs at presentation were: Temperature (T) 97.9 F., heart rate (HR) 112, respiratory rate (RR) 18, blood pressure (BP) 167/93 mm Hg and oxygen (O2) saturations were 100%. Lung exam revealed decreased breath sounds (BS) and some wheezes. The cardiovascular system (CVS) S1 S2 was normal (N). The abdomen was soft and nontender (NT). He was oriented to person, place and time.  The chest x-ray showed clear lungs.  The patient was treated with Magnesium, Steroids and bronchodilators via Nebulizers. The patient was placed on bilevel positive airway pressure (BIPAP).

The patient was admitted to the hospital with diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation.  He was initially on BIPAP, but the respiratory support was discontinued. The patient was started on Prednisone 20 mg daily. The patient also was placed on Pulmicort and bronchodilators. The patient improved with prescription therapy treatment (Rx) and was cleared for discharge by a specified date however, due to the patient's social situation and multidisciplinary team approach was initiated to facilitate discharge.

This patient did not need acute inpatient hospitalization.  He could have been placed on Observation status while diagnostic testing and treatment were initiated. This patient was afebrile and hemodynamically stable. The patient had responded to treatment in the Emergency Department. No wheezing was heard on lung exam as per History & Physical. 
This patient could have been treated in the outpatient setting after initial evaluation and treatment in the Emergency Department and discharged on oral Steroids, bronchodilator and oral antibiotics if needed with close follow-up in an outpatient setting. The insurer's prior denial was appropriate as the patient did not meet Milliman Care Guidelines (MCG) criteria for Chronic Obstructive Pulmonary Disease (COPD) admission criteria. 

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient.
The denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Back Pain
Pain Management

The patient is a female with a history of hip and leg pain. The provider is seeking coverage for facility-based facet contrast injection (CPT codes 64493 and 64494) performed in early 2019. This procedure was previously denied with documentation stating "it is not shown to be effective."

The health plan's determination is overturned. The requested services are medically necessary.
As noted in "Evaluation and Treatment of Lumbar Facet Cysts" first-line treatment is "nonsurgical management consisting of oral non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy, bracing, epidural steroid injections, and/or cyst aspiration." While literature also shows that cysts often reoccur first line treatment continues to include cyst aspiration as it often provides symptomatic relief - as it did in this case. Additionally, while aspiration of this patient's cyst was via radiographic assistance "Long-Term Effectiveness of Direct CT-Guided Aspiration and Fenestration of Symptomatic Lumbar Facet Synovial Cysts" did show significant benefit and as the provider's procedure note stated, there was aspiration of "clear synovial fluid" at level of L4-5 facet with patient reporting decrease in pain score from 7/10 to 4/10 (pre and post-posture). Lastly, "Outcome of Percutaneous Lumbar Synovial Cyst Rupture in Patients with Lumbar Radiculopathy" found that synovial cyst rupture eliminated the need for surgical interventions for 80% of the patients (during the follow-up period ranging from 6 to 24 months).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Issue under review: Braces

Determination: 
The Braces are medically necessary.

The patient is a male child. The patient has two "automatic qualifying conditions." First, he has a deep impinging overbite with soft tissue damage to the palate. Second, he has an impacted upper left lateral incisor (tooth #10). Impacted permanent anterior teeth where extraction is not indicated, is a qualifying condition for automatic benefits. The patient needs the expansion appliance recommended to widen his upper jaw and allow room for this impacted tooth to erupt. Orthodontic treatment is medically necessary for this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: moderate upper arch crowding, moderate lower arch crowding, traumatic deep bite with damage to gums and upper front teeth are slightly ahead of the lower

Treatment: D8080 - Comprehensive dental braces

The insurer denied coverage D8080 - Comprehensive dental braces. The denial was reversed.

This patient is a female child. Per the orthodontic treatment plan the patient has moderate upper arch crowding, moderate lower arch crowding, traumatic deep bite with damage to gums and her upper front teeth are slightly ahead of the lower. Per the handicapping labio-lingual deviation (HLD) index report the patient has an automatic disqualifier as she has a deep impinging overbite with severe soft tissue damage.

The insurer has denied coverage for D8080 - Comprehensive dental braces, as not medically necessary.

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, a Handicapping Labiolingual Deviation 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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive 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.  This is confirmed by several studies.  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.  

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

Based on the above, the medical necessity for D8080- Comprehensive dental braces is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history significant for inclusion body myositis. He has a medical history significant for inclusion body myositis, human immunodeficiency virus (HIV), diabetes mellitus type 2, atherosclerotic coronary vascular disease, chronic embolism and osteoarthritis. He has a history of bladder cancer, myocardial infarction and pulmonary embolism Personal care service hours 12 hours per day 7 days a week split shift for a total of 168 hours per week is requested. This was denied based upon medical necessity. The patient has been approved for 12 hours day 7 days a week for total of 84 hours a week. The health plan's determination is upheld. The service hours which are provided are sufficient to meet the patient's needs including activities of daily living (ADLs) and Instrumental Activities of Daily Living (IADLs).
The patient had a face-to-face clinical assessment using State New York Uniform Assessment System (UAS), it was noted that many of his abilities to function remained the same since prior assessment
It was noted that the patient is able to walk less than 10 feet with the assistance of a roller walker. Services were previously denied as hours for companionship, safety supervision or when tasks are not being performed are typically not included according to medical necessity. There were no needs noted during the nighttime hours between 9:00 PM and 9:00 AM other than safety supervision. There were no specific needs including ADLs or IADLs that were required to be performed during that time. The patient has significant weakness, however, he does not have any significant needs for nocturnal turning such as bedsores or other nighttime treatments.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with Crohn's Disease, which is primarily confined to the colon. The patient has either not responded to, had adverse side effects, or loss response to 6MP (mercaptopurine), mesalamine, methotrexate, and anti- tumor necrosis factor (TNF) agents. She later eventually failed Entyvio. She has extra-intestinal manifestations with joint stiffening and erythema (E) nodosum. There is a possibility she has concomitant psoriatic arthritis.  The patient had been started on Stelara. She commenced therapy on every (Q) 8 week dosing, however, there was a dose escalation to Q 4 weeks because the response to Q 8 week therapy was inadequate.  The patient's provider has recommended Stelara 90 mg Q 4 weeks. This request was denied by the plan because the requested dose exceeds the maximum allowed based on her weight. Higher doses are only approved for psoriasis or psoriatic arthritis. The health plan's determination is upheld.
Ustekinumab is a human immunoglobulin (Ig) G1k monoclonal antibody that blocks the biologic activity of interleukin (IL) -12 and IL-23 by inhibiting receptors for these cytokines on T cells, natural killer cells and antigen presenting cells. Induction therapy with ustekinumab is given intravenously with weight-based dosing. Maintenance dosing is 90 milligrams (mg) subcutaneously every eight weeks. In two induction trials (UNITI-1 and UNITI-2), over 1300 patients with Crohn's disease and nonresponse to anti-TNF therapy were assigned to intravenous ustekinumab (either 130 mg or 6 mg/kilogram) or placebo for eight weeks. In both trials, patients treated with ustekinumab had higher clinical response rates at week 6 compared with placebo. During the maintenance phase, 397 patients who responded to induction therapy with ustekinumab were assigned to receive subcutaneous ustekinumab (90 mg either every eight or every 12 weeks) or placebo. During the maintenance phase, patients treated with ustekinumab every eight weeks or every 12 weeks had higher rates of remission at week 44, compared with placebo (53, 49, and 36 percent, respectively). Long term 3 year data from UNITI also show that 8 and 12 week dosing are equally effective. A very large open label pharmacodynamic study (ref 3) demonstrated that antibodies to ustekinumab are rare and they could not identify a target threshold trough concentration. In their supplementary table they demonstrated that Q4 week dosing (physicians were permitted to dose escalate as they saw fit) was not advantageous clinically over Q 8 week dosing. Standard of care is to use Stelara every 8 weeks, not every 4 weeks. Therefore, the requested service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Cardiac /Circulatory Problems/Congestive Heart Failure 
Durable Medical Equipment 
The patient with a history of obesity, diabetes, hypertension and hyperlipidemia. The patient  was admitted to the hospital with acute decompensated heart failure. An echocardiogram showed a left ventricular ejection fraction of 20-25%. Guideline-directed medical therapy for congestive heart failure was initiated. Cardiac catheterization showed no obstructive coronary artery disease. A Life Vest wearable cardioverter defibrillator (WCD) was prescribed.The health plans determination of medical necessity is overturned in whole. 
Yes, the requested WCD was medically necessary. Based on the medical literature, use of the wearable cardioverter defibrillator (WCD) was medically necessary in this instance.
The medical literature supports the use of the WCD in this instance:
Depressed left ventricular systolic function is a risk factor for, and powerful predictor of, sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support implantable cardioverter defibrillator (ICD) implantation in patients, such as this patient , with nonischemic cardiomyopathy, and left ventricular ejection fractions of 35% or less.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation with rapid ventricular response

Treatment: Inpatient hospital admission

The insurer denied coverage inpatient hospital admission. The denial was upheld.

This patient is a male with a past medical history notable for hypertension, arrhythmia, chronic obstructive pulmonary disease (COPD), and possible sleep apnea. He presented to the Emergency Room with complaints of palpitations. He was found to have atrial fibrillation with rapid ventricular response, with heart rates in the 140-150s. He was admitted and started on a Cardizem infusion. He spontaneously converted to sinus rhythm and was discharged home.

The patient presented with atrial fibrillation. The remainder of the cardiac workup was unremarkable, including an unremarkable cardiac troponin. He remained clinically and hemodynamically stable. Inpatient admission was not medically necessary for this patient. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Inpatient admission criteria were not met.  Although the patient had a new onset of symptoms, medical necessity criteria were not met for any other additional extenuating circumstances. 

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

Based on the above, the medical necessity for the inpatient hospital admission of is not substantiated.  The insurer's denial is upheld.