Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spinal stenosis
Treatment: Insertion of a lumbar interspinous process stabilization device without decompression or fusion (22869)

The health plan should not cover the proposed lumbar interspinous spacer device at L3-L4 without decompression or fusion as there is no evidence in the literature of clear and significant effectiveness of the procedure in treating lumbar spinal stenosis. 

The patient is male with history of chronic low back pain with intermittent claudication secondary to lumbar spinal stenosis of more than five years who has failed more than six months of conservative management that includes non-steroidal anti-inflammatory drugs (NSAIDs), opioids, physical therapy, epidural steroid injections, home exercise program, and he is not a candidate for surgical decompression.

In the study by Zaina, it was stated that Cochrane analysis showed low-quality evidence from a single study including 191 participants that favored the interspinous spacer versus usual conservative treatment at six weeks, six months and one year for symptom severity and physical function. 

In the study by Tekmyater, low back pain severity improved from 76.8  22.2 mm preoperatively to 39.9  32.3 mm at 12 months with only 48% improvement. 

The requested Insertion of a lumbar interspinous process stabilization device without decompression or fusion (22869) is not likely to be more beneficial than any standard treatment(s) for the insured's condition or treatment.  

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient because as stated above, the proposed spinal procedure is not medically indicated and not likely to be more beneficial than any standard treatments for lumbar spinal stenosis.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spinal stenosis
Treatment: Insertion of a lumbar interspinous process stabilization device without decompression or fusion (22869)

The health plan should cover the proposed insertion of a lumbar interspinous process stabilization device without decompression or fusion (22869).

The requested Insertion of a lumbar interspinous process stabilization device without decompression or fusion (22869) is likely to be more beneficial than any standard treatment(s) for the insured's condition or disease.  

The patient is a male with history of severe spinal stenosis who is not a good candidate for spinal surgery. The patient is trying to avoid invasive surgery.  The patient has failed conservative treatments in the form of physical therapy (PT), medications, and epidural steroid injections.  

The patient is a male in whom a Vertiflex Superion (insertion of lumbar interspinous process stabilization device without decompression or fusion) has been offered for the treatment of symptomatic moderate neurogenic claudication from lumbar spinal stenosis at L3-4.  The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, pain medications including opiate medications such as Percocet.  The patient was offered an alternative surgery in the form of a lumbar laminectomy/decompression with instrumentation.  This is a considerably more invasive procedure which often reduces and restricts the patient's mobility after surgery and can limit their ability to return to gainful employment especially if it involves manual labor.  Therefore, the options are limited.  The patient does have radiographic evidence of significant spinal stenosis limited primarily to one level, the L3-4 level.  The patient has had good responses to epidural steroid injections; however, they have been short-lived.  Therefore, with the exception of more invasive surgical laminectomy, the interspinous process stabilization (Vertiflex Superion) is the only other option that the patient has not failed.  The patient has had epidural steroid injections, physical therapy and the other options that have been shown to be helpful in the literature. Vertiflex Superion (VS) has been shown to be effective in multiple peer reviewed articles.  It is been shown to be as effective as lumbar laminectomy at five years.  Risks of the procedure are much less compared to conventional "open surgery".  Postoperative recovery time is much shorter, and lumbar range of motion is preserved compare to instrumentation.  Given the above, the requested VS is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spinal stenosis
Treatment: Insertion of a lumbar interspinous process stabilization device without decompression or fusion (22869)
The insurer denied spine surgery.  The denial is upheld.

The health plan should not cover the proposed insertion of a lumbar interspinous process stabilization device without decompression or fusion (22869).

The patient is a male with chronic low back pain and radicular symptoms.  The patient reportedly has had at least six months of conservative care including physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs) and pain medications as well as epidurals.  Magnetic resonance image (MRI) of the lumbar spine showed anterolisthesis at L3-4 and L4-5 with stenosis at L2-3, L3-4, and L4-5.  The attending physician (AP) recommends insertion of Superion interspinous spacer at L3-4. 

The records do not show the duration of conservative care including physical therapy. Physical therapy records that show at least six weeks of treatment are not included for review. An appropriate trial of conservative care is required before considering surgical intervention.

However, even if a trial of conservative care was completed, the patient has multiple level stenosis on the MRI and the procedure is being recommended at a single level.  Treatment of L3-4 alone is unlikely to relieve all the stenosis and therefore the patient has a high probability of residual symptoms as it is not addressing all the levels of neurocompression.  The spacer is not FDA approved for use at multiple levels.

The insertion of a lumbar interspinous process stabilization device without decompression or fusion (22869) is not likely to be more beneficial than any standard treatment(s) for the insured's condition or disease.

A standard laminectomy is more likely to be beneficial as it will address all the levels of stenosis and remains the gold standard of treatment for lumbar stenosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment Implant placement for tooth #12
The insurer denied Implant placement for tooth #12
The determination is overturned

The patient presented for evaluation and treatment of tooth number #12. Provided for review are previous letters of appeal and denial, a narrative from the provider explaining that tooth #12 was extracted, full mouth radiographic images, and health plan language. The denial was on the basis that the dental implant is not the only way of replacing the missing tooth and that the documentation provided does not support the medical necessity of placing an implant with other conventional methods being viable options in replacement of the tooth. At issue is the medical necessity of the planned treatment of implant placement (6010) for #12.

Based on the diagnosis of partial edentulism and diminished posterior support, the only treatment that can address both diagnoses is that of a dental implant. With the diagnosis of partial edentulism as well as diminished posterior support the only therapy capable of addressing both diagnoses is that of implant therapy as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis. After the implants have integrated, they will require restorations in the form of abutments and crowns in order to complete the tooth replacement. This is standard in tooth replacement involving implants. Therefore, the treatment of implant placement (6010) for #12 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth
Treatment: Braces
The insurer denied the Braces. 
The denial is overturned. 

The patient male. The request is for orthodontic benefits as well as follow up visits.

Yes, the proposed braces and follow-up visits are medically necessary. 

The patient has impacted upper right and left lateral incisors and canines. Having impacted anterior teeth where extractions are not indicated are automatic qualifiers according to the handicapping index scale. Medical necessity is established for orthodontic treatment as well as the follow-up visits to oversee progress of treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Braces
The insurer denied the Braces.
The denial is overturned.

The patient is a male. The request is for orthodontic benefits.

Yes, the proposed braces are medically necessary.  

The patient's lower left and right canines are in crossbite (reverse bite). Having anterior teeth in crossbite with attachment (gum) loss is an automatic qualifier according to the handicapping index scale. This case is medically necessary to correct the problems.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld. 

This is a male patient with history of attention deficit disorder who presented to the Emergency Department (ED) with complaints of right lower quadrant pain radiating to the umbilicus, nausea and vomiting. The patient was afebrile. On exam, the patient's abdomen was soft with mild right lower quadrant (RLQ) tenderness to palpation without guarding. The patient's computed tomography (CT) scan of the abdomen revealed acute appendicitis with no abscess. The patient's white blood cell (WBC) count was 5.19. The patient was admitted to the hospital for a laparoscopic appendectomy. The patient underwent an uneventful laparoscopic appendectomy with pathology that revealed acute appendicitis with peri-appendicitis. After a period of medical stability he was discharged home.

Based upon the MCG Health Inpatient and Surgical Care 24th Edition Appendectomy, without Abscess or Peritonitis, by laparoscopy ORG: S-175 (ISC) optimal recovery course includes floor to discharge with the following milestones completed: hemodynamic stability; successfully uncomplicated lap appendectomy; no evidence of postoperative or surgical site infection; diet tolerated; pain absent or managed; no evidence of ileus or bowel obstruction; oral medications and oral diet. Based upon the records provided, the patient reached these milestones, and was discharged following observation. According to the MCG's clinical guidelines for the goal length of stay, this patient's procedure was an ambulatory procedure. The patient presented to the hospital and was admitted and was taken to the operating room was discharged later that day after an uneventful lap appendectomy. The patient did well postoperatively and had stable vital signs and was sent home on the same day, following a period of observation. The patient did not have any comorbidity that warranted extended stay or inpatient admission. The procedure was uncomplicated and the patient did not have ileus, postop bleeding, and signs of peritonitis, wound infection, or complication. Thus, the patient could have had the appendectomy performed under an observation status without an inpatient admission. 

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

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

Diagnosis: Dyspnea
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission.  
The denial is upheld. 
This is a male patient with a history of hyperlipidemia and coronary artery disease. The patient had reported symptoms of increased fatigue, shortness of breath with minimal exertion, as well as dyspnea on exertion. A nuclear stress test was performed that was significant for mid anteroseptal hypokinesis with an ejection fraction of 59%. The patient presented for a scheduled elective cardiac catheterization. The procedure report indicated that the patient was found to have mild 50% in-stent restenosis of the mid left anterior descending (LAD) artery stent, 70% proximal stenosis of the first obtuse marginal branch (OM1), 90% proximal stenosis of the 1st left posterolateral branch (LPL), and 100% proximal chronic total occlusion of the right coronary artery. Drug-eluting stents (DES) were placed. The patient was admitted to the telemetry unit following the procedure. The patient was monitored overnight, remained stable, and had no significant events on telemetry. He was discharged. 

The inpatient admission was not medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty. 

The insurer acted reasonably, with sound medical judgement, and in the patient's best interest. The patient could have had the procedure followed by a period of observation. There was no indication for inpatient admission. 

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: Overturned

Endocrine/metabolic/nutritional
Pharmacy/Prescription Drugs

Diagnosis: Growth Hormone Deficiency
Treatment: Nutropin AQ. 
The insurer denied Nutropin AQ. 
The health plan's determination is overturned. 

This patient is a female, with growth hormone deficiency (GHD). According to the records, the patient failed 2 growth hormone stimulation tests. Her pretreatment height at 7.1 years old was 106.68 cm (-3.04 standard deviation score (SDS)) and at 8.83 years old was 114.935 cm (-2.94 SDS) with height velocity over 1.63 y of 4.8 cm/year. Her height on therapy at 10.5 years old was 135.4 cm (-0.81 SDS). At issue is the medical necessity of Nutropin AQ.

Nutropin AQ is medically necessary for this patient. This patient met biochemical criteria for GH. The GH stimulation testing peaked at less than 10ng/ml. The patient met auxological criterion 1 as her height is more than 3 SD below the mean. The patient met both auxological and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary.
The patient is a continuing therapy patient. The physician reports that her height velocity slowed on 1.4 mg daily. The physician chose to increase her dose to 1.6 mg daily. The patient's height velocity improved on this new dose. Titration of growth hormone dosing is an art that is largely based on height velocity as well as remaining within generally accepted dosing guidelines.
Given the fact that the patient failed to have a normal height velocity on the 1.4 mg, and increased to 1.6 mg was reasonable. This dose is not excessive. The current request for Nutropin AQ is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Tonsil Squamous Cell Cancer 
Treatment: PET/CT scan 

The insurer denied a PET/CT scan. The determination is overturned. 

The patient has a locally advanced tonsil squamous cell carcinoma staged tumor (T) 2 nodes (N) 1 metastasis (M) 0. He was treated with concurrent chemotherapy and radiation therapy that completed. Follow up positron emission tomography (PET) scan is recommended to evaluate the status of his disease and to assist in determining further treatment if needed. He did have a follow up computed tomography (CT) scan of the neck which revealed a residual mass in the neck. At issue is the medical necessity of a PET/CT scan. 

The requested health service of PET/CT, head to thigh, is considered medically necessary for this patient. The requested PET/CT for this patient post treatment is considered medically appropriate and necessary as this will assist in determining further therapy such as neck dissection or additional chemotherapy. This patient has had a CT scan post treatment that revealed a residual mass in the neck. The CT scan can not determine if this is viable cancer remaining or fibrosis. The PET/CT can determine if this is residual cancer and can assist in making further treatment recommendations. This is supported by excellent studies published in peer reviewed journals as well as National guidelines such as the American Society of Radiation Oncology (ASTRO) and National Comprehensive Cancer Network (NCCN).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Persistent Asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The treatment with Nucala is medically necessary.

The patient is a male child with allergic rhinitis, seasonal allergies, eczema, and severe persistent asthma that remains poorly controlled despite routine albuterol/Atrovent three times daily, low and high dose Flovent, low and high dose Symbicort, Dulera, recently added Spiriva, and multiple courses of systemic steroids. He has been on a course of systemic steroids almost monthly for the past year. In addition, he takes Singular and Flonase. With all of these interventions, he has missed numerous days of school, has daily and nightly symptoms, and is unable to participate in his usual activities. His care is jointly managed with Allergy/Immunology and Pulmonology. Testing revealed an eosinophil count of 100, difficult to interpret due to frequent courses of systemic steroids. He has been prescribed Nucala to help control his asthma and prevent need for frequent systemic steroid courses.

Mepolizumab is a type of biologic therapy, a monoclonal antibody against the IL-5 (interleukin 5) receptor on eosinophils, reducing eosinophilia and associated asthmatic symptoms. In the appropriate patient population, it is quite effective in decreasing need for recurrent courses of systemic corticosteroids. 

This patient has severe persistent asthma that is uncontrolled despite extensive routine and rescue treatments. He has received almost monthly courses of systemic corticosteroids to help control his symptoms. Both his pulmonologist and his allergist agree that the next course of action should be treatment with an anti-IL5-receptor monoclonal antibody, specifically Nucala, to help manage his symptoms and decrease his dependence on systemic steroids. 

To date, authorization has been denied because of inadequate eosinophil count to meet administration criteria. However, corticosteroids are known to decrease the eosinophil count, an effect that lasts for weeks after discontinuation of the steroids. This patient's eosinophil count of 100 is not a reliable indicator of his degree of eosinophilia because of his back to back systemic steroid treatment courses. What is clear is that despite the aggressive management of his severe persistent asthma, deemed severe eosinophilic asthma by his subspecialists, he remains significantly symptomatic, negatively impacting his daily functioning. Based on his history, current treatment profile, and severity of illness, mepolizumab is medically necessary and appropriate for him.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Gastrointestinal/Crohns
Treatment: Coverage of Prescription medication
The insurer denied the coverage of the prescription medication.
The denial is upheld.

The health plan's determination is upheld in whole. The patient's provider requested approval for Pentasa 500 milligrams (mg) capsule. It did not meet the formulary exception policy of the HP and it was denied. Formulary alternatives include mesalamine and balsalazide, unless the patient has failed this therapy or has had serious side effects.

There is no superiority to Pentasa, the formulary drugs (generic mesalamine and balsalazide) have not been ineffective according to the records submitted for review. The patient is an adult with Crohn's Disease beginning as a teen. Patient has had previous small bowel resections. The patient recently experienced abdominal pain and rectal bleeding. On the patient's most recent colonoscopy there was mild inflammation in the transverse colon but otherwise normal to the terminal ileum. After this finding Pentasa was prescribed. An upper endoscopy revealed reflux esophagitis.
The role of Pentasa, Balsalazide and generic mesalamine (these are all essentially the same drug with a different delivery mechanism) in a patient with Crohn's Disease is debatable. For mild disease confined to the colon sulfasalazine has been shown to be better than placebo. For mild small bowel disease (suggested by magnetic resonance imaging (MRI)) probably none of these drugs are superior to placebo. In a young patient with a history of aggressive Crohn's requiring small bowel resection, such as this patient, the standard of care is a biologic such as infliximab. Taking all of this into account there is no reason the patient cannot be placed on the formulary alternative of generic mesalamine.