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

Diagnosis: Crowding; crossbite.
Treatment: D8080 Orthodontic Treatment, D8670 Periodic Visit.
The insurer denied the D8080 Orthodontic Treatment, D8670 Periodic Visit.
The denial is overturned.

The patient is a female. The request is for dental benefits for orthodontic treatment and periodic visits.

Per the provider's dental clinical summary, the patient presents with Skeletal class I relationship, class II canines, moderate maxillary crowding, right posterior crossbite, deep bite, functional shift to the right, anterior crossbite with gingival attachment loss (mandibular right lateral incisor and canine).

The health plan denied coverage for the braces, because the patient did not score a 26 on the HLD (Handicapping Labio-Lingual Deviation) Index report, the score necessary for approval for orthodontic treatment.

The provider appealed the claim based on the diagnoses in the dental clinical findings.

Yes, the requested orthodontic treatment and periodic visits are medically necessary.
As stated in the dental clinical summary, and as evident in the photos, the patient presents with an anterior crossbite with gingival attachment loss (maxillary right lateral incisor and canine). Furthermore, the patient is also in posterior crossbite on the same side.

The severity and the extent of the crossbite (entire upper right side) will affect the ability to properly chew food, proper speech, and the ability to maintain adequate oral hygiene, which can eventually lead to gum disease.

Per the HLD (Handicapping Labio-Lingual Deviation) Index report, an anterior crossbite with attachment loss is an automatic qualifier for orthodontic treatment.

No, the health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.
If this crossbite is not treated, the complications of decreased proper function as it relates to chewing, speech, and compromised oral hygiene can only lead to more dental problems in the future.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Hypertension.
Treatment; Inpatient stay.
the insurer denied the inpatient stay. The health plan's determination is upheld. 

This patient is a  female who is postpartum day #(number) 8 status post spontaneous vaginal delivery who presented for severe range blood pressure. The patient was noted to have blood pressure that was mild at home which prompted follow-up to the clinic with blood pressures were 173/117, 172/119 and 160/100 over the course of 2 minutes. The patient denied headache, visual changes, confusion, right upper quadrant pain or shortness of breath. She otherwise felt healthy. The patient had labs during her last admission for delivery which were all negative. The patient has allergies to amoxicillin and latex. The patient has significant past medical history for chronic hypertension and gastroesophageal reflux disease. The patient had a prior history noted for 1 prior term delivery and 1 prior spontaneous miscarriage. She was admitted for hypertension. 

The inpatient hospital admission was not medically necessary.
In this case, the patient presented with chronic hypertension in the severe range. She was given IV labetalol 20 and 40 mg (milligram)  IV (intravenous) followed by oral Nifedipine 30 mg XL (extended release). Fetal status was not considered as the patient was postpartum. There was no acute range blood pressure ongoing after initial therapy with IV medications and oral medications. The patient was noted to have mild range blood pressures without any hypertensive emergency ongoing and her labs were all normal. There was no evidence of end organ damage in this case. There was no evidence of cerebral infarction or intracerebral hemorrhage. There was no evidence of vision loss or unstable angina. The patient had no history or symptoms suggesting myocardial infarction, pulmonary edema, aortic dissection, seizures, or acute renal failure. The patient was noted to have normal renal function as measured by her creatinine and had a normal physical exam with normal neurologic exam. There is no evidence of intracranial abnormality or indication for imaging.
The patient required no antihypertensive therapy or magnesium. Given the absence of any change in her status and normal laboratory values, there was no suspicion of preeclampsia in this case and this would not require treatment with magnesium sulfate unless there was proteinuria or lab abnormalities. In this case, review of the prenatal record noted similar blood pressures in pregnancy consistent with preexisting chronic hypertension. Thus, care in this case could be provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male with cervical degenerative disc disease (DDD) and pain for several years. Symptoms also included numbness and paresthesias of bilateral hands. He was treated preoperatively with pain medications as needed. Past medical history (PMH) was significant for obstructive sleep apnea (OSA), depression, and anxiety. Pre-operative medical clearance was obtained. The patient was American Society of Anesthesiologists (ASA) II.

He was taken to the operating room (OR) for C (cervical) 3-5 and C7/T (thoracic) 1 anterior cervical discectomy and fusion (ACDF) with ROH (removal of hardware) C5-7. An operative Penrose drain was placed. Post-operatively, the patient was kept intubated for airway management.

The inpatient hospital stay was medically necessary for this patient.

Per the Milliman Care Guidelines (MCG) Anterior Cervical fusion guidelines, the goal length of stay is ambulatory to 1-day post-op. A brief extended stay of 1-3 days may be needed for extensive surgery (multilevel, extensive dissection). This patient had an extensive surgery given the number of levels involved. The procedure did require an approach surgeon (ENT) and post-operative intubation for 24 hours. As stated in the guidelines, a brief stay extension is expected, "especially if surgery involves 3 or more levels." Therefore, his stay was extended past the expected ambulatory/1 day goal stay. As such, an inpatient hospital admission was indeed appropriate given the complexity of the case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic back pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is overturned. 

The patient is a female who presented to the emergency room for left leg spasms. 
Her pain was rated 10/10. She had a past medical history of type 2 diabetes insulin dependent, hypokalemia, rheumatoid arthritis on prednisone, chronic back pain on pregabalin and tizanidine. Her history and physical notes left gluteal pain that radiates down the back of her leg on the same side and associated with tingling in her anterior calf on the same side. The symptoms worsen upon movement of her trunk and leg. Significant worsening of left leg pain, even with light palpation has resulted in the inability to walk. Her exam noted a positive straight leg raise on the left and full strength in the left lower extremity, no saddle anesthesia, no focal sensory or motor deficit. Pain on palpation and with movement of left lower extremity. 

The patient had a herniated disc with left L (lumbar) 4 nerve root compression by imaging that failed outpatient treatments. Her pain was not relieved by three medications in the emergency room. She was treated with IV (intravenous) morphine the next day and Pain Management was consulted and added medications. Her medications were changed the following day with improvement, but she continued to have difficulty ambulating. Later, in the hospital stay her pain was controlled and she was able to ambulate independently. The inpatient stay was medically necessary per MCG (Milliman Care Guidelines) Low Back criteria. Extended care was needed for medication and possible surgical intervention. 

The insurer's denial of coverage for an inpatient admission should be overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription drugs. 
The insurer denied Botox 600 units every 12 weeks. 
The denial is upheld.

The patient is a male with a diagnosis of lower limb spasticity. Additional diagnosis includes incomplete paraplegia, tight heel cords, acquired, bilateral; paraplegic-spastic gait.
Available records include progress note which documents that patient received injection of 500 units of onabotulinumtoxinA in April and had, "good result for a brief period after receiving total dose 500 units split between gastrocs and soleus bilaterally." Physical exam does not include documentation of spasticity. There is documentation of, "heel cords very tight," and "joint tightness" on ankles however this tightness is not categorized as a spasticity versus contracture versus bony limitation. Also available is progress note which does document spasticity as modified Ashworth of 1 in both knees.
The patient previously received 100 units of Botox (onabotulinumtoxinA) and the dose was increased after assessment of effect of initial dose. The most recent injection was 500 units. Request was made for 600 units. The patient's function reported indicates that the patient ambulates with walker and crutches.
The subject under review is the medical necessity for Botox 600 units every 12 weeks.

The health plan's determination is upheld in whole.

The current Food and Drug Administration (FDA) indication is a maximum of 400 units every 12 weeks for the treatment of lower limb spasticity. Request is documented for 600 units. There is a lack of documentation for clinical necessity for quantity of 600 units of onabotulinumtoxinA in excess of the FDA indicated quantity 400 units with minimum 12-week interval between injections. There is no documentation of why the patient would not benefit from more frequent injections of the FDA approved amount of 400 units instead of the documented plan of injection 600 units.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female with spastic quadriplegia CP (cerebral palsy), status post multiple spinal surgeries complicated by infection. She presented to hospital on with right hip pain. She had previously undergone removal of hardware from her spine and replacement with plastic closure. She required readmission for Baclofen withdraws. She presented with ongoing hip pain and was admitted. She underwent aspiration, removal of hardware and irrigation/debridement. Her post-surgical course was non-complicated.

Yes, the Inpatient admission was medically necessary.
The records show the young girl had a complex, unique and extensive clinical condition. She was a quadriplegic CP (cerebral palsy) patient with a history of multiple infections. She would be at extremely high risk for complications. She was immunocompromised and required treatment by several subspecialties.

The patient required infectious disease evaluation as it would be important to assess whether a chronic infection was present to a new site (Hip). This would require awaiting culture reports as treatment would change based upon presence of infection. She required empiric IV (intravenous) antibiotics while awaiting the cultures. She required laboratory assessment of inflammatory markers.

The patient was bedbound and when seen by PT (physical therapy), and could not move her hip. She was not able to be mobilized to wheelchair. She had severe limitations and had spasm to require multiple medications.

It would be important to monitor the patient wound for evidence of drainage.

Based upon the complexity of the patient's condition, the admission and length of stay were appropriate. These services could not have been provided at a lower level of care.

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: Upheld

Diagnosis: Aortic Stenosis.
Treatment: Transcatheter Aortic Valve Replacement (TAVR).

The insurer denied coverage for TAVR.
The denial is upheld.

This case involves a male referred for TAVR to treat severe aortic stenosis. The patient has a history of severe pulmonary hypertension. He presented earlier complaining of dyspnea on exertion and an episode of syncope. Prior to the earlier presentation, the patient was able to walk for 2-3 miles and play tennis. Work up revealed a 99% mid left anterior descending (LAD) lesion, and the patient underwent successful percutaneous coronary intervention (PCI). Following PCI, he noted no change in symptoms. Physical examination revealed 4/6 systolic ejection murmur. Echocardiography demonstrated moderate to severe aortic stenosis with a valve area index of 0.7 square centimeters/square meter (cm2/m2), a gradient of 20 millimeters of mercury (mmHg) and left ventricular ejection fraction (LVEF) 70% with normal wall motion. Computed tomography (CT) scan revealed a heavily calcified aortic valve with an area of 1.2cm2 and an Agatston score of 2107. Asked to assess medical necessity of TAVR.

The health care plan acted reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with dyspnea on exertion and syncope.  Following PCI to the left anterior descending artery, symptoms of dyspnea did not improve. Echocardiogram revealed severe pulmonary hypertension and moderate to severe aortic stenosis, with a low gradient (20mmHg) and valve area index of 0.7cm2/m2. These findings are consistent with a diagnosis of low gradient aortic stenosis. Appropriate use criteria for TAVR and surgical aortic valve replacement (SAVR) published by the American College of Cardiology consider TAVR to be appropriate in patients with severe aortic stenosis with a valve area of <1.1cm2 and indexed AVA [aortic valve area] of <0.7cm2/m2. (Reference 1)

This patient does not meet criteria for severe aortic stenosis based on the data provided in the medical records and does not have severe aortic stenosis. Current European Society of Cardiology guidelines recommend conservative management in low flow, low gradient, severe aortic stenosis. (Reference 2)

Such patients have been demonstrated to have a prognosis similar to patients with moderate AS [aortic stenosis] (Reference 3). In conclusion, this patient suffers from moderate AS. Current echocardiographic findings do not support a diagnosis of severe AS and current guidelines do not support TAVR. In conclusion TAVR is not medically necessary in this case.

The insurer's denial of coverage for transcatheter aortic valve replacement (TAVR) to treat aortic stenosis is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic Pain.
Treatment:  Pain Management (Trigger Point Injections).
The insurer denied the  Pain Management (Trigger Point Injections).
The denial is upheld.

The patient is a female. Per a note she has history of dysuria and myofascial pain, tried physical therapy for the pelvic floor with persistent pain in the pelvic floor muscles. She has tried flexeril, severe banding and pain of the obturator internus, levator and coccygeal muscles

A follow up visit was the same as above.

The request is for trigger point injections with botox for the pelvic floor. The health plan denied coverage for the requested as trigger points were not identified on examination.

No, the requested Trigger Point Injections are not medically necessary.
The use of botox in pelvic floor muscle spasm is encouraging but data from robust trials need to support its continued use in future.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The health plan denied coverage of the trigger point injections because trigger points were not identified on examination. The denial is being appealed because of refractory pelvic floor pain.

The use of botox in pelvic floor muscle spasm is encouraging but data from robust trials need to support its continued use in future. The health plan's denial was reasonable.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and Visits
The insurer denied Braces and Visits.
The determination is overturned.

The patient has an anterior crossbite on tooth 7. She presented with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 30-36 months of orthodontics to address the crowding and crossbite. The treatment was denied due to a lack of medical necessity. At issue is the medical necessity of braces and visits.

The requested treatment is medically necessary.
This patient presented with an anterior crossbite on tooth 7. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3)
If left untreated, the damage that will likely occur to the patients teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, treatment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain; leg pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure.
The denial is overturned.

The patient is a male with chronic low back pain not responsive to conservative management. His treating provider diagnosed him with vertebrogenic low back pain and recommended the Intracept procedure.

The procedure was denied coverage by the health plan due to it being considered experimental/investigational. This denial is being appealed.

Yes, the health plan should cover the Intracept procedure.
All of the medical literature on the Intracept procedure over the past roughly seven years has demonstrated the efficacy and safety of the procedure.  See the references below.

Yes, the Intracept procedure is more beneficial than any standard treatment for the insured's condition or disease.
There is no other interventional treatment for vertebrogenic low back pain other than the Intracept procedure in this patient's case. Candidates for the procedure have failed conservative management (rest/activity modification, medication management, physical therapy) and have MRI (magnetic resonance imaging) finding of Modic changes in one or more lumbar vertebrae.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain; leg pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure.
The denial is upheld.

The patient is a male with low back and leg pain. He has tried Tylenol, NSAIDs (nonsteroidal anti-inflammatory drugs), muscle relaxants, physical therapy, HEP (home exercise program), and a bilateral L4 (fourth lumbar spine) TFESI (Transforaminal Epidural Steroid Injection). MRI (magnetic resonance imaging) of the lumbar spine is significant for multilevel degenerative changes, worse at L4-5 (fourth lumbar spine vertebra  fifth lumbar spine vertebra), where there is a disc herniation, facet arthropathy, ligamentum flavum thickening resulting in severe foraminal and canal stenosis with compression of the cauda equina nerve roots increased vs prior study.

The request for Intracept procedure was denied coverage by the health plan as experimental/investigational. This denial is being appealed.

No, the health plan should not cover the Intracept procedure for this patient.
A service is considered medically appropriate when it meets the accepted standards of medicine and is needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms. There must be peer-reviewed medical literature based on scientific data that shows a treatment is safe and effective for treating or diagnosing a medical condition. It must be necessary to meet patients basic health needs and it must be correct for the diagnosis.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings.

The patient does not meet inclusion and exclusion criteria in the current published studies. As such, the Health plan should not cover the Intracept procedure for this patient, as its efficacy and safety is unknown.

No, the Intracept procedure is not more beneficial than any standard treatment for the insured's condition or disease.
Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on type 1 or type 2 Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. The patient does not meet inclusion and exclusion criteria in the current published studies. The requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Stelara 90 mg every 4 weeks
The insurer denied Stelara 90 mg every 4 weeks.
The determination is overturned.


The patient has ulcerative colitis (pancolitis) complicated by stricture and gastrointestinal bleeding requiring transfusion. She has failed mesalamine, Humira, high-dose Remicade, and Entyvio. She started Stelara and was on Stelara 90 milligrams (mg) every 4 weeks. A colonoscopy with biopsies showed extensive pseudopolyps, ulcerations, and erythema; biopsies showed mildly active chronic colitis. Her disease is now well-controlled on Stelara 90 mg every 4 weeks. At issue is the medical necessity of Stelara 90 mg every 4 weeks for the treatment of ulcerative colitis.

Yes, the Stelara 90 mg every 4 weeks is medically necessary. The current medical literature supports the request for Stelara 90 mg every 4 weeks. The patient has failed conventional therapy including Remicade, Humira, and Entyvio, which are recommended for the treatment of ulcerative colitis; she then had improvement on Stelara [1-3]. Stelara has shown efficacy for the treatment of ulcerative colitis in a Phase III trial, UNIFI [1,4]. This trial demonstrated that a single intravenous dose of Stelara induced clinical remission in a significantly greater proportion of patients than placebo did, as measured by both clinical response and endoscopic response; this result was attained in a patient population which was 50% biologic-refractory. Recent studies have demonstrated that Stelara 90 mg every 4 weeks is safe and well-tolerated for the treatment of inflammatory bowel disease, with recovery of effectiveness in patients with active disease [5-7].
A recent study showed that 43% (percent) of ulcerative colitis patients on Stelara required dose escalation, and over 50% of those with dose escalation achieved corticosteroid-free remission, and long-term improvement in endoscopic inflammation [8]. In this case, the patient has moderate to severe ulcerative colitis, has failed multiple alternatives, and has some disease activity even while on Stelara every 4 weeks (demonstrated on colonoscopy with biopsies). Therefore, a decrease of the current Stelara dose (90 mg every 4 weeks) or a change to another medication may be ineffective, and may result in complications such as toxic megacolon, dysplasia leading to colorectal cancer, ulcerative colitis flare, hospitalization, need for surgery, or other complications. For all of these reasons, the request to continue Stelara 90 mg every 4 weeks is as medically necessary for the treatment of this patient's ulcerative colitis.