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

Diagnosis: Dental Problems (severe overjet and anterior open bite).

Treatment: D8080 braces and D8670 monthly visit.

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

The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including severe overjet, anterior open bite and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 27 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements. 

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care the HLD index is utilized. This index provides 6 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 completes the second portion of the index arriving at 27 points on the HLD index to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 21 points on the HLD index (7 overjet, 12 anterior open bite, and 2 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.

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

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

Based on the above, the medical necessity for D8080 braces and D8670 monthly visit is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Retinal tears, status post laser.

Treatment: The assistant surgeon utilized during the vitrectomy (procedure code 67036-82-68).

The insurer denied coverage for the assistant surgeon utilized during the vitrectomy (procedure code 67036-82-68).

The denial is upheld. 

This is a male patient with a history of retinal tears, status post laser, who underwent retinal surgery (vitrectomy with endolaser in the right eye). A pars plans vitrectomy, removal of the posterior capsular opacity, endorser and air-fluid exchange in the right eye was performed. It was noted that no qualified resident was available to help the surgeon perform scleral depression/indentation for the surgeon to examine and treat the peripheral retina. The ability to visualize and work in the region of the vitreous base during vitrectomy surgery is important.  

An assistant surgeon is required for this procedure to assist with scleral depression (allowing the surgeon to view the peripheral retina). The surgeon cannot perform scleral depression himself while doing the surgery, since his hands are occupied with the actual surgical instruments.

Review of the surgical report indicates that the assistant surgeon is listed as a fellow. As per nationally accepted guidelines (Medicare), a fellow is considered similar to a resident. Thus, billing as an assistant would not be considered appropriate. "For direct graduate medical education (DGME) and indirect medical education (IME) payment purposes, a resident means an intern, resident, or fellow who is formally accepted, enrolled, and participating in an approved medical residency program including programs in osteopathy, dentistry, and podiatry as required to become certified by the appropriate specialty board."

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

The medical necessity for the assistant surgeon utilized during the vitrectomy (procedure code 67036-82-68) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo.
Treatment: Inpatient hospital admission.

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

This female patient has a past medical history of fibroids, sickle cell trait (not disease, confirmed with patient), vertigo, migraines, and a questionable history of hypertension. She was brought in by ambulance from work with complaints of dizziness, nausea/vomiting, and hypertension. She noted everything was spinning. She denied a headache and blurred vision. She presented to the Emergency Department (ED) with subjective complaints of dizziness. She stated "room started spinning" while she was sitting down. She described a feeling of both lightheadedness and dizziness. She had nausea and vomiting. There was no shortness of breath or chest pain. She denied focal weakness. She had a similar episode 3 weeks prior to presentation at the ED. She was a current every-day smoker. She had no abnormal saccades on head impulse test. She had saccades on leftward gaze. Her blood pressure was 148/79. Her pulse was 68. The examination was not classic for either central or peripheral vertigo, and a code stroke was called. The computed tomography (CT) scan was preliminarily negative. Neurology diagnosed the patient as benign paroxysmal positional vertigo (BPPV). She was given intravenous (IV) Ondansetron, IV Meclizine, and Diazepam The physical examination of unidirectional nystagmus and added history of prior episodes supported this. The patient was symptomatically improved, but had persistent symptoms on standing. The Epley maneuver was performed. She was able to sit, but she asked to sit when the provider tried to walk her. The encounter diagnosis was vertigo. The patient was admitted in order to rule out a central cause.

The patient did have dizziness. However, she had a normal focal neurological examination. These findings were consistent with BPPV and she would not have required admission to rule out a central cause. Any further testing to rule out a central cause could have been done on an observation basis. 

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 inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Digestive System
Inpatient Hospital

Diagnosis: Abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male with history of hypertension and diabetes who presented to the hospital with a chief complaint of right lower quadrant abdominal pain that started on the prior evening. There was concern for appendicitis. He denied fevers, chills, nausea, vomiting and diarrhea. Vital signs showed temperature 98.0 Fahrenheit, heart rate 84, blood pressure 145/100, and oxygen saturation 98%. On physical exam, heart was regular, breath sounds were normal, abdomen was firm and tender in the right lower quadrant, and there was no neurologic deficit. Labs showed sodium 136, potassium 4.6, glucose 104, creatinine 1.2, calcium 10.4, white blood cell (WBC) 8.1, hemoglobin 16.1, platelets 251, aspartate aminotransferase (AST) 34, and alanine aminotransferase (ALT) 46. A computed tomography (CT) imaging demonstrated mesenteric/epiploic appendicitis infarction near the cecum and possible infarction of the kidney. The patient was admitted for suspected inflammatory bowel disease/Crohn's disease and abdominal pain. The plan of care included surgery consult, pain management, auto immune serologies, lipid profile, smoking cessation counseling, glycosylated hemoglobin, and no food by mouth. 

The inpatient stay was medically necessary. The patient required vascular surgery and general surgery consultation because of concerns for ischemia and concerns about the increased risk of future ischemic episodes. While he did have improvement in symptoms and no other witnessed acute episodes of ischemia, he was at increased risk and aggressive evaluation was appropriate. This required the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Problems (Class I molars, overjet, overbite, open bite, anterior crowding, ectopic eruption).
Treatment:  D8080 Comprehensive Orthodontic Treatment of Adolescent Dentition.

The insurer denied coverage for D8080 Comprehensive Orthodontic Treatment of Adolescent Dentition.  The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including Class I molars, overjet, overbite, open bite, anterior crowding, ectopic eruption and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 26 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements. 

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care the HLD index is utilized. This index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points on the HLD index to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 8 points on the HLD index (3 overjet, 3 overbite, and 2 labiolingual spread), which is below the threshold of 26 points to support orthodontic care.

D8080 Comprehensive Orthodontic Treatment of Adolescent Dentition is not considered medically necessary for this patient.

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

Based on the above, the medical necessity for D8080 Comprehensive Orthodontic Treatment of Adolescent Dentition is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Prostate Cancer.
Treatment:  High Intensity Focused Ultrasound (HIFU).

The insurer denied coverage for High Intensity Focused Ultrasound (HIFU).  The denial is upheld. 

This male patient has a history of stage T1c prostate cancer, Gleason Grade Group 2, intermediate risk. Prostate specific antigen (PSA) was 6.3.  Treatment options were discussed, and the patient chose to have a High Intensity Focused Ultrasound (HIFU) treatment for his prostate cancer.  

The insurer has denied coverage for HIFU as not medically necessary.  The insurer stated that the requested treatment has not been proven effective for the patient's condition.  

HIFU has been applied for both whole gland/partial gland ablation for prostate cancer.  However, HIFU still lacks FDA approval for treatment of prostate cancer.  American Urological Association (AUA)/ASCO (American Society of Clinical Oncology) guidelines do not endorse HIFU as a treatment option for low risk or intermediate risk prostate cancer.  They state: "Clinicians should inform intermediate-risk prostate cancer patients who are considering focal therapy or high intensity focused ultrasound that these interventions are not standard care options because comparative outcome evidence is lacking."  Similarly, the National Comprehensive Cancer Network (NCCN) indicates that "cryotherapy or other local therapies are not recommended as routine primary therapy for localized prostate cancer due to lack of long-term data comparing these treatments to radiation or radical prostatectomy."

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

The medical necessity is not substantiated.  The carrier's denial of coverage for High Intensity Focused Ultrasound (HIFU), should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems. 
Dental/Orthodontic Procedure. 

Diagnosis: Anterior crossbite. 
Treatment: Comprehensive Orthodontic Treatment. 

The insurer denied Comprehensive Orthodontic Treatment. 
The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 7. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite. 

The Comprehensive Orthodontic Treatment of the Adolescent Dentition (Braces) and Periodic Orthodontic Treatment Visit is medically necessary for this patient. This patient presents 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. If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Taltz
The insurer denied Taltz.
The determination is upheld.

The patient has moderate to severe and generalized psoriasis. The patient has tried and failed topical steroids, oral Soriatane, phototherapy, and the biologic agents Humira, Cosentyx, and Stelara. The patient is doing well on Taltz samples, and Taltz is under review.

The patient has no documented treatment failure with, or true medical contraindication to, either Methotrexate, Otezla, Cimzia, or Tremfya. These agents are of similar efficacy, and have a similar level of adverse effects, as the requested Taltz. These agents are all appropriate for this patient's particular clinical scenario and past treatment history. 

Therefore, consistent with the current medical literature, Taltz would not be more effective than the formulary alternatives.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Palmoplantar psoriasis.

Treatment: Formulary Exception for Taltz autoinjector (3 pack) 80 milligrams per milliliter (mg/mL) AUTO INJECT. 

The insurer denied coverage for Formulary Exception for Taltz autoinjector (3 pack) 80 mg/mL AUTO INJECT. 

The denial is upheld. 

This is a female patient who has palmoplantar psoriasis and failed topical steroids.  The patient is requesting Taltz but was denied by the insurer because she has not failed disease-modifying anti-rheumatic drugs (DMARDS) or preferred agents.

Sanchez et al. (2017) states "Adalimumab-humira, guselkumab-Tremfya, ixekizumab-Taltz, secukinumab-Cosentyx, and ustekinumab-Stelara all showed > 80% efficacy for the treatment of hyperkeratotic PP [palmoplantar psoriasis], while infliximab and ustekinumab showed moderate efficacy for the treatment of pustular PP, and infliximab was the most efficacious treatment for PPP [palmoplantar pustulosis]."  Note that many of agents on the formulary are noted to be have similar efficacy as Taltz.

Choi et al. (2017) states "Psoriasis is a chronic inflammatory disease.  In the treatment of psoriasis, cyclosporine is commonly prescribed systemic agents.  However, long-term use of cyclosporine is not recommended because of side effects such as nephrotoxicity or hypertension."                                                       

The patient has no indication in the notes they would suffer from an adverse reaction to preferred agents. Based on the records provided for review systemic agents have not been trialed.     

There is insufficient medical literature to support the requested medication, Taltz over the available formulary drugs.  The preferred agents are standard of care treatments for this patient's clinical scenario.

The carrier's denial of the Request for Formulary Exception for Taltz autoinjector (3 pack) 80 milligrams per milliliter (mg/mL) AUTO INJECT is upheld.
Appeal type: Medical necessity
Decision: Overturned

Respiratory
Inpatient Hospital

Diagnosis: pneumonia
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a girl who presented with cough, shortness of breath, and decreased oxygen saturation. She was well until 2 weeks prior to presentation when she developed a cough that was treated with corticosteroids and albuterol. Her symptoms progressed and she was seen in the primary care office and was given albuterol and dexamethasone. However, her cough continued to worsen. She returned to the doctor's office again and was given intravenous (IV) prednisone. The following day she had a fever to 100.5 F and she also developed decreased urine output. She received another albuterol treatment and had an oxygen reading of 88%. She was transported by emergency medical services and received oxygen in transit.

The inpatient hospital admission was medically necessary for this patient.
This is a young girl who presented with progressively worsening cough, shortness of breath, and hypoxemia. She was also drinking less than usual. She was appropriately treated as an outpatient with bronchodilators and corticosteroids, but her symptoms continued to worsen. On the day of presentation, she was hypoxemic and required supplemental oxygen, and had accessory muscle use and tachypnea. She required inpatient admission for intravenous fluids and antibiotics, supplemental oxygen and bronchodilator treatment as needed, and close monitoring with additional treatments as needed.
The decision making at the time of admission for this patient was consistent with her young age, the presence of worsening cough, respiratory distress, and hypoxemia, and the need for intensive treatments including supplemental oxygen, fluids, and antibiotics, with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Cardiac
Inpatient hospital

Diagnosis: Syncope
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned

The patient presented with a chief complaint of syncope. Past history included diabetes, human immunodeficiency virus (HIV), hyperlipidemia, hypertension and coronary artery disease (CAD) status post pacemaker. She reported experiencing a cold sweat before losing consciousness but did not complain of blurry vision or double vision. Vital signs showed temperature 98 Fahrenheit, heart rate 61, respiratory rate 16, and blood pressure 170/91. On physical exam, heart was regular, breath sounds were normal, there were no cranial nerve deficits, and skin was warm and dry. Labs showed white blood cell (WBC) 8.76, hemoglobin 11.9, platelets 291, sodium 139, potassium 3.8, creatinine 1.2, calcium 9.0, magnesium 1.74, and brain (or B-type) natriuretic peptide (BNP) 173. Head computed tomography (CT) was negative for evidence of acute stroke but did show a remote lacunar infarct. There was also evidence of chronic ischemia. The patient was admitted for syncope with concern for seizures versus cerebrovascular accident (CVA) versus acute coronary syndrome (ACS).

The inpatient hospital admission was medically necessary. The patient presented as a relatively complex case of syncope due to her multiple risk factors for both orthostatic hypotension and neurogenic dysfunction, and she needed to be treated and then discontinued on Midodrine. Other antihypertensives also needed to be adjusted. In addition, she required pacemaker interrogation. The intensity of her work up, and the fact that her anti-hypertensive therapy was contributing to syncope increased her complexity.
The patient required consultations with cardiology and neurology and extensive adjustment of her antihypertensive therapy/midodrine. She also had a history of CAD with pacemaker placement. Overall, it was appropriate to admit her to the inpatient level of care due to her complexity and the complexity of her treatment plan.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Fractured and decayed teeth. 
Treatment: Dental Procedures. 

The health plan denied the Dental Procedures. 
The health plan's determination of medical necessity is overturned, in part. 

The patient is a female who presents with fractured and decayed teeth. Crowns are being requested on teeth #7, #8, #9, #10, #12, and #13, and root canal treatment on teeth #12 and #13. 

At issue is the medical necessity of the requested treatment. 

The health plan's determination of medical necessity is overturned, in part. 

According to the submitted radiographs, there is no visible radiographic evidence of large decay or large missing tooth structure on teeth #7 and #8. Teeth #9 and #10 have small horizontal fractures on the incisal edge; however, the fractures are not missing enough tooth structure to warrant the need for crowns. Teeth #12 and #13 appear to have large decay on the distal surface of the teeth that are in close proximity to the pulpal horns. Therefore, root canal treatment for these teeth is warranted in this case. A tooth that is root canal treated has a high chance of fracturing due to loss of tooth structure from the root canal procedure. When a tooth with a root canal fractures, the tooth cannot be saved, and extraction is then needed. Therefore, crowns on teeth #12 and #13 are medically necessary to prevent fracturing of the teeth. 

As such, the request for crowns on teeth #7, #8, #9, and #10 is not medically necessary. However, the request for crowns and root canal nerve treatment on teeth #12 and #13 are medically necessary.