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

Diagnosis: Hearing Problem/Loss
Treatment: Computed Tomography (CT) of orbits (eyes), sella (bony area behind the eye), or outer, mid, and inner ear without contrast (dye)

The health plan denied: Computed Tomography (CT) of orbits (eyes), sella (bony area behind the eye), or outer, mid, and inner ear without contrast (dye)

The determination is: Overturned.

The patient is a male with a history of bilateral conductive hearing loss as documented on audiogram. His provider requested a computed tomography (CT) scan of the temporal bone to evaluate for otosclerosis as a possible cause.
At issue is the medical necessity of the CT scan of the of orbits (eyes), sella (bony area behind the eye), or outer, mid, and inner ear without contrast (dye).

The health plan's determination of medical necessity is overturned in whole.
Yes, the requested health service/treatment of computed tomography (CT) of orbits (eyes), sella (bony area behind the eye), or outer, mid, and inner ear without contrast (dye) is medically necessary for an appropriate workup for otosclerosis for this patient. The patient has conductive hearing loss of unknown etiology after examining the ears and cleaning cerumen. The next diagnostic step in appropriate evaluation would be to image the middle ear, which can be best accomplished by a CT scan of the temporal bone without contrast.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thrombocytopenia
Treatment: Inpatient Hospital Admission:
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

The patient is a toddler male with review for inpatient hospitalization for a diagnosis of thrombocytopenia. The patient was status post maternal haploidentical stem cell transplant for sickle cell disease complicated by cytomegalovirus (CMV) viremia, hemorrhagic cystitis and non-oliguric acute kidney injury stage III. The patient was admitted for thrombocytopenia work-up after receiving hepatitis A, hepatitis B, meningococcal and influenza vaccines. The patient had a platelet count of 23,000 with a baseline platelet count that was normal and was admitted for further work-up. The patient underwent bone marrow aspiration and biopsy without evidence of acute leukemia or blasts identified.

The proposed inpatient hospital admission was not medically necessary.

The patient was admitted as a toddler male status post maternal haploidentical stem cell transplant for sickle cell disease. The patient had post-transplant complications of cytomegalovirus (CMV) viremia, hemorrhagic cystitis and non-oliguric acute kidney injury. The patient was admitted after having immunizations and developing thrombocytopenia. The patient's platelet count was 23,000 with a normal baseline platelet count. The patient underwent bone marrow aspiration biopsy during the admission.
In this case, acute inpatient admission would not have been considered medically necessary for this patient. On routine blood work, the patient was found to have a platelet count in the 40,000 range and repeated twice with similar results. The patient did not have any clinical history of bruising, bleeding or other complications secondary to this thrombocytopenia. The patient had recently received multiple vaccinations. During the hospitalization the patient did not have any clinical care that required inpatient level of care. The patient did have a pulmonary aspiration biopsy which is an outpatient procedure. The patient was admitted for thrombocytopenic work-up which could have been safely managed at an ambulatory/outpatient level of care. There was no inpatient level of care needs. Indications for acute inpatient level of care would include severe life-threatening bleeding, active mucosal bleeding that not readily controllable, and absolute platelet count less than 10,000. The patient did not have any of these conditions. As such, the patient could have been safely managed at a lower level of care. Observation services would have been appropriate and there was no documentation to support insufficient response to a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes.
Treatment: Diabetic Medical Equipment (DME)/Durable medical equipment (Continuous glucose monitoring device).
The health plan denied the requested Durable medical equipment (Continuous glucose monitoring device) as not medically necessary. 
The health plan's determination is overturned. 

This is a female with type 2 diabetes. She is on insulin injections three times daily. She has difficulty checking her glucose with traditional lancets. Her hemoglobin A1C (HbA1c) was 10.3%.
At issue is the medical necessity for the requested durable medical equipment (continuous glucose monitoring device).

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

The requested continuous glucose monitoring device is medically necessary. This request is for a continuous glucose monitor for a patient with uncontrolled type 2 diabetes. In a randomized controlled trial, Dexcom continuous glucose monitoring was shown to lower hemoglobin A1C in patients with uncontrolled type 2 diabetes on multiple daily insulin injections (adjusted difference in mean change of hemoglobin A1C with use of continuous glucose monitoring, -0.3%. In a second study of 101 patients with type 2 diabetes on two or more injections per day, use of the continuous glucose monitoring system significantly improved hemoglobin A1C levels. The changes in HbA1c were -0.82% vs. -0.33% in the intervention group using the continuous glucose monitoring system and control group, respectively, and 68.6% of the patients in the intervention group using the continuous glucose monitoring system had their HbA1c reduced by 0.5% compared with 30.2% in the control group, and 39.2% had their HbA1c reduced by 1.0% vs. 18.6% in the control group without an increased frequency of hypoglycemia. [1] This patient has uncontrolled type 2 diabetes, and she takes insulin injections three times daily. Her hemoglobin A1C was very elevated at 10.3%. In this clinical situation, as outlined above, the use of continuous glucose monitoring (CGM) has been shown to reduce hyperglycemia. Without CGM, this patient will remain at significant risk of ongoing hyperglycemia which would increase her risk for retinopathy, neuropathy, and nephropathy. 
Therefore, the requested continuous glucose monitoring device is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 braces, D8670 monthly visits and D8680 retainer
The insurer denied coverage for D8080 braces, D8670 monthly visits and D8680 retainer.
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radio graph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, 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 HLD (Handicapping Labio-Lingual Deviation) index as required stating the patient exhibits 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 this required handicapping malocclusion medical necessity requirement on the HLD index attaining a score of 19 points on review by internal reviewers. 

Upon review of the submitted documentation, 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, New York State requires, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-lingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used which utilize 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 conditions of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition is met and support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labio-lingual 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. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 braces, D8670 monthly visits and D8680 retainer is substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Alcohol Withdrawal.
Treatment: Hospital Admission.
The insurer denied the hospital admission.
The health plan's determination is overturned.

The patient is a male who was admitted to the hospital for possible alcohol withdrawal. He has a history of alcohol withdrawal and dyslipidemia. He left against medical advice (AMA) the day after admission. 

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

The requested health service/treatment of hospital was medically necessary for the patient. On presentation the patient had a severe presentation of alcohol withdrawal and was not stable for an alternate level of care. The patient had some nausea and vomiting with alcohol use. He requested detox. His last drink was at 3pm. The patient stated that he felt better and left against medical advice. He was started on Thiamine and Folic acid. He was also started on Proton-pump inhibitors (PPI's). He had some nausea and tremors. He left against medical advice the day after admission and was stable at discharge.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion 

Treatment: D8080 braces and D8670 monthly visits x 12

The insurer denied coverage for D8080 braces and D8670 monthly visits x 12

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crossbite among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 13 points by internal reviewers when 26 points are required for approval. 

Upon review of the submitted documentation (study models were not provided for review) 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, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the Handicapping Labio-lingual 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labio-lingual 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. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 braces and D8670 monthly visits x 12 is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Proton beam therapy. 

The insurer denied proton beam therapy. The health plan's determination is upheld. 

This patient is a male with a Thymoma post resection. Radiation therapy is recommended to this region to decrease its risk of recurrence and proton beam approach is requested. The request is for proton beam radiation therapy. 

No, the proposed health service or treatment of proton beam therapy is not likely to be more beneficial than any standard treatment for the insured's life threatening or disabling condition or disease. 

The health plan's determination is upheld. Based on the provided clinical information and the provided Aetna CPB 0270 on proton beam radiotherapy, the requested proton beam therapy is considered not medically necessary. There is a lack of any significant clinical trials published in peer reviewed journals supporting the benefits and safety of proton radiation over conventional standard of care photon beam radiation therapy with intensity modulated radiation therapy (IMRT). In this clinical scenario only case controlled comparison plans were provided, not a comparison of the actual patient and his unique anatomy and tumor location. This treatment is also not supported by National Comprehensive Cancer Network (NCCN) Guidelines with category 2a support. There are small dosimetric studies that show potential for improved outcomes with decreased side effects. However, additional phase III clinical trials are needed to determine the exact benefits and safety of proton beam radiation therapy for this patient's clinical scenario. The requested proton beam radiation therapy should be denied.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Proton beam therapy. 

The insurer denied proton beam therapy. The health plan's determination is overturned.  

This is a male patient with history of Masaoka stage IIA, World Health Organization (WHO) Type B1 thymoma s/p (status post) resection. He has been recommended to proceed with a course of postoperative radiotherapy to the resection bed. 

The proton beam radiation therapy is likely to be more beneficial than standard photon radiation for the patient's thymoma. The treating provider has supplied a proton/photon plan comparison which reveals that the proton plan is able to significantly minimize the exposure to the patient's heart, great vessels, and coronary vessels. If delivered, the photon radiation plan is expected to lead to a significantly higher risk for cardiac morbidity/mortality. Proton beam radiation is also expected to significantly reduce the patient's risk for radiation-induced secondary malignancy. 
Proton beam radiation therapy for management of thymoma is supported by numerous high quality prospective clinical outcomes reported in the peer reviewed medical literature. The patient's prognosis is very good for long term survival; thus, it is critical to minimize his risk for serious radiation-induced toxicity.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Proton beam therapy. 

The insurer denied proton beam therapy. The health plan's determination is overturned.  

This is the case of a male patient who was diagnosed with stage IIa thymoma. The patient had surgery and was recommended adjuvant radiation therapy (RT). He is being evaluated for Proton beam therapy. 

The proposed Proton Beam Therapy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Proton beam reduces secondary cancers compared to intensity modulated radiation therapy (IMRT). There are several data studies to support this.
The attending provider has provided DVH (dose volume histogram) comparison of Proton beam therapy and intensity modulated radiation therapy (IMRT). The Mean Heart dose from Proton beam is 1009 cgy (centigray) compared to 1676 cgy from IMRT. This is very important for a young patient who has a curable disease. This high dose from IMRT will cause long term cardiac morbidity and mortality for this young patient. This can be avoided from Proton beam. Thus, Proton beam therapy is likely to be more beneficial for this young patient. Proton beam therapy is clinically well tolerated after surgical resection of thymoma and is associated with a significant reduction in dose to critical structures without compromising coverage of the target volume.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrostomy tube drainage
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
Patient with Chronic lung disease and pulmonary hypertension presenting with complaints of gastrostomy tube drainage. Prior gastrostomy (g) tube was removed and since then there had been a chronic granuloma requiring silver nitrate cauterization. The patient was admitted for concern for gastrocutaneous fistula from prior G (gastrostomy) tube site. Lab and Xray were done.  Silver nitrate was applied, and the patient's mom was taught on how to apply triamcinolone cream every 72 hours and sterile dressing was applied. No further drainage noted. The granuloma had been responding well to silver nitrate and topical steroids. Upper gastrointestinal (GI) tests negative for fistula. Pediatric surgery was involved, and they cleared the patient. 

During the time of hospitalization there was no hemodynamic instability and no need for oxygen or airway support. Patient was at baseline mental status. No need for broad spectrum antibiotics and no lab perturbation. Due to the above facts, the patient could be managed in observational status. 

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: low back and bilateral lower extremity pain
Treatment: a lumbar (L)5 - sacral (S)1 anterior lumbar interbody fusion
The insurer denied coverage for 22853, insertion of interbody biomechanical device with integral anterior instrumentation for device anchoring, when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace; 22558, arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar; 20930, allograft, morselized, or placement of osteo-promotive material, for spine surgery only, and related inpatient hospital day.
The denial is upheld. 

The patient is an adult female who presented with a history of Hashimoto's diseases, psoriasis, and degenerative disc disease and back pain. She was seen complaining of low back and bilateral lower extremity pain. It was recommended she undergo a lumbar (L)5 - sacral (S)1 anterior lumbar interbody fusion.

She has no tenderness in the lumbar spine, there is some pain on flexion and extension of the lumbar spine, there is no significant motor weakness, there is Sacral (S)1 radiculopathy on electrodiagnostic studies performed, and there is no instability radiographically. There is no significant disc abnormality which would necessitate a lumbar fusion.      

"Spinal fusion surgery is a commonly performed procedure, both in the United States and around the world. First reported, it was initially performed to inhibit the progress of deformity in patients with Pott's disease. 1 Now, 500,000 arthrodesis are performed in the United States every year, and the rate has been increasing. 2 Spinal fusion is the bony union of two or more vertebral bodies. The goal is to join together consecutive motion segments for the purpose of stabilizing an unstable spine. Common causes of instability include degenerative, traumatic, metastatic, or infectious. Solid arthrodesis is also desired for long-term stability after surgery to correct a spinal deformity, such as sagittal imbalance or scoliosis." (Cruz et al.).

Furthermore, corticosteroid injections, radiofrequency ablative therapy, spinal cord stimulators, kyphoplasty, TENS units, and surgeries such as laminectomy, spinal fusion, or discectomy are possible treatments options as well for refractory cases." (Casiano, V. E. et al.).                                                         

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 22853, insertion of interbody biomechanical device with integral anterior instrumentation for device anchoring, when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace; 22558, arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar; 20930, allograft, morselized, or placement of osteo-promotive material, for spine surgery only, and related inpatient hospital day services is not substantiated.