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

Diagnosis: Malocclusion
Treatment: Braces
The insurer denied coverage for braces
The denial is upheld
 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radio graph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, open bite, and anterior crowding among other findings and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 26 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 12 points on the HLD index. 

Upon review of the submitted documentation 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, 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 Labiolingual 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 12 points on the HLD index (2 overjet, 8 open bite, 2 labiolingual spread) which is below the threshold of 26 points to support 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. 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 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 braces (comprehensive orthodontic treatment) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 Braces, D8670 Monthly Visit x12
The insurer denied: D8080 Braces, D8670 Monthly Visit x12
The denial is upheld.

The patient is an adolescent female. The case is a standard New York State appeal to review the medical necessity of proposed comprehensive orthodontic treatment of a pediatric dental patient with a malocclusion. The case was previously denied coverage by the health plan as not medically necessary and is now appealed with the claim that the previous review did not consider the excessive overjet and associated lip incompetence.

The requested braces and monthly visits are not medically necessary.

The case is a standard New York State appeal to review the medical necessity of the requested comprehensive orthodontic treatment of a pediatric dental patient with a malocclusion. The case was previously denied coverage by the health plan as not medically necessary and is now appealed with the claim that the previous review did not consider the excessive overjet and associated lip incompetence.
The patient is an adolescent female with a maxillary overbite malocclusion, without evidence of trauma from occlusion to the palate. There is no speech or swallow pathology report. Coverage is to be considered for an overjet of 9 or more mm (millimeters), with associated speech / swallow pathology. This patient has an overjet of 7-8 mm (millimeters), without any enclosed speech/pathology report. To qualify, the request requires an HLD (Handicapping Labio-Lingual Deviation) report score of 26 or greater. This patient has an HLD (Handicapping Labio-Lingual Deviation) score of 11.
Therefore, given the above, the requested braces and monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease.
Treatment: Stelara.
The insurer denied Stelara. 
The health plan's determination is upheld.

This patient is a male with a history of Crohn's disease. He tried and failed infliximab monotherapy. Under review is the use of Stelara in addition to infliximab (dual biologic therapy).

Stelara is not medically necessary for this patient. Dual therapy with Stelara and infliximab is not medically necessary. There is no sufficient scientific evidence supporting the concurrent use of Stelara and infliximab in treating pediatric Crohn's disease. The available literature is mainly from case reports and does not allow a well supported conclusion regarding the long term safety or efficacy of this combination. The clinical practice guidelines have not yet adopted concurrent use of biologics in treating pediatric Crohn's disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia.

Treatment: Venofer, procedure code J1756.

The insurer denied coverage for Venofer, procedure code J1756.

The denial is upheld.
 

This is a pregnant female who has been diagnosed with iron deficiency anemia. It is noted the patient has tried and failed oral iron. There are no labs for iron provided for review. The patient's hemoglobin is normal.

"Iron deficiency and iron-deficiency anemia are associated with increased morbidity and mortality in a wide range of conditions. In many patient populations, this can be treated effectively with oral iron supplementation; but in patients who are unable to take or who do not respond to oral iron therapy, intravenous iron administration is recommended. Furthermore, in certain conditions, such as end-stage kidney disease, chronic heart failure, and inflammatory bowel disease, intravenous iron administration has become first-line treatment. One of the first available intravenous iron preparations is iron sucrose (Venofer), a nanomedicine that has been used clinically since 1949. Treatment with iron sucrose is particularly beneficial owing to its ability to rapidly increase hemoglobin, ferritin, and transferrin saturation levels, with an acceptable safety profile." (Macdougall et al., 2020).

"Oral iron-replacement therapy is the mainstay of treatment for iron-deficiency anemia, but it is often poorly tolerated or ineffective. Hemoglobin response at day 14 of oral iron may be useful in assessing whether and when to transition patients from oral to intravenous (IV) iron. Hemoglobin responses less than (&lt;) 1.0 grams per deciliter (g/dL) at day 14 of oral iron identify subjects with iron-deficiency anemia who should be transitioned to IV iron supplementation." (Okam et al., 2017).

The proposed use of Venofer, procedure code J1756 is not necessary. There is no submitted evidence supporting iron deficiency such as transferrin saturation (TSAT) or ferritin to support iron deficiency. Intravenous (IV) iron is not indicated unless iron deficiency is documented.

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 Venofer, procedure code J1756 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic Procedure

Diagnosis: Dental Problems- Teeth Spacing Problem
Treatment: Dental/Orthodontic Procedure-Orthodontics
The health plan denied the Orthodontic treatment as not medically necessary. The reviewer has overturned in whole the health plan's determination. 

The patient in question has crossbites of anterior teeth 6 and 7. She presents with a skeletal Class III malocclusion with severe crowding in the maxilla and the mandible. Tooth 14 is completely blocked out to the lingual. The patient has an anterior open bite on teeth 10 and 11. She is treatment planned for 24-36 months of orthodontics to address the crowding, crossbite and open bite, but the treatment was denied due to lack of medical necessity.

The health plan has not acted with sound judgment and in the best interest of the patient. This patient presents with anterior crossbites on teeth 6 and 7, as well as severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular teeth that can lead to periodontal defects.1,2,3 It appears tooth 28 migrating labially in the arch. If left untreated the damage that will likely occur to the patients' teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: atrial fibrillation. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The health plan's determination is upheld. 

The patient is a woman with obstructive sleep apnea, on continuous positive airway pressure (CPAP), hypertension, diabetes, obesity, status/post (s/p) gastric sleeve, congestive heart failure and persistent atrial fibrillation (AF). She presented for an electrophysiologic study and radiofrequency catheter ablation. She underwent successful AF cryoablation. She was monitored on telemetry overnight. 

The inpatient hospital stay is not medically necessary. 
Electrophysiology study and catheter ablation is generally considered an outpatient or observation status procedure. In this case, the patient did not have any active comorbid condition, hemodynamic instability or procedural complication which would necessitate inpatient admission. A lower level of care is appropriate, Multicenter studies have shown the feasibility and safety of same day discharge for patients similar to this patient who are undergoing catheter ablation for atrial fibrillation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction
Treatment: Inpatient Hospital Stay

Diagnosis: Substance Abuse/Addiction-Alcohol Abuse/Addiction
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history (PMH) of alcohol dependence and hypertension (HTN) who was admitted with complaints of (c/o) alcohol withdrawal. Vital signs were notable for tachycardia. Physical examination was notable for no apparent distress (NAD), awake, alert, and oriented to person, place, and time (AAOx3), bilateral hand tremors, and Clinical Institute Withdrawal Assessment (CIWA) 8. Lab work was unremarkable. An electrocardiogram (EKG) showed no acute ischemia. The patient was diagnosed with alcohol withdrawal and treated with intravenous fluids (IVF) and benzodiazepines (BZDs). The patient was discharged in stable condition. What is at issue is the patient's inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o alcohol withdrawal. The patient did not have an acute co-morbid illness requiring inpatient treatment, high risk for delirium tremens, history of withdrawal seizures, long-term intake of large amounts of alcohol, serious psychiatric condition (e.g., suicidal ideation, psychosis), or severe alcohol withdrawal symptoms. This patient was found to have mild alcohol withdrawal with documented CIWAs, treated with BZDs, IVF, and telemetry. These interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Myasthenia gravis. 
Treatment: Mestinon 60mg (milligram) Tablets. 
The insurer denied Mestinon 60mg Tablets. 
The determination is overturned. 

The patient has myasthenia gravis. The drug was denied because the patient has not tried and failed pyridostigmine. The provider attests that the patient has tried and failed pyridostigmine in a letter of medical necessity. The determination was appealed.
At issue is the medical necessity of Mestinon 60 milligrams (mg).

The formulary alternative has been ineffective. The only formulary alternative is pyridostigmine. The provider indicates that the patient has tried and failed pyridostigmine in a letter of medical necessity. As such, the medication has been ineffective. The health plan's determination is overturned in whole.
Appeal type: Formulary Exception
Decision: Upheld

Skin Disorders
Pharmacy/Prescription Drugs

Diagnosis: Plaque Psoriasis
Treatment: Sotyktu
The insurer denied the request for Sotyktu.
The health plan's determination is upheld.

The patient is a female with moderate to severe plaque psoriasis affecting up to 20 percent (%) of her body surface area including involvement of the hands and feet. She has previously failed therapy with topical corticosteroids, ultraviolet (UV) phototherapy, and Otezla.

The formulary drugs Stelara, Skyrizi, Tremfya, Enbrel, Cimzia, and Cosentyx have not been ineffective, would not have adverse effects, and would be as effective as the non-formulary drug Sotyktu. The patient has not had trial of other formulary drugs among Humira, Skyrizi, Stelara, Cosentyx, Cimzia, Enbrel, and Tremfya, nor has a contraindication to these other preferred plan alternative formulary drugs. These formulary drugs are Food and Drug Administration (FDA) approved for moderate to severe plaque psoriasis and have shown good efficacy with acceptable safety profiles when used to treat plaque psoriasis.
Review of phase III clinical trial data shows Sotyktu achieving a psoriasis area and severity index (PASI) of 75 in psoriasis patients of 58.4% after 16 weeks of therapy. This is inferior to the PASI 75 rates seen in phase III clinical trials with Humira, Cimzia, Stelara, Cosentyx, Tremfya, and Skyrizi, which show PASI 75 rates between 67% and 91% at their primary endpoints. The patient does not have a clinical reason to not use Humira, Cimzia, Stelara, Cosentyx, Tremfya, or Skyrizi as well. Therefore, Sotyktu has inferior efficacy compared to multiple formulary treatments that are available for the patient to use instead. For the above reasons, the use of Sotyktu is not considered medically appropriate or necessary at this time.

The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: Braces
The insurer denied coverage for braces
The denial is upheld 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that 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 Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen 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 the required handicapping malocclusion medical necessity requirements on the HLD index attaining 13 points on review by internal reviewers.

Upon review of the submitted documentation 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, 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 Labiolingual 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 deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer with a total of 13 points (4 points overjet, 6 points overbite, 3 points labiolingual spread).

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 cited here. 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 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 braces is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute allergic reaction
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient presented to the Emergency Department (ED) for evaluation of acute allergic reaction to a peanut cookie. In the ED the patient had worsening symptoms of throat closing, shortness of breath (SOB) and tongue swelling. The patient was given a epinephrine (epi) pen and symptoms improved. The patient was admitted for acute angioedema symptoms and was treated with Solumedrol, antihistamines and once stable the patient was discharged.

In this case, while he had allergic symptoms, he was hemodynamically stable without severe signs and symptoms. Care and monitoring could have been done at a lower level of care such as observation. Therefore, emergent admission is considered not medically necessary for this patient.

"Food allergy is a pathological, potentially deadly, immune reaction triggered by normally innocuous food protein antigens. The prevalence of food allergies is rising, and the standard of care is not optimal, consisting of food-allergen avoidance and treatment of allergen-induced systemic reactions with adrenaline." (Yu, W. et al. 2016).

"Conclusion: Clinicians should consider secondary immunodeficiencies in the differential diagnosis of a patient with recurrent infections and abnormal immunologic evaluation. The use of biological agents for the treatment of inflammatory conditions and malignancies is an increasingly important cause of secondary immunodeficiency." (Tuano, K. S. et al. 2021).

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 emergent admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This case involves an adult who was admitted to the hospital. The patient had a history of scoliosis, cystic bronchiectasis, polycythemia, asthma, chronic obstructive pulmonary disease, pulmonary hypertension, and was oxygen dependent. The patient complained of severe chest pain that was exacerbated with movement. The patient reported nerve pain in the extremities which was new since a week and a half ago. She reported a productive cough. Her troponin was negative, and the electrocardiogram did not suggest a cardiac cause of pain. Tenderness to palpation of the chest was noted. The patient had seen multiple providers at outside facilities/Emergency department visits with worsening of her symptoms and pain. Vital signs noted a temperature of 99.4 degrees F (Fahrenheit), pulse of 84, respirations of 20, blood pressure of 136/80, and oxygen saturation of 95% on room air. There was a plan to admit the patient due to chest pain with advanced lung disease and electrical pain going down the body. The patient received intravenous morphine, a fentanyl patch, and Toradol. Radiographs were consistent with bronchiectasis. The discharge diagnoses included musculoskeletal chest pain, bronchiectasis, cystic in nature, oxygen dependency, leukocytosis, and depression. The patient was deemed stable for discharge.

Per the cited references, admission to the hospital is recommended for patients with chest pain when there is hemodynamic instability, respiratory distress, when chest pain is indicative of serious diagnosis other than coronary artery disease, or for severe pain that requires acute inpatient management such as when intravenous opioid treatment is needed beyond observation care. In this case, the patient presented to the hospital with complaints of chest pain. There was a plan to admit the patient due to chest pain with advanced lung disease and electrical pain going down the body. The patient received intravenous morphine, fentanyl patch, and Toradol. Radiographs were consistent with bronchiectasis. Discharge diagnoses included musculoskeletal chest pain, bronchiectasis, cystic in nature, oxygen dependency, leukocytosis, and depression. The initial cardiac work-up was unrevealing. However, the patient was noted to have intractable pain that required intravenous pain medication. The patient's pain was insufficiently responsive to nonpharmacologic and nonopioid pharmacologic analgesia. Sufficient pain control was not achieved, and the patient required active adjustment to medications, dose and route. Thus, admission to the inpatient unit was supported.

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 inpatient stay is substantiated.