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

Diagnosis: Malocclusion.
Treatment: Full Braces and Monthly Brace Adjustment Visits.
The insurer denied coverage for Full Braces and Monthly Brace Adjustment Visits.
The denial is overturned.

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, maxillary and mandibular crowding, excessive overjet and deep impinging overbite among other clinical findings. The orthodontist has completed the Handicapping-Labiolingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. 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. The orthodontist is appealing on behalf of the patient. 

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, an HLD index is utilized. 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 met and does support comprehensive orthodontic care as on examination of the intraoral clinical images there is evidence of palatal gingival recession due to direct impingement of the teeth on the gingival soft tissues. In this case, the clinical circumstance does meet insurer and plan criteria to justify 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.  

The clinical circumstance as presented do substantiate medical/dental necessity of orthodontic care.

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

The insurer's denial of coverage for Full Braces and Monthly Brace Adjustment Visits is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post uterine artery embolization

Treatment: full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

The patient has a history of uterine fibroids complicated by menorrhagia status post recent uterine artery embolization who presented 2 days later Emergency Department (ED) for an emergency evaluation due to severe, progressively worsening pelvic pain associated with nausea, recurrent vomiting (approximately 10 episodes), and new inability to tolerate oral intake. 

On initial presentation, the patient had suprapubic tenderness to palpation with voluntary guarding. Laboratory studies were remarkable for leukocytosis and severe microcytic anemia (hemoglobin 6.7 g/dl (grams per deciliter) with MCV (mean corpuscular volume) 52 fl [femtoliters]). Computed tomography (CT) abdomen/pelvis demonstrated enlarged uterus with area of central devascularization and air within the central portion of the uterus consistent with history of uterine artery embolization. In the emergency department, the patient was administered intravenous fluid hydration, intravenous ondansetron, intravenous ketorolac, and levofloxacin, and started on blood transfusion with two units of packed red blood cells 

Following uterine artery embolization, most women experience postembolization syndrome, which consists of pelvic pain and cramping, nausea, vomiting, fever, fatigue, myalgias, malaise, and leukocytosis. These symptoms occur within the first 48 hours of the procedure and gradually improve over seven days. Patients who do not gradually improve should be evaluated for other conditions, such as sepsis.

This patient had symptoms of postembolization syndrome. However, in addition, the patient was severely anemic and met the transfusion guidelines for use of blood components: her hemoglobin was less than 8g/dl, so transfusion was necessary.   Transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home). The need for transfusion is not a reason for admission.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Schizophrenia, dementia.
Treatment:  Skilled Nursing Facility.

The insurer denied the Skilled Nursing Facility.  The denial is overturned.

The patient is an adult female with a complex past medical history including schizophrenia, dementia, and a right lower extremity deep venous thrombosis (DVT) resulting in functional deficits with cognition, mobility, and activities of daily living (ADLs).  She was admitted to a skilled nursing facility (SNF); however, the stay was denied by her health plan for not being medically necessary.

The proposed skilled nursing facility is medically necessary.

The clinical standards of the health plan criteria provided require a patient to require skilled therapy and skilled nursing.  This patient has deficits in mobility and activities of daily living (ADLs) that would benefit from skilled physical therapy and occupational therapy, and she also had significant cognitive deficits that would benefit from occupational therapy and speech therapy.   In addition, the patient has skilled nursing needs, such as daily subcutaneous injections for deep vein thrombosis (DVT) treatments.  Based on that information, the patient meets the health criteria.  Also, the patient's complex past medical and psychiatric history in addition to her functional deficits are too severe to be managed at a lower level of care.

The recommended length of stay for this patient is two weeks, at which point in time a re-evaluation for continued medical necessity should take place.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ruptured Right Tubal Ectopic Pregnancy. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female who presented to the emergency room with severe abdominopelvic pain. A beta human chorionic gonadotropin (BHCG) was positive, and an ultrasound revealed a right ectopic pregnancy and free fluid in the abdomen. The patient underwent a laparoscopic salpingectomy without complications, with a blood loss of 2000 cubic centimeters (cc). She received a blood transfusion. The patient was transferred to the post-anesthesia recovery unit (PACU) and underwent an uneventful recovery, and was transferred with normal vital signs, afebrile with adequate pain control. On postoperative day #1, the patient had normal vital signs, was afebrile, tolerating a normal diet and was taking oral pain medication. She was discharged on postoperative day #1. 

The proposed treatment was not medically necessary. 

The medical records and peer-reviewed medical literature were thoroughly reviewed. A laparoscopic salpingectomy is an invasive procedure which requires postoperative care and monitoring.  The patient had no significant co-morbidities to support an immediate postoperative inpatient admission. She had an uncomplicated laparoscopic salpingectomy. Her immediate postoperative condition revealed stable vital signs. The patient was hemodynamically stable with no severe pain. The patient's postoperative recovery as an inpatient was uncomplicated. There is no evidence in the submitted medical records that the patient's recovery was complicated or that there was existing, indicated co-morbidities to support inpatient admission. 

Laparoscopic salpingectomy is an invasive procedure that requires immediate postoperative care in an acute care setting, and the post anesthesia care unit (PACU) care is within the standard of care for this indication. This procedure also requires postoperative care and monitoring. Therefore, the patient also required postoperative care after the post anesthesia care unit (PACU) discharge. However postoperative care for this procedure does not universally require subsequent acute inpatient care unless the postoperative course is complicated or the patient's co-morbidities are significant enough to support that level of care. The patient is this case does not meet those standards. Therefore, the patient could have been reliably discharged from the recovery room to a unit of a lesser level of care rather than as an acute inpatient admission. Therefore, the services were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 myocardial infarction

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

This adult male presented to the hospital complaining of worsening dyspnea on exertion with inability to walk more than three steps accompanied by diffuse abdominal pain. Past medical history was significant for hypertension and chronic obstructive pulmonary disease. On arrival to the hospital, vital signs were stable (blood pressure 96/54 mmHg [millimeters of mercury], pulse 97 beats per minute). Physical examination revealed no major abnormality. A 12-lead ECG (electrocardiogram) revealed sinus rhythm with no evidence of ischemic ST (interval on ECG) or T (interval on ECG) wave abnormalities. Serum blood testing revealed elevated troponin levels (127 ng/L [nanograms per liter]), elevated Brain type natriuretic peptide (2148 pg/l [picograms per liter]) and elevated creatinine (1.6mg/dl [milligrams per deciliter]). Computed tomography (CT) chest revealed no evidence of pulmonary embolism or aortic dissection. Emphysema and bronchiectasis with severe architectural distortion in the left upper lobe was noted. The patient was admitted to telemetry for evaluation and treatment. Serial high sensitivity troponin levels trended downward. Overnight telemetry monitoring revealed a period of Mobitz II AV (atrioventricular) block prompting cardiology consultation. Echocardiogram demonstrated normal left ventricular function without wall motion abnormalities. The patient was treated for chronic obstructive pulmonary disease (COPD) exacerbation and discharged with pulmonary follow up. 

This patient presented with abdominal pain, dyspnea and an elevated serum troponin level. His pretest probability of coronary artery disease is intermediate (Reference 1). Utilizing the HEART (history, ECG, age, risk factors, troponin) score, he was considered intermediate risk (Reference 2). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati, et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events [myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography, and ischemia work up were warranted prior to discharge. The patient was ultimately diagnosed with COPD exacerbation that likely contributed to a type 2 myocardial infarction (Reference 4). In conclusion, given the patient's presentation and multiple cardiac risk factors, inpatient hospital admission was appropriate. Based on the above, the insurer's denial must be overturned. 

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

The medical necessity for an inpatient hospital admission service is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decay
Treatment: White glass with metal crown-tooth, nerve treatment on bicuspid tooth # (number) 5, and D3320 nerve treatment on bicuspid tooth #5. 
The health plan denied the requested white glass with metal crown-tooth, nerve treatment on bicuspid tooth #5, and D3320 nerve treatment on bicuspid tooth #5. 
The health plan's determination is overturned.

The patient is a female who presents to the office for the treatment of white glass with metal crown-tooth CPT (current procedural terminology) 2751, buildup for tooth # (number) 5 (2954), and D3320 nerve treatment on bicuspid tooth #5. Provided for review is a letter from the provider, radiographic images, and letters of appeal and denial.

At issue is the medical necessity for the requested health service/treatment of white glass with metal crown-tooth, nerve treatment on bicuspid tooth #5, and D3320 nerve treatment on bicuspid tooth #5.

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

Based on the provided documentation, the requested health service/treatment of white glass with metal crown-tooth, nerve treatment on bicuspid tooth #5, and D3320 nerve treatment on bicuspid tooth #5 is medically necessary for this patient. Due to the presence of decay approaching the nerve and the presence of decay, the treatment requested is the only treatment that can address the current condition. Removal of the decay as well as treatment of the affected tooth structure through root canal is the only way to remove the infection and the amount of decay requires a crown as well as buildup to replace the missing tooth structure as well as to allow for proper crown form.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncopal Episode. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult male with no significant past medical history except for arrhythmia in childhood who presented to the emergency department for evaluation of a syncopal episode.  On arrival to the emergency department, the patient was afebrile and hemodynamically stable.  On exam, the patient was awake and alert without any focal neurologic deficits.  His initial laboratory work-up was unremarkable.  Twelve-lead electrocardiogram (EKG) showed sinus bradycardia with sinus arrhythmia.  Chest x-ray did not demonstrate any acute cardiopulmonary abnormalities.  

The patient was admitted to the inpatient unit and was evaluated by cardiology.  A transthoracic echocardiogram was obtained which demonstrated normal biventricular function without significant valvular abnormalities.  His syncopal episode was thought to be vasovagal in nature and therefore the patient was discharged with outpatient follow-up. 

The proposed inpatient hospital admission was not medically necessary. 

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion.  There was no evidence of ischemia or ventricular arrhythmias.  The patient did not have evidence of advanced conduction disease such as complete heart block on his electrocardiogram.  His echocardiogram did not demonstrate any structural cardiac abnormalities.  The patient did not have any evidence of trauma as a result of his syncopal episode.  Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tendon Problem
Treatment: Orthotics - Foot Inserts
The health plan denied the requested foot inserts as not medically necessary.
The health plan's determination is overturned.

The patient is a female who presented to the office with a chief complaint of severe plantar fasciitis. The patient was complaining of pain in both feet, as well as continuous fatigue with ambulation in conventional shoe gear for the past 4 months. The patient complained of pain in her arch. The pain seemed to be getting worse with time and was relieved with less walking. Standing in place also causes pain. On exam, the patient was noted to have severe pes planus with pronation syndrome bilaterally with plantar fasciitis. She was also noted to have a functional limb length discrepancy; however, there were no measurements provided. The patient had pain on palpation to the sinus tarsi and along the course of the posterior tibial tendons. Range of motion causes her pain. She was diagnosed with posterior tibial tendonitis, sinus tarsitis, plantar fasciitis, and flatfoot. The patient has undergone conservative treatment in the form of Achilles tendon stretching, ankle support, rest, ice, compression, elevation (RICE) treatment, over-the-counter (OTC) inserts, anti-inflammatory medications, and physical therapy. The patient is being recommended custom molded orthotics.

At issue is the medical necessity of the requested health service/treatment of foot inserts.

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

The requested health service/treatment of foot inserts is medically necessary for this patient. The patient has documented pain and deformity in her feet. She was diagnosed with plantar fasciitis, posterior tibial tendon dysfunction, and flatfeet. She has exhausted conservative care in the form of stretching, ankle support, RICE treatment, OTC inserts, anti-inflammatory medications, and physical therapy without relief. Based on the submitted documentation, it appears the reason for the denial of the custom molded orthotics was due to a lack of documentation of conservative treatment in the providers notes. However, on review of the documentation, it shows the conservative treatment was tried and failed, including stretching. The next course of treatment would be custom molded orthotics. Thus, the requested health service/treatment of foot inserts is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept Procedure (thermal destruction of intraosseous basivertebral nerve)
The insurer denied: Intracept Procedure (thermal destruction of intraosseous basivertebral nerve)
The denial is upheld.

The patient is an adult male that presented with a history of neck pain, occipital pain as well as pain radiating down the right greater than left arm. The patient has back pain with tightness in the calves. The patient has had stretches, home exercises, and oral medications without lasting relief. The patient's diagnosis includes vertebral genic low back pain and cervical spondylosis with cervical vertebrae five (C5) / cervical vertebrae six (C6) disc degeneration. Per the appeal letter: The patient has a history of chronic low back pain due to degenerative disc disease that resulted in development of vertebrogenic pain identified by degenerative endplate changes Modic on magnetic resonance image (MRI). The patient has had pain for greater than six months and failed for treatments for greater than six months. Previous treatments include medication management, injection, and radiofrequency ablation. It was noted that the magnetic resonance image showed Modic changes at lumbar vertebrae five (L5) and sacral vertebrae one (S1). 

The health plan should not cover the Intracept procedure.

Based on the provided documentation, the requested procedure is not recommended at this time. Although the patient has a history of low back pain, there were no indications of Modic type changes on the MRI (magnetic resonance imaging) provided. Although there was some discogenic degenerative disease, there was no mention of Modic changes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion 
Treatment: D8080 Braces and D8670 monthly visit x (times) 12
The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.
The denial is upheld.

Upon review of the submitted documentation (study models were not provided for review), 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 the HLD 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 34 points to justify orthodontic care. Of note is that the treating provider scored both anterior crowding AND Ectopic eruption. As per the HLD requirements/instructions, the treating provider was to score only one of the two conditions, whichever is most severe. Removing 10 points for anterior crowding results in a score of 24 points based on the treating provider's assessment if the index is completed accurately. This reviewer concurs with the HLD index of the insurer attaining 16 total points (2 overjet, 5 overbite, 5 anterior crowding and 4 labiolingual spread).

Regarding the validity of the HLD 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. 

The decision is to uphold the denial as the clinical circumstance, as presented, does not substantiate the medical/dental necessity of orthodontic care. This treatment request does not meet the accepted criteria for approval.

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for D8080 braces and D8670 monthly visit x (times) 12 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia areata
Treatment: Xeljanz 10 milligrams (mg)
The insurer denied coverage for Xeljanz 10 mg.
The denial is overturned.

This is a pediatric patient with a history remarkable for alopecia areata affecting a significant amount of the scalp. The patient has failed systemic therapy with minoxidil tablet. The patient was given a trial of Xeljanz with significant improvement and no noted side effects. The request is for medical continuation of Xeljanz therapy at pediatric dosing. 

Based on the provided documentation, the patient requires systemic therapy and has exhausted reasonable available options. Xeljanz has been shown to decrease the inflammation leading to hair loss and has been shown safe and effective in the pediatric population based on case reports. The patient has responded favorably to Xeljanz for several months and has not had noticeable side effects. The denial is overturned and the use of Xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment.

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

The medical necessity for Xeljanz 10 milligrams (mg) is substantiated.