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

Diagnosis: Dental Problems (skeletal class II malocclusion, retruded mandible, maxillary spacing and mandibular crowding and excessive overjet)
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 upheld. 

This is a female patient who was evaluated for orthodontic treatment. The orthodontist recommended comprehensive orthodontics due to skeletal class II malocclusion, retruded mandible, maxillary spacing and mandibular crowding and excessive overjet. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index and has chosen the automatically qualifying condition of overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater than 3.5mm with reported masticatory/speech difficulties to support orthodontic necessity. 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 on the HLD index.

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, the 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 overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. 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 attaining 14 points (i.e., 9 points overjet, 3 points overbite, 2 points labiolingual spread).
 
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 visits x 12 is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental or Orthodontic Procedure. 
The insurer denied white glass with gold crown tooth # 2. 
The denial is upheld.

The patient is a male who presented to the office of his dental provider for evaluation and treatment of tooth #2. Provided for review are previous letters of appeal and denial, multiple radiographic images, two pages of American Dental Association (ADA) claim forms, and health plan documents.
The subject under review is the medical necessity for the white glass with grown crown for tooth #2. Previous denials have been on the basis that there is no decay under the current crown.

The health plan's determination is upheld in whole.

As there is no radiographic evidence of decay, no clinical documentation of decay, nor any other rationale offered for the replacement of the current restoration, the service of D2752 white glass with gold crown for tooth #2 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neurogenic cough secondary to vagal neuropathy
Treatment: Procedure code 64408 x 1- superior laryngeal nerve block
The insurer denied coverage for procedure code 64408 x 1- superior laryngeal nerve block.
The denial is overturned. 

This is a female patient with a history of hyperthyroidism on levothyroxine. The patient was diagnosed as having neurogenic cough secondary to vagal neuropathy. She had used various medications over several years but had no relief from her cough. The patient underwent 2 superior laryngeal nerve blocks. According to the patient's medical records, she had approximately 1 month of significant improvement with the superior laryngeal nerve blocks; and she continued amitriptyline nightly. 

Peer reviewed literature is consistent in reporting efficacy of superior laryngeal nerve blocks for patients with the diagnosis of neurogenic cough secondary to vagal neuropathy when medical therapy has failed. A 2020 systemic review and meta-analysis of the various interventions for neurogenic cough secondary to vagal neuropathy concluded that "procedural therapy should be considered in the armamentarium of neurogenic cough treatments, particularly in patients refractory to, or intolerant of, the side effects of medical therapy" (Wamkpah NS, Peterson AM, Lee JJ, et al., 2020).

The health plan did not act reasonably nor with sound medical judgment nor in the best interest of the patient. Peer-reviewed literature substantiates the efficacy of the use of superior laryngeal nerve blocks for patients with the diagnosis of neurogenic cough secondary to vagal neuropathy when medical therapy has failed. This was the case of the patient who for number of years tried conservative therapy and only found relief with the 2 nerve block procedures.

The denial should be overturned as the superior laryngeal nerve blocks were indicated and efficacious for the patient.

The carrier's denial of the requested coverage for procedure code 64408 x 1- superior laryngeal nerve block is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Herniated Nucleus Pulposus
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She presented to hospital and underwent L4-5 (fourth lumbar spine vertebra - fifth lumbar spine vertebra) discectomy.  

The patient was admitted to the med-surgical floor and was treated with IV (intravenous) fluids, oxycodone, IV Dilaudid and IV Zofran. The patient was seen post-operatively and was noted to have complete resolution of her preoperative leg pain, and incisional pain was well-controlled.

The patient was seen by physical therapy the following day and discharged home.

No, the inpatient admission was not medically necessary.

This was a young and healthy patient that underwent an uncomplicated lumbar discectomy surgery. She was noted to be comfortable a few hours after surgery. There was no indication for admission. This type of surgery is typically done as an outpatient procedure. 

It is better to get patients out of the hospital unless there is a medical benefit or reason for them staying longer. Studies have shown lower complication rates in patients that go home the same day after a lumbar discectomy. 

Therefore, as there was no indication for admission, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe obstructive sleep apnea.  

Treatment: A laboratory based continuous positive airway pressure (CPAP) titration, code 95811 (Polysomnography with CPAP).  

The insurer denied coverage for the laboratory based CPAP titration, code 95811 (Polysomnography with CPAP).  

The denial is overturned.  

This is a female patient with a documented 2 year history of severe obstructive sleep apnea.  Her Apnea Hypopnea Index (AIH) has been determined as 37.  She has had an extensive trial of automated continuous positive airway pressure (CPAP). The patient stated that her apnea was worsened by heartburn.  She was experiencing difficulty maintaining sleep, nasal congestion, snoring reported both by herself and others and others witnessed apnea irregular nighttime breathing. The automated CPAP was not providing the efficacy which was needed by the patient. She now requires an in-house titration study for possible conversion to CPAP or bi-level positive airway pressure (Bi-PAP) and possible addition of appropriate sleep medications.  

Peer-reviewed literature documents that automated CPAP is not sufficient or efficacious in many patients. Literature notes that for more detailed and complex evaluations and interventions such as bi-level positive airway pressure the automated system is not recommended.  

The health care plan acted neither reasonably nor with sound medical judgment in the best interest of the patient. The patient had failed utilization of automated CPAP which is well documented in peer-reviewed literature and is not recommended for more complex interventions and diagnoses.  Due to the failure of automated CPAP and the persistent need for effective intervention there should be the at home laboratory-based CPAP titration.  

The coverage for a laboratory based CPAP titration, code 95811 (Polysomnography with CPAP) is medically necessary for this patient as automated CPAP failed to provide efficacious intervention.  

The denial of coverage for the laboratory-based CPAP titration, code 95811 (Polysomnography with CPAP) should be overturned as the automated CPAP was unable to properly take care of the patient who has severe obstructive sleep apnea.  

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

The carrier's denial of coverage for a laboratory based CPAP titration, code 95811 (Polysomnography with CPAP) is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with a history of alcohol abuse, hypertension, gastritis, and recurrent hypokalemia.  She was directed to the emergency department after outpatient labs demonstrated a potassium of 2.2.  It was noted that the patient had been noncompliant with potassium supplementation.  The patient noted decreased oral intake, diarrhea, and muscle cramps.  

The patient was afebrile; the blood pressure was 160/23; the pulse was 70.  Labs at the hospital were notable for a bicarbonate 40, potassium 2.2, creatinine 0.6, and sodium 142.  The patient was admitted to telemetry where intravenous and oral potassium, and intravenous magnesium, were administered.  Oral antihypertensive agents were provided.  The patient left the hospital against medical advice.

No, the proposed inpatient admission was not medically necessary.

The patient had hypokalemia with muscle cramping.  However, there was no muscle weakness on examination.  The admitting physician did not comment on the electrocardiogram, and there was no evidence of ventricular arrhythmia.  The patient was hemodynamically stable and afebrile.  Although the blood pressure was elevated, there was no documentation of hypertensive emergency.  Intravenous antihypertensive agents were not administered; the patient's home antihypertensive regimen was ordered.  There was no evidence of alcohol withdrawal or profuse diarrhea.  In addition, the patient did not fail observation care treatment for hypokalemia.  In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the member in making this determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drug (Skyrizi). 

The health plan denied the requested prescription drug. The health plan's determination is upheld. 

The patient is a male with moderate to severe psoriasis (15% body surface area involvement) of the hands, fingers, elbows, scalp, and face. There is possible toenail involvement but no joint involvement. The patient has tried and failed topical Triamcinolone, Clobetasol, and Halobetasol. The patient has tried phototherapy for years without sufficient improvement. 

The medical necessity of Skyrizi is under review. 

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

No. The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate or alternative oral therapies. 

Skyrizi is being prescribed out of patient and/or provider convenience or preference rather than true medical necessity. First-line systemic therapies that are medically indicated and appropriate for this patient have not yet been utilized, so that the requested Skyrizi is not medically necessary. 

Modern dermatology literature [1-4]supports the use of the preferred medications as similarly efficacious to the requested Skyrizi, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend the use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Skyrizi is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Cancer/Breast Cancer
Pharmacy/Prescription Drugs 
Diagnosis: Breast Cancer
Treatment: Pharmacy/Prescription Drugs (Pembrolizumab)
The health plan denied the requested prescription drug. The health plan's determination is upheld.

This patient is a female with locally advanced triple negative breast cancer. Records are conflicting, but it appears the patient is receiving neoadjuvant chemotherapy. The patient appears to be receiving Carboplatin. She may also be receiving Taxol (or Pemetrexed depending on the documentation). Keytruda has been recommended in addition to cytotoxic therapy and is under review.

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

No. There is a paucity of data demonstrating a benefit in outcomes for patients receiving neoadjuvant Pembrolizumab in this clinical scenario. Although preliminary data is promising, an overall survival benefit has not been demonstrated and it is not yet clear if there is a disease-free survival benefit. To date neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate recommend its use outside the setting of a clinical trial. There are several active clinical trials evaluating the use of this agent in this setting including, but not limited to, NCT03289819, NCT04373031, and NCT03639948. Lacking definitive outcomes data, the use of Pembrolizumab in the neoadjuvant setting does not meet criteria for medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Disorder.
Treatment:  Braces and Monthly Visits.

The insurer denied Braces and Monthly Visits.  The determination is upheld.

The patient has maxillary and mandibular crowding and many unerupted permanent teeth.  The orthodontist noted in the diagnosis that tooth number (#) 22 is impacted.  The patient is treatment planned for 36-42 months of comprehensive orthodontics with canine exposure and ligation.  At issue is the medical necessity of braces and monthly visits.

Orthodontic treatment is not medically necessary for the patient at this time.  He is in the process of losing his remaining primary teeth, as they are replaced with permanent teeth.  Research indicates the following risk factors for impacted canines in patients over 10 years of age (2):  1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side (The patient does not have this, as shown in the panoramic radiograph), 2) The canines cannot be palpated, and occlusal development is advanced (occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption), 3) The lateral incisor is proclined and tipped distally (Photographic evidence does not indicate proclined lateral incisors), and 4) On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided).

While that study shows risk factors for impacted maxillary canines, there is nothing in this panoramic radiograph to suggest that tooth #22 will be unable to erupt.  Studies show that impacted mandibular canines are rare (3), and none of the records support a diagnosis requiring treatment at this time.  The patient does have maxillary and mandibular crowding; however, the patient does not exhibit any of the criteria to suspect that the canine is impacted.  Therefore, orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-Amputation
Treatment: Skilled Nursing Facility
The health plan denied the Continued Stay at a Skilled Nursing Facility as not medically necessary. 
The reviewer upholds the health plan determination in whole. 

The patient has a past medical history of type 2 diabetes mellitus on insulin, coronary artery disease (CAD), status/post (s/p) coronary artery bypass graft (CABG), status/post (s/p) bioprosthetic aortic valve replacement, chronic kidney disease (CKD) Stage 3, peripheral arterial disease (PAD) status/post (s/p) angioplasty and stents, who was admitted to the hospital and had a right below knee amputation (BKA) for right foot diabetic foot ulcer, osteomyelitis and gangrene. Patient was subsequently discharged to a Skilled Nursing Facility (SNF) for rehabilitation. Patient had very slow progress to achieve improvement in mobility, transfers, and independence due to stump pain issues, decreased muscle strength, left heel wound and poor intolerance to rehab.

The requested continued health service/ treatment of continued stay at the SNF was not medically necessary. There was no evidence that there were active co-morbidities (for example, chronic obstructive pulmonary disease (COPD), dialysis, cerebrovascular accident (CVA) or congestive heart failure (CHF)) that would complicate transfer training, wound care, and stump education, which would warrant continued stay at the SNF. The patient already had 14 days for rehab. This appeared reasonably sufficient to complete transfer training, wound care, and stump education.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mental Health. 
Treatment: Home Health Care. 
The insurer denied Consumer Directed Personal Assistance Services for medical necessity. 
The denial was upheld. 

This patient is a female who was born at 25 weeks gestation. She has a history of a Neonatal Intensive-Care Unit (NICU) stay with diagnoses of retinopathy of prematurity (ROP), hydronephrosis, status/post (s/p) bilateral inguinal hernia repair, chronic lung disease, oropharyngeal dysphagia, tracheomalacia, head mass, and developmental delays. Her medications include diuril, spironolactone, famotidine, and lansoprazole. She receives physical therapy services through Early Intervention (EI). Her mother additionally reports home use of 1/4 liter (L) of oxygen as needed for shortness of breath. She also takes thickened feeds (formula with added baby cereal) due to silent aspiration episodes.
The NICU records are provided, in addition to a summary of her stay. In addition, there is a physical therapy note from Early Intervention program  as well as an EI evaluation done via telehealth.
At issue is whether Consumer Directed Personal Assistance Services are medically necessary.

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

The Consumer Directed Personal Assistance Services are not medically necessary for this patient.
This is a former preemie who has chronic lung disease due to prematurity. She takes oral medications daily for this condition and is reported to use intermittent oxygen as needed for shortness of breath episodes. She also takes thickened feeds (formula with baby cereal) due to silent aspiration of thin liquids, though does take all nutrition orally. She also receives physical therapy through Early Intervention program services.
Based on the infant's current age and medical condition, the patient's needs can be met by parents and caregivers and do not require home health services. She does not have a feeding tube, tracheostomy/ventilator, intravenous (IV) needs, or other care or monitoring that requires care above that necessary or expected for an infant. Given the age of this patient, this infant has a reliance on adults for all activities of daily living.  However, there are no extraordinary needs which would require special care for activities of daily living beyond routine care for an infant.
Therefore, the Consumer Directed Personal Assistance Services are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Knee pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female with worsening right knee pain.  Her past medical history was significant for hypertension, hyperlipidemia, obesity (BMI [body mass index] 34.66) and diabetes.  She was diagnosed with osteoarthritis and had failed conservative treatment.  She was admitted to hospital for an elective right total knee replacement.  The patient had a varus deformity, crepitus and painful motion.  Her x-ray report was that of bone on bone in medial compartment. 

The patient's surgery was non-complicated with EBL (estimated blood loss) of 100 ml (milliliters).  The tourniquet time was 51 minutes. 

The patient's post-surgical course was non-complicated.  She was able to walk with supervision on POD (postoperative day) #1.  She was discharged.

No, the Inpatient admission was not medically necessary.

The medical record demonstrates a non-complicated post-surgical course.  The patient underwent an arthroplasty with EBL (estimated blood loss) of 100 cc (cubic centimeters) and tourniquet time 51 minutes.  The blood loss was extremely low.  The tourniquet time was also in the low range. 

The patient had no problems with her wound.  Her vital signs were stable.  She had received spinal anesthesia with saphenous nerve block, i.e. (id est), analgesia obtained.  She was able to be mobilized on a timely basis and had completed PT (physical therapy) services.  She did not require treatment for an underlying medical condition. 

These findings were consistent with the previous determination, i.e. (id est), no bleeding, infection, fever nor severe problems.  There were no extenuating circumstances to require admission. 

These findings do not substantiate the level of care and length of stay as provided.  A lower level of care would have been appropriate.