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

Diagnosis: Asthma.

Treatment Symbicort (brand).

The insurer denied coverage for Symbicort (brand).

The denial is upheld.

The appeal is based upon the patient having previously been on Symbicort but developed an itchy facial rash when he used the generic version of Symbicort. The doctor wrote in an appeal form that "powder forms giving patient allergic reaction" "when by insurance requests switched for generic budesonide/formoterol developed severe allergic reaction requiring ER [emergency room] visit". An emergency department (ED) note states the patient had a facial rash for 10 days and that the patient had "these symptoms" when using generic Symbicort in the past. Cat exposure and increased chest symptoms were also described. The skin examination was normal. The pharmacy log shows many prescriptions/refills for budesonide/fomoterol months ago. Past medical history was positive for asthma, hip pain, prior total hip replacement (THR), seasonal allergies, heavy weight and elevated liver function tests (LFT). Medications listed include budesonide/fomoterol. The ED visit and rash were recounted, but the skin examination was described as only having dermatophytosis and being dry. Wheezing was noted. No mention of intolerance or prior reactions to powder asthma sprays was described. 

The plan states that covered asthma  long-acting beta agonists (LABA) with inhaled corticosteroids (ICS) include Wilexa, generic Symbicort and generic fluticasone/salmeterol powder. 

Currently generic Symbicort is created by Astra Zeneca although other companies are planning to make their formulations. There are no differences between brand Symbicort and the Astra Zeneca generic except the label.

Thus, there is no reason to expect that the patient would have side effects to generic Symbicort but not to brand Symbicort. There is no documentation that the patient had side effects limiting the use of budesonide/fomoterol except for the complaint of rash that was described. There is no mention of intolerance or prior reactions to powder asthma sprays in the progress notes.

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

The insurer's denial of coverage for Symbicort (brand) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary Ciliary Dyskinesia (PCD)

Treatment: genetic testing (screening for aneuploidy)

The insurer denied coverage for genetic testing (screening for aneuploidy).

The denial is overturned.

This is the case of a female who, along with her husband, are carriers for primary ciliary dyskinesia (PCD). Genetic testing (screening for aneuploidy) was performed. The insurer has approved the preimplantation genetic testing for monogenic disorders (PGT-M) component of this genetic testing, but not the preimplantation genetic testing for aneuploidy (PGT-A).

Preimplantation genetic testing for PGT-M has been demonstrated to be beneficial since without this testing, there would be a 25% (percent) effected child, 50% carrier state, and 25% noncarrier state.

Preimplantation genetic testing for aneuploidy (PGT-A) has been found to be 98% accurate and to be beneficial in this patient since 50% of these embryos would be expected to be abnormal due to the age effect on aneuploidy rates. Women in their middle adulthood ages have had increased live birth rates when undergoing in vitro fertilization (IVF) when the embryos had PGT-A testing. "At this age and older, preimplantation genetic testing for aneuploidy led to more cumulative births." (1)

In conclusion, PGT-A (the requested service to be covered) has been demonstrated to be more beneficial in such a middle adulthood patient as opposed to not being tested.

In summary, testing for PGT-A as well as the PGT-M procedures would be considered medically necessary treatment for the patient's condition.

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

The insurer's denial of coverage for the genetic testing (screening for aneuploidy) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep impinging overbite with severe soft tissue damage

Treatment: D8080 (braces)

The insurer denied coverage for D8080 (braces).

The denial is overturned.

This is a teen male patient with no documented history. He presented to the Orthodontist's office for an evaluation. X-rays and pictures were taken. Handicapping labio-lingual deviation (HLD) score was 17. The patient had a deep impinging overbite with severe soft tissue damage. He also had an overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. The treating Orthodontist recommended D8080 braces. 

Per An Introduction to Orthodontics, one or more of these dental traits that would have an adverse effect on the longevity of dentition, indicating high need for correction:

1)	Increased Overjet
2)	Increased traumatic Overbites
3)	Anterior crossbites causing decreased periodontal support
4)	Unerupted impacted teeth (where there is danger of pathology)
5)	Crossbites associated with mandibular displacements.

According to the Index of Orthodontic Treatment Need (IOTN), used in Contemporary Orthodontics by Profit a Grade 4 is considered to be in the category of Severe/Need treatment with one of these conditions:

1)	Increased overjet greater than 6 mm, but less than or equal to 9 mm.
2)	Reverse overjet greater than 3.5 mm with no masticatory or speech difficulties
3)	Reverse overjet greater than 1 mm but less than 3.5 mm with recorded masticatory difficulties
4)	Anterior or posterior crossbites with greater than 2 mm discrepancy
5)	Posterior lingual crossbite with no functional occlusal contact
6)	Severe contact point displacements greater than 4 mm
7)	Extreme lateral or anterior open bites greater than 4 mm
8)	Increased and complete overbite with gingival or palatal trauma
9)	Partially erupted teeth, tipped, and impacted against adjacent teeth.

If the overjet is greater than 9 mm, this is an automatic qualifier. In addition, the patient has a severe malocclusion and orthodontics is medically necessary. 

Per the clinical records, the patient shows a high need for orthodontics. The increased overjet indicates a high need for correction.

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

The insurer's denial of coverage for D8080 braces is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque Psoriasis.

Treatment for Otezla 30 milligram tablet.

The insurer denied coverage for Otezla 30 milligram tablet.

The denial is upheld.

The patient is an adult female with biopsy proven psoriasiform dermatitis who has failed numerous topical therapies. There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Otezla for this patient's condition as an accepted standard of practice over alternative therapies. Based on the evidence-based literature, the Otezla (apremilast) tablets are not medically necessary. There is no comparative, controlled studies showing that Otezla has a superior efficacy and safety profile to the formulary alternatives such as phototherapy and methotrexate. 

According to the "national physician specialty society recommendations" for psoriasis- the American Academy of Dermatology Psoriasis Guidelines- and dermatology literature, phototherapy and methotrexate are effective treatments for the management of psoriasis. (1-3) Within the peer-reviewed literature, Racz et al writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks." (4) Mehta et al writes "Ultraviolet (UV) B (type of therapy) phototherapy is most appropriate for patients with >10 % [percent] affected body surface area who have not responded to topical treatments... narrowband (NB)-UVB ...effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile." (5)

Additionally, West et al 2016 conducted a review of eleven comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index [PASI75] at primary endpoint. Thus, methotrexate is an effective first-line treatment for the management of psoriasis. (6) Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Otezla is not necessary. There is no documentation provided that the patient has tried and/or failed phototherapy or methotrexate. The patient also has no true contraindications listed to a preferred treatment modality that would make the use of Otezla medically more appropriate than the other options. 
 
Therefore, the administration of Otezla (7) is not strongly supported for this patient, and Otezla is not medically necessary for this patient based on the current evidence-based medical literature.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient.

The insurer's denial of coverage for Otezla 30 milligram tablet for the treatment of plaque psoriasis is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I, maxillary and mandibular crowding excessive overjet, and deep impinging overbite

Treatment braces (D8080).

The insurer denied coverage for braces (D8080).

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 skeletal Class I, maxillary and mandibular crowding excessive overjet, and deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. 

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, 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. In this case, the clinical circumstance does meet 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. This is confirmed by several studies. 

Each of these peer-reviewed articles concludes that this index is a valid and reliable determined of need for orthodontic care. As this is an accepted methodology, this had been determined to represent an appropriate approach for assessing orthodontic need. 

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

The insurer's denial of coverage for braces (D8080) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-idiopathic short stature .
Treatment: Pharmacy/Prescription Drugs-Humatrope. 
The insurer denied Humatrope. 
The denial is upheld. 

The patient is a male diagnosed with idiopathic short stature (ISS). As reported; he started growth hormone (GH) therapy he went from being below 5th percentile to the 9th percentile. Once the GH therapy was discontinued his height velocity was again stunted and he has regressed to the 6th percentile. His GH stimulation test with arginine and clonidine peaked at 3 and 23.3 respectively. His Insulin-like Growth Factor 1 (IGF1) was 169. Testes were 5 cubic centimeters (cc) bilaterally with Tanner 2 as well as pubic hair. The subject under review is the medical necessity for Humatrope.

No, the requested Humatrope is not medically necessary for this patient. The peer reviewed literature including consensus clinical guidelines, randomized controlled trials are summarized below:
Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2], [3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4], [5], [6], [7], [8], [9].  The patient does not have a pretreatment height less than or equal to -2.25 SD(Standard Deviation). The patient therefore does not meet idiopathic short stature criteria. The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe maxillary crowding, anterior crossbite.
Treatment: D8080 (Braces) and D8670 (Monthly Visit x 12) (Pre-Service).
The insurer denied the D8080 (Braces) and D8670 (Monthly Visit x 12) (Pre-Service).
The denial is overturned. 

The patient is a female with severe crowding and anterior crossbite of two teeth.

Yes, the proposed D8080 (Braces) and D8670 (Monthly Visit x 12) are medically necessary.
When a patient has a crossbite, this means the upper teeth are inside of the lower teeth, which is backwards to what is normal. This will, over time, contribute to trauma and/or breakage of teeth because the teeth are meshing incorrectly. This condition can also contribute to future temporomandibular (TMJ) problems (i.e., pain) because it places extra pressure on the temporomandibular (TMJ) joints which can cause premature breakdown. Orthodontic treatment is needed to correct the crossbite.

This patient has two anterior teeth (#7 and #10) that are in crossbite with gingival (gum) recession. This is an automatic qualifier for treatment. Orthodontic treatment is the only way to correct this. The 12 monthly follow-up visits are medically necessary to monitor tooth movements and for wire and rubber band changes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.

Treatment insertion of braces and adjustment of braces.

The insurer denied coverage for insertion of braces and adjustment of 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 overjet and impacted permanent anteriors. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. 

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, and 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 impacted permanent anteriors where extraction is not indicated. This reviewer finds this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care as #11 appears to be erupting and #6 appears to be in the process of doing so as well. This reviewer concurs with the findings of the insurer of attaining 13 points on the HLD index (7 points overjet, 2 points overbite, 4 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.

Each of the 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 clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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 insertion of braces and adjustment of braces is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior Crossbite with Gingival Attachment Loss.

Treatment D8670 Periodic Orthodontic treatment visit.

The insurer denied coverage for D8670 Periodic Orthodontic treatment visit.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (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 to support orthodontic necessity. 

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, and 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 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 not met as there is no evidence of gingival attachment loss or gingival recession and therefore 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 attaining 20 points (3 overjet, 4 overbite, 10 anterior crowding, 3 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.

Each of the 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 clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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 D8670 Periodic Orthodontic treatment visit is upheld. Medical necessity is not substantiated.