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

Diagnosis:  Asthma.
Treatment:  Dupixent.

The insurer denied Dupixent.  The health plan's determination is upheld. 

The patient is a female with asthma.  Per the health plan, Dupixent was denied, since the patient did not meet criteria for requested medication.  She has not used a medium to high dose inhaled corticosteroid agent and accommodation with leukotriene receptor antagonist or Spiriva for at least 3 months trial.  The suggested medications include budesonide/formoterol or fluticasone/salmeterol.  Per the provider, the patient has been under his care for asthma.  She has eosinophilia conformed on recent blood work.  She does not tolerate the dry powder inhalers like Advair because it causes thrush.  The patient has had multiple asthma exacerbations in the last year and uses her rescue inhaler frequently.

Dupilumab (Dupixent) is not medically necessary for this patient at this, based on the following:

Although this patient is reported to have severe persistent asthma, there is no documentation in the pharmacy records that she has been compliant with high-dose inhaled corticosteroids, and this medication was most recently refilled.  Prior to that there have been several months or longer since the medication was filled.

The patient needs to demonstrate compliance with high-dose inhaled corticosteroids and long-acting beta agonist, together with LTRA (Leukotriene receptor antagonists) (montelukast) for at least 3 months.

There should be documented evidence of poor asthma control - frequent use of rescue inhaler, uncontrolled symptoms, frequent exacerbations.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior open bite, severe crowding in her upper jaw, upper left permanent canine erupting ectopically (out of place). 
Treatment: Braces. 

The insurer denied the braces. The denial is overturned. 

The patient is a female. The request is orthodontic benefits. 

Yes, the proposed braces are medically necessary. 

Aside from the patient having a handicapping index score of 26 (which is high enough for benefits), she also has and anterior open bite, severe crowding in her upper jaw, and an upper left permanent canine erupting ectopically (out of place). Due to the anterior open bite and the upper left canine being totally out of place, the patient has no ability to have "canine guidance" during the chewing cycle. This means that all her teeth, when she chews, will bang into each other in an uncoordinated fashion and eventually cause trauma and/or breakage to some teeth. This needs to be corrected with orthodontic treatment. For all these reasons, this case has medical necessity for dental benefits.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteopenia.
Treatment: Prolia (J0897).

The insurer denied coverage for Prolia (J0897). The denial is upheld. 

This is a female patient with a history of generalized anxiety disorder, hypothyroidism, major depressive disorder, hyperlipidemia, colonoscopy, chronic pain syndrome, neoplasm of the skin, vitamin D deficiency, obesity, cellulitis, joint pain in the right hand and limb, and osteopenia who was seen by her primary care doctor for administration of Prolia injection. The patient's bone scan done in the past showed very slight asymmetrical increased activity in the left hip joint which might indicate the presence of early osteoarthritis. The patient's bone densitometry axial skeleton which was also done in the past revealed osteopenia and a 10-year probability of major osteoporotic fracture of 9.1 % and hip fracture of 1.1%.

As per literature review, Prolia (denosumab) is a medication which is useful in the treatment of postmenopausal women with osteoporosis at high risk for fracture. As a biologic drug, it is man-made and closely resembles proteins, called antibodies, which naturally occur in the body. In this case, it stops a molecule, called receptor activator of nuclear factor kappa-B ligand (RANKL), which normally causes bone turnover. By blocking RANKL, this medication (denosumab) helps to strengthen bones. Denosumab is generally not viewed as a first-line therapy and is usually given to patients when they are unable to take bisphosphonates or have unsuccessful results.

In this case, the patient's records show a diagnosis of osteoporosis is not present. The patient has osteopenia. The records show tolerance to her alendronate medication, which is an appropriate first-line medication for treatment and prevention of osteoporosis. There is no evidence of inability to take this bisphosphonate medication. There is no documentation of contraindications for uses of other medications, as well. There are also no reports of previous fracture or other risk conditions for this patient. The patient's most recent bone density was without evidence of osteoporosis. 

Thus, Prolia (denosumab) is not considered medically necessary for this patient at this time. 

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 Prolia (J0897) is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite.
Treatment: Braces.
The insurer denied the braces.
The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits and monthly visits.

Yes, the proposed braces and monthly visits x12 are medically necessary.  

The patient has an anterior crossbite (reverse bite) of his lower incisors with gingival attachment loss (gum loss). This is an "automatic qualifier" according to the handicapping index scale. The monthly visits are necessary to follow orthodontic progress.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain, Arm Numbness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female.  She had a past medical history significant for hypertension (HTN), dyslipidemia (DL), diabetes mellitus (DM), paroxysmal ventricular tachycardia status post ablation and  non-ischemic cardiomyopathy, which resolved after ablation.  The patient presented with intermittent burning chest pains, non-radiating, non-exertional, after large meals, worse when laying down. The patient recently underwent a transthoracic echocardiogram (TTE) with her cardiologist, which was reportedly normal. The patient was hemodynamically stable. Troponin was negative. Electrocardiogram (ECG) revealed normal sinus rhythm, left ventricular hypertrophy (LVH), and no acute ischemic changes. The patient was admitted to rule out acute coronary syndrome (ACS). A coronary computed tomography angiogram (CTA) was performed, which revealed normal coronary arteries. The patient was discharged with a plan for outpatient cardiology follow-up. 

No, the proposed treatment was not medically necessary.

This patient presented for evaluation of atypical chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a coronary computed tomography angiogram (CTA), which revealed no evidence of obstructive coronary disease. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems-Overbite/Underbite.
Treatment: Dental Treatment/Orthodontic/Braces.
The health plan denied the service of braces as not medically necessary for this patient. 
The reviewer has upheld the determination in whole.

The patient in question has a Class I occlusion with appropriate overbite and overjet. The patient has moderate maxillary and mandibular crowding and  is treatment planned for 24-30 months of orthodontics to correct the malocclusion.

The patient has some crowding. The overbite is appropriate and there is no indication of damage to the incisors in the photographs. The  cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There is no medical reason to correct the malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1 This patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion.2 If the teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Holt-Oram syndrome. 
Treatment: In-vitro fertilization cycle with embryo biopsy (codes S4015, 89290, 89291, S0122, and S0128). 

The insurer denied coverage for in-vitro fertilization cycle with embryo biopsy (codes S4015, 89290, 89291, S0122, and S0128). 

The denial is upheld. 

This is a female patient with a past medical history of Holt-Oram syndrome. After undergoing an embryo transfer, the patient was able to give birth to a healthy male baby. The patient returned to the fertility clinic because she was looking to expand her family. The quality and staging of her remaining cryopreserved embryo was reviewed during her consultation. According to her treating physician, the chances of conception are low due to the quality of the patient's current frozen embryo. Therefore, the patient is seeking another vaginal oocyte retrieval to conceive a healthy pregnancy. 

The patient has no diagnosis of infertility. Currently, the patient has two euploid non-affected Holt-Oram syndrome embryos frozen. The patient would like to undergo more in-vitro fertilization cycles and bank more embryos for possible future use. There is no detail available about the frozen embryos. The provider wrote that these embryos were not of good quality but it is not clear what that means. By standard of care, only good embryos are biopsied. In addition, those embryos were tested, and were found to be euploid and not affected by the Holt-Oram syndrome. The patient had a healthy child using those embryos. So, it is questionable as to why these embryos were frozen if they were not of good quality. 

According to the American Society for Reproductive Medicine (ASRM)'s recommendations about the number of embryos to transfer, it is advised given this patient's age, to transfer a single euploid embryo. The reason for that recommendation is because the odds of a successful cycle and live birth are very good estimated at more than 65%. As per medical record review, the aim of this patient is to conceive a healthy child (rather than to collect embryos) and considering there are two euploid embryos available, the odds of conception and live birth are excellent. Thus, additional in-vitro fertilization cycles are not medically necessary for this patient. If the patient does not conceive despite transfer of her embryos, then at that time, in-vitro fertilization cycle may be necessary. If the transfer of these embryos fails, this will only lead to delay of 2-3 months and such a delay should not significantly affect this patient's ovarian reserve. 

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

The carrier's denial of coverage for requested in-vitro fertilization cycle with embryo biopsy (codes S4015, 89290, 89291, S0122, and S0128) should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Dental Problems
Treatment: Periodontal Scaling and Root-Planning, per Quadrant [D4341/UR and D4341/LR]
The insurer denied Periodontal Scaling and Root-Planning, per Quadrant [D4341/UR and D4341/LR]. The health plan's determination is upheld. 

The patient is a female who presents for evaluation and treatment of her upper right and lower right dentition with scaling and root planning (D4341). Provided for review are previous letters of appeal and denial, a letter from the provider from an unknown date, full mouth radiographic images from 7/20/20, two pages of American Dental Association (ADA) claim forms, and periodontal indices. In question is the medical necessity of the planned treatment of scaling and root planning 4341 for UL (upper left) and UR (upper right).

The Periodontal Scaling and Root-Planning, per Quadrant [D4341/UR and D4341/LR] is not medically necessary for this patient. Although there are deeper probing depths, this does not equate the to the presence of attachment loss. As periodontal disease requires the presence of attachment loss and as there is no documented clinical attachment loss and as the radiographic appearance shows the bone level at the CEJ (cemento-enamel junction), there is not any evidence provided of attachment loss. Further supporting the absence of attachment loss is the presence of intact lamina dura throughout the upper right and lower right quadrants of the mouth.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease

Treatment: Laboratory test Prometheus Anser IFX (code 84999)

The insurer denied coverage for the laboratory test Prometheus Anser IFX (code 84999).

The denial is upheld. 

This is a male patient with a diagnosis of Crohn's disease. The patient had a history of colonoscopy in the past and biopsies were consistent with mild chronic inactive colitis.  The patient recently initiated Remicade and was on his fourth dose. The patient continued to have urgency, some nocturnal loose stools, and some bleeding as well as some mild cramping. The patient's blood was drawn to check his infliximab levels and antibody levels. The patient was also recommended for stool cultures and magnetic resonance imaging (MRI). It was noted that pending the results of the studies the patient may need to switch biologics to a different mechanism of action or increase his dose or shorten his interval. It was noted that the patient remains symptomatic with symptoms of active colitis including urgency, abdominal cramping, loose stools, and bleeding. The patient's provider indicated that the infliximab levels and antibody levels were sent to determine whether or not the patient had adequate drug levels to support continuation of treatment.  

The denial of coverage for the laboratory test Prometheus Anser IFX (code 84999) should be upheld. There is a lack of literature to support early utilization of Anser IFX. The patient was initiated Remicade and was only on his fourth dose. There was a lack of indications that the patient had a decrease in therapeutic response to warrant trough level evaluation. 

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of the laboratory test Prometheus Anser IFX (code 84999) should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease

Treatment: Laboratory test Prometheus Anser IFX (code 84999)

The insurer denied coverage for the laboratory test Prometheus Anser IFX (code 84999).

The denial is overturned. 

This is a male patient diagnosed with Crohn's disease of the large intestine. The office visit note indicates that the patient had a history of indeterminate colitis, possible Crohn's disease. The patient just received his first Remicade dose after 3 loading doses.  The patient continued to be symptomatic. The patient had a blood draw to check for infliximab levels and antibody levels. Pending the results of the studies, the provider indicated that the biologics may need to be switched to a different mechanism of action, or the patient's dose may need to be increased. The provider requested Anser IFX testing. 

The patient had a history of indeterminate colitis, and possible Crohn's colitis, who had received his fourth dose of Remicade. This was the patient's first 8-week dose after 3 loading doses. The patient continued to be quite symptomatic with symptoms of active colitis including urgency, abdominal cramping, loose stools, and bleeding.  Therefore, infliximab levels and antibody levels were sent in order to determine whether or not the patient had adequate drug levels and that he had not developed early antibody formation that would inhibit the efficacy of the drug. The provider indicated that given the active symptoms after an appropriate loading dose and an initial maintenance dose, testing for infliximab levels was appropriate in the setting in order to help guide therapy and arrange for future dose adjustments or medication changes in the future if necessary.

As per literature review, there is scientific evidence for checking infliximab levels as checked by this test. The laboratory test Prometheus Anser IFX does not need final approval from the appropriate regulatory bodies for this diagnosis as it is overseen by the Clinical Laboratory Improvement Amendment (CLIA). In this case, this patient is a good candidate for this laboratory test, Prometheus Anser IFX because he has inflammatory bowel disease that is currently refractory to Remicade (infliximab) treatment. This requested service is not a treatment, but a test to determine whether the patient's infliximab is effective or not. The test results can help make that determination. The test would be the best available treatment for this patient at this time because the patient has not responded to Infliximab and consideration is being given to changing this biologic agent. It is appropriate to check levels of Infliximab as well as antibodies against it before switching.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of the laboratory test Prometheus Anser IFX (code 84999) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease

Treatment: Laboratory test Prometheus Anser IFX (code 84999)

The insurer denied coverage for the laboratory test Prometheus Anser IFX (code 84999).

The denial is overturned. 

This is a male patient who has Crohn's disease, a type of inflammatory bowel disease (IBD), and has been on treatment with Remicade. The patient is reported to have symptoms of active colitis with loose stools and bleeding. Thus, infliximab concentration and antibody level were obtained.

As per the Clinical Gastroenterology and Hepatology (2019) article, "Appropriate Therapeutic Drug Monitoring of Biologic Agents with Inflammatory Bowel Disease", the conclusion was that consensus was achieved towards the utility of therapeutic drug monitoring of biologics in IBD, particularly for anti-tumor necrosis factor (TNF) therapies, such as Remicade (infliximab) (Papamichael et al., 2019). 

The American Journal of Gastroenterology (2010)'s article on "Clinical Utility of Measuring Infliximab and anti-chimeric antibody concentration in patients with inflammatory bowel disease" also supports that the measurement of antibodies and infliximab concentration impacts management and is clinically useful (Afif et al., 2010). 

In this case, this patient has IBD and is having active symptoms while on treatment with Remicade (infliximab). Peer-reviewed literature supports the use of infliximab levels and antibody levels. The requested laboratory test, Anser IFX is a Clinical Laboratory Improvement Amendment (CLIA)-certified laboratory test. The patient is a good candidate because he is having continued symptoms on Remicade. Anser IFX is the best available method for managing his treatment. Scientific literature has shown that therapeutic drug monitoring is beneficial in managing treatment of patients with IBD. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of the laboratory test Prometheus Anser IFX (code 84999) should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Durable Medical Equipment (DME). 
The insurer denied power wheel chair. 
The denial is upheld in whole.

The patient is a female with medical history significant for human immunodeficiency virus (HIV), diabetes mellitus type II (DM II), asthma, chronic sciatica, cerebrovascular accident (CVA), chronic kidney disease and chronic pain syndrome.
The subject under review is the medical necessity for a power wheel chair.

The health plan's determination is upheld in whole.

The requested health service of Power wheelchair is not medically necessary for this patient. It is not standard of care to prescribe a power wheelchair in an individual without clear documentation of gait and balance deficits as-well-as supporting documentation for why a customized manual wheelchair would not suffice.
All records were reviewed. The patient is a female with medical history significant for HIV, DMII, asthma, chronic sciatica, CVA, chronic kidney disease and chronic pain syndrome. While right sided weakness was reported by patient to be worsening there was no clinical documented support. For example, there were two clinical encounters by a nurse practitioner. On the first encounter this provider noted under "Right sided weakness" that patient should continue ultra-light rollator as directed and "Start Wheelchair Miscellaneous -, as directed." The provider noted that weakness was residual to the patient's stroke and the plan was to continue physical therapy (PT) with notation that patient "Complains of (C/o) increased right lower extremity (RLE) weakness, requested motorized wheelchair." Despite this reported worsening weakness, the physical exam failed to provide support as all it stated under Neuro was "unsteady gait r/t h/o CVA, using rollator." There was no muscle testing during this visit or any other visit to support increased weakness. In addition, documentation did not include any information about the patient's stroke - ischemic vs. hemorrhagic, the location of stroke in the brain, any treatment received, whether the patient had received post stroke rehab, etc. Furthermore, despite the provider stating that the patient was to continue physical therapy there were no therapy documents nor a wheelchair evaluation by Physical Therapy to support the medical necessity of a motorized wheelchair. Lastly, the second visit was a telephone visit and did not provide any relevant physical exam findings.
Medical necessity for a power wheel chair is not established.