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

Diagnosis: Cognitive impairment, cervicalgia, gait ataxia, coronary artery disease and chronic low back pain with lower extremity radiculopathy.
Treatment: Increase Personal Care Services To 10 hours a day; 7 days a week for a total of 70 Hours A Week.
The insurer denied the Increase Personal Care Services To 10 hours a day; 7 days a week for a total of 70 Hours A Week.
The denial is overturned. 

The patient is a female with a history of cognitive impairment, cervicalgia, gait ataxia, coronary artery disease and chronic low back pain with lower extremity radiculopathy. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 70 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 70 hours/week Personal Assistance Services is deemed medically necessary.

The patient is a female with a history of cognitive impairment, cervicalgia, gait ataxia, coronary artery disease and chronic low back pain with lower extremity radiculopathy.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).

Recent correspondence from the patient's medical provider indicates with due to worsening cognitive and functional decline over the past few months, the patient's gait ataxia has worsened and she recently sustained a significant fall at home. Her ability to complete ADLs (activities of daily) has significantly decreased. Hence, the currently approved plan of 42 hours/week Personal Assistance Services is not sufficient to meet the patient's current needs. For these reasons, the proposed treatment 70 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara
The insurer denied Stelara. The health plan's determination is overturned. 

The patient is a male with Crohn's disease. 

Yes, Stelara every 4 weeks in this case is supported by current medical literature and is likely to be more beneficial for this patient. Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's Disease, as this patient has. In this case, the patient has failed Stelara every 8 weeks; continuation of dosing every 8 weeks may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient. For all of these reasons, Stelara 90 mg every 4 weeks is supported as likely to be more beneficial than any standard treatment for the treatment of Crohn's disease in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara
The insurer denied Stelara. The health plan's determination is overturned. 

The patient is a male under treatment for Crohn's Disease (CD). The provider has asked for a dose increase to Stelara 90 mg (milligrams) Q (every) 4 weeks. He also has significant autism and is difficult from a behavioral perspective to give intravenous (IV) infusions. The patient was initially managed with azathioprine but progressed through that therapy.

Yes. Stelara every 4 weeks is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. There has been an accumulation of data on large groups of patients that have consistently shown that dose escalation of Stelara is worthwhile and beneficial for patients in the majority of instances.
Appeal type: Experimental/Investigational
Decision: Overturned

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

The patient is a male with a request for Stelara every four weeks to treat Crohn's disease. The appeal letter describes initial treatment with azathioprine. He was started on Stelara every eight weeks. 

Stelara every 4 weeks is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. There are multiple conventional treatment options available to treat Crohn's colitis that have not been tried, failed, contraindicated in this case. The patient can be placed on immune modulator methotrexate with mesalamine enema for left sided colitis. Alternatively, there are first-line biologic agents that have not been tried and failed before requesting dose escalation of Stelara. These include Remicade, Humira, or Entyvio. Therefore, the request for Stelara every four weeks is not medically necessary and not supported by literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Extreme prematurity, extremely low birth weight
and respiratory distress
Treatment: Hospital (Interfacility) Transfer
The insurer denied the Hospital (Interfacility) Transfer.
The denial is upheld. 

The patient is an extremely premature, extremely low birth weight, twin A male infant born by spontaneous vaginal delivery.  This was a monochorionic diamniotic twin pregnancy that was complicated by stage III twin-to-twin transfusion syndrome.  The patient was born after the mother had laser ablation therapy and an amnioinfusion for twin-to-twin transfusion syndrome that resulted in preterm premature rupture of membranes, possible abruption and preterm labor.  Apgar scores were 4 and 9.  Because of extreme prematurity, extremely low birth weight and respiratory distress, the infant was admitted after birth directly to the neonatal intensive care unit (NICU). The infant's neonatal intensive care unit (NICU) hospitalization was remarkable for respiratory distress syndrome, respiratory failure, respiratory insufficiency of prematurity, hospital acquired pneumonia, thrombocytopenia, anemia, hypotension, hyperbilirubinemia, hypernatremia, patent ductus arteriosus ligation, hyperglycemia, hypertension, aortic thrombus, presumed adrenal insufficiency, stage I zone II retinopathy of prematurity, thermoregulatory support and nutritional support.  A request was made to transfer the infant to the neonatal intensive care unit (NICU) at another facility so the infant could be closer to his parent's home.  The infant remained hospitalized in the neonatal intensive care unit (NICU) at the initial hospital and management at that time included the following: respiratory support with continuous positive airway pressure (CPAP) and supplemental oxygen; nutritional support with gavage feedings; and treatment with oral medications (caffeine, chlorothiazide, hydrocortisone, spironolactone).

No, the proposed Hospital (Interfacility) Transfer is not medically necessary.

The proposed treatment, transfer from the initial hospital to the transfer hospital is not medically necessary.  The medical records document that the infant was being appropriately cared for at the initial hospital and it was capable of continuing to care for the infant until he was ready for discharge to home.  The request for transfer was made for convenience purposes so the infant could be closer to his parents' home and was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class II with retruded mandible, maxillary and mandibular crowding, excessive overjet and impacted canines).
Treatment: D8080 Braces.
The insurer denied coverage for D8080 Braces.
The denial is upheld. 

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II with retruded mandible, maxillary and mandibular crowding, excessive overjet and impacted canines. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying conditions of impacted permanent anteriors where extraction is not indicated, and overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater that 3.5 mm with reported masticatory/speech difficulties. 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 attaining only 21 points on review by their internal reviewers.

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, an HLD index is utilized. This index provides 6 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  automatic qualifying conditions of impacted permanent anteriors where extraction is not indicated and overjet greater than 9 mm with incompetent lips or reverse overjet greater that 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that these automatically qualifying conditions are not met and do not support comprehensive orthodontic care. This reviewer concurs with the findings of the insurer of attaining 21 points on the HLD index (5 points overjet, 12 points anterior open bite, 4 points labiolingual spread).

D8080 Braces is not considered medically necessary for this patient.

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

Diagnosis: Dental Problems (skeletal Class I, midline shift, overjet, overbite and impacted canines).
Treatment: Dental braces and the follow-up visits.
The insurer denied coverage for dental braces and the follow-up visits.
The denial is overturned. 

This patient is a male child who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, midline shift, overjet, overbite and impacted canines.  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.  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 attaining only 6 points on review by their internal reviewers.  

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, New York State requires the use of an orthodontic index.  The HLD index provides 6 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 that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Dental braces and the follow-up visits are considered medically necessary for this patient.

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

The carrier's denial of dental braces and the follow-up visits should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: D8080 Braces and D8670  Monthly Visit x12
The insurer denied the D8080 Braces and D8670  Monthly Visit x12.
The denial is overturned.

The patient is a male.  The request is for dental benefits for orthodontic treatment (braces) and monthly visits.
A dental clinical exam was performed and orthodontic records were made; the clinical summary states the patient presents with a severely deep over-bite with palatal impingement--partial impaction of tooth #11 and impacted teeth #18, 31. The treatment plan was presented to the patient and his parents.

Yes, the proposed treatment of orthodontic therapy with monthly visits is medically necessary.

The patient presents with a severe overbite as evidenced in the photos. The upper anterior teeth fully cover the lower anterior teeth with the biting edge of the lower teeth going into the upper gums of the upper front teeth.  A severe overbite like this can result in gum recession, trauma to the upper gums; and eventually gum disease and tooth loss, as well as difficulty with speech and chewing.

Severe overbites, if left untreated, tend to get worse over time and with age. The possibility of muscle strain, jaw pain and other dental complications can have an overall negative impact on the patient's long-term oral health.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Problems (skeletal Class I, vertical growth pattern, maxillary and mandibular crowding, deep bite, excessive overjet and impacted maxillary canines).
Treatment:  Braces and treatment visits.

The insurer denied coverage for braces and treatment visits.  The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, vertical growth pattern, maxillary and mandibular crowding, deep bite, excessive overjet and impacted maxillary canines.  The orthodontist has not submitted the Handicapping Labio-Lingual Deviation (HLD) index as required as it is not in the submitted documentation. 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 attaining only 15 points on review by their internal reviewers.  

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 the HLD index is utilized.  This index provides 6 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 did not submit an HLD index but presumably claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated.  This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. This reviewer concurs with the findings of the insurer of attaining 15 points on the HLD index (4 points overjet, 2 points overbite, 5 points anterior crowding, 4 points labiolingual spread).  Since the patient's HLD index is less than 26 points, orthodontic care is not warranted.

Braces and treatment visits are not considered medically necessary for this patient.

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

The carrier's denial of coverage for braces and treatment visits should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Problems. 
Treatment:  Orthodontic Braces.

The insurer denied orthodontic braces.  The denial is overturned.

The patient is a female with Skeletal Class II malocclusion. Severe overjet and overbite. The subject to be determined is the medical necessity for orthodontic braces.

The health plan's determination is overturned.

The requested treatment of orthodontic braces is medically necessary for this patient. With an overjet of 10 millimeter (mm), function is severely affected, especially when it comes to incising food with the front teeth. Also, the lower incisors are impinging on the maxillary palatal tissues posterior to the maxillary incisors which can be destroyed during mastication. Thus, it is the standard of care to treat patients displaying this amount of severe overjet.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing crown; Missing upper teeth. 
Treatment: D2750 Crown #7, D5213 Partial Upper Denture, Pre-service. 

The insurer denied the D2750 Crown #7, D5213 Partial Upper Denture, Pre-service.
The denial is overturned. 

The patient is a male. He is requesting new crown on tooth #7 as well as a cast partial denture in the upper arch. 

Yes, the D2750 Crown #7, D5213 Partial Upper Denture are medically necessary. 

Tooth #7 is missing a crown in the x-ray provided. The tooth has had a root canal procedure and needs a crown to restore it. It does not look decayed on the x-ray, and it has good bone support. 

The patient has multiple missing upper teeth. A case partial denture would replace his missing teeth in a predictable way. There are enough teeth with good bone support to hold the denture properly.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dizziness.
Treatment:  Inpatient admission.

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

The patient is a female who presented to the emergency ward with the complaint of weakness, dizziness and vomiting. At presentation her vital signs, neurological examination and neuroimaging were normal. She was admitted for further evaluation. Magnetic resonance image (MRI) of the brain was negative for stroke. The patient improved with treatment and was suspected of having labyrinthitis versus positional vertigo. She was discharged home.

No, the proposed inpatient hospital admission for dates of service was not medically necessary.

The patient presented with vertigo. Her evaluation was negative at presentation and the severity of her symptoms did not warrant acute inpatient admission. Risk stratification for acute stroke/transient ischemic attack (TIA) does not warrant acute inpatient admission.  The diagnostic testing, monitoring, neurology consultation and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eczema of scalp and ears
Treatment: Fluocinolone acetonide scalp 0.01% ex oil
The insurer denied the Fluocinolone acetonide scalp 0.01% ex oil.
The determination is upheld.

The patient has a history of eczema of the scalp and ears. It was reported that she has been on no regular treatment. The exam revealed eczematoid changes in both conchal bowls. It is documented that she failed treatment with hydrocortisone. Fluocinolone acetonide, 0.01% ex oil was recommended and is under review for medical necessity.
The requested health service/treatment of fluocinolone acetonide scalp 0.01% ex oil is not medically necessary for this patient.
Atopic dermatitis, also known as atopic eczema, is a chronic relapsing inflammatory skin condition. It is not documented in the clinical information provided that the patient's condition was severe. The basis of treatment for atopic dermatitis is to provide moisturization for dryness, control pruritus, and manage inflammation of the eczematous lesions. According to the American Academy of Dermatology, low-potency topical corticosteroids are generally suggested for maintenance therapy, whereas intermediate and high-potency topical corticosteroids are recommended for the acute control. This is not documented as having been exercised in the clinical information provided as it is documented that the patient was not currently on therapy.
Clinically this is a patient reported to have eczema of the scalp and ears. It is documented that the patient failed a trial of hydrocortisone; when and for how long is not documented. According to the provided formulary listings, formulary alternatives expected to be tried and failed prior to the use of fluocinolone acetonide 0.01% ex oil include mometasone lotion, triamcinolone lotion and fluocinolone 0.025 cream or ointment. As this is not documented, the requested health service/treatment of fluocinolone acetonide scalp 0.01% ex oil is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pregnancy. 
Treatment: Inpatient hospital stay. 

The insurer denied coverage for inpatient hospital stay. 

The denial is overturned. 

This female patient presented at around 18.6 weeks gestation complaining of vaginal bleeding. The patient's physical examination revealed bulging membranes in the vagina. The patient was admitted to labor and delivery for further care. The patient delivered a demised female infant. The placenta followed 25 minutes later. Following the delivery, the patient complained of lightheadedness. The patient's hemoglobin level was initially 8.1 and was later 7.8. The patient was dizzy. The patient was given intravenous (IV) fluid bolus and she was started on a Methergine series. The patient responded well to treatment. The patient was tolerating oral intake and voiding. The patient was discharged home in stable condition. 

It has always been the standard of care to admit patients for delivery. This patient was pregnant in active labor. Admission was medically necessary to deliver the patient. The admission is primarily to observe for the progression of labor, monitor the patient for any complication (uterine rupture) and for delivery and postpartum management (retained placenta, bleeding). Note that this patient bled significantly and was anemic and there was concern about the need for a transfusion so admission to monitor this patient's bleeding, her vital signs, and hematocrit were all medically necessary. 

According to the American College of Obstetricians and Gynecologists (ACOG) coding guidelines, the following services are included in the delivery services: (1) Admission to the hospital; (2) The admission history and physical examination; (3) Management of uncomplicated labor, vaginal delivery (with or without episiotomy, with or without forceps, with or without vacuum extraction), or cesarean delivery, external and internal fetal monitoring provided by the attending physician; (4) Intravenous (IV) induction of labor via oxytocin (CPT codes 96365 - 96367) or misoprostol; (5) Delivery of the placenta; any method; (6) Repair of first or second degree lacerations; (7) Control of bleeding. 

The Milliman Care Guidelines also states clearly that admission is medically necessary for delivery. Thus, based on all of the above, the acute inpatient admission was medically necessary for this patient. 

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

The carrier's denial of coverage for the inpatient admission should be overturned. The medical necessity is substantiated.