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

Diagnosis:  Dental Problems (skeletal class I, vertical growth pattern, maxillary spacing and mandibular crowding, posterior crossbite, and anterior crossbite (maxillary right lateral incisor).
Treatment:  D8080 braces and D8670 monthly visit x 12.

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.  The denial is upheld. 

This is a female patient who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal class I, vertical growth pattern, maxillary spacing and mandibular crowding, posterior crossbite, and anterior crossbite (maxillary right lateral incisor).  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. 

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 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 the insurer and the plan criteria to justify orthodontic care.  This reviewer concurs with the Handicapping Labio-Lingual Deviation (HLD) index of the insurer attaining 17 points (i.e., 3 overjet, 1 overbite, 5 anterior crowding, 4 labio-lingual spread, 4 posterior crossbite).

The coverage for D8080 braces and D8670 monthly visits x 12 is not 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 D8080 braces and D8670 monthly visit x 12 should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gestational Hypertension
Treatment: Inpatient Hospital 
The health plan denied the medical necessity of the inpatient stay. 
The health plan's determination is upheld.

The patient is a pregnant female with diabetes who presented with elevated blood pressure. She was admitted as an inpatient to evaluate her blood pressure and rule out preeclampsia. She was asymptomatic. She had labs performed and a 24-urine collection. All were negative. There is a question of the medical necessity of the inpatient hospital admission.

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

The requested health service/treatment of an inpatient stay is not medically necessary for this patient.

The patient was admitted for laboratory evaluation secondary to her hypertension. Her hypertension was not in severe ranges prior to her admission nor during her admission. She had no symptoms and was hemodynamically stable. She had no contraction, hemorrhage, nor infection. She had no kidney or liver disease. She had no lung disease nor end organ disease. She had no fetal complications. The work up was appropriate, however there is no reason that this could not have been performed at an alternate level of care. She received no inpatient admission therapies, and the monitoring could have been performed at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic Procedure

Diagnosis: Dental Problems-Overbite
Treatment: Dental/Orthodontic Procedure-Braces
The health plan denied the treatment of braces as not medically necessary. The reviewer has upheld the denial in whole.

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

The patient has very minor crowding. The overbite is deep but 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 minor crowding, 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. Aligning of the teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. 2. If the teeth were aligned it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Crohn's Disease
Treatment: Pharmacy/Prescription Drugs-Infliximab
The health plan denied the treatment of Infliximab 10mg/kg every 4 weeks as not medically necessary. 
The reviewer has overturned in whole the health plan determination.

The patient was diagnosed with Crohn's Disease (CD). The disease has been complicated by peri-anal disease as well as upper tract involvement. The patient had drainage of a perianal abscess. The patient underwent an abdominoperineal resection (APR) with end colostomy. The patient has failed multiple therapies including 6-mercaptopurine(MP), Humira + methotrexate (MTX), Stelara and Entyvio and is currently on a combined regimen of Infliximab 10 milligrams (mg) / kilogram( kg) every (Q) 4 weeks and Entyvio 300 mg Q 8 weeks. Infliximab dose has been escalated due to low drug levels on customary doses. On the current combined therapy of Infliximab+ Entyvio the patient has done relatively well since the time at which Entyvio was started as part of combination therapy as well as the addition back of methotrexate and budesonide. Dose escalation at that time was performed because of active ileitis seen on colonoscopy.
The requested treatment is medically necessary for this patient. The Infliximab dose was escalated based on low trough drug levels at conventional doses. As indicated by the American Gastroenterological Association drug levels are an excellent way to optimize biologic therapy.[1] Drug levels allow one to dose adjust to have trough levels in the targeted range between 7-10 microgram(ug) /milliliter(ml). Because of this patient's unique pharmacodynamics, a dose of 10 mg/kg Q 4 weeks was necessary.
The use of combined biologics (e.g. infliximab + vedolizumab) with differing mechanisms of action is becoming standard of care for patients with recalcitrant Crohn's Disease.[2] This patient has failed several individual agents, in fact all that are Food and Drug Administration (FDA) approved. Colonoscopy demonstrated severe ileitis even with the use of high dose monotherapy Infliximab. It was medically necessary to add in Entyvio to reduce the need for steroids, hospitalization, and future surgeries.[3]
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Failing long standing preexisting composite restorations on teeth 8 and 9. 
Treatment: D2740 all white glass crown, Tooth 8 and D2740 all white glass crown, Tooth 9. 

The insurer denied coverage for D2740 all white glass crown, Tooth 8 and D2740 all white glass crown, Tooth 9. 

The denial is overturned. 

This is a female patient who presented for comprehensive dental treatment and failing long standing preexisting composite restorations on teeth 8 and 9 was noted. There is radiographic evidence of open margins. Based on these clinical findings, the dentist recommended placement of full coverage crowns on these teeth. 

Upon review of the documentation, particularly the radiograph, the preexisting composite restorations placed on these teeth appear to be failing. The margins are open. Radiographically there appears to be possible recurrent caries under the restorations. Given this clinical circumstance, replacement of these restorations with full coverage crowns is indicated. There is adequate bone support of these teeth and adequate coronal structure to successfully support fixed crown restorations. In this patient, crowns are a conservative restorative option which would represent a standard of care for this clinical circumstance in general dental practice. As such, these services which are also a covered service for this individual would be deemed medically necessary. 

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

The carrier's denial of coverage for D2740 all white glass crown, Tooth 8 and D2740 all white glass crown, Tooth 9 is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain And Swelling In The Scrotum.
Treatment: Inpatient admission.

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

The patient is a male. He was admitted through the ER (emergency room) with scrotal swelling for seven months. 

The patient's vitals were temperature 97.7, blood pressure 143/98, heart rate 89.  An ultrasound demonstrated a huge complex right scrotal fluid collection concerning for a complex right hydrocele with possible left orchitis.  IV (intravenous) antibiotics were started.  The WBC (white blood cell) count was 5800.  Urology concluded that he had hydroceles.

The patient was discharged home against medical advice.

No, the Inpatient admission was not medically necessary.

The patient's care could have been provided at a lower level of care than acute inpatient.  The IV (intravenous) antibiotics and observation of clinical status did not require an acute inpatient level of care because care could have been provided at an observation level of care.  After admission, he was afebrile and hemodynamically stable.  There was no evidence of abscess or destabilization that required operative intervention or an acute inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Obstructive Sleep Apnea
Treatment: Inspire Upper Airway Stimulation System [Hypoglossal Nerve Stimulation]
The health plan denied the Inspire Upper Airway Stimulation System [Hypoglossal Nerve Stimulation].
The determination is upheld.

This is a patient with severe obstructive sleep apnea (OSA) who cannot tolerate continuous positive airway pressure (CPAP) therapy. A sleep study showed he had an Apnea-Hypopnea Index (AHI) of 68.5 with no central apneas. His body mass index (BMI) at that time was 32.3.
An office note indicatedthat the patient had a previous septoplasty, turbinectomy, tonsillectomy and uvulopalatopharyngoplasty (UPPP) . No other significant sources of obstruction were noted on physical exam. A drug induced sleep endoscopy showed no concentric collapse. At issue is whether the Inspire Upper Airway Stimulation System [Hypoglossal Nerve Stimulation] likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease?
There is insufficient evidence that the proposed treatment (HG Nerve stimulator) is likely to be more beneficial then any standard treatment for this patient's condition.
Studies that have investigated the effectiveness of the hypoglossal nerve stimulator typically included only patient with a BMI less than (<) 32 and an AHI of 15 -65.
For this reason the current Food and Drug Administration (FDA) guidelines exclude patient with a BMI greater than (>) 32 or AHI > 65. Therefore, this patient would be excluded based on his weight and severity of OSA. A 2016 study of targeted hypoglossal nerve stimulation by Friedman et. al. did include patients with an AHI greater then 65 and found that having an AHI less then 65 was a predictor of successful surgical outcome.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Obstructive Sleep Apnea
Treatment: Inspire Upper Airway Stimulation System [Hypoglossal Nerve Stimulation]
The health plan denied the Inspire Upper Airway Stimulation System [Hypoglossal Nerve Stimulation].
The determination is upheld.

This is a patient with sleep apnea. He has an apnea hypopnea index (AHI) of 68.5. His body mass index (BMI) is 32.3. The patient cannot tolerate continuous positive airway pressure (CPAP). An oral appliance has been attempted previously. His previous surgeries have included a uvulopalatopharyngoplasty (UP3), Tonsillectomy, Septoplasty, and Turbinoplasty. A sleep endoscopy did not reveal concentric collapse at the level of the oropharynx and hypopharynx. At issue is whether the proposed Inspire Upper Airway Stimulation System [Hypoglossal Nerve Stimulation] is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Inspire Upper Airway Stimulation System [Hypoglossal Nerve Stimulation] is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The current indications for the use of the hypoglossal nerve stimulator for the treatment of sleep apnea include an AHI between 15 and 65. There is only 1 study investigating the use of hypoglossal nerve implant in patients with AHI greater than 65, and this study only reported results of 4 patients with an AHI greater than 65 (1). Thus, there are no well designed trials investigating the use of the hypoglossal nerve implant in patients with AHI greater than 65 in the literature. There is inadequate data on its use in this population. Without published studies showing efficacy, the Hypoglossal nerve implant cannot be said that it is more beneficial than standard treatment for sleep apnea.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Radiology Services (including Ultrasound)

Diagnosis: Cough
Treatment: CT scan
The insurer denied a CT scan of the chest. 
The health plan's determination is overturned. 

The patient is a man with a long history of tobacco use, hypertension (HTN), hyperlipidemia, asthma, allergies, gastroesophageal reflux disease (GERD), and anxiety who had has a persistent cough without obvious etiology. He has had chest x-rays (CXR) that were normal, clear lungs, no effusions. He has not responded to high dose ICS-LABA, tiotropium, and montelukast. Under review is the medical necessity of Computed Tomography (CT) Chest without Contrast (Dye).

The requested CT scan is medically necessary. This patient has already had a routine evaluation for less concerning causes of cough, has already failed asthma and allergic rhinitis therapy, and has had two normal CXRs, including one a month prior. At this point, for persistent cough, a CT thorax would be a necessary next step to evaluate for alternative and/or more concerning causes of cough.

The patient has a chronic cough that is not explained by history and physical or by a recent CXR. In a case of unexplained cough with a normal CXR, a CT thorax is a typical next step in evaluation to help look for occult or subtle infection, endobronchial lesions, ILD (Interstitial lung disease), etc.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatitis C virus during pregnancy

Treatment: Harvoni (ledipasvir - sofosbuvir)

The insurer denied coverage for Harvoni (ledipasvir - sofosbuvir).

The denial is upheld. 

This is a pregnant female patient who has been diagnosed with hepatitis C. The patient has genotype 1a and is treatment naive. The patient's fibrosis score was F1. The patient's physician has requested Harvoni instead of the formulary alternative, Mavyret because of concerns for the patient's pregnancy.

Hepatology Communications 2019 Jan 3 (1) 20-28 has an article titled "Hepatitis C in Pregnancy: A Unique Opportunity to Improve the Hepatitis C Cascade of Care." The article states that given the lack of safety data of direct acting antivirals during pregnancy, it is recommended to treat hepatitis C virus (HCV) prior to pregnancy or to delay until after pregnancy.

The American Journal of Obstetrics and Gynecology November 2017 Volume 217 Issue 5 has an article titled "Hepatitis C in Pregnancy: Screening, Treatment and Management."  The recommendation is that direct-acting antiviral (DAA) regimens only be used in the setting of a clinical trial or that antiviral treatment is deferred to the post-partum period.

The Food and Drug Administration (FDA) has evaluated Harvoni and the use in pregnancy is addressed. It is stated that no adequate human data are available to establish whether or not Harvoni poses a risk to pregnancy outcomes.

As to date, there is no recommendation from the American Association of the Study of Liver Diseases (AASLD) that a person with stage F1 hepatitis C virus (HCV) should be treated during the pregnancy. It is advised to treat prior to the pregnancy and to monitor the HCV ribonucleic acid (RNA) and liver function. There is a recommendation to repeat the HCV viral level after the pregnancy to see if it spontaneously cleared.

In this case, this patient has a F1 fibrosis score.  It would be appropriate to wait until after the pregnancy to treat this patient's hepatitis C virus (HCV) infection. At that time, there would be no contraindication to using the formulary drug Mavyret. As per literature review, Harvoni 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. 

The carrier's denial of coverage for Harvoni (ledipasvir - sofosbuvir) should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Nursing Services (including Private Duty Nursing)

Diagnosis: Dementia
Treatment: Personal Care Aide 
The insurer denied the Personal Care Aide (PCA) Level 2: 12 Hours per Day/7 Days per Week (Total of 84 Hours per Week). 
The health plan's determination is overturned. 

The patient is a female with past medical history of hearing loss, glaucoma, bowel and bladder incontinence, insomnia, restless leg syndrome, bed bound status, multiple falls, constipation, gastroesophageal reflux disease (GERD), edema, depression, severe dementia, and osteoporosis who had been assigned PCA (personal care assistant) services 8 hours/day, 7 days/week to total 56 hours/week following assessment tool. The patient was assessed at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, and shopping while maximal assistance with tasks of managing medication, phone use, bathing, dressing lower body, walking, locomotion, and transfer toilet. With tasks of personal hygiene, dressing upper body and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of bed mobility and eating.
There was a request to increase PCA services to 12 hours/day, 7 days/week, to total 84 hours/week. 

Personal Care Aide (PCA) Level 2: 12 Hours per Day/7 Days per Week (Total of 84 Hours per Week) is medically necessary for this patient.
The patient has documented medical diagnoses that are progressive including dementia, osteoarthritis, hearing loss and glaucoma. The patient requires at least some assistance with all activities of daily living (ADL)/Instrumental activities of daily living (IADL) as noted in both assessment tools. The patient no longer has the same level of assistance with informal help due to her daughter's own medical diagnoses and limitations. The patient would need PCA services outside of the time that her daughter is able to provide care. The plan failed to account for unscheduled and unpredictable care needs that occur over a continuum of time. The patient has bowel and bladder incontinence and requires assistance with tasks of walking, locomotion, transfer toilet, and toilet use all of which are unpredictable and unscheduled care need. An increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: maxillary spacing and mandibular crowding.
Treatment: Braces.

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

The patient is a female with maxillary spacing and mandibular crowding and many unerupted permanent teeth. The orthodontist mentioned in the diagnosis that tooth #11 is impacted. The patient is treatment planned for 36 months of comprehensive orthodontics with canine exposure and ligation.

No. Orthodontic treatment (Braces) is not medically necessary for the patient at this time. She is in the process of losing her 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:
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.)
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.)
The patient does have maxillary spacing and mandibular crowding and treatment may be indicated in the future. However, the patient does not exhibit any of the criteria to suspect these canines are, in fact, impacted. For this reason, the requested treatment is not medically necessary at this time.