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

Diagnosis: Dental problems (maxillary and mandibular crowding, class I malocclusion, increased overbite, midline deviation and anterior crossbite with gingival attachment loss)

Treatment: D8080 braces and D8670 monthly visits x 12

The insurer denied coverage for D8080 braces and D8670 monthly visits x 12.

The denial is overturned.

This is a male patient who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding, class I malocclusion, increased overbite, midline deviation and anterior crossbite with gingival attachment loss. 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. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining a score of 20 points on the HLD index where 26 points is required. 

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care the HLD index is utilized. This index provides 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 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 clearly met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Thus, the coverage for D8080 braces and D8670 monthly visits x 12 is 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.

Based on the above, the medical necessity for D8080 braces and D8670 monthly visits x 12 is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with a two-day history of severe rectal pain. There is a past history of a rectal abscess. He was seen in Urgent Care and diagnosed with a perianal abscess and prescribed antibiotics and pain medication. He was next seen by Surgery in an outpatient setting. His abscess was not able to be drained at that visit and the patient was referred to the Emergency Department. 

Evaluation in the Emergency Department documents a temperature of 98.1 and a white blood cell count of 12,440. The patient received intravenous Cipro, Flagyl and Morphine. A Surgery consult was obtained, and the patient was sent to the Ambulatory Surgery Unit (ASU) for a planned surgery the next day. The patient was taken to Surgery where he was found to have a horseshoe abscess with an associated mid-posterior fistula. The abscess was drained, and a Penrose drain was placed in the cavity. A seton was placed through the fistulous tract. He was admitted to acute inpatient status following surgery. 

Post-operatively, the patient remained afebrile (maximum temperature was 99) with rapid return of bowel and bladder function and was able to resume diet and ambulate without difficulty. He was discharged home on Flagyl and oxycodone to be followed as an outpatient.

No, the proposed treatment was not medically necessary.

Following presentation to the Emergency Department, the patient was appropriately admitted to the Ambulatory Surgery Unit for surgery the following day. However, post-operatively, standard of care does not generally include inpatient admission, unless the patient meets certain criteria.  

Post-operatively, this patient remained afebrile (maximum temperature was 99) with rapid return of bowel and bladder function and was able to resume diet and ambulate without difficulty. The services provided during the acute inpatient stay did not rise to the levels of intensity/severity required to justify the stay. 

Therefore, the denial of the inpatient stay is upheld as that level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Ulcerative colitis.
Treatment:  Humira.
 
The insurer denied Humira.  The health plan's determination is upheld. 

This patient is a female.  She has a history of ulcerative colitis.  She has tried and failed mesalamine and corticosteroids.  The requested service is treatment with Humira.  The plan denied coverage for Humira because it is not Food and Drug Administration (FDA)-approved for children with ulcerative colitis.

Humira is not medically necessary for this patient.

Humira is FDA approved for adults with ulcerative colitis (UC) and Crohn's disease (CD) in addition to pediatric Crohn's disease.  Despite not being FDA-approved for children with UC, Humira is acceptable in treating children with ulcerative colitis after failing the available and FDA approved biologic infliximab.  Using Humira as a first line biologic in pediatric ulcerative colitis is not studied adequately.  The current standard of care is to start with infliximab as the biologic treatment of choice in the case of conventional therapy failure.  In the case of inadequate response, or loss or response, Humira can then be used.

Per the clinical practice guidelines for the management of pediatric ulcerative colitis:
"1. Infliximab (IFX) should be considered in chronically active or steroid-dependent UC, uncontrolled by 5-ASA and thiopurines, for both induction and maintenance of remission.  2. Adalimumab or golimumab could be considered in those who initially respond but then lose response or are intolerant to IFX, based on serum levels and antibodies". 

Per Aloi, Marina et al.: "In this cohort of children with UC, ADA (Humira) had a favorable short- and long-term efficacy, allowing to recover a significant percentage of patients intolerant or not-responding to IFX (infliximab)".

There is no evidence that Humira is superior to infliximab in terms of safety or efficacy in treating pediatric ulcerative colitis.  Therefore, based on the available scientific evidence, using Humira (off-label) before trying the FDA approved infliximab, is not considered medically necessary.  This patient can be treated safely with infliximab.
Appeal type: Medical necessity
Decision: Overturned

Infectious disease
Home Health Care

Diagnosis: COVID-19, dementia
Treatment: Personal Care HHC - Level 2 Personal Care Services
The insurer denied Personal Care HHC - Level 2 Personal Care Services. The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, hyperlipidemia, congestive heart failure, coronary artery disease, atrial fibrillation, recurrent urinary tract infection (UTI), urinary incontinence, sacral decubitus ulcer, dementia, anemia, and recent Covid-19 infection who had hospitalization with the diagnosis of metabolic encephalopathy. The patient was hospitalized again with Covid-19 infection, with placement of percutaneous endoscopic gastrostomy (PEG) tube and treatment of a stage 4 decubitus ulcer. The patient had an assessment tool performed over the phone noting that she required total assistance for all tasks except transfer toilet which was maximum assistance. This assessment noted the patient had PCA (personal care assistant) services 4 hours/day x 5 days/week after her previous hospitalization and following this assessment the patient was assigned PCA services, level 2, 24 hours/day, live-in, 7 days/week.

The Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: Increase to 24 Hours per Day (Split Shift) was medically necessary for this patient.

The patient has multiple medical problems including dementia, decubitus ulcer, recurrent UTI, non-ambulatory status, and recent Covid-19 infection. She requires turning and repositioning every two hours, as documented on two occasions in her hospital records. In its denial the plan commented that the patient did not have a change from the previous assessment noting that most of the patient's needs were already assessed at total assistance. The plan also indicated that the request for 24 hour/day, split-shift, 7 days/week PCA services would be for safety monitoring but the increase in services would be to assist the patient with safe completion of activities of daily living (ADL) and instrumental activities of daily living (IADL). The patient has unscheduled and unpredictable care needs over a continuum of time. The patient requires total assistance with toileting and incontinence cares. 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. The requested increase in PCA service hours to split-shift is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Impacted maxillary canines.
Treatment:  D8070 braces and D8670 monthly visits x 4.

The insurer denied coverage for D8070 braces and D8670 monthly visits x 4.  The denial is overturned.

This is a female child, who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics, due to the patient's impacted maxillary 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, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index, attaining only 17 points on review by 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 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.

Thus, the coverage for D8070 braces and D8670 monthly visits x 4 is considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, lumbar spinal stenosis, rheumatoid arthritis, osteoporosis
Treatment: Personal Care Services 6 hours per day, 7 days per week.
The insurer denied the Personal Care Services 6 hours per day, 7 days per week.
The denial is upheld. 

The patient is a female with a history of coronary artery disease, lumbar spinal stenosis with associated lower extremity sciatica, rheumatoid arthritis and osteoporosis. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living. An appeal review has been requested for potential approval of 6 hours per day, 7 days per week of personal care services to offer increased support for activities of daily living.

The proposed personal care services 6 hours per day, 7 days per week is not deemed medically necessary. 

This is a female with a history of coronary artery disease, lumbar spinal stenosis with associated lower extremity sciatica, rheumatoid arthritis and osteoporosis. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living. However, an in home assessment of the patient's functionality and ability to perform activities of daily living was completed and revealed that the currently approved plan of 4 hours per day, 5 days per week of personal care services is sufficient to meet the patient's current needs. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed personal care services 6 hours per day, 7 days per week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems

Treatment: Crown-porcelain fuse to predominate base metal for teeth numbers 14 and 31

The insurer denied coverage for the crown-porcelain fuse to predominate base metal for teeth numbers 14 and 31.

The denial is upheld.

This is a female who presented to the dentist for dental evaluation and treatment. Full coverage crowns were recommended on tooth number 31 and endodontically treated tooth number 14 with recurrent decay under the preexisting crown. The insurer has denied these services stating that they are not medically necessary treatment.

Tooth number 14 exhibits significant recurrent decay/caries markedly undermining and compromising tooth integrity and tooth structure and involving the root structure. This decay under the preexisting crown clinically is subgingival and radiographically extends below the alveolar bone height. Effectively, this tooth will remain a retained root tip. The extent of caries renders this tooth a poor support for full coverage restoration.  
Additional definitive treatment after caries removal in the attempt to maintain this tooth in the arch would require periodontal crown lengthening surgery as there is inadequate biologic width, further compromising crown and root ratios, leaving less tooth structure than currently exists as support of a fixed crown. As this tooth would be prosthetically poor support for a crown restoration, it is determined that the services as recommended are not medically necessary.

In regards to tooth number 31, possible occlusal decay is noted on this tooth but no other significant change is identified affecting this tooth. Based on the radiographic images provided for review, a direct placement restoration would be appropriate treatment for this tooth in lieu of a crown. 

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient.

Based on the above, the medical necessity for crown-porcelain fuse to predominate base metal for teeth numbers 14 and 31 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchitis

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.

This is a male patient who presented to the Emergency Department (ED) with complaints of pleuritic type of chest pain. The patient also complained of some productive cough with yellow brown phlegm. He denied fever or shortness of breath (SOB). His past medical history was significant for asthma, hypertension (HTN), gout, and arteriovenous malformation (AVM) with cerebrovascular accident (CVA).

At presentation, the patient's vital signs were blood pressure 151/84, heart rate 103, temperature 99.4, and oxygen (O2) saturation 94%. The patient was described to be in no respiratory distress. Lung examination revealed bilateral wheeze. The patient's cardiovascular system was normal. He was awake and alert. His white blood cell (WBC) count was 14.4, hemoglobin 12.4, electrolytes and blood urea nitrogen (BUN)/ creatinine were within normal limits. The patient's electrocardiogram (EKG) had some non-specific changes. His troponin was negative. A preliminary read of the patient's electromagnetic radiation (x-ray) of the chest revealed a questionable right lower lobe (RLL) infiltrate but the official reading was no infiltrate or no pulmonary edema. His admission diagnosis was asthma/pneumonia.

The patient was initially treated with intravenous (IV) Rocephin and Azithromycin. IV steroids, bronchodilators via nebulizer, and Singulair were also added to the regimen. The patient remained stable after admission. Repeat EKG and troponins were unremarkable. The patient's chest pain was thought to be non-cardiac in origin. He was restarted on maintenance oral (PO) blood pressure medications. The patient was discharged on day 3 of admission on PO antibiotics and PO steroid taper with the rest of his maintenance medications.

This patient did not need acute inpatient hospitalization. By day 2 of admission the patient remained afebrile and was in no acute distress. There was mild wheeze on lung examination. WBC was 20 (the patient was on steroids). Viral panels were negative. By day 3 of admission the patient was switched to PO steroids, PO antibiotics and discharged home. This patient did not need acute hospitalization. He could have been placed on observation status while diagnostic testing and treatment were initiated. The patient did not have pneumonia. The patient's diagnosis was bronchitis.

The patient's asthma was mild and responded to steroids and bronchodilators. By day 2 of admission the patient was afebrile and hemodynamically stable.  He was not hypoxic, was tolerating orally, and was ambulatory. The patient was stable for discharge on oral antibiotics and bronchodilator and tapering steroids with close follow-up in an outpatient setting. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative colitis.
Treatment: Apriso 0.375 gm capsule.
The insurer denied coverage for the Apriso 0.375 gm capsule.
The denial is upheld.

The patient has a history of ulcerative colitis. The patient developed a headache with mesalamine treatment and swollen lymph nodes with mercaptopurine (6MP). There is a progress note that states that the patient was afebrile and denies rash abdominal pain, weight loss or change in appetite. There was no colonoscopy report submitted.

The American Gastroenterology Association (AGA) has published the AGA Clinical Practice Guidelines on the Management of Mild- to- Moderate ulcerative colitis. The guidelines state that the main stay of therapy for mild to moderate ulcerative colitis (UC) is the aminosalicylate (5-ASA) class of medications including sulfasalazine, mesalamine, and diazo-bonded 5-ASA. There is a strong recommendation with moderate quality of evidence that mesalamine and diazo-bonded 5-ASA are effective for mild to moderate ulcerative colitis, sulfasalazine is considered an acceptable alternative.

Based on the progress notes submitted, it appears that the patient's condition is of mild to moderate severity. Giving an aminosalicylate (5-ASA) medication is appropriate treatment. The patient had a headache with mesalamine. However, the insurance company has offered other 5-ASA medications including balsalazide and sulfasalazine. Mesalamine is an azo-bonded prodrug that is recommended by the American Gastroenterology Association (AGA). The guideline states that therapeutic efficacy and safety are similar with the different 5-ASA preparations. The insurance company has offered formulary alternatives to mesalamine; therefore, the use of Apriso is not 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 Apriso 0.375 gm capsule is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, Shortness of breath

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This is a female patient with a history of hypertension (HTN) who presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) for 1 day and elevated systolic blood pressure at home. She was seen in the ED two days prior for dizziness, nausea and HTN, which improved after administration of Zofran. The patient returned to the ED with complaints of SOB and that her blood pressure was 190/100 at home. The patient's initial vital signs included blood pressure (BP) 226/112, heart rate 95, respiratory rate 24, temperature 98.5, and oxygen saturation 96% on room air.  

On physical examination in the ED, the patient was noted to be well-appearing, alert and oriented with a normal cardiovascular, pulmonary and neurological exam. The patient was treated with intravenous (IV) and oral labetalol with improvement and then amlodipine was added to losartan for her BP control. The patient's electrocardiogram (EKG) revealed normal sinus rhythm with no acute ST elevation or depression, and that was unchanged from her prior EKG. The patient's chest X-ray was also unremarkable. The patient's echocardiography findings showed mitral annular calcium, calcified trileaflet aortic valve with normal opening and mild regurgitation, normal left ventricular systolic function and mild diastolic dysfunction (stage 1). The patient's Cardiolite stress testing to 89% maximum peak heart rate was normal. The patient was discharged home on day 2 of admission on losartan-hydrochlorothiazide and amlodipine.

Based on the review of the medical record and literature, there is no clinical evidence that this patient required an acute inpatient admission to treat her HTN or to determine that her dyspnea was not related to an acute coronary syndrome (ACS). The patient could have been monitored with diagnostic testing performed at a lower level of care, such as Observation status. The patient's clinical workup in the ED showed no evidence that this patient was at increased risk for short-term adverse cardiovascular events requiring inpatient monitoring and management. Thus, inpatient admission was 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 the inpatient admission is upheld. The medical necessity is not substantiated.