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

Diagnosis: Axial low back pain.
Treatment: Facet joint injections.
The insurer denied: Facet joint injections.
The denial is upheld.

The patient is an adult female. Per the appeals letter, the patient has a history of axial low back pain that is rated 7/10. The patient has tried three months of activity modification, physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs) and over-the-counter pain killers. Severe pain is noted over the L3-4, L4-5 and L5-S1 facet joints with positive facet loading maneuvers. X-ray showed multilevel degenerative disc disease and facet arthropathy. The patient presented with a history of low back pain mostly on the right side that does not radiate. The patient continues to have difficulty walking due to low back pain. 
Physical therapy helped reduce spasms slightly with increased range of motion in the short-term. Examination was positive for pain over L3-L5. Pain was axial. A facet loading test was positive. Diagnoses included lumbago and lumbar facet arthropathy. The request for facet joint injections was denied by the health plan due to lack of imaging studies showing that there is no other obvious cause of the patient's pain.

The proposed facet joint injections are not medically necessary.

Based on the documentation provided, the requested procedure is not considered medically necessary in this case. The patient has a history of low back pain that is axial and non-radicular. 
Despite prior conservative treatments including physical therapy, activity modification as well as medications, the patient continued to be symptomatic. Though the patient has tried prior conservative treatments, there was no provided imaging such as magnetic resonance imaging (MRI) to support the requested procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis.
Treatment: Dupixent (dupilumab).
The insurer denied: Dupixent (dupilumab).
The denial is upheld.

The patient is an adolescent female with atopic dermatitis. She has been treated with topical steroids and calcineurin inhibitors. The provider is requesting Dupixent. The health plan requires use of phototherapy and systemic immunosuppressants prior to use of Dupixent.

The proposed use of Dupixent is not medically necessary.

According to the recommendations provided by Simpson et al. (2017), steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy. While oral immunosuppressive medications may not be specifically Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis, their use is considered standard and well supported in the medical literature. Therefore, Dupixent is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I, vertical growth pattern, mild.
maxillary crowding, moderate mandibular crowding.
Treatment: Insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustments of braces (periodic orthodontic treatment visit).
The insurer denied: Insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustments of braces (periodic orthodontic treatment visit)
The denial is overturned.

The patient is a teenaged female requesting orthodontic treatment. The patient has a Class I malocclusion and has mild upper and lower crowding and a crossbite of anterior teeth #7 and 27. The prior denial was due to the patient having a handicapping score of 10.

The proposed insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustments of braces (periodic orthodontic treatment visit) are medically necessary.

The patient has an anterior tooth crossbite (reverse bite) between teeth #7 and 27, with loss of gingival (gum) attachment. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem, and the case has medical necessity. Additionally, periodic adjustments are needed to make sure all treatment is progressing properly according to plan.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: Intracept procedure
The insurer denied coverage for the Intracept procedure.
The denial is upheld.

This patient is morbidly obese, with a Body Mass Index (BMI) of 48. He has chronic low back pain. His medication trials have included Skelaxin, Hydrocodone with Acetaminophen and Diazepam. He is doing a Home exercise program. He has tried cold/heat and transcutaneous electrical nerve stimulation (TENS). One progress note states he has not had physical therapy (PT) or Chiropractic. Another states that he had tried these with minimal improvement. He has had multiple interventional procedures including Epidural Steroid injections, facet injections and radiofrequency (RF) ablation. His magnetic resonance imaging (MRI) shows Modic changes at lumbar (L) 4-L5 and L5-sacral (S)1. The request is for RF ablation of the basivertebral nerves (BVNs).	

The publications to date have been company sponsored and had methodology flaws. There are no published data on long term complication rates. There are other evidence- based interventions available to this patient. This procedure is unlikely to be more beneficial than the standard approaches.

Conger, et al (3) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain (CLBP) who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the BVN. Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Urits, et al (5) also commented on the need for more research on this promising technique: "reproducible large RCTs (randomized control trials) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of CLBP and improve the quality of life of CLBP patients in the near future."

In sum, this procedure is not likely to be more beneficial than the standard of care.

In summary, the denial of intraosseous ablation (heat destruction) of the BVNs (nerve branches that supply the lower vertebrae) (Intracept procedure) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Iron deficiency anemia
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This patient had a history of a gunshot wound (GSW), lobectomy, and a pulmonary embolism and was referred from the clinic for severe iron deficient anemia. She was complaining of shortness of breath (SOB) on exertion. She was also having chronic diarrhea and heavy menstrual bleeding. She was hemodynamically stable. The abdominal exam was benign. The hemoglobin was 6 with a baseline hemoglobin of 8. The gastroenterologist advised that she was not having active gastrointestinal bleeding and did not require urgent endoscopic intervention. She received a transfusion and was advised to have outpatient endoscopic testing.

Clinical indications for admission for Iron Deficient Anemia [Milliman Care Guidelines (MCG) M-35] include hemodynamic instability, active bleeding that cannot be controlled with observation care, altered mental status, severe cardiac arrhythmias, severe thrombocytopenia, acute renal failure, and having evidence of cardiac ischemia that persists after observation care. The patient did not have these conditions.

This patient had chronic anemia and a decrease in her baseline hemoglobin. She required a transfusion, but this could have been given on an ambulatory basis. She did not meet MCG criteria for admission for Iron Deficient Anemia. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Failure.

Treatment: Automatic external defibrillator (code K0606) rendered.

The insurer denied coverage for automatic external defibrillator (code K0606) rendered.

The denial is overturned.

The patient presented to the hospital with chest pain. Work up revealed non- ischemic heart failure with severely reduced biventricular function. Cardiac catheterization revealed no significant coronary disease and an elevated left ventricular (LV) end diastolic pressure. Electrocardiogram was significant for atrial fibrillation and revealed a left ventricular ejection fraction (LVEF) of 10-15 percent (%). The patient was treated with guideline directed medical therapy and discharged with a wearable defibrillator. Subsequent cardiac magnetic resonance imaging (MRI) performed revealed an LVEF of 19%. Repeat echocardiogram in following three months of guideline directed medical therapy and restoration of sinus rhythm, demonstrated an LVEF less than 30%. The patient was implanted with a dual chamber implantable cardioverter-defibrillator (ICD) device.

This patient presented with severely depressed LVEF and new onset of heart failure in addition to the patient's history of atrial fibrillation. The Sudden Cardiac Death Heart Failure Trial (SCD-HFT) demonstrated that such patients have a significant risk of sudden cardiac death and benefit from ICD therapy. In addition, cardiologists must always attempt to treat reversible causes of cardiomyopathy prior to implanting an ICD. During this period of diagnostic testing and treatment, patients are at risk for sudden cardiac death and must be protected. Wearable LifeVest defibrillator therapy provides such protection while physicians determine whether treatment will result in an improvement in cardiac function. If medical therapy fails to result in an improvement in this patient's LVEF and functional class, then an implantable device would be recommended. This patient's severely depressed LVEF places him at high risk for sudden cardiac death during titration of anticongestive therapy. Guideline statements from the Heart Rhythm Society/American Heart Association and the American College of Cardiology specify that wearable LifeVest defibrillator therapy should be utilized during periods when patients are at risk of sudden cardiac death. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for automatic external defibrillator (code K0606) rendered is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental issues
Treatment: Bridge on Teeth 18, 19, 20 and 21
The insurer denied Bridge on Teeth 18, 19, 20 and 21.
The health plan's determination is overturned. 

The patient is a female who presents for evaluation and treatment of teeth # (number) 18, 19, 20 and 21. 

Bridge on Teeth 18, 19, 20 and 21 is medically necessary for this patient. The treatment of removable partial denture is not equivalent to that of a fixed partial denture based on the fact that it requires preparation of uninvolved teeth across the arch, is tissue born and moves when chewing, and requires the patient to manage the prosthesis while chewing. The fixed partial denture will only involve the adjacent teeth and replaced the missing teeth in a manner that is closest to what the patient had prior to tooth loss. The requested treatment is indicated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Class I occlusion.
Treatment: braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is upheld. 

The patient is a male with a Class I occlusion with 6 millimeter (mm) overbite and 3mm overjet. He has moderate maxillary and mandibular crowing. He is treatment planned for orthodontics to correct his malocclusion. 

Braces and monthly visits are not medically necessary. 
While the patient is 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.2 This patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient has a 3mm overjet, but this amount of overjet does not affect oral health related quality of life.
Regarding the potential effects of his malocclusion on speech - the malocclusions most commonly seen affecting speech are Class III malocclusion, and either anterior open bite or posterior crossbite. The patient has none of these malocclusions. In fact, the research shows a deep bite actually has a protective relationship to speech distortion. Therefore, orthodontic treatment is unlikely to improve the patient's articulation. His speech problems are likely unrelated to his malocclusion.
If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and shortness of breath
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult female patient was hospitalized for chest pain and shortness of breath. Her past medical history was significant for gastric carcinoma treated with chemotherapy and currently in remission and cholecystectomy. The patient presented to the 
emergency department for evaluation of crushing, central chest pain which began the evening prior. Initially, the patient's blood pressure was 177/77, heart rate was 120, respiratory rate was 18, oxygen (O2) saturation was 98% (percent) and she was afebrile. There are no significant other findings on physical exam. Labs revealed a normal troponin and pro-brain natriuretic peptide (BNP). The 
patient was mildly anemic. Electrocardiogram (EKG) showed sinus rhythm, rate 85. Chest film reported mild peribronchial cuffing in both lungs. Echocardiogram revealed hyperdynamic left ventricular systolic function with an ejection fraction (EF) greater than 75% and mild left ventricular hypertrophy (LVH). Follow-up troponin was elevated at 0.015, but the third troponin was normal. The patient's D-dimer was elevated, but her ventilation perfusion (V/Q) lung scan came back as low probability for pulmonary embolism (PE). The patient responded to medical measures, including pantoprazole and DuoNebs. Tachycardia resolved and the blood pressure improved to 130/66 on the day of discharge. Clinical impression was asthma with a component of anxiety; she had recently arrived from Bangladesh. This is an appeal of the denied claim for 
the acute inpatient hospital stay.

The proposed treatment was not medically necessary.

Based on opinion and the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the Milliman Care Guidelines (MCG) for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism, aortic dissection or acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care she received, including management of chest pain from suspected gastroesophageal reflux disease (GERD) with a component of anxiety from situational stress like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right shoulder pain.
Treatment: Physical therapy treatment services.
The insurer denied coverage for physical therapy treatment services.
The insurer's denial was upheld.

This is a patient with right shoulder pain. A right shoulder magnetic resonance imaging (MRI) scan demonstrated a full thickness tear of the supraspinatus tendon. Treatment included physical therapy. Physical therapy (PT) treatment is under review.  

There were no physical/occupational therapy treatment notes made available for review providing objective clinical information to support the medical necessity for treatment. The physical/occupational therapy treatment notes are required to establish the medical necessity of a structured out-patient physical/occupational therapy treatment program. The provision of extensive physical/occupational therapy, without documented functional improvement is essentially maintenance treatment and therefore not medically necessary.  

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

From a physical medicine & rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, based on the enclosed clinical information available for review, physical therapy (PT) treatment was not medically necessary.

Based on the above, the insurer's denial must be upheld. The medical necessity for physical therapy treatment services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion 

Treatment: braces and monthly visits

The insurer denied coverage for braces and monthly visits

The denial is upheld 
 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index Report 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. 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 23 points on review by internal reviewers. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of 
cross bite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Based on the above, the insurer's denial must be upheld. The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient. The medical necessity for braces and monthly visits services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III subdivision left malocclusion 
Treatment: Insertion of Braces (Comprehensive Orthodontic Treatment of the Adolescent Dentition) and Adjustment of Braces (Periodic Orthodontic Treatment Visit)
The insurer denied insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) and adjustment of braces (periodic orthodontic treatment visit). The health plan's determination is overturned. 

The patient in question is a female with impacted tooth # (number) 20. This tooth is unable to erupt due to crowding. She presents with a Class III subdivision left malocclusion and significant crowding. Tooth 21 is touching tooth 19 and tooth 20 is completely blocked out of the arch. 

Insertion of braces and adjustment of braces (comprehensive orthodontic treatment of the adolescent dentition and periodic orthodontic treatment visit) are medically necessary for this patient.

Approximately 10% (percent) of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. If left untreated, the damage that can occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.