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

Diagnosis: Oligodontia.

Treatment: D6010, implant placement for tooth 2, tooth 3, tooth 4, tooth 5, tooth 6, tooth 7, tooth 8, tooth 9, tooth 10, tooth 11, tooth 12, tooth 13, tooth 14, and tooth 15.

The insurer denied coverage for D6010, implant placement for tooth 2, tooth 3, tooth 4, tooth 5, tooth 6, tooth 7, tooth 8, tooth 9, tooth 10, tooth 11, tooth 12, tooth 13, tooth 14, and tooth 15.

The denial is upheld.

Based on the submitted documentation which includes copy of panoramic radiograph, dental treatment note, narrative letter and insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist recommended endosteal implants in the areas as enumerated above. The dentist requested implants over removable partial dentures presumably due to patient's reported dysphagia, nausea, and potential bone atrophy. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in the maxilla and mandible. As regards to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. The documentation provided does not support, justify, or substantiate the requested treatment. Therefore, as other acceptable alternative treatments are appropriate, and removable dentures (full and partial removable) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from possible self-reported difficulty and bone atrophy, the endosteal implants and associated services are considered elective and not medically necessary.

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

The insurer's denial of coverage for D6010, implant placement tooth 2, tooth 3, tooth 4, tooth 5, tooth 6, tooth 7, tooth 8, tooth 9, tooth 10, tooth 11, tooth 12, tooth 13, tooth 14, and tooth 15 is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visits (x12)

The insurer denied coverage for D8080 braces and D8670 monthly visits (x12).

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, it appears that 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 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 a Handicapping Labio-Lingual Deviation 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 crossbite nor 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 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.  This is confirmed by several studies as referenced below. 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.

Uphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. Braces and monthly visits are not medically necessary for this patient.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visits (x12) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Cancer Screening
The insurer denied Oncotype DX Prostate. 
The denial was upheld.

This patient is a male with low volume, low stage, Gleason grade group 1 prostate cancer. His prostate revealed no nodule; clinical stage of cancer is T1c. He is being managed with active surveillance. As part of his therapeutic decision process, an Oncotype DX testing was performed.
At issue is the medical necessity of the Oncotype DX Prostate.

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

The requested health service/treatment of Oncotype DX Prostate is not medically necessary for this patient.
Based on current guidelines of American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN), the recommended test is not endorsed as it has not been shown to improve net health outcomes. ASCO notes, "Tissue-based molecular biomarkers (evaluating the sample with the highest volume of the highest Gleason pattern) may improve risk stratification when added to standard clinical parameters, but the Expert Panel endorses their use only in situations in which the assay results, when considered as a whole with routine clinical factors, are likely to affect a clinical decision. These assays are not recommended for routine use as they have not been prospectively tested or shown to improve long-term outcomes-for example, quality of life, need for treatment, or survival." (1) NCCN notes that the test has not been subjected to randomized controlled studies and has not been shown to improve net health outcomes. (2)
Therefore, the requested health service/treatment of Oncotype DX Prostate is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: rule out cancer
Treatment: MRI scan
The insurer denied Magnetic Resonance Imaging (MRI) of the Stomach Area without and with Contrast (Dye). 
The health plan's determination is upheld.

The patient is a female with family history of breast cancer in her mother, gastric cancer in her maternal grandfather, and breast cancer in two of her maternal grandfather's sisters. She had finding of a PALB2 (Partner and Localizer of BRCA2) genetic mutation (heterozygous). She underwent magnetic resonance imaging, which showed a normal pancreas and no suspicious abdominal findings. 

The Magnetic Resonance Imaging (MRI) of the Stomach Area without and with Contrast (Dye) is not medically necessary for this patient.
Although multiple guidelines differ, all recommend screening when there is a significant family history in addition to carriage of a high-risk gene. The American College of Gastroenterology guidelines recommend screening for pancreatic cancer in patients with the PALB2 gene in addition to a first- or second-degree relative with pancreatic cancer. The U.S. Preventive Services Task Force (USPSTF) did not assess screen for pancreatic cancer in patients at high risk (i.e, those with positive genetic testing or a family history). The International Cancer of the Pancreas Screening (CAPS) Consortium recommends screening in carriers of the PALB2 mutation only if there is a first-degree relative with pancreatic cancer. The American Gastroenterological Association review on pancreas cancer screening in high-risk individuals states that while PALB2 confers increased risk, screening is recommended only in patients with a first- or second-degree relative affected by pancreatic cancer.
The provided documentation does not state that the patient has a first- or second-degree relative with pancreatic cancer. American College of Radiology Appropriateness Criteria do not make a clear recommendation, citing lack of clear screening guidelines and lack of data. Therefore, based on the submitted information, the MRI is not supported by guidelines for pancreatic cancer screening.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lambert-Eaton Myasthenic Syndrome.
Treatment: Firdapse 10mg Tablet 1.5 For 30 Days.
The insurer denied the Firdapse 10mg Tablet 1.5 For 30 Days.
The denial is upheld.

The patient is a female with paraneoplastic Lambert Eaton Syndrome. She was treated with plasmapharesis and IVIG (intravenous immunoglobulin) and started on Firdapse with improvement in her condition.

No, the requested Firdapse is not medically necessary.
There is no documented reason as to why the patient cannot be treated with the preferred medication, Ruzurgi. This medication has been demonstrated to be effective for her condition and is considered a standard-of-care treatment option here. There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Firdapse relative to the preferred Ruzurgi (Ivanovski and Miralles).

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Occupational Therapy. 

The insurer denied occupational therapy. 
The denial is upheld.

The patient is a male with a diagnosis of lack of coordination. Clinical records available include a letter from the children's therapy, occupational therapy (OT) initial evaluation, a progress note which indicates activities/exercises performed as play. The initial evaluation documents the standardized instruments of Hawaii Early Learning Profile 2nd Ed. (HELP-2) with decreased attention and minimal deficit in fine motor skills.
The subject under review is the medical necessity for the occupational therapy.

The health plan's determination is upheld.

The requested occupational therapy health service is not medically necessary for this patient. Transition to Home Exercise Program is appropriate when patients have reached a plateau or when the activities performed in therapy can be performed by non-skilled caregivers/parents who have received training by therapists which is the case for this patient. Skilled occupational therapy is not necessary in this case.
The patient's therapy progress notes do not support the medical necessity for the standards of practice for occupational therapy. No indication of interventions which can only be provided by a skilled therapist, no indication of progress towards goals, and no medically necessary goals are documented in the clinical information submitted nor is there any notation of activities which cannot be performed within the home exercise program environment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Disorders-Other-TIA/transient ischemic attack
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

The patient has a past medical history (PMH) of transient ischemic attack (TIA) and bilateral vertebral artery dissection and was admitted with complaints of (c/o) acute onset of right arm numbness and vision loss. Vital signs were unremarkable. Physical exam was unremarkable. Lab work was unremarkable. Imaging studies including a chest x-ray (CXR) showed no acute disease, a computed tomography angiography (CTA) of the neck showed arterial dissection of the right vertebral artery with 95% (percent) luminal narrowing. The patient was diagnosed with acute right vertebral artery dissection and treated with anti-platelets and close clinical monitoring with expert consultation. The vertebral artery dissection was subsequently determined to be related to previously known dissection. The patient was discharged in stable condition. 

The hospital stay was medically necessary at an acute inpatient level of care. This patient with a complicated neurological history presented to the emergency department (ED) with c/o acute onset of right arm numbness and vision loss and was ultimately diagnosed with TIA. This patient's clinical status was unusually tenuous given the patient's prior history of vertebral artery dissection and evidence of an acute vertebral artery dissection on imaging in the ED, per initial read. It is important to consider the heightened risk of early ischemic events in these events and the potential need for rapid access to risk-modifying treatments such as revascularization and anticoagulation. The inpatient admission appropriately permitted the medical staff to complete a rapid diagnostic evaluation to determine the cause of the TIA, implement immediate measures to optimize potentially compromised cerebral perfusion, if necessary, and start secondary prevention strategies without delay, including endarterectomy if there is carotid stenosis or anticoagulation if a cardioembolic source is identified, or severe hypertension (HTN) treatment, should it be necessary. Overall, given the patient's medical history and critical imaging finding on admission, the patient required an inpatient level of care for appropriate medical care.

Regarding the provided Milliman Care Guidelines (MCG) Health, 24th edition criteria, the patient met the following: admission is indicated for 1 or more of the following: arterial dissection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I Occlusion
Treatment: Braces
The insurer denied Adjustment of Braces (Periodic Orthodontic Treatment Visit) and Insertion of Braces (Comprehensive Orthodontic Treatment of the Adolescent Dentition). The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion with 5 millimeter (mm) overbite and 4 mm overjet. She has maxillary and mandibular crowding. Tooth 3 is in crossbite. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion.

The Adjustment of Braces (Periodic Orthodontic Treatment Visit) and Insertion of Braces (Comprehensive Orthodontic Treatment of the Adolescent Dentition) is not medically necessary for this patient.

There is no medical reason to correct the patient's malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are no functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient's overjet is more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 mm. If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis
Treatment: Kesimpta 20MG/4ML Auto injector pens
The insurer denied the Kesimpta 20MG/4ML Auto injector pens
The denial is upheld.

The patient is a male with multiple sclerosis (MS). He has not been treated with
any other disease modifying therapy. The provider is requesting Kesimpta. This
was denied coverage as he has not tried and failed the preferred agents, Tysabri and Ocrevus.

No, the treatment with Kesimpta is not medically necessary.
There is no documented reason as to why the patient cannot be treated with the
preferred formulary agents for his condition. There are agents on the formulary,
specifically, oreclizumab and natalizumab, which are considered highly effective
and aggressive treatment options. All of the preferred agents are FDA (United
States Food and Drug Administration)-approved for his condition, based on highquality clinical trials published in the peer-reviewed medical literature (Rae-Grant et
al.). There are no high-quality clinical trials or standard of care guidelines
supporting the preferential use or superiority of Kesimpta relative to the preferred
agents. There is no evidence that Kesimpta is as effective as natalizumab or
ocrelizumab.

Therefore, given the above, Kesimpta is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis.
Treatment: Kesimpta 20MG/4ML Auto injector pens.
The insurer denied the Kesimpta 20MG/4ML Auto injector pens.
The denial is upheld. 

The patient is a male with multiple sclerosis (MS).  He has not been treated with any other disease modifying therapy. The provider is requesting Kesimpta. This was denied coverage as he has not tried and failed the preferred agents, Tysabri and Ocrevus.

No, the treatment with Kesimpta is not medically necessary.
There is no documented reason as to why the patient cannot be treated with the preferred formulary agents for his condition. There are agents on the formulary, specifically, oreclizumab and natalizumab, which are considered highly effective and aggressive treatment options. All of the preferred agents are FDA (United States Food and Drug Administration)-approved for his condition, based on high-quality clinical trials published in the peer-reviewed medical literature (Rae-Grant et al.). There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Kesimpta relative to the preferred agents. There is no evidence that Kesimpta is as effective as natalizumab or ocrelizumab.

Therefore, given the above, Kesimpta is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological-Infection post hysterectomy
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient presented to the emergency room with abdominal pain. She also had vaginal discharge, fever, and nausea. Her history was significant for a hysterectomy one week prior and a history of premature ventricular contractions and cardiac catheterization. A computed tomography (CT) scan showed multiloculated pelvic fluid suspicious for an infectious process. Vital signs were normal however her blood pressure was low at 89/57 in the emergency room per the letter. Physical examination showed pelvic tenderness. She was admitted as an inpatient with antibiotics, fluids and laboratory tests provided. She was also given pain medication and a vulvar laceration was sutured. She was discharged the following day. Hospital records were not provided.

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient.
No hospital records were provided for review; however, the patient appears from the letters that she could have been admitted under a lower level of care status for monitoring of the response to treatment. There was no hemodynamic instability, pulmonary collapse nor metabolic concerns. She did have one low blood pressure however other blood pressures were normal. Hemoglobin was mildly low at 9.7 with a repeat stable at 9.0. She did not have any cardiac concerns nor a complication of her cardiac history. She was not hemorrhaging, nor did she need additional surgeries/procedures. She could have been observed at a lower level of care and then discharged home, which is exactly what happened. The determination is limited by the information provided in letters.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Crisis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient in this case has a history of sickle cell disease.  She was admitted to the hospital with sickle cell crisis. She complained of worsening back and leg pain and also palpitations. It was noted that she had been recently hospitalized and had signed herself out AMA (against medical advice) as she wanted to be home for her birthday. She came back to the hospital with worsening pain. At the time of admission vital signs were notable for mild tachycardia and mild hypertension. Hemoglobin was 7.9g/dl.  She was admitted and started on Dilaudid IV (intravenous), Benadryl IV(intravenous) and folic acid supplementation.  She was also treated with IV (intravenous) fluids. She was treated with Lovenox due to her history of pulmonary embolism.  She left against medical advice after three days because her mother was unwell.

No, the inpatient stay was not medically necessary.
This patient was hospitalized with pain but had no severe anemia and no hemodynamic compromise or active infection or any other significant complication due to sickle cell disease. She was treated with pain medication but left against medical advice, indicating that she did not clearly require hospital admission for management of her pain.  Given that and given lack of any other indication for acute care hospitalization in this case, the hospital admission in this case was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.