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

Diagnosis: Dental Problems (skeletal Class I, Class II canines, maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss). 

Treatment: D8080 Braces and D8670 Monthly Visit x12.

The insurer denied coverage for D8080 Braces and D8670 Monthly Visit x12.

The denial is overturned. 

This is a male patient who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, Class II canines, maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss.  The orthodontist has completed the Handicapping Labio-Lingual (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, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining a score of 17 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, an HLD index is utilized.  This index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used, utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary.

In this case, the treating orthodontist claims 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 met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.
 
Regarding the validity of the HLD 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 cited 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.

The healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient. D8080 braces and D8670 monthly visit x 12 is considered medically necessary for this patient.  

The medical necessity for D8080 Braces and D8670 Monthly Visit x12 is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use. 
Treatment: Substance Abuse: Inpatient hospital.
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned. 

This is a female patient who was admitted to inpatient hospital detoxification treatment.  She reportedly had active withdrawal symptoms including tremors, diaphoresis, nausea, headache, dizziness, high blood pressure, and had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 14.  She was noted as drinking 1 to 1 1/2 pints of vodka per day.  She had a history of hypertension, elevated liver function tests (LFT's), depression and anxiety.  She had alcohol hepatitis. She was put on a Librium taper and was prescribed Lorazepam as needed for detoxification treatment.  The care plan was implemented until the patient signed out against medical advice (AMA).

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  In this case, this patient had been using large amounts of alcohol daily including up to 1 1/2 pints of vodka per day and had active alcohol withdrawal including a CIWA of 14 and alcohol withdrawal including tremors, diaphoresis, nausea, headache, dizziness, high blood pressure, and was at risk of complicated and life-threatening withdrawal.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24 hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use large amounts of alcohol, needed detoxification medications including a Librium protocol and Lorazepam prn, and she had comorbid medical issues and psychiatric issues including hypertension, elevated LFT's, depression and anxiety.  She continued to drink large amounts of alcohol daily despite negative consequences from alcohol and lacked the coping skills to stop alcohol use and needed 24 hour hospital detoxification as she was considered a high risk medically.  She needed 24 hour treatment then as she was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including possible life threatening withdrawal such as delirium tremens.  She reportedly left AMA.  This was a high risk patient who had withdrawal symptoms and was drinking large amounts of alcohol, who left AMA and was considered a high risk medically for severe, complicated, and life threatening withdrawal.   

Inpatient hospital detoxification treatment was medically necessary.  It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient then.

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized periodontal pocketing

Treatment: D4341 Deep Gum and Root Cleaning, All Four Quadrants

The insurer is denied coverage for D4341 Deep Gum and Root Cleaning, All Four Quadrants.

The denial is upheld. 

This female patient with no documented history. The patient presented to the dentist's office. The patient's teeth x-rays were taken. The treating dentist determined that the patient needed D4341 Deep Gum and Root Cleaning, All Four Quadrants.

Based on the submitted documentation which includes copies of full mouth series radiographs, periodontal charting, and insurer correspondence, it appears that this patient presented for evaluation for dental services and periodontal therapy. The dentist reported periodontal chartings indicating 2-4 millimeter (mm) generalized periodontal pocketing. The recommended treatment was scaling and root planing in all four maxillary and mandibular quadrants. The insurer has denied the service as the information provided does not show evidence of moderate to severe periodontal disease and therefore does not meet clinical criteria to support scaling and root planing.  The patient is appealing the decision.
	
Upon review of the submitted documentation, in particular the periodontal probing and bitewing radiographs, there is minimal if any loss of alveolar bone height affecting these teeth. The increased pocket depths likely represent pseudopocketing due to superficial calculus accumulation and poor oral hygiene.  It is focal and isolated to only a few teeth in these quadrants. There is minimal significant periodontal probing with no periodontal probing over 4 millimeter (mm) depth. And bleeding on probing is not documented. The insurer has correctly applied the clinical criteria in denying scaling and root planing services.

The coverage for D4341 deep gum and root cleaning, all four quadrants is not considered medically necessary as the clinical and radiographic documentation do not support or substantiate scaling and root planing services.

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

The carrier's denial of coverage for the D4341 Deep Gum and Root Cleaning, All Four Quadrants is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (Skeletal Class I molars, Class I canines, excessive overjet, low labial frenum and deep impinging overbite).
Treatment: D8080 Braces.
The insurer denied coverage for D8080 Braces.
The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I molars, Class I canines, excessive overjet, low labial frenum and deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index, attaining 8 points on review by their internal reviewers.  

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD Index is utilized. This index provides 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 deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer, attaining 8 points (i.e., 3 points overjet, 4 points overbite, and 1 point labiolingual spread).

D8080 braces are not considered medically necessary for this patient.  

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

The carrier's denial of coverage for D8080 Braces should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

This case involves a female with a history of hypertension and diabetes who presented to the hospital with acute chest pain. The patient reports experiencing central chest pain, described as sharp, 9 out of 10 on the pain scale, occurring at rest, with a partial resolution when she arrived in the emergency department. There is no radiation of the pain. The patient follows with a cardiologist every 6 months, secondary to prior syncopal episodes. She has undergone an implanted loop recorder and had a negative stress test around that time. She was brought into the emergency department for an assessment. Initial vital signs show a temperature of 97.9, respirations of 18, and blood pressure 150/82. On exam, the chest is nontender, lungs are clear, and there is no respiratory distress. Cardiac rhythm shows regular rate and rhythm with no lower extremity edema or jugular vein distention (JVD). The rest of the exam is unremarkable. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The requested health service/treatment of inpatient stay is not medically necessary for this patient. This patient's presentation can be managed under a lower level of care, as is the standard of care.

This presentation involves a relatively low-risk chest pain scenario, with a low heart score, validated in multiple studies. For this type of presentation, the standard of care is overnight monitoring, with serial cardiac enzymes, telemetry monitoring, and serial electrocardiograms (EKGs). If an acute coronary syndrome is ruled out as the cause of the chest pain, a typical patient is released home. Based on the provided documentation, the patient ruled out for acute coronary syndrome with serial cardiac enzymes since serial EKGs, which showed no evidence of ST-segment (interval between ventricular depolarization and ventricular repolarization) changes. The patient had recent cardiac stress testing within the past 12 months of hospitalization, which was normal. There is no indication for admission to inpatient care. There is no evidence of hemodynamic instability, respiratory distress, evidence of aortic dissection as potential alternative causes for the patient's chest pain other than angina and myocardial infarction. The clinical literature is clear on the evaluation and treatment algorithm of chest pain and is validated to multiple studies. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient stay

The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is female with chest pain and shortness of breath for 2 days. The patient reported sharp, pinching chest pain intermittently at the left side of her sternum. (According to the cardiology consult, she described her chest pain as "a little pricking" in the right side of her chest 4/10 at its worse, not related to exertion but worse with inspiration).

The pain started the day prior to admission. She also reported difficulties sleeping during the night secondary shortness of breath. She has 3 pillows orthopnea. She also had mild leg swelling. This was one of her multiple admission with shortness of breath for last several months.

The patient has history of congestive heart failure (CHF), hypertension (HTN), chronic kidney disease (CKD) III and asthma. She also is morbidly obese.

On physical examination her vital signs were normal, she had wheezing and decreased breath sounds. The rest of her physical examination was unremarkable. The patient underwent a computed tomography (CT) angiography, and it revealed no evidence of pulmonary emboli.

The Inpatient Hospital Admission is not medically necessary for this patient. The patient presented with CHF exacerbation and atypical chest pain. Based on her presentation, her CHF exacerbation was mild. Her BNP was not very high, her CXR revealed mild CHF and her physical examination did not suggest severe respiratory distress. The patient responded well to IV Lasix and her condition improved.

The patient had atypical chest pain, and the cardiology service did not believe that she had indication for work up of her chest pain. Her recent coronary angiography was unremarkable. The patient received IV Lasix with good response. Her cardiac MRI could have been performed at a lower level of care.

Based on above, the inpatient level of care was not medically necessary. A lower level would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Areata Totalis.
Treatment: Xeljanz 5MG (milligram) OR TABS.

The insurer is denied coverage for Xeljanz 5MG (milligram) OR TABS.  The denial is upheld.

This male patient has a history of affecting scalp, eyebrows, axillae, arms and legs.  He is status post dexamethasone with minimal improvement and Xeljanz denied in the past.  He has also trialed ezetimibe/ simvastatin without any improvement.  The patient was treated with intralesional Kenalog on more than 8 lesions on the scalp/eyebrows treated with a total of 0.8cc (cubic centimeters) and 2.5mg/cc to eyebrows and 5cc at 5mg/cc to scalp.  The patient tolerated the injections without event.  The physician is requesting authorization of Xeljanz for the patient.

This is a male with alopecia areata totalis affecting scalp, eyebrows, axillae, arms and legs.  Xeljanz has been requested.

Xeljanz is not medically necessary for the patient's condition, alopecia areata.  The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, DPCP (Diphenylcyclopropenone), calcipotriene, and anthralin. (1-7)  

Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata, further studies are needed to demonstrate the long term efficacy and safety of Xeljanz.  It is noted that the Food and Drug Administration (FDA) released a finding that shows  increased risk of deep vein thrombosis and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10mg bid (twice a day). (1)   

The standard of care for treatment of alopecia areata would necessitate an attempt to use the above mentioned non-systemic options for the treatment of alopecia areata.  

The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possible improve alopecia areata, including light therapy, squaric acid, DPCP (Diphenylcyclopropenone), and anthralin. (8-11)

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

The carrier's denial of coverage for Xeljanz 5MG OR TABS is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Braces and monthly visits. 

The insurer denied braces and monthly visits.  The denial is overturned.

The patient is a male with an anterior crossbite on tooth 7. He presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. He is treatment planned for orthodontics to address the crowding and crossbite. The subject under review is the medical necessity for braces and monthly visits for this patient.

The health plan's determination is overturned.

The requested treatment of braces and monthly visits is medically necessary for this patient. This patient presents with an anterior crossbite on tooth 7. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.1,2,3 If left untreated the damage that will likely occur to the patients teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Respiratory
Inpatient Hospital

Diagnosis: COPD
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a man who presented to the hospital. He had a history of human immunodeficiency virus (HIV), heart failure, chronic obstructive pulmonary disease (COPD), alcohol abuse, and chronic humerus fracture. He presented with a fall, increasing wheezing, and pain in the left arm and lower back. He stated that he was drinking alcohol and while walking on the streets, someone pushed him and he fell and landed on his left arm. The pain was rated three out of 10 in severity. He also reported wheezing and shortness of breath for the past four days. He denied fevers, loss of taste and smell, and weakness. Vital signs showed temperature 98.2 Fahrenheit, heart rate 90, respiratory rate 20, and blood pressure 150/88. On physical exam, heart was regular, breath sounds head wheezing bilaterally, abdomen was soft and nontender, and he had spinal tenderness in the lumbar region. Labs showed white blood cell (WBC) 5.2, hemoglobin 14.7, platelets 261, sodium 139, potassium 4.4, and creatinine 0.8. In the emergency department, the patient at one point stated that he wanted to leave and then later stated he preferred to stay because he had no one at home to take care of him. The patient was admitted for acute COPD exacerbation and alcohol withdrawal. 

The inpatient emergency admission was not medically necessary. The reason is that the patient was hemodynamically stable, had stable blood pressure, an oxygen saturation of 95%, and a respiratory rate of 20 at the time of presentation to the emergency department. The patient had no respiratory distress or hypoxia at the time of presentation. He did have wheezes and was diagnosed with COPD exacerbation but the presentation was consistent with a severity of COPD that is routinely managed at a lower level of care. The emergency department notes indicate that the patient initially planned to leave the emergency department but then stayed in the hospital due to the absence of a caretaker at home. The emergency department attending note indicates that the patient specifically said that he could not go home because he was homeless. Overall, while the patient did receive care during the hospital stay, the decision to admit him to the inpatient level of care was not supported by his clinical status in the emergency department. He could have safely been cared for at a lower level of care. Ultimately the decision to admit this patient appears to have been related to his homelessness and not to the presence of an acute medical condition.