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

Diagnosis: Dental Problems. 
Treatment: Braces.

The insurer denied braces. 
The denial is upheld in whole.

The patient is a female with a Class II occlusion with 3-millimeter (mm) overjet and 7mm overbite. The maxillary and mandibular arches have crowding. Tooth 11 is blocked out to the labial. She is treatment planned for orthodontics to correct her malocclusion, but her insurance company rejected the claim on the basis that treatment is not medically necessary.
The subject under review is the medical necessity for braces.

The health plan's determination is upheld.

The requested treatment with braces is not medically necessary for this patient. There is no medical reason to correct her malocclusion with braces. The patient has crowding. Her bite is deep but there is no indication of damage to the incisors or the palate in the photographs, and her cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided there is severe soft tissue damage (or any soft tissue damage) on this patient. While the patient does have a deep bite, that alone is not a medical necessity to treat. There are functional problems that can 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. Although the dental evaluation indicates a bilateral posterior crossbite the supplied photos do not show any crossbites. The patient has a 3mm overjet, but this amount of overjet does not affect oral health related quality of life.(2) 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. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic low back pain.
Treatment: Back Surgery.
The insurer denied the Back surgery.
The determination is overturned.


The patient has a history of low back pain of several year's duration. She had tried medications including amitriptyline, tramadol, non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxers and Tylenol with no success. She had failed epidural injections, facet blocks, radiofrequency ablation and physical therapy (PT) in the past. The physical exam (PE) was unremarkable. Lumbar magnetic resonance imaging (MRI) was significant for Modic type 2 changes at lumbar (L) 5- sacral (S) 1 with severe loss of disc height at L5-S1. This patient was recommended to have an Intracept procedure for her persistent back pain.
At issue is the medical necessity of the Intracept procedure.

The requested procedure is medically necessary. The Intracept system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient has persistent back pain consistent with L5-S1 Modic changes. She had failed extensive treatments including epidural injections, facet blocks, radiofrequency ablation and PT. Further intervention is medically necessary to improve her pain and functional level. Given the patient's clinical scenario, the Intracept procedure is medically necessary as the appropriate next step intervention.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who had presented to the emergency department with the complaints of ten out of ten abdominal pain.  The pain was sharp.  The patient had a history of hypertension, atrial fibrillation and a history of colonic perforation with a colostomy. The patient received supportive care, intravenous morphine, a computed tomography (CT) scan and a surgical consultation.

The proposed inpatient admission was not medically necessary.
While the care was medically appropriate, the care was not medically necessary at the level at which it was rendered.

The health plan act reasonably, with sound medical judgment and in the best interest of the patient.
Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid Obesity. 
Treatment: Procedure code 43644, bariatric surgical procedure and subsequent hospital admission. 

The insurer denied coverage for procedure code 43644, bariatric surgical procedure and subsequent hospital admission. 

The denial is overturned. 

The National Institutes of Health has indicated that bariatric surgery is appropriate for all patients with a body mass index (BMI) greater than 40, or for patients with a BMI of 35 to 40 with associated comorbid conditions. Obesity-related comorbidities are conditions that are directly caused by obesity or contribute to the severity of the condition. Obesity-related conditions include: cardiovascular problems, diabetes mellitus, obstructive sleep apnea, asthma, musculoskeletal conditions, and various reproductive conditions [1, 2]. 

Per the clinical documentation, this is a patient who has struggled with obesity for years. She has failed numerous dieting programs, including Weight Watchers, Nutrisystem, and the Mediterranean Diet. The patient has a history of hypertension and degenerative joint disease of the knee. Her BMI was 51.7. The patient has participated in nutritional counseling and was evaluated by psychology. There are no contraindications to bariatric surgery, and the procedure is medically necessary. 

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient. 

The insurer's denial of coverage for procedure code 43644, bariatric surgical procedure and subsequent hospital admission overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: alopecia areata (AA)
Treatment: Xeljanz
The insurer denied Xeljanz. 
The health plan's determination is upheld.

The patient is a male with alopecia areata (AA). His scalp has greater than 50% hair loss in patches. He has failed intralesional Kenalog. 

Xeljanz is not medically necessary for this patient.
There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Xeljanz for this patient's condition as an accepted standard of practice in the U.S. (United State). There is no documentation the patient has exhausted all topical options, and that it would therefore be medically necessary to start systemic treatment with Xeljanz, which would carry a higher side effect profile. It is noted that the patient has tried and failed intralesional steroids. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Xeljanz prior to the standard of care alternatives such as methotrexate in combination with oral corticosteroids, and the topical medications aforementioned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Blood Disorder. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Eliquis. 
The denial is upheld.

The patient is a male with a history of a left lower extremity superficial venous thrombosis (provoked) and a left lower extremity deep vein thrombosis with pulmonary embolism. The patient is heterozygous for the Factor V Leiden mutation. He is currently on Eliquis; this is under review.

Neither Xarelto nor Warfarin have been demonstrated to be inferior to Eliquis. The included documentation does not indicate that this patient is intolerant of either of the formulary alternatives nor that he has failed them; similarly, there is a paucity of documentation indicating this patient has a contraindication to the formulary alternatives. Neither the authors of UpToDate nor the peer-reviewed literature recommend one of these agents as being superior to another and thus given their relative equivalency, the formulary options are reasonable and would not have adverse effects that the non-formulary alternative would.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cardiac dysrhythmia, peripheral vascular disease (PVD), hypertension (HTN), chronic obstructive pulmonary disease (COPD)

Treatment personal care assistant (PCA) services of 7 days times 24-hours continuous care split shift per week

The insurer denied coverage for personal care assistant (PCA) services of 7 days times 24-hours continuous care split shift per week.

The denial is upheld.

This is a patient with multiple medical problems including cardiac dysrhythmia, peripheral vascular disease (PVD), hypertension (HTN), chronic obstructive pulmonary disease (COPD) and urinary incontinence.  She lives alone with 24-hour live-in PCA.  Under review is the medical necessity for Personal Care Assistant (PCA) Services from 24-hour live in, 7 days/week to 24-hours continuous care split shift, 7 days per week.

The Uniform Assessment System reports documents the patient's substantial functional deficits.  Extensive assistance to total dependence is required for meal preparation, housework and managing medications.  Activities of daily living tasks such as personal hygiene, lower body dressing and toilet use require maximal assistance.  The patient is bladder incontinent and requires maximal assistance for functional mobility.  However, memory was only "minimally impaired."  In addition, the office visits notes from the patient's treating physicians, document her medical conditions as chronic and stable (including the more recent treatment for post viral fatigue syndrome).  The patient's medical condition and functional deficits have been staffed appropriately with her current 24-hour live-in PCA without requiring the requested 7 days/week, 24-hours continuous care split shift PCA care.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  The requested coverage for Personal Care Assistant (PCA) Services of 7 days times 24-hours continuous care split shift per week is not medically necessary.  

The insurer's denial of coverage for Personal Care Assistant (PCA) Services of 7 days times 24-hours continuous care split shift per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acoustic Neuroma
Treatment: Proton beam therapy, image guided radiation therapy 

The insurer denied proton beam therapy, image guided radiation therapy.
The determination is upheld. 

The patient presented with a left vestibular schwannoma. She underwent surgery last year. She was evaluated for radiation using proton beam, which is under review.

The requested health service/treatment of proton beam therapy, image guided radiation therapy is not medically necessary for this patient.
This treatment is not in accordance with generally accepted standards of medical practice in the United States. The National Comprehensive Cancer Network (NCCN) guidelines do not mention proton beam therapy for schwannoma. The generally accepted standard of medical practice in the United States for this clinical condition is gamma knife treatment. Proton beam is not the standard of care for this condition. The attending provider (AP) provided comparison of proton and photon and the doses to organs at risk (OAR) are within acceptable range.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left renal stone

Treatment: Inpatient hospital stay 

The insurer denied coverage for the inpatient hospital stay.

The denial is upheld.

This is a patient with past medical history of a left kidney stone, severe obesity, hypertension, hyperlipidemia, and diabetes. The patient presented to the hospital with a large left renal stone; but removal of the stone was aborted due to the length of time required to gain percutaneous access to the left kidney. The patient was admitted by Surgery-Urology for hemodynamic monitoring and preoperative planning over the weekend with surgery planned for the following week. Because of a full elective surgery schedule, the surgery was again cancelled. The patient was discharged home at this point to follow up with urology and hopefully have surgery scheduled for later that week. 

The criteria for admission were not met. The appeal on behalf of the hospital is noted and read in detail. Per Milliman Care Guideline (MCG) Health (25th): 

i)	Renal colic + Kidney stones - Patient fails to meet indications for admission
ii)	Nephrostomy, percutaneous - Patient fails to meet criteria for extended stay (bleeding, renal pelvic injury, colon/ lung injury)
iii)	Urologic surgery or procedure GRG - Patient meets the discharge parameter within 24 hours post procedure also for reference ii) (above) patient meets the ORG discharge parameter within 24 hours postop 

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

The insurer's denial of coverage for the inpatient hospital stay is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headaches. 
Treatment: Ajovy. 

The insurer denied the Ajovy. 
The denial is upheld. 

The patient is a female with migraine headache disorder. She has tried and failed nortriptyline, venlafaxine, topiramate XR (extended release) and verapamil for migraine prevention. The provider has requested Ajovy. 

No, the requested Ajovy is not medically necessary. 

The patient has not completed an adequate trial of any first line oral migraine preventive agent at appropriate doses. There is no documented reason the patient cannot be treated with these medications. All of the preferred agents are considered first line, standard of care, oral migraine preventive agents (Schwedt). 

There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Ajovy relative to the preferred oral agents. 

Therefore, given the above, the requested Ajovy is not medically necessary. 

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

Diagnosis: Pulmonary Hypertension
Treatment: Opsumit
The insurer denied the Opsumit.
The determination is overturned.


The patient has a history of primary pulmonary hypertension, along with many other medical problems, who is currently being treated with Sildenafil, Bosentan, and Uptravi. Her cardiologist would like to change therapy from Bostenan to Opsumit (macitentan, an endothelin receptor antagonist). The reasons for the change are ease of administration - she only has to take one dose of Opsumit per day versus two of Bostentan. Opsumit also does not require monitoring of her liver function tests once per month. The goal of the switch will be to make it more likely that she will be compliant with her medications. Opsumit was denied by the health plan due to it not being Food and Drug Administration (FDA) approved for children under 18 years of age.
At issue is the medical necessity of the Opsumit.

The Opsumit is medically necessary for this patient. She requires multiple therapies for her pulmonary hypertension. Opsumit is preferable to Bosentan due to its decreased hepatotoxicity and relative ease of administration. Although Opsumit is not yet FDA approved, it has been shown to be safe and effective in children (Schweintzger, Albinni). Further, Opsumit has been used as an off-label treatment for pulmonary hypertension for many years in children (Ezekian) with many benefits. Further, the best interest of the patient is to make it easier for her to receive therapy and to decrease her risk of liver injury by stopping Bosentan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease.
Treatment: Increase Home Care/Personal Care Hour(s) To 24 Hour(s) Per Day (split shift).
The insurer denied the Increase Home Care/Personal Care Hour(s) To 24 Hour(s) Per Day (split shift).
The denial is upheld.

The patient is a female. Her conditions include Alzheimer's disease and cognitive impairment. Denial of increase home care/personal care (PCA) hours to 24 hours per day, split shift, is being appealed. The health plan approved 24 hours/day, live-in.

The patient's Uniform Assessment System (UAS) evaluation completed, shows severely impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, bathing, personal hygiene, dressing, bed mobility and eating; and maximal assistance with managing medications. The patient is bedbound. She wears diapers for bowel incontinence.

An appeal letter notes the patient has several chronic medical condition. Her health is deteriorating. It notes the patient should not be left alone, because she is unaware of her surroundings. She does not sleep at night and screams all night.

No, the Increase Home Care/Personal Care Hour(s) To 24 Hour(s) Per Day (split shift) is not medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase in personal care hours to 24 hours per day, split shift, is being appealed. The health plan approved 24 hours/day, live-in.

The patient has several chronic conditions including Alzheimer's disease and cognitive impairment. Per UAS (Uniform Assessment System) evaluation completed, the patient requires assistance with all ADLs (activities of daily living). The patient is bedbound. She has bowel and bladder incontinence. The appeal letter from her doctor notes the patient's health has deteriorated. States the patient is unaware of her surroundings, does not sleep at night and should not be left alone. This patient has significant cognitive and physical impairments. However, the patient does not have continuous nighttime PCA (personal care assistance) needs. PCA (personal care assistance) is not indicated for supervision or when no tasks are being performed.

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

Diagnosis: Malocclusion.
Treatment: D8080 braces.
The insurer denied coverage for D8080 braces.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified a Class I malocclusion with 4 millimeter of overjet, 4 millimeter of overbite, an ectopic maxillary canine and mild upper and lower crowding. The Orthodontist has completed the handicapping labio-lingual deviation (HLD) index attaining 22 total points. 

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 does not claim any automatic qualifying condition and completes the second portion of the index arriving at 22 points to justify orthodontic care. This reviewer has determined from the records the patient has an ectopic upper right maxillary canine with mild upper and lower crowding. His HLD score was determined to be 21.

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 cited below.
 
Each of the 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 clinical circumstance as presented does not meet and substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

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

D8080 braces are considered not medically necessary for this patient.

The insurer's denial of coverage for braces is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction/Alcohol Abuse/Addiction
Treatment: Other/Custodial Care

The health plan denied the requested custodial care as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a past medical history significant for hypertension with hypertensive heart disease, rhabdomyolysis, alcohol abuse, general muscle weakness, lack of coordination, low back pain and alcoholic polyneuropathy. This review is for the medical necessity of long-term custodial care.  At issue is the medical necessity of the requested custodial care.

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

No, the requested health service is not medically necessary for this patient.
The patient is a male with hypertension, substance abuse with alcohol and secondary effects from chronic alcoholism. The patient was initially admitted subsequent to acute care hospitalization for difficulty ambulating, repeated falling and he was seeking a detoxification program. The patient was homeless prior to nursing home confinement. He was then treated in skilled care and subsequently transferred to custodial care. The patient has remained in custodial care confinement.
The patient is able to ambulate with an assistive device. He is able to direct his own care. The patient is able to transfer toilet and eat independently. He does not meet specific criteria for inpatient confinement and custodial care. Alternate locations may be more appropriate for this patient. In the appeal letter, it stated they are concerned that the patient may relapse and needed an appropriate facility prior to discharge. I think it is reasonable to say this patient has a high risk of relapse for chronic alcoholism without appropriate long-term treatment options available. However, this does not necessarily create a medical necessity for inpatient custodial care for this patient. Ongoing custodial care services are not medically necessary for this patient.