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

Diagnosis: Endocrine/Metabolic/Nutritional/Obesity
Treatment: Surgical Services
The health plan denied the requested liver biopsy as not medically necessary.
The health plan's determination is upheld.

This patient is a female who underwent laparoscopic Roux-en-Y gastric bypass. The patient's liver was noted to be fatty infiltrated, and a wedge liver biopsy was performed during the procedure. Findings of moderate macrovesicular steatosis was found.

At issue is the medical necessity of the liver biopsy performed.

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

Routine liver biopsy, in particular, wedge liver biopsy during bariatric surgery has not been documented in any prospective or high-level study to be medically necessary. National guidelines from American Society for Metabolic and Bariatric Surgery (ASMBS) to support routine liver biopsy are not available at this time.

Non-alcoholic steatohepatitis (NASH)/non-alcoholic fatty liver disease (NAFLD) are common conditions associated with morbid obesity and grossly, some element of fatty liver can be seen in a majority of patients undergoing bariatric surgery. The benefit of routine liver biopsy, however, without a preoperative diagnostic finding or clinical concern of NASH or a plan to follow with a biopsy at an interval time to assess the progression of disease has not been documented in any high-level prospective study. Separately, liver biopsy for evaluation of steatosis/fibrosis are best performed through a core needle or tru-cut biopsies which provide long cylindrical cores of liver parenchyma approximately 1 to 2 centimeter (cm) in length by approximately 0.2 cm in width. More than one pass as necessary can also be performed. Although a wedge liver biopsy may provide more/larger overall tissue to assess, it is performed on the very edges of the liver, may not capture the full detail of the liver parenchyma as these biopsies are often subcapsular, which may give the false impression of increased fibrosis exaggerating the finding of steatosis (as compared to a core biopsy of the same individual within a more central area of the liver with long cylindrical core).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: D8080 Braces. 

The insurer denied coverage for D8080 braces. 

The denial is overturned. 

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 recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss (mandibular left canine) in addition to other clinical findings.  The orthodontist has completed the Handicapping Labiolingual Deviation Index (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. 

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, Handicapping Labiolingual Deviation (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
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. 

The healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for D8080 braces is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent. 

The insurer denied Dupixent. 
The health plan's determination is upheld. 

The patient is a female with moderate to severe atopic dermatitis that includes the wrists, dorsal hands, and arms. The patient has tried and failed topical clobetasol, halobetasol, betamethasone, and tacrolimus, as well as prednisone tapers. The patient's sleep and social interactions have been impacted by the severity of this patient's disease. Dupixent is under review for medical necessity. 

Dupixent is not medically necessary for this patient. The patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Cyclosporine). Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with standards of care based on current medical literature reviews, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal occlusion and Class II canine. 
Treatment: Braces (D8080) and Monthly Visits x12 (D8670). 

The insurer denied the Braces (D8080) and Monthly Visits x12 (D8670). 
The denial is overturned. 

This patient is a female with Class I skeletal occlusion and Class II canine. There is moderate upper and lower crowding, left posterior crossbite, moderate overjet and impacted upper left canine. 

The health plan's prior denial was due to a handicapping index at 15. 

Yes, the proposed braces and monthly visits x12 are medically necessary.
The patient has an impacted upper left canine (tooth #11). Having an impacted, permanent anterior tooth where extraction is not indicated, is an "automatic qualifier". This case has medical necessity and orthodontic treatment is needed to correct this and other problems. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.

Treatment: D8080 braces and D8670 monthly visits.

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

The denial is upheld.

This is a female patient with a class I malocclusion. The patient has moderate maxillary and mandibular crowding with an overjet of 6 millimeters (mm) and an overbite of 4 mm. Orthodontic treatment was planned; she has a Handicapping labio-lingual deviation (HLD) score of 23.

The provider states that the patient automatically qualifies as there is a deep bite. In order to qualify with a deep bite, there must be documentation that the lower incisors are destroying the soft tissue of the palate. The photographs do not show that there is damage to the palatal tissues. The criteria for a deep bite are not met. This reviewer agrees with the insurer's dental director that the overjet is 6 mm, overbite is 4 mm, there is both maxillary and mandibular crowding and the labiolingual spread is 3 mm. Therefore, as the HLD is below 26, the guidelines for braces and monthly visits are not met.

The patient does not have a handicapping malocclusion and the HLD the score is below 26. The treatment is not considered medically necessary. 

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

The insurer's denial of coverage for the D8080 braces and D8670 monthly visits is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.

Treatment: D8080 braces and D8670 monthly visits.

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

The denial is overturned.

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 recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss (mandibular left canine) in addition to 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. 

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 Labiolingual 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 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 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.

Braces and monthly visits are considered medically necessary for this patient.

The health plan did not act 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 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: TIA(transient ischemic attack).
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a male with no remarkable past medical history, who was admitted for right arm heaviness and numbness. Review of system was positive for additional symptoms of weakness, light headedness, and mild ataxia. The patient was afebrile (Temperature of 36.8 Celsius), described as awake, alert, and not in acute distress. His blood pressure was 147/81, pulse rate of 87, respiratory rate of 20, and oxygen saturation of 97% on room air. Physical examination was unremarkable for positive clinical findings. The neurologic examination was reported as normal on admission. The patient was admitted for transient ischemic attack (TIA) and rule out of acute stroke. 

The inpatient hospital admission was not medically necessary. The patient was admitted for subjective symptoms that were concerning for a stroke versus transient ischemic attack (TIA). The patient had no objective focal neurologic deficits and imaging studies were unremarkable for acute neurologic finding. In this case, a lower level of care would have been appropriate to monitor the patient and rule out a stroke.
The documentation does not support inpatient level of care given the lack of positive findings on imaging and presence of hemodynamic stability. The patient did not require intravenous treatment, procedural interventions, or Tissue Plasminogen Activator (TPA).
Patients with neurologic symptoms consistent Transient Ischemic Attack (TIA) or minor stroke are at increased risk for recurrent stroke, and therefore require urgent evaluation to assess the need for immediate intervention. The American Heart Association and American Stroke Association recommends admission to the hospital for patients with TIA who meets certain criteria based on risk stratification and evidence-based guidelines. There is a risk stratification score called the ABCD2 (Estimates the risk of stroke after a suspected TIA) score which can help identify patients at high risk for short-term stroke. In this case, patient's ABCD2 score is calculated at 1-2 points, which estimates a 1.0% 2-day risk of stroke after a suspected TIA. Given the low-risk stratification, patient could have been safely monitored for 24-48 hours at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: fever

Treatment: hospital admission

The insurer is denied coverage for hospital admission

The denial is upheld. 

This female patient has a history of liver transplant as an infant, cholecystectomy and mild developmental disability.

According to documentation, patient presented with fever 101.0 Fahrenheit and right knee pain. She had fever in the emergency department that resolved, remained hemodynamically stable. Laboratory values showed normal white blood count (WBC) and chronic anemia. Infectious Diseases recommended no antibiotic intervention as her knee pain resolved with Tylenol and no pathology was noted on x-ray. Their clinical impression was transient fever due to recent COVID (coronavirus) vaccination. Based on the findings, patient met criteria for observation level of management. She did not meet criteria for acute hospitalization.

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 hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: fever

Treatment: hospital admission

The insurer is denied coverage for hospital admission

The denial is upheld. 

This female patient has a history of liver transplant as an infant, cholecystectomy and mild developmental disability.

According to documentation, patient presented with fever 101.0 F and right knee pain. She had fever in the emergency department that resolved, remained hemodynamically stable. Laboratory values showed normal white blood count (WBC) and chronic anemia. Infectious Diseases recommended no antibiotic intervention as her knee pain resolved with Tylenol and no pathology was noted on x-ray. Their clinical impression was transient fever due to recent COVID vaccination. Based on the findings, patient met criteria for observation level of management. She did not meet criteria for acute hospitalization.

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 hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied porcelain crown for tooth # 18. 
The denial is upheld.

The patient is  female who presented to the office of her dental provider for evaluation and treatment of tooth # (number)18. Included for review are previous letters of appeal and denial, a narrative from the dental provider explaining a crack along 2/3 the pulpal floor of tooth #18, periapical radiographic images, one pages of American Dental Association (ADA) claim forms, health plan language, and multiple explanation of benefits (EOB) letters. In question is the medical necessity of the treatment of porcelain crown for tooth #18.

The health plan's determination is upheld in whole. 

Based on the provided documentation, the health service of porcelain crown on tooth #18 was not medically necessary for the patient.
The clinical images and radiographic images do not support any amount of decay that would require the need for full coverage restoration. There was no clinical documentation of the residual tooth structure after removal of the previous composite to corroborate the claim by the provider that the tooth had a fracture or crack line.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This patient was seen in the emergency department.  He indicated he was at home when he passed out.  He was given aspirin via emergency medical services and was noted to be hypoxic.  He indicated he was beginning to remember everything that happened.  He did not have complaints of chest pain or shortness of breath.  The physical examination revealed he was in no acute distress.  He was alert and oriented to person, place and time and was able to speak in full sentences.  His initial vital signs revealed a blood pressure of 120/93 with a heart rate of 87 bpm (beats per minute).  Oxygen saturation was 95% (percent).  The recommendation was made for laboratory diagnostic studies.  The documentation indicated there a was consult by neurology in addition to cardiology.  It was recommended he be admitted for additional studies and management.  While admitted, he did undergo additional studies.  He had an ejection fraction of 55%.  There were no significant findings based on laboratory studies.  A Computed tomography angiography (CTA) of the chest was nonacute, although there was noted to be a 2.1 cm (centimeter) rounded opacity to the left lower lobe.  The carotid ultrasound performed was also unremarkable.  A 24-hour electroencephalogram (EEG) was recommended, given the possibility of post ictal state.  He did continue with treatment and did not have any further adverse events.  The documentation detailed he continued to improve and underwent additional testing to include orthostatics which were negative.  It was recommended he be discharged, given no further adverse events.  He was discharged with recommendation to follow-up.

The patient had a syncopal episode, but the neurological exam by the Neurologist was normal/non-focal.  The cardiac exam in the emergency room (ER) was also unrevealing.

The syncopal episode could have been evaluated as an outpatient.  Therefore, he could have been treated in a lower level.  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 the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Poorly controlled diabetes, cocaine abuse, decreased functional mobility, and necrotizing soft tissue infection of right gluteus, status post excision debridement and IV (intravenous) antibiotics
Treatment: Custodial Care (long term care)
The insurer denied the custodial care (long term care).
The denial is upheld.

The patient is a male with a history including poorly controlled diabetes, cocaine abuse, decreased functional mobility, and necrotizing soft tissue infection of right gluteus, status post excision debridement and IV (intravenous) antibiotics. Denial of custodial care (long term care) is being appealed. During the time period, the patient performs most ADLs (activities of daily living) independently, including toileting, dressing and feeding. He ambulates ad lib (without previous preparation) without assistive devices. His wound treatment includes cleaning with normal saline, wet-to-dry.

No, the requested custodial care (long term care) was not medically necessary.

Custodial care is care primarily for the purpose of assisting a patient in ADLs or in meeting personal rather than medical needs, and which is not specific treatment for an illness or injury. It is care that cannot be expected to substantially improve a medical condition and has minimal therapeutic value. Such care includes assistance with walking, bathing or dressing; transfer or positioning in bed; normally self-administered medicine; meal preparation; feeding by utensil, tube or gastrostomy; oral hygiene; ordinary skin and nail care; catheter care; suctioning; using the toilet; enemas; or preparation of special diets and supervision over medical equipment or exercises or over self-administration of oral medicine. This patient does not meet criteria for custodial care because he does not require assistance as noted above. He does not require assistance with ADLs, medications, or diet. The requested custodial care (long term care) was not medically necessary.

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: Pancreatic Cancer
Treatment: Octreotide
The insurer denied coverage for Octreotide.
The denial is upheld.

This is a patient with a history of pancreatic cancer. He had a Whipple procedure to treat pancreatic cancer. The patient was discharged from the hospital with the drain in place. The physician recommended administering 100 micrograms (mcg) of subcutaneous (SC) Octreotide three times a day (TID).

Octreotide acetate is a potent inhibitor of growth hormone, glucagon, and insulin. It also inhibits the release of serotonin, gastrin, vasoactive intestinal peptide, secretin, motilin, pancreatic polypeptide, and decreases splanchnic blood flow. It is used to treat symptoms of carcinoid tumors/syndrome (flushing and diarrhea) and vasoactive intestinal peptide secreting adenomas (diarrhea). [1] The development of pancreatic fistulas is a common complication after pancreatic resections. Octreotide is a somatostatin analog. As somatostatin is known to inhibit gastroenteropancreatic exocrine secretion, Octreotide has been studied and used prophylactically to prevent the development of postoperative pancreatic fistulas. Its prophylactic use is controversial. Multiple meta-analyses and randomized controlled trials have been conducted and there has been no compelling evidence that Octreotide and somatostatin analogues contribute to a higher closure rate of pancreatic fistulas or to the prevention of postoperative complications after pancreatic surgery. [2-5] Other studies have indicated that Octreotide does not prevent pancreatic fistulas and may actually potentiate postoperative complications in patients with certain risk factors. [5] Patients have been reported to develop pancreatitis after its continued use or withdrawal. [1, 5] This patient had pancreaticojejunostomy and Octreotide was prescribed due to a post-operative pancreatic leak/fistula. 

Per clinical documentation, this patient has a history of high-grade adenocarcinoma of the pancreas. The patient underwent a Whipple procedure. A Blake drain was placed, and there was noted to be increased output. Fluid amylase was elevated and consistent with a pancreatic leak. A CT (computed tomography) scan of the abdomen and pelvis demonstrated peripancreatic fluid. The patient was started on Octreotide. The patient was discharged with Octreotide subcutaneously three times per day. Based on peer-reviewed literature and the current indications, Octreotide acetate is not medically necessary in this clinical scenario. Octreotide is not FDA (food and drug administration) approved for this clinical indication. [6]

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

The insurer's denial of coverage for Octreotide is upheld. Medical necessity is not substantiated.