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

Diagnosis: Anterior crossbite with gingival attachment loss.

Treatment: D8080 braces and D8670 monthly visit.

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

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 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 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. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining a score of 16 points on the HLD index where 26 point 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, 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. 

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 is considered medically necessary for this patient.

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is 
overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: anterior crossbite with gingival attachment loss of the mandibular left canine.
Treatment: braces (comprehensive orthodontic treatment).
The insurer is denied coverage for braces (comprehensive orthodontic treatment).
The denial is overturned. 

This female patient has no documented history.

Upon review of the submitted documentation, 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 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 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.
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 comprehensive orthodontic treatment and periodic orthodontic treatment visits (codes D8080 and D9670) are considered medically necessary for this patient.

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

The carrier's denial of coverage for the braces (comprehensive orthodontic treatment) is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior Crossbite with gingival attachment loss.

Treatment D8080 braces and D8670 monthly visit.

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

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 Labiolingual Deviation Index (HLD) 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 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 not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 5 points (1 overjet, 1 overbite, 3 labiolingual spread).
 
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the D8080 braces and D8670 monthly visit  is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite Associated with Mandibular Displacement.

Treatment: D8670 monthly visit x (times) 13 and D8080 braces.

The insurer denied coverage for D8670 monthly visit x 13 and D8080 braces.

The denial is overturned.

The patient has a significant malocclusion that can negatively affect the dentition. The patient has a right unilateral crossbite that is causing deviation of the mandible. 

Per An Introduction to Orthodontics by Laura Mitchell, one or more of these dental traits that would have an adverse effect on the longevity of dentition, indicating high need for correction: 

1)	Increased Overjet.
2)	Increased traumatic Overbites.
3)	Anterior crossbites causing decreased periodontal support.
4)	Unerupted impacted teeth (where there is danger of pathology).
5)	Crossbites associated with mandibular displacements.

Per the clinical records, the patient does meet the above requirements. The patient has a crossbite associated with mandibular displacement. There is a high need for orthodontic treatment.

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

Based on the above, D8670 monthly visit x 13 and D8080 braces is medically necessary. 

The insurer's denial of coverage for D8670 monthly visit x 13 and D8080 braces is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: skeletal Class I; normal vertical growth pattern; permanent dentition; Class II canines; moderate maxillary crowding; moderate mandibular.

Treatment: D8080 braces and D8670 monthly visit.

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

The denial is upheld.

This is the case of a female who was evaluated for orthodontic treatment. A clinical examination and analysis consisting of a dental and jaw evaluation revealed the following findings: skeletal Class I; normal vertical growth pattern; permanent dentition; Class II canines; moderate maxillary crowding; moderate mandibular crowding; deep bite; Impacted third molars; anterior crossbite with gingival attachment loss (mandibular right canine). The following automatic qualifier was chosen on the patient's Handicapping Labio-Lingual Deviation (HLD) Index report documented: crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The dental director states that the patient's HLD is 20. The provider states that the patient automatically qualifies as there is an anterior crossbite. 

According to the Index of Orthodontic Treatment Need (IOTN), used in Contemporary Orthodontics by Profit, a Grade 4 is in the category of Severe/Need treatment with one of these conditions:

1- Increased overjet greater than 6 millimeters (mm), but less than or equal to 9 mm.
2- Reverse overjet greater than 3.5 mm with no masticatory or speech difficulties.
3- Reverse overjet greater than 1 mm but less than 3.5 mm with recorded masticatory difficulties.
4- Anterior or posterior crossbites with greater than 2 mm discrepancy.
5- Posterior lingual crossbite with no functional occlusal contact.
6- Severe contact point displacements greater than 4 mm.
7- Extreme lateral or anterior open bites greater than 4 mm.
8- Increased and complete overbite with gingival or palatal trauma.
9- Partially erupted teeth, tipped, and impacted against adjacent teeth.
10- Present of supernumerary teeth. 

The patient does not have any of the above conditions. 

To qualify with an anterior crossbite, there must be clinical attachment loss and recession of the gingival margin. There is no clinical attachment loss and recession of the gingival margin evident on the photographs. The attachment is normal and there is a normal amount of attached gingiva. The tooth is buccally placed and this is the reason the gingival level is not at the same level. If in the correct position, the gingival levels would be equal.

The patient does not have a severe handicapping malocclusion and the HLD score is below 26. Therefore, as the HLD is below 26, the guidelines for braces and monthly visits are not met and the request is not medically necessary.

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

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

Diagnosis: Crossbite, crowding.
Treatment: Braces and Periodic Treatment Visits.
The insurer denied the Braces and Periodic Treatment Visits.
The denial is overturned.

The patient is a male requesting orthodontic benefits and periodic follow-up visits. He has a severely deep bite and severe crowding.

Yes, the proposed braces and periodic treatment visits are medically necessary.
The patient has a deep, impinging overbite with severe soft tissue impingement of his palate. This is an automatic qualifier for orthodontic treatment according to the handicapping index scale. Orthodontic treatment is needed to correct this. The periodic visits are to adjust the braces and monitor ongoing treatment. They are also medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior Crossbite.

Treatment: braces and monthly visit.

The insurer denied coverage for braces and monthly visit.

The denial is upheld.

According to the documentation submitted, this is the case of a female patient who was evaluated for orthodontic treatment.
The provider states that the patient automatically qualifies as there is an anterior crossbite. To qualify with an anterior crossbite, there must be clinical attachment loss and recession of the gingival margin. There is no clinical attachment loss and recession of the gingival margin evident on the photographs. The lower left Casper is submerged below the occlusal plane and if in the correct position the gingival levels would be equal to the adjacent teeth. 
If an automatic qualifier is not met then the patient needs to meet a score of 26 on the Handicapping Labiolingual index (HLD). The insurer indicates that the HLD score is 13. This reviewer concurs with the score of 13.
According to the Index of Orthodontic Treatment Need (IOTN), used in Contemporary Orthodontics by Profit a Grade 4 is considered to be in the category of Severe/Need treatment with one of these conditions:

1-	Increased overjet greater than 6 mm (millimeter) but less than or equal to 9 mm.
2-	Reverse overjet greater than 3.5 mm with no masticatory or speech difficulties.
3-	Reverse overjet greater than 1 mm but less than 3.5 mm with recorded masticatory difficulties.
4-	Anterior or posterior crossbites with greater than 2 mm discrepancy.
5-	Posterior lingual crossbite with no functional occlusal contact.
6-	Severe contact point displacements greater than 4 mm.
7-	Extreme lateral or anterior open bites greater than 4 mm.
8-	Increased and complete overbite with gingival or palatal trauma.
9-	Partially erupted teeth, tipped, and impacted against adjacent teeth.
10-	Present of supernumerary teeth. 

The patient has none of the above conditions. The health plan acted reasonably with sound medical judgment in best interest of the patient.

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

Diagnosis: Gender dysphoria
Treatment: Breast Surgery (mammaplasty augmentation)
The insurer denied the Breast Surgery (mammaplasty augmentation)
The denial is overturned. 

The patient is a male to female transgender. She has been living as a female for several years. She has been on hormone therapy since 2018. She has had minimal breast growth with hormone therapy. Her mental health professional recommends breast augmentation surgery. Bilateral breast augmentation is planned.

Yes, the requested Breast Surgery is medically necessary.
Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines:

Criteria for Breast/Chest Surgery (One Referral)
Criteria for breast augmentation (implants/lipofilling) in MtF (male to female) patients:

1) Persistent, well-documented gender dysphoria;
2) Capacity to make a fully informed decision and to consent for treatment;
3) Age of majority in a given country (if younger, follow the SOC [standard of care] for children and adolescents);
4) If significant medical or mental health concerns are present, they must be reasonably well controlled.

Although not an explicit criterion, it is recommended that MtF (male to female) patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

The patient meets these guidelines. She has well documented gender dysphoria and has been on hormone therapy for years. Breast growth with hormone therapy has been maximized. She is the age of majority.  Significant mental health concerns are not documented. The requested breast augmentation is consistent with the WPATH (World Professional Association for Transgender Health) criteria and is therefore medically necessary.

Breast augmentation is consistent with the standard of care for this patient and is the most appropriate treatment for this patient's diagnosis of gender dysphoria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Elevated troponin, history of coronary artery disease
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned. 

The patient is an adult female with a past medical history significant for polysubstance abuse, hepatitis C, syphilis, seizure disorder, schizophrenia, COPD (chronic obstructive pulmonary disease), CAD (coronary artery disease), status post prior myocardial infarction, and CVA (cerebrovascular accident).  She presented to the ER (emergency room) due to suicidal ideation and plan, requiring inpatient psychiatric admission.  Patient reported no chest pain.

The patient had an elevated troponin, and given her history of CAD (coronary artery disease), she was admitted to internal medicine inpatient service, rather than psychiatric floor, to be ruled out for ACS (acute coronary syndrome).  After being cleared by cardiology service, the patient was transferred to inpatient psychiatry.

Yes, the inpatient admission was medically necessary.

The patient presented with suicidal ideation and plan and had required inpatient psychiatric admission due to her underlying psychiatric condition and suicidal thoughts.  Her cardiac enzymes were elevated, which in a patient with a known history of CAD (coronary artery disease) and prior MI (myocardial infarction) was suspicious for ACS (acute coronary syndrome) and required further work-up, which cannot be done in inpatient psychiatric setting.  As such, the patient required an admission to inpatient medical service for work-up and clearance prior to admission to  the psychiatry unit.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left-sided chest pain

Treatment: Inpatient hospitalization

The insurer is denied coverage for inpatient hospitalization.

The denial is overturned. 

This female patient has a history of sickle cell trait, chronic microcytic anemia, obesity, vitamin D deficiency, hypertension, systemic lupus erythematosus (SLE) pericarditis with pericardial effusion (status post pericardial window).

Risk assessment of patients presenting with chest pain and non-ST elevated myocardial infarction (NSTEMI) was reviewed by Hedayati et al. [3] Using the HEART (History, EKG [electrocardiogram], Age, Risk factors, and troponin) score risk stratification schema, this patient would have a high risk of major adverse cardiac events (defined as myocardial infarction, need for percutaneous coronary intervention, need for coronary artery bypass grafting, or death) in the six weeks following presentation. 

This patient, with multiple medical problems including sickle cell trait and lupus, presented to the hospital with chest pain, an abnormal EKG and positive troponin levels. Her pretest probability of coronary artery disease was intermediate. [1] Utilizing the HEART score, she was considered high risk for major adverse cardiac events in the setting of NSTEMI (7 points). [2] 

These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. The patient was ultimately diagnosed with myocarditis and required observation and treatment. Additional observation and management of myocarditis/pericarditis was necessary in this case. Up to 9% of patients presenting with myocarditis can develop fulminant myocarditis, resulting in lethal ventricular arrhythmia and cardiogenic shock. [5] In conclusion, given the patient's presentation and multiple cardiac risk factors, inpatient hospital admission was appropriate.

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

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

Diagnosis: Syncope

Treatment inpatient hospitalization

The insurer denied coverage for inpatient hospitalization

The denial is upheld

This is the case of an adult female patient that presented to the hospital following an episode of syncope as well as several episodes of flushing, lightheadedness and near syncope. Past medical history was significant for hypertension and episodes of syncope and near syncope that typically responded to Gatorade intake. Of note, the patient reported discontinuing antihypertensive therapy several weeks earlier. On the day of presentation, the patient noted flushing and lightheadedness without syncope and went home from work. She had similar symptoms at home and ultimately lost consciousness after standing up to walk to the car and go to the Emergency Department (ED). Vital signs on presentation were stable with blood pressure (BP) of 104/93 and pulse 102 beats per minute. Physical examination was unremarkable. Electrocardiogram (ECG) revealed normal sinus rhythm without ST 9 (interval on ECG) or T (interval on ECG) wave abnormalities and normal QRS (interval on ECG) axis and conduction intervals. Computed tomography (CT) scan of the head revealed no abnormalities. Electroencephalogram (EEG) revealed no abnormalities. Echocardiogram was completely normal and demonstrated no valvular pathology and a preserved left ventricular ejection fraction (LVEF) (65% [percent]) with no regional wall motion abnormalities. Serum blood testing revealed serum blood urea nitrogen (BUN) was 9 and Creatinine 0.9 consistent with volume depletion. The patient was admitted to the hospital for observation. She was treated with intravenous (IV) fluids and subsequently discharged home.  

According to the American Hospital Association/ American College of Cardiology/ Heart Rhythm Society (AHA/ ACC/ HRS) guidelines such patients should be managed utilizing a structured ED observational protocol. (1) In a study of individuals presenting to the emergency room, patients that were low-risk or intermediate-risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing. (2) In this case, the patient had a normal echocardiogram and a normal 12 lead ECG. The clinical presentation was consistent with an etiology of volume depletion. Acute inpatient admission was not medically necessary for this patient.

This patient presented with syncope that occurred after standing up. She had a past medical history of orthostatic symptoms with syncope and near syncope. Physical examination revealed no major abnormality. A 12 lead ECG revealed no abnormalities. Echocardiography revealed a structurally normal heart with a normal LVEF. This patient falls into a low-risk group for syncope.  

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. Acute inpatient admission was not necessary.  

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