Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/ Back Pain
Treatment: Surgical Services (All)
The health plan denied the requested spinal surgery as experimental/investigational. 
The health plan's determination is upheld.

This is a female who has a long history of low back pain. Most of her pain is axial with radiation into the buttocks. She had a lumbar epidural injection with mild pain relief. The patient had other treatments including physical therapy (PT) and pain medications without success. A physical exam revealed increased pain on flexion and moderate facet loading. A magnetic resonance imaging (MRI) revealed multilevel disc bulge, facet arthropathy, and subarticular stenosis contacting the descending (sacral) S1 nerve roots, which slightly increased compared to the prior study.
The issue is whether the INTRACEPT procedure is an appropriate and medically necessary intervention for this patient.

I uphold, in whole, the health plan's determination.

The proposed health service or treatment spinal procedure is unlikely to be beneficial for the insured's medical condition.
The INTRACEPT system was designed to treat low back pain from vertebral body by ablating intraosseous nerves. Reviewing of the available medical records did not reveal adequate evidence that this patient's pain is from vertebral bodies. This patient responded to a prior epidural injection, which indicated lumbar radiculitis is a potentially a significant pain generator. Physical exam was remarkable for facet load test, which suggested facet arthritis might contribute to her symptomology. An MRI revealed multilevel disc bulges and facet joint arthropathy. Truumees's study supported the efficacy of the INTRACEPT procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded. (table 1 exclusion criteria in this study). [1]
Given this patient's medical history, physical exam , MRI reading, and the current clinical evidence, she is not an appropriate candidate for this INTRACEPT procedure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine Fibroids
Treatment:  Surgery (uterine artery embolization)
The insurer denied the  Surgery (uterine artery embolization)
The denial is upheld.

The patient is a female with symptomatic uterine myomas who was recommended to undergo uterine artery embolization for treatment. Coverage was denied because it is deemed to be not medically necessary.

No, the uterine artery embolization is not medically necessary.
There are no data in the peer-reviewed literature from well-controlled large randomized trials to show that this treatment has long term safety and efficacy. It is not standard of care, it is not supported by peer reviewed data, it is not supported by professional organizations, and it is thus not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
There are no long-term efficacy or safety data to support this treatment. There is no evidence on the safety of this treatment in patients seeking fertility-sparing treatment options.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD/emphysema.
Treatment: Chest Wall Compression Device.
The insurer denied the Chest Wall Compression Device.
The denial is upheld.

The patient is a female with chronic obstructive pulmonary disease (COPD)/emphysema who has shortness of breath and phlegm production.  She is prescribed the smart vest to improve pulmonary secretion clearance. This is denied due to lack of medical necessity. This denial is being appealed.

No, the proposed treatment is not medically necessary.
The patient has chronic obstruive pulmonary disease (COPD)/emphysema. Although the patient has phlegm production, it is not in a copious amount. The patient's computed tomography (CT) of the chest does not show bronchiectesis. The patient has not tried and failed manual chest physiotherapy. The requested smart vest is 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: Overturned

Diagnosis: Dental Caries.
Treatment: Endodontic therapy.
The insurer denied coverage for Endodontic therapy.

The denial is overturned

Based on the submitted documentation which includes copies of full mouth series radiographs, and insurer correspondence, it appears that this patient presented to the dentist for dental care.  Caries was noted on teeth number 4, 7 and 29 on examination and endodontic therapy was recommended for these teeth.  The insurer has denied these services stating that the services are not medically necessary as the documentation does not meet medical necessity criteria.  The patient is appealing the decision.

Upon review of radiographs, they support the recommended treatment. The teeth exhibit carious lesions focally involving or approximating the pulp chamber radiographically.  These teeth would require endodontic therapy in order to maintain them and prevent future infection in this patient.  These teeth will have adequate residual coronal structure for support of post and core and crowns and adequate residual periodontal alveolar bone height.  The standard of care in general dental practice would be endodontic therapy for these teeth and subsequent post and core and crowns, as recommended, which would have an excellent long-term prognosis with the recommended treatment.

Coverage for cleaning root canal, crown and post and hard material under cap (post and core) for teeth number 4, 7 and 29 is medically necessary as the clinical and radiographic documentation support these services, and these services would be a standard of care in general dental practice. 	

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

Based on the above, the medical necessity for the cleaning inside roots of tooth (root canal), metal cap (crown) and post, and hard material under cap (post and core) for teeth 4, 7, and 29 is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite with gingival attachment loss.

Treatment D8080 braces and D8670 monthly visits.

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

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 (right mandibular canine), among other clinical findings. The orthodontist has completed the handicapping labio-lingual deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. 

Upon review of the submitted documentation, 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 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 16 points (3 overjet, 3 overbite, 3 ectopic eruption, 5 anterior crowding, 2 labiolingual spread).

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 clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

The healthcare plan acted reasonably and 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 upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Durable Medical Equipment. 
The insurer denied Functional electrical muscle stimulator. 
The denial is overturned.

The patient is a female with complete thoracic (T)4-T5 spinal cord injury (SCI) from skiing accident. She is status/post (s/p) spinal fusion surgery.
Records include discharge summary from wheelchair assessment, initial evaluation for wheelchair, and for physical therapy (PT)/functional training, re-evaluation, first appeal document after request for RT300 functional electrical stimulation (FES) therapy system (E0770) citing inability to stand independently, patient results report, Food and Drug Administration (FDA) device listing, product manual and supporting literature. The issue at hand is the medical necessity of the requested RT300 FES therapy system.

The health plan's determination is overturned.

The requested FES is medically necessary. This is medically necessary based on current evidence for benefit for patients with complete SCI for aerobic fitness and muscle benefits. A newer systematic review shows evidence for improved aerobic fitness and lower body muscle health in chronic SCI. The patient fits into categories in cited literature that makes this device medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Home Health Care 
The insurer denied increase in home care/personal care HHC - Level 2 Personal Care Services, per 15 minutes increase to 40 hours per week.
The denial is upheld.

The patient is a male with a with a past medical history of type 2 diabetes, rheumatoid arthritis, tremors, gastroesophageal reflux (GERD), hypertension, and urge incontinence falls who had been assigned personal care services. This review is for the medical necessity of request to increase Home Care/Personal Care home health care (HHC) - Level 2 Personal Care Services to 40 hours per week. 18 hours per week was approved. The patient underwent an assessment. He lives at home with his spouse. Regarding his functional status, he is cognition independent with no memory problems, he is able to communicate and understand others. He has no vision or hearing difficulty. He requires assistance with instrumental activities of daily living (IADLs) as follows: maximal assistance with meal prep, maximal assistance with housework, limited assistance with managing medications, independent with finances, extensive assistance with stairs, maximal assistance with shopping, and extensive assistance with transportation.

Uniform assessment was reviewed. It is noted that patient required maximal assistance with meal prep, maximal assistance with housework, extensive assistance with managing medications, extensive assistance with finances, extensive assistance with stairs, maximal assistance with shopping, and extensive assistance with transportation. The subject under review is the medical necessity for the increase in home care/personal care services. 

Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 40 hours per week is not medically necessary for this patient. Based on the assessment, the patient has remained fairly stable with no significant change in functional status. There have been no reported falls, hospital admissions, or new diagnoses resulting in significant morbidity that may have resulted in decreased functional ability to require an increase in services. There were no new reports regarding recommendations for additional aide service which would be medically necessary for the patient above and beyond those documented with the previous nursing assessments. Thus, increased hours are not medically necessary per documentation provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems
Treatment: Implant Placement, Tooth 10, Tooth 19, and Tooth 30
The insurer denied Implant Placement, Tooth 10, Tooth 19, and Tooth 30. The health plan's determination is upheld. 

The patient is a male who presents for evaluation and treatment of teeth # (number) 9, 10, 11, 19, and 30. Provided for review are previous letters of appeal and denial, a narrative from the provider, a full mouth panoramic radiograph from an unknown date, one page of American Dental Association (ADA) claim forms, a health history, and clinical notes.

Implant Placement, Tooth 10, Tooth 19, and Tooth 30 is not medically necessary for this patient
There is nothing in the documentation that indicates that the patient has had a partial denture provided and that the partial denture did not function correctly. There is nothing in the provided documentation that shows that the patient uses a partial denture currently. Further, based on the provided documentation, the teeth do not appear to have been prepped for a partial denture in the past. There has been no evaluation of any current prosthesis by the doctor. The need for implants has not been established. Hence the treatment of implant placement for sites #10,19, and 30 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep Impinging Overbite
Treatment: Braces (comprehensive orthodontic treatment)

The insurer denied coverage for braces (comprehensive orthodontic treatment).
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 deep impinging overbite. The orthodontist completed the Handicapping Labio-Lingual Deviation (HLD) index as required and chose the automatically qualifying condition of deep impinging overbite with severe soft tissue damage. 

Upon review of the submitted documentation, 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 met and does support comprehensive orthodontic care as on examination of the intraoral clinical images there is evidence of multifocal palatal gingival recession due to direct impingement of the teeth on the gingival soft tissues. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

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

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

Diagnosis: Cellulitis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of prostate cancer, peripheral vascular disease (PVD), bladder cancer, and prior cellulitis and was admitted with complaints of (c/o) right lower extremity (RLE) erythema. Vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD) and mild swelling of the right lower extremity (RLE) to the medial aspect of the right lower area past the knee. Lab work was notable for a white blood cell count (WBC) of 11.2. Imaging studies, computed tomography angiography (CTA) of the right lower extremity (RLE) showed no evidence of endovascular infection. The patient was diagnosed with cellulitis and treated with intravenous (IV) antibiotics and by mouth (PO) fluids. Due to a recent infection of same area, the patient was discharged on long-term antibiotic suppression therapy by infectious disease (ID). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The patient presented to the Emergency Department (ED) with c/o RLE erythema. The patient was afebrile, did not appear toxic, had no unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, severe leukocytosis, features of systemic inflammatory response syndrome (SIRS), animal or human bite with extensive damage, high risk location (face, neck, hand, genitals), pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. The patient was treated with intravenous (IV) antibiotics, and this could have been safely provided at a lower level of care, with frequent reevaluation to assess response to therapy.
Regarding the provided Milliman Care Guidelines (MCG) criteria, the patient did not have hemodynamic instability, altered mental status (AMS), failure of outpatient therapy, limb-threatening infection, significant immunosuppression, bacteremia, suspected necrotizing tissue infection, severe oral cellulitis, cutaneous gangrene, orbital infection, perianal infection, or severe pain.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chronic Thrombocytopenia

Treatment: inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is modified.

According to the medical records, the patient has a history of brain meningioma, splenomegaly, portal hypertension, thrombocytopenia, chronic back pain and headache. She was admitted complaining of abdominal pain, body aches, headache, and generalized weakness x (times) 3 weeks.  She was admitted for further evaluation to Medicine Service, and she was treated symptomatically with acetaminophen. She was discharged.

Once oncology saw her and diagnosed her thrombocytopenia as chronic and not dangerous, there was no acute need to remain inpatient. Dates exclusive and after are not medically necessary.   There were, in the end, no new findings of diagnoses. Oncology had mentioned malignancy and planned a bone marrow for occult potential malignancy. Therefore, the continued stay was not necessary and gynecology consultation could have been done on an outpatient basis.

"Splenomegaly is one of the major clinical manifestations of primary myelofibrosis and is common also in other chronic Philadelphia-negative myeloproliferative neoplasms, causing symptoms and signs and affecting quality of life of patients diagnosed with these diseases. We aimed to study the impact that such alteration has on thrombotic risk and on the survival of patients with essential thrombocythemia and patients with Polycythemia Vera (PV)." (Accurso, V. et al.. 2019).                                                         
   
The health plan acted reasonably in part with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital stay is modified. Medical Necessity is substantiated for 1 day. However, denial is upheld for 2 days.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chronic Thrombocytopenia

Treatment: inpatient hospital stay

The insurer denied coverage for inpatient hospital stay

The denial is modified.

According to the medical records, the patient has a history of brain meningioma, splenomegaly, portal hypertension, thrombocytopenia, chronic back pain and headache. She was admitted complaining of abdominal pain, body aches, headache, and generalized weakness x (times) 3 weeks.  She was admitted for further evaluation to Medicine Service, and she was treated symptomatically with acetaminophen. She was discharged.

Once oncology saw her and diagnosed her thrombocytopenia as chronic and not dangerous, there was no acute need to remain inpatient. Dates exclusive and after are not medically necessary.   There were, in the end, no new findings of diagnoses. Oncology had mentioned malignancy and planned a bone marrow for occult potential malignancy. Therefore, the continued stay was not necessary and gynecology consultation could have been done on an outpatient basis.

"Splenomegaly is one of the major clinical manifestations of primary myelofibrosis and is common also in other chronic Philadelphia-negative myeloproliferative neoplasms, causing symptoms and signs and affecting quality of life of patients diagnosed with these diseases. We aimed to study the impact that such alteration has on thrombotic risk and on the survival of patients with essential thrombocythemia and patients with Polycythemia Vera (PV)." (Accurso, V. et al.. 2019).                                                         
   
The health plan acted reasonably in part with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital stay is modified. Medical Necessity is substantiated partially substantiated.