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

Dental Problems/Impacted Teeth
Treatment: Dental/Orthodontic Procedure
The health plan denied the requested additional sedation as not medically necessary.
The health plan's determination is overturned.

The patient is a male with a retained maxillary left primary cuspid #H and an impacted maxillary left cuspid #11 which appears to be on the palate. The Oral and Maxillofacial Surgeon requested a prior authorization for the following:
- Code 7140 Removal of tooth #H
- Code 7280 Expose tooth #11
- Code 7283 Bond bracket to tooth #11
- Code 9239 Moderate sedation first 15 minutes
- Code 9243 Moderate sedation additional 15 minutes
- Code 9243 Moderate sedation additional 15 minutes
- Code 9243 Moderate sedation additional 15 minutes
All the above procedures were given prior authorization except for Code 9243 - additional 15 minutes of sedation x 2. The patient is appealing the denial of 2 units of sedation.

The health plan's determination of medical necessity is overturned, in whole. The sedation time will be determined by the amount of sedation needed for the procedure plus recovery. This will be reflected in the Anesthesia / Sedation record.

Yes, the requested health service/treatment of intravenous (IV) Sedation each 15 minutes x 2 units is medically necessary for this patient. This request is for a prior authorization. The exact amount of sedation that is medically necessary will be determined by the extent of the surgery, how the patient reacts to the surgery, the recovery period, and the duration of the sedation. The anesthesia / sedation records will verify exactly how many units are needed.
Anesthesia time begins when the doctor initiates the anesthesia and monitoring protocol, and medications are delivered. The time ends when the patient can be safely left under the observation of trained personnel. The level of anesthesia is determined by the provider's documentation of the anesthetic effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment; Renal failure; Diabetes

Treatment: Personal care services.

The insurer denied coverage for personal care services.

The denial is overturned. 

This female patient has a past medical history of cognitive impairment, acute kidney failure, and non-insulin dependent diabetes mellitus, carotid artery stenosis, cirrhosis secondary to chronic biliary obstruction, malnutrition, acute hepatic encephalopathy, weakness and urinary incontinence. An increase to personal care services (PCS), level 2, for a total of 24 hours a day, split shift, 7 days a week is being requested.

The New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016:
(a) 	Definitions and scope of services.

(1) 	Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision.  Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.
      (2) 	Continuous personal care services means the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for a patient who, because of the patient's medical condition, needs assistance during such calendar day with toileting, walking, transferring, turning and positioning, or feeding and needs assistance with such frequency that a live-in 24-hour personal care aide would be unlikely to obtain, on a regular basis, five hours daily of uninterrupted sleep during the aide's eight hour period of sleep.

Based on the review of the medical record and literature, the request for increased hours of PCS is considered medically necessary for this patient. The Uniform Assessment System (UAS) form indicates that the patient is dependent on incontinence needs and assistance is required with toileting and transfers.  

The insurer notes that the nighttime needs are infrequent. Regardless, this patient's incontinence needs are unplanned and have the potential of leaving the patient for many hours in a wet diaper, and at risk for infection. The patient has cognitive and physical limitations including incontinence and trouble with transfers and toileting that would support the need for these increased services. 

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

The medical necessity for personal care assistance services, level 2, for a total of 24 hours a day, split shift, 7 days a week is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pectus excavatum deformity
Treatment: Surgical Repair of Chest 
The insurer denied the Surgical Repair of Chest. 
The health plan's determination is overturned. 

This case involves a girl with a pectus excavatum deformity. Her deformity has been progressive as documented by her surgeon with serial office visits. The medical work up has included a computed tomography (CT) scan of the chest which demonstrated a Haller index of 3.5 and cardiac compression due to the deformity.
A resting echocardiogram did not demonstrate functional impairment. Neither pulmonary function testing nor cardiac function testing was performed during exertion. Importantly, her psychologist has confirmed the impact of this deformity on the child's psychological and emotional well-being. Her objective professional findings are that the chest wall deformity is creating a great deal of emotional distress for this patient, as well as a lack of confidence and impaired self-esteem. She also documents the elevated risk of detrimental long-term effects on this child in the future if the deformity is not corrected.

The Surgical Repair of Chest (Pectus Excavatum Deformity) is medically necessary for this patient.
Referencing Up-To-Date and the surgical literature as a source of current knowledge and treatment recommendations, and also consistent with routine clinical practice, the surgical correction of pectus excavatum is clearly indicated in patients such as this. She has a clinically significant pectus excavatum deformity as described by the severity of the chest wall defect (in this case clearly in the clinically severe range with Haller index of 3.5), cardiopulmonary morbidity (documented as reduced exercise tolerance in the surgeons clinic notes), and psychosocial impact of the defect on the patient as clearly documented by this patient's psychologist in writing.
Moreover, review of the CT scan images clearly documents impingement of the posterior sternum on the right heart. While stress testing was not performed it was discussed in the surgeons note and he accurately points out that there is a wide variability in the range of normal values for adolescence which depends on the patient's age and physical development. In addition, the reliability of stress testing is also highly variable dependent upon the effort expended by an individual making abnormal criteria all the more difficult to establish.
Surgical repair is the generally accepted standard practice for treatment of clinically significant pectus excavatum, and is durable long term. Impaired exercise tolerance and cardiac compression will be reduced or completely reversed by surgical correction. Surgical correction of the deformity will predictably lead to a normal appearance of the chest wall contour and will reduce or completely resolve the adverse psychosocial impact of the deformity. Psychosocial outcomes are functional outcomes. It is important to realize that psychological well-being and mental health concerns are paramount, and are important to take into account in the adolescent age group.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain/Falls
Treatment: Continued skilled nursing facility (SNF) Stay
The insurer denied the Continued SNF Stay.
The determination is upheld.


The patient had an observation stay related to hypoglycemia and associated weakness. The patient had reported recurrent falls related to lumbar back pain (history of lumbar surgery several years prior). She was admitted to subacute rehabilitation. Documentation noted that patient had requested coverage for continued skilled nursing facility (SNF) care but the plan denied this request stating it was not medically necessary "and there was no documentation of discharge planning. There was a delay by the facility in planning for member's discharge." At issue is the medical necessity of continued inpatient stay.
The requested continued skilled nursing facility stay is not medically necessary for this patient as documentation does not support skilled nursing facility stay. The patient has a medical history significant for chronic low back pain with history of lumbar surgery and diabetes mellitus. Therapy documented that patient was contact guard assist (CGA) for lower body dressing, bathing, toileting and toilet transfers. She remained CGA for these tasks and eventually she progressed to stand by assist (SBA) for lower body dressing and bathing while remaining CGA for toilet transfers and toileting. The only significant progress was that physical therapy documented that patient was SBA for transfers (not toilet transfers which remained CGA). This minimal amount of progress, though, does not support continued skilled stay. Additionally, this reviewer would like to note that while the patient has a 7 step home with 1 handrail it was also noted multiple times by therapy that the patient had a "ramp entrance." Lastly,  she was ambulating 60 feet with a wheeled walker (WW) CGA but while the patient's distance did slowly improve she was still requiring CGA with ambulation. This level of progress does not support continued skilled stay. Additionally, there were no provider notes documenting a skilled medical or nursing need.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 diabetes mellitus.

Treatment: E0784 x 1, insulin pump.

The insurer denied coverage for E0784 x 1, insulin pump.

The denial is overturned. 

This is a male patient diagnosed with type 1 diabetes mellitus (DM). This request is for Tandem insulin pump. The patient is on multiple dose injection (MDI) of basal insulin as well as boluses of insulin prior to meals and snacks based on blood glucose (BG) values, exercise level and carbohydrate intake. He uses Dexcom Continuous Glucose Monitoring (CGM) G6 as well. He checks his BG at least 10 times per day. He has frequent episodes of hypoglycemia. He is on Basaglar 7 units; Humalog with insulin to carb ratio (ICR) 1:10 to 1:15 and insulin sensitivity factor (ISF) was 1:50. The patient has glucose levels in the 50s and 60s. He also has nocturnal hypoglycemia.

According to the American Diabetes Association (ADA), the accepted criteria for initiation of insulin pumps in type 1 diabetes (5-7) state that an insulin pump is medically necessary when a patient/caregiver is disciplined, motivated, compliant and knowledgeable, takes multiple daily injections, self-adjusts insulin doses and is able to monitor blood glucoses 4-6x per day (8). The new insulin pumps include calculation software which has been shown to be beneficial (9,10). 

This patient has type 1 diabetes. The patient has documentation of nocturnal hypoglycemia despite being on a low dose of Basaglar 7 units. In patients with insulin sensitivity such as this patient, an insulin pump is likely to be effective and eliminate the hypoglycemia that the patient is having at night because of the ability to reduce the basal rate at night versus the day which cannot be done with Basaglar. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The insurer's denial of coverage for E0784 x 1, insulin pump is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Viral Hepatitis C. 
Treatment: Epclusa, Pre-service. 

The insurer denied the Epclusa, Pre-service. 
The denial is upheld. 

The patient is a male with chronic hepatitis C, genotype 2, treatment naive. He has a viral load of 3.01 million IU/ml (international units/milliliter). There is no Fibroscan or Fibrosure showing degree of fibrosis. He has laryngeal cancer, and needs treatment of HCV (Hepatitis C virus) before his cancer is treated. His provider is requesting treatment with Epclusa. 

No, the treatment with Epclusa is not medically necessary. 

The medical literature supports that it is necessary to know the degree of fibrosis in patients with chronic hepatitis C. While the patient had an US (ultrasound) of the liver, that does not evaluate for degree of fibrosis. In order for degree of fibrosis to be assessed, one would need a liver biopsy or more commonly a Fibroscan or Fibrsoure test. Starting Epclusa without knowing if the patient has cirrhosis is not clinically appropriate or accepted standard of medical care, and is not medically necessary. 

It is not known if the patient has cirrhosis, as there has not been a test measuring the degree of fibrosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic low back pain.

Treatment: Magnetic resonance imaging of the lower back without contrast.

The insurer denied coverage for the magnetic resonance imaging of the lower back without contrast. 

The denial is overturned. 

This is a female patient who had chronic low back pain with increasing pain which radiated down her left leg.  A physical exam demonstrated a positive straight leg raise sign. The patient stated that she had tried an inversion table, heat and ice, chiropractic as well as trials of Norco and Gabapentin.

Clinical practice guidelines support performing Magnetic Resonance Imaging (MRI) after failing conservative therapy and increasing pain. The American College of Radiology (1) criteria for appropriateness states: "Imaging is considered in those patients who have had up to 6 weeks of medical management and physical therapy that resulted in little or no improvement in their back pain."  This patient fulfills these criteria.

Similarly, North American Spine Society (NASS) and several other societies reviewed clinical practice guidelines (2,3) and found more abnormalities in patients with chronic low back pain than controls. 

It was medically reasonable and necessary for the patient to have a non-contrast MRI. The health plan did not act reasonably with sound medical judgment.

The insurer's denial of coverage for the magnetic resonance imaging of the lower back without contrast is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetic foot ulcer.

Treatment: Power wheelchair.

The insurer denied coverage for a power wheelchair.

The denial is upheld. 

This is a male patient with diabetes mellitus, peripheral neuropathy and diabetic foot ulcer. Currently under review is the request for a power wheelchair.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the clinical records do not support the medical necessity of the requested power wheelchair. The insurer denied the requested wheelchair due to lack of documentation regarding whether the patient's home can provide adequate access between rooms, in and out of the home, maneuvering space, over surfaces, and a secure storage space for the operation of the power wheelchair. The Home Assessment Evaluation Form completed by the supplier confirms the patient's bathroom and kitchen are not wheelchair accessible. In addition, the treating providers do not address alternatives such as a manual wheelchair and/or using off-loading lower extremity bracing. In addition, the most recent office visit note from the podiatrist indicated the patient's foot ulcer was improving with the use of a total contact cast and without the use of a power wheelchair.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient; the requested power wheelchair is not medically necessary.

The carrier's denial of coverage for a power wheelchair is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overbite

Treatment: Orthodontic care

The insurer denied coverage for the orthodontic care.

The denial is upheld. 

This male patient presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal class I molars, maxillary and mandibular spacing, proclined incisors, and deep impinging overbite.  The orthodontist has completed the Handicapping Labiolingual (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity.  The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 12 points on review by internal reviewers.  The patient's father is appealing on behalf of the patient.

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 deep impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care.  In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 12 points (6 points overjet, 4 points overbite, and 2 points 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. (1-3).

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

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

The insurer's denial of coverage for comprehensive orthodontic treatment (code D8080) and periodic orthodontic treatment visits (code D8670) is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral foot pain
Treatment: Custom Shoe Inserts (L3000x2) Pre-service
The insurer denied the Custom Shoe Inserts (L3000x2) Pre-service
The denial is overturned. 

The patient is a male. He presented to his foot doctor's office for follow-up for bilateral foot pain.  His left foot was worse than his right foot.  He had been prescribed icing, stretching, Advil, change in shoes, he had also worn orthotics previously.  He was diagnosed with bilateral tibial tendonitis, bilateral plantar fasciitis with flat feet based on his clinical examination.  Custom orthotics were recommended.

Yes, the Custom Shoe Inserts (L3000x2) are medically necessary.
The clinical records explained that the patient had tibial tendinitis and plantar fasciitis.  The denial letter stated that this device -custom foot orthotics- are typically utilized when conservative care has failed.  The clinical records clearly documented that the patient had tried and failed Advil, icing, stretching and shoe modifications.  In addition, he had previously worn custom orthotics, and the orthotics had been outgrown one year prior.

All the criteria for using custom orthotics in this case have been met and are in the clinical documents provided by the physician.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Crohn's Disease.
Treatment: Lab Work/Blood Tests.
The health plan denied the requested therapeutic drug testing of anti-Adalimumab antibodies. 
The health plan's determination is overturned.

This is a female who has Crohn's disease. She underwent an ileocecal resection. Recently, she has been maintained on Adalimumab injections every two week. She is doing clinically well. As part of her ongoing care, her pediatric gastroenterologist recommended obtaining serum Adalimumab concentrations and anti-Adalimumab antibody levels. The health care plan is declining coverage on the grounds that this is experimental and investigational.

The health plan's determination regarding the proposed health service or treatment is overturned, in whole.

There is no doubt that biologic therapies have changed the treatment of inflammatory bowel disease dramatically. Outcomes have improved; prolonged corticosteroid therapy is rarely necessary today. However, there are issues with the use of biologics. They must be given consistently on a schedule, either injection or infusion. Failure to do so runs the risk of allowing the body to develop antibodies to the drug. Subtherapeutic levels may also lead to antibody formation. There are multiple reasons for low levels - intermittent administration, severe inflammation, low serum albumin.

Current data show that maintaining a therapeutic level of 8-10 is associated with a good clinical response. Early detection of antibody formation allows intervention with a medication such as Methotrexate to prevent further antibody development and allow continuation of the therapy.

Not measuring concentrations means assuming that levels are therapeutic. The first indication of subtherapeutic levels may be a return of disease activity and clinical symptoms.

Although the denial has been correct based on current language in the plan's documents, it needs to be updated. The standard of care today is measurement of concentrations and antibody levels. Therefore, the plan's determination should be overturned.