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

Diagnosis: Class I malocclusion.
Treatment: D8080 Braces & D8670 Follow-Up Visits.

The insurer denied the D8080 Braces & D8670 Follow-Up Visits.  The denial is overturned.

The patient is a female. The request is for orthodontic benefits. The patient has a Class I malocclusion. She has multiple anterior teeth in crossbite (reverse bite) and severe crowding in the lower jaw. The denial was due to the Salzmann index not being more than 25.

Yes, the proposed treatment is medically necessary.

The patient has severe crowding in her lower jaw. This has caused several areas of crossbite, where her lower teeth are in front of her upper teeth. This is not a good situation. This has also caused some gum recession from the gumline of her lower canines. This "anterior crossbite with gum recession" is an "automatic qualifier," according to the handicapping index scale. Over time, the teeth will bang together during the chewing cycle, causing trauma, fractures and/or loosening of teeth. This most probably will contribute to temporomandibular joint (TMJ) issues in the future because the teeth cannot mesh properly without causing undue strain on the TMJ and the out of place teeth. In order to prevent much trauma in the future to her oral structures, this patient needs orthodontic treatment to correct her very poor bite. This case has medical necessity.

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: Diverticulitis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented with abdominal pain. She had a history of previous episodes of diverticulitis. She was afebrile and the vital signs were stable. Lower abdominal tenderness was present without rebound or guarding. A computerized axial tomography (CAT) scan showed acute uncomplicated diverticulitis. There was also a question of appendicitis, but no surgical interventions were advised. She was started on intravenous (IV) antibiotics and then switched to oral antibiotics.

Clinical indications for admission for acute diverticulitis (Milliman Care Guidelines M-150) include hemodynamic instability, peritoneal signs, persistent gross bleeding, or significant complications seen on imaging. This imaging abnormality can be a fistula, obstruction, perforation, or abscess. The patient did not have these conditions. She also did not have bacteremia, severe vomiting, an inability to maintain oral hydration after observation care, or need an inpatient surgical intervention.

This patient had an uncomplicated diverticulitis. IV hydration and pain medications could have been given in the emergency room. Afterwards, she could have been discharged on a course of oral antibiotics. She did not meet Milliman Care Guidelines (MCG) criteria for admission for acute diverticulitis. She could have been managed with observation status. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ESRD (end stage renal disease)

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned. 

The patient is an adult male with history of end stage renal disease (ESRD) on dialysis, chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DM) who presented to the emergency department (ED) with complaint of orthopnea, dyspnea on exertion and pleuritic chest pain. The patient was initially seen in physician's office who noted rales halfway up over the bilateral lung fields. The patient was sent to the ED. As per ED note, the patient's temperature was 98.8, heart rate was 99, respiratory rate was 18, blood pressure was 172/98 and oxygen (O2) saturation was 93% (percent). The patient reported some blood-tinged respiratory secretions, but was in no acute distress. The lung exam revealed bilateral rales. The heart sounds were normal, the abdomen was soft, and there was no cyanosis, clubbing or edema. 

The patient's white blood cell (WBC) count was 11.1, hemoglobin (Hb) was 10.7, and the blood urea nitrogen (BUN)/creatinine was 48/9.8. The troponin was 0.09 and brain natriuretic peptide (BNP) was 35,000.

An electrocardiogram (EKG) showed flipped T (interval on EKG) waves V5 (chest leads) V6 (chest leads), new compared to prior EKG. Chest x-rays revealed bilateral congestive changes. A computed tomography (CT) showed mediastinal adenopathy, bilateral effusions and perihilar ground glass opacity (GGO). Mediastinal adenopathy and infiltrates were new compared to previous CT.

The patient was admitted to Telemetry. Acute coronary syndrome (ACS) was ruled out. Consultations were obtained from Infectious Disease (ID), Renal, Pulmonary and Cardiology. The patient was noted to be hypoxic and so was placed on O2 by nasal cannula (NC). He was given intravenous (IV) Lasix for diuresis. Maintenance cardiac medications were started. Steroids were initiated as per Pulmonary recommendations. ID recommended rule out tuberculosis (though less likely). Empiric IV antibiotics for community acquired pneumonia (CAP) were started. The patient was undergoing workup for vasculitis given the CT changes and some blood-tinged respiratory secretions. Dialysis was continued per Renal. The patient slowly improved over the next few days and he was discharged home on oral medications.

Given the multiple medical issues in this patient with multiple comorbidities, it was appropriate to admit this patient for diagnostic testing and treatment.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac Circulatory Problems. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Eliquis. 
The denial is overturned. 

This patient is a male with a past medical history significant for hypertension, hyperlipidemia, and coronavirus 2019 (COVID- 19) infection. Records show that the patient presented to the emergency department (ED) with worsening shortness of breath and acute respiratory failure with hypoxia. A computed tomography angiography (CTA) of the chest demonstrated extensive acute bilateral pulmonary embolism (PE). The patient was admitted for evaluation and initiation of anticoagulation. He was initially started on intravenous (IV) heparin then switched to apixaban. After symptomatic improvement and resolution of hypoxia, the patient was discharged home. The patient's health plan has denied coverage for prescription benefit exception request for apixaban on the grounds the patient has not met prescription benefit exception criteria of failing or intolerance to the formulary anticoagulants, warfarin and Xarelto. The patient's treating provider is appealing this denial. 

At issue is whether Eliquis would be as effective as the formulary drugs, warfarin and Xarelto.

The health plan's determination is overturned in whole. 

Based on the patient's recent diagnosis of acute bilateral PE and the dangers of interruption of anticoagulation posed by switching to another anticoagulant such as Xarelto, apixaban (Eliquis) is the preferable anticoagulant for this patient. The patient requires continued anticoagulation without interruption to reduce risk of worsening pulmonary embolism, clinical decompensation, and mortality. Furthermore, based on published medical literature on the treatment of patients with warfarin compared to apixaban for acute venous thromboembolism (VTE) and the American College o Chest Physicians (CHEST) Guideline and Expert Panel Report on Antithrombotic Therapy for VTE Disease, apixaban is preferable over warfarin given a lower risk of bleeding. (1, 2)  For these reasons, Eliquis should be approved for the treatment of acute bilateral pulmonary embolism (PE) in this case. Prescription benefit exception for apixaban (Eliquis) should be granted given its superiority over warfarin due to a lower risk of bleeding and the likelihood of exposing the patient to potential harm by switching the patient to Xarelto at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plantar Fasciitis
Treatment: Durable Medical Equipment (shoe inserts)
The insurer denied the durable medical equipment (shoe inserts).
The denial is upheld.

The patient is a male. He is diabetic and was diagnosed with plantar fasciitis. He was prescribed activity modification and conservative care, including stretching. When these failed, he was prescribed custom orthotics.

No, the requested shoe inserts are not medically necessary.

The device in question, custom molded orthotics, have not been shown to be any more efficacious than over the counter orthotics in the treatment of heel pain or plantar fasciitis. Physical therapy, injections, and home stretching exercises are still the gold standard in treating plantar fasciitis.

Meta-analysis analyzing several level 1 and level 2 studies, including over 1800 patients, was reviewed by researchers (1). They included over eight different types of custom orthotics in patients with plantar fasciitis. They found no difference in short-term pain relief among people who used custom-made orthotics compared with people who used store-bought versions. They also found that orthotics were not better at relieving pain or improving function compared with other treatments for heel pain, such as stretching, wearing a heel brace, or using a splint at night.

Therefore, given the above, the requested shoe inserts are not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The DME (durable medical equipment) is not medically necessary as described above, and therefore the health plan acted with sound medical judgement.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission

The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented to the ED (emergency department) for evaluation of new crushing chest pain. It started while he was walking to the bus and subsided with rest when he sat down in the bus. His PMH (past medical history) is pertinent for depression, anxiety and HIV (human immunodeficiency virus).

The clinical impression was ACS/UA (acute coronary syndrome/unstable angina). He underwent urgent cardiac catheterization with successful PCI (percutaneous coronary intervention) with stent to the critical proximal LAD (left anterior descending) stenosis on the same day. Troponin was marginally elevated and chest film was clear. There were no procedural complications and he was discharged to home.

This is an appeal of the denied claim of the requested Acute Inpatient Hospital Stay for this patient.

No, the Inpatient admission was not medically necessary.
In this particular case, the patient underwent successful and uncomplicated cardiac catheterization with coronary angiography and PCI (percutaneous coronary intervention) on the same day. The information provided does not support the medical necessity for inpatient admission after his coronary intervention. This procedure when uncomplicated, as in this patient's case, is routinely performed at a lower level of care with overnight observation. There is no documentation of unstable medical conditions like AMI (acute myocardial infarction), contrast nephropathy, acutely decompensated CHF (congestive heart failure), life-threatening cardiac arrhythmia, procedural complications, or other medical instability or acute care needs that would require acute inpatient management. Therefore, the inpatient admission was not medically necessary, based on the submitted information and the current published medical literature evidence-based standards.

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

Diagnosis: Malocclusion. 
Treatment: Braces with Monthly visits. 

The insurer denied coverage for braces with monthly visits. 

The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite and anterior crowding and has recommended Orthodontics. The orthodontist has completed the Handicapping Labiolingual Deviation Index (HLD) attaining 17 total points to support orthodontic care. The insurer has denied coverage tor orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 21 points by internal reviewers on the HLD index. 

Upon review of the submitted documentation (study models were not provided for review) 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 (HLD) is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition
and completes the second portion of the index arriving at 17 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 21 points on the HLD index (4 overjet, 4 overbite, 10 anterior crowding and 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note is in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval. 

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 referenced below. 

Braces and monthly visits are not considered medically necessary for this patient. 

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

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

Diagnosis: Obesity
Treatment: liver biopsy

The health plan denied the liver biopsy as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who underwent laparoscopic gastric bypass; if fatty liver was visualized, a wedge liver biopsy would be obtained. The operative report states that the liver appeared fatty and therefore a wedge liver biopsy was performed. Findings revealed liver parenchyma with slight/borderline steatosis.
At issue is the medical necessity of the liver biopsy performed.

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

No. Routine liver biopsy during bariatric surgery is not standard practice and generally does not support risk benefit considerations, particularly if the patient has no pre-operative history or clinical findings/consequences of fatty liver and if the findings are not going to be surveyed with subsequent biopsy to determine response/progression. Some degree of non-alcoholic steatohepatitis (NASH) / non-alcoholic fatty liver disease (NAFLD) can be seen grossly in patients undergoing bariatric surgery. There is significant improvement of fatty liver/NASH/NAFLD with weight loss after bariatric surgery. Separately, liver wedge biopsy v. tru cut or core needle biopsy may over-estimate the degree of steatosis or not provide an accurate representation, as it is being performed on the edge of liver v. tru-cut or core needle biopsy which shows a deeper column of liver parenchyma. Although a liver wedge biopsy may provide more tissue available to assess, these biopsies are often subcapsular, which may give the false impression of increased fibrosis. Therefore, long cylindrical cores of liver parenchyma about 1 to 2 centimeters (cm) in length by 0.2 cm in width with core needle biopsy may be more accurate for assessing NASH/NAFLD. There is no national guideline from the American Society for Metabolic and Bariatric Surgery (ASMBS) that supports routine liver biopsy during bariatric surgery. There is no high-level prospective trial documenting outcome benefits for routine liver biopsy during bariatric surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Revisional bariatric surgery & concomitant liver biopsy
Treatment: Laparoscopic Procedure (liver biopsy) CPT 47397

The insurer denied the Laparoscopic Procedure (liver biopsy) CPT 47397.
The denial is upheld.

The patient is a woman who underwent revisional bariatric surgery (laparoscopic roux en Y gastric bypass [conversion from prior gastric band] and concomitant liver biopsy) performed. The records support that she had a BMI (body mass index) of 61. The operative dictation states that the surgeon obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provides the diagnosis of mild steatosis of liver biopsy.

The surgeon submitted code 47397 (liver biopsy, wedge). The health plan rationale for denial of coverage for liver biopsy letter is that there is no documentation of objective signs or symptoms of liver disease to warrant liver biopsy. Per this letter guidelines on the use of liver biopsy in clinical practice, routine biopsy of the liver with bariatric surgery is not mentioned. Appeal material is provided by the surgeon.

No, the liver biopsy was not medically necessary.
The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of roux en Y gastric bypass performed. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant liver biopsy. The operative dictation also describes no liver pathology that would indicate liver biopsy.

According to generally accepted criteria, routine liver biopsy is not medically necessary in conjunction with bariatric surgery. Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.

In this case the patient is morbidly obese, with a body mass index of 61. Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology.

Therefore, given the above, the liver biopsy was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The health plan acted reasonably with the determination of medical necessity regarding liver biopsy in this case. Accepted indications for liver biopsy include: Documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy (47379 liver biopsy, wedge).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fatty Liver, Morbid obesity.
Treatment Liver Biopsy.
The insurer denied the Liver Biopsy.
The determination is upheld.

The patient underwent bariatric surgery (laparoscopic Roux en Y gastric bypass and concomitant liver biopsy). The records support that he had a body mass index (BMI) of 46.47 kilograms per square meter (kg/m2). The operative dictation states that the surgeon obtained a wedge liver biopsy from the left lobe of the liver. The submitted records do not include any pre-surgical lab, imaging or clinical data to indicate liver pathology. The pathology report provides the diagnosis of mild steatosis. The provider submitted CPT code 47100 (liver biopsy, wedge).
At issue is the medical necessity of a liver biopsy.
The submitted documentation does not support the medical necessity of concomitant liver biopsy at the time of the Roux en Y gastric bypass. There is no documentation of liver pathology as might be obtained by pre-operative imaging or lab data to warrant a liver biopsy.
Accepted indications for liver biopsy include: Documentation of signs or symptoms of liver disease (abnormal liver function tests of unknown etiology, knowledge of a specific diagnosis that will likely alter the treatment plan, known liver disease where prognostic information about fibrosis may guide subsequent treatment, the presence of a mass or lesions or focal or diffuse abnormalities seen on imaging studies of unknown etiology). In this case there is no such documentation to warrant wedge liver biopsy. A routine liver biopsy is not an accepted or standard aspect of bariatric surgery.[1]
According to generally accepted criteria, a routine liver biopsy is not medically necessary in conjunction with bariatric surgery.[1] Liver biopsy is indicated if there is a suspicious growth on the liver, if there is scarring of the liver or if there is a condition of the liver as indicated by pre-operative imaging or lab data that requires biopsy.
In this case the patient has morbid obesity with a body mass index of 46.47 kilograms per square meter (kg/m2). Lab data and pre-operative imaging are not included with the review material. There is no description of clinical symptomatology to indicate liver pathology.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Prosthetics. 

The insurer denied passive prosthesis and glove. 
The denial is overturned in part. 

The patient is a male with congenital left-hand amputation. He currently uses a myoelectric prosthesis for activities of daily living (ADL). He is in need of a new passive prosthesis since he cannot use powered prosthesis on the Sabbath. 

The health plan's determination is overturned in part. 

The requested passive left arm prosthesis is medically necessary for ADL assistance and is standard of care to provide this for congenital amputee. The silicone glove is not medically necessary. The silicone glove does provide increased durability and benefits for a pediatric patient which can help with self-esteem and acceptance of the prosthesis by the patient and peers, however, this component is not medically necessary.