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

Diagnosis: Class I malocclusion
Treatment: Braces
The insurer denied braces. 
The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 10. She presents with a skeletal Class I malocclusion with severe crowding in the maxilla and mandible. She is treatment planned for 24 months of braces to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

The braces are medically necessary for this patient.

This patient presents with an anterior crossbite on tooth 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Adjustment of braces and insertion of braces.
The insurer denied adjustment of braces and insertion of braces.  The determination is upheld.

The patient is a male with a Class I malocclusion, mild maxillary crowding and mild mandibular crowding, moderate overjet and severe overbite. The issue for review is whether the adjustment of braces and insertion of braces are medically necessary.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 21 with no auto qualifiers. Auto qualifiers include cleft palate deformity or craniofacial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment of adjustment of braces and insertion of braces is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: decreased mobility
Treatment: Home Care / Personal Care Level 2 Personal Care Services Increase to 84 Hours per Week
The insurer denied Home Care / Personal Care Level 2 Personal Care Services Increase to 84 Hours per Week
The health plan's determination is overturned. 

The patient is a male with past medical history of hypertension, hyperlipidemia, atherosclerosis of the aorta, dysphagia, percutaneous endoscopic gastrostomy (PEG) tube, history of colon cancer, gastroesophageal reflux disease (GERD), constipation, bladder incontinence, and Type 2 diabetes mellitus (DM).

Home Care / Personal Care Level 2 Personal Care Services Increase to 84 Hours per Week are medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased PCA services. The assessment indicated that the patient needed maximum assistance with a task of toilet use. The patient therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The assessment also underestimated the patient's care needs based on the letter provided by the patient's PCP (primary care provider) showing a change in patient's status since the previous assessment. The patient's daughter is disabled and is unable to provide informal support. The requested increase in PCA (personal care assistant) services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression and gait disorder, not otherwise specified. 
Treatment: Increase Personal Care Services 24 Hours a Day, 7 Days a Week (live in). 
The insurer denied: Increase Personal Care Services 24 Hours a Day, 7 Days a Week (live in). 
The denial is upheld. 

This is an elderly female with depression and gait disorder, not otherwise specified. The request is for an increase in her personal care services. A final adverse determination denial note demonstrated the patient had previously received personal care services in the following manner: 6 hours per day for 4 days a week, 5 hours per day for 3 days a week. The request was for personal care services of 24 hours per day for 7 days per week. At that time, a recent assessment 2 months ago demonstrated that the patient needed help with meal preparation, housekeeping, laundry, shopping, dressing, bathing, transferring, and toileting. It was noted that the patient lived alone with a supportive caregiver. It was noted that the patient had ataxia and required assistive device for ambulation. Minimal clinical information was provided other than attestation from the patient's physician noting that the patient was confined to her home as a result of her depression and gait disorder not otherwise specified. 

The requested increase in personal care services 24 hours a day, 7 days a week (live in), is not medically necessary. 

In this instance, minimal clinical information was provided to justify the increase in personal care attendant services. There was no demonstration of active comorbidities other than advanced age. There was no evidence of skin breakdown. The clinical information that was provided demonstrated that sufficient hours were devoted to housekeeping, meal preparation, laundry, shopping, dressing, bathing, transferring, toileting without any other need demonstrated. In the absence of further information to justify the increase in hours, there was no clear rationale to demonstrate that the patient required increased personal care attendant services. At the present time, with what is provided, the current hours are sufficient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper quadrant pain
Treatment: Inpatient stay
The insurer denied: Inpatient stay
The denial is upheld.

The patient is a female that presented to the emergency department with right upper quadrant pain radiating to the right flank and associated nausea. She was started on pain medications, anti-emetics, and intravenous fluids. Labs showed elevated liver enzymes of aspartate aminotransferase/alanine aminotransferase (AST/ALT) of 400/200 and ultrasound showed cholelithiasis without evidence of fluid or wall thickening. Magnetic resonance cholangiopancreatography (MRCP) was ordered to further investigate the elevation in her liver enzymes. She was admitted and magnetic resonance cholangiopancreatography showed no sign of choledocholithiasis or liver disease. She then went for laparoscopic cholecystectomy and was discharged on day #4. Her inpatient admission was denied due to not meeting inpatient criteria. 

The acute inpatient admission was not medically necessary. 

The goal length of stay for laparoscopic cholecystectomy is ambulatory status. Acute inpatient admission after laparoscopic cholecystectomy is indicated when: 
- patient fails to achieve discharge status criteria. 
- conversion to open procedure 
- severe infection 
-care for comorbidities (e.g., pancreatitis, sepsis, heart failure, renal failure) and expect brief to moderate stay extension 
- complications of procedure, including bile duct injury and intraoperative or postoperative bleeding. 
The discharge criteria that needed to be met prior to discharge are: hemodynamic stability, ambulatory status, clean operative site, managed pain and absent nausea, and achieved voiding status. This patient does not have any notation in operative note or post-operative notes of any complications intra-operatively or post-operatively. She does not have gangrenous cholecystitis, 
signs of systemic infection, or comorbidities requiring inpatient stay. No documentation indicates a post-operative course requiring acute inpatient admission. This patient's care could 
have been managed in lower level of care such as observation status. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back surgery due to back and bilateral leg pain. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The health plan's determination is overturned. 

The patient is a female who presented for an elective L (lumbar)3/4 laminectomy with diskectomy. Indication for surgery was back and bilateral leg pain which failed non-operative management. The patient had left lower extremity (LLE) weakness pre-operatively. Past surgical history (PSH) was significant for prior L4-S (sacral) 1 fusion. Intraoperative, the patient experienced a small durotomy which was primarily repaired and further addressed with Duragen and Duraseal. Post-operatively, hospitalist and physical therapy (PT) services were consulted. The patient was slow to progress with PT. She required several days of therapy in order to be able to be safely discharged home. 

The inpatient hospital admission was medically necessary. Lumbar laminectomy is typically performed as an outpatient. Unfortunately, as can happen in surgery, this patient experienced intra-operative and post-operative challenges such as durotomy and extensive physical therapy. The patient had pre-operative weakness in her left lower extremity (LLE) which can slow down physical therapy progress. Given the patient's need to remain in the hospital for more than 2 midnights, her appropriate level of care would be inpatient. The patient was not able to be safely discharged prior to postoperative day (POD) 7. Her care could not have been rendered at a lower level of care for the duration of her stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld. 

This is an adult patient with a history of asthma, gastroesophageal reflux disease (GERD), anxiety and depression. The patient presented to the emergency department with shortness of breath, wheezing and cough.

Vital signs on presentation were reported as: Temperature 98.2 (degrees) Fahrenheit (F), Heart Rate (HR) 106, Respiratory Rate (RR) 16, Blood Pressure (BP) 103/74, Oxygen (O2) saturation 97% (percent) on room air (RA). The patient's Peak Expiratory Flow (PEF) was 120 with unknown baseline. The patient had bilateral wheezes on exam and was alert and oriented to person, place and time.

The patient was treated with intravenous (IV) steroids, magnesium, bronchodilators via nebulizer and Azithromycin. The patient's admitting laboratory results were: white blood cells (WBC) 12.8, electrolytes were within normal limits and the patient's chest X-ray was normal.

The patient improved with treatment and day 2 vital signs were: Temperature 98.4 F, HR 90, RR 18, BP 115/69, O2 saturation 98% on RA. The patient's Peak Expiratory Flow (PEF) was 150-170. The patient's lungs were clear.

The patient was afebrile and hemodynamically stable with no hypoxia. The patient was tolerating oral fluids and could have been placed in observation while treated. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Issues. 
Treatment: D6010 Implant Placement (Tooth 3); D6059 Abutment Supported Porcelain Fused to Metal Crown, High Noble Metal (Tooth 3); and D6057 Custom Abutment (Tooth 3). 
The insurer denied D6010 Implant Placement (Tooth 3); D6059 Abutment Supported Porcelain Fused to Metal Crown, High Noble Metal (Tooth 3); and D6057 Custom Abutment (Tooth 3). 
The health plan's determination is overturned. 

The patient is a male who presents for the treatment of tooth # (number) 3. Provided for review are letters of appeal and denial, letters from additional ear, nose, and throat (ENT) providers, radiographic images, clinical notes, American Dental Association (ADA) claim forms, explanation of benefits, health plan language, and letters of appeal by the patient. 

Implant Placement (Tooth 3); Abutment Supported Porcelain Fused to Metal Crown, High Noble Metal (Tooth 3); and Custom Abutment (Tooth 3) is medically necessary for this patient. 
As the patient is missing tooth #3, they have the diagnosis of partial edentulism as well as diminished posterior support. With the diagnosis of partial edentulism as well as diminished posterior support, the only therapy capable of addressing both diagnosis is that of implant therapy as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis. Fixed partial dentures do not offer additional support and actually depend on the residual dentition to replace the missing tooth simply putting additional load on the residual teeth without replacing the loss. Removable partial dentures are tissue supported prosthesis and do not offer any support to the dentition as they are designed to become passive upon load. After the implants have integrated they will require restorations in the form of abutments and crowns in order to complete the tooth replacement. This is standard in tooth replacement involving implants. Hence the entire dental treatment plan is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility
Treatment: Personal Care Services for 140 hours per week 
The insurer denied Personal Care Services for 140 hours per week 
The health plan's determination is overturned. 

This is a female patient with a history of diabetes mellitus type 2, neuropathy, hypertension, arthritis, osteopenia, osteoarthritis, gastroesophageal reflux disease (GERD), depression, tension headaches, and bladder incontinence. 

Personal Care Services for 140 hours per week are medically necessary.
There is documentation in the Uniform Assessment System (UAS) of the patient requiring at least maximal assistance with tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs. A tasking tool should not have been utilized to calculate hours given that the patient has unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) of the patient requiring assistance with toileting.
The patient lives with her husband and son and therefore has informal support. However, it cannot be assumed that the informal support person can provide all needed care outside of the approved personal care services hours as informal supports must be voluntary. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in personal care services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tongue Cancer
Treatment: Proton Radiation Therapy
The insurer denied: Proton Radiation Therapy
The denial is upheld.

The patient is an adult male with stage T0N1bM0 (no evidence of primary tumor, spread to a lymph node no larger than 3 centimeters, no distant metastases) p16 (human papilloma virus-positive)-squamous cancer of oral tongue status post left hemi-glossectomy and left neck dissection. Proton beam therapy is being requested to deliver post-operative radiation treatment.

The requested proton radiation therapy is not medically necessary.

Currently, published high grade clinical outcome evidence of proton beam therapy relative to photon radiation therapy for post-operative treatment of head and neck cancer is not sufficient to consider proton beam therapy as the standard of care. Available peer-reviewed publications on proton beam therapy for head and neck cancer are on potential benefits derived from non-randomized studies and dosimetric and biological considerations that are theoretic. These published studies suggest that proton beam radiation offers superior dosimetry to photon radiation treatment dosimetry, and side effects of proton beam therapy are evidenced to offer potentially less local side effects compared to photons in several types of malignancy. However, no clinical outcomes studies on proton beam therapy versus photon (intensity-modulated radiation therapy [IMRT]) have been published to conclusively state any advantage of protons to the current standards that exist for post-operative radiation therapy for head and neck cancer, as in this case. Proton beam therapy for head and neck cancer is currently being investigated in phase 2 and phase 3 clinical trials. It is, therefore, not possible to draw any conclusions on the benefits of proton beam therapy compared to photon intensity-modulated radiation therapy in this patient's case. Therefore, the requested health service is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Rheumatoid arthritis

Treatment: Orencia subcutaneous (SQ) 125 milligrams (mg)

The insurer denied coverage for Orencia subcutaneous (SQ) 125 milligrams (mg)

The denial is upheld

 
A search was performed for Abatacept (Orencia). The clinical pharmacology is submitted below:

Abatacept is a disease-modifying antirheumatic drug (DMARD) used in the management of rheumatic conditions, such as rheumatoid or psoriatic arthritis, and for the prophylaxis of acute graft-versus-host disease.

Abatacept is indicated in adult patients for the treatment of moderately-to-severely active rheumatoid arthritis and in patients greater than or equal to (>=) 2 years of age for the treatment of active psoriatic arthritis. In patients two years of age and older, abatacept is also indicated for the treatment of moderately-to-severely active juvenile idiopathic arthritis.

Abatacept is also indicated for the prophylaxis of acute graft-versus-host disease, in combination with methotrexate and a calcineurin inhibitor such as tacrolimus, in patients two years of age and older who are undergoing hematopoietic stem cell transplantation from a matched or 1 allele-mismatched unrelated donor.

There is no report of how anti tumor necrosis factor (TNF) antibodies will be affected. There is no mention of anti TNF antibodies in the clinical research. The report of a specific inflammatory pathway being blocked, and clinical effect is not confirmed. The mechanism of action inhibits T cells with no report about other specific antibody or anti  TNF.
 
There are no extenuating factors which support this medication vs formulary. There is no evidence of standard medication causing detriment or complication. Recent literature (see below) does not report increased risk of cancer or infection from standard medication.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non-formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Orencia subcutaneous (SQ) 125 milligrams (mg) is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.

Treatment: Procedure code 64628, thermal destruction of intraosseous basivertebral nerve and code 64629, thermal destruction of intraosseous basivertebral nerve.

The insurer denied coverage for procedure code 64628, thermal destruction of intraosseous basivertebral nerve and code 64629, thermal destruction of intraosseous basivertebral nerve.

The denial is upheld.

This adult male has chronic low back pain. He has had an Epidural Steroid injection without sustained pain relief. He is taking Tylenol.  He has not had 4 weeks of a non-steroidal anti-inflammatory drug (NSAID) trial. There is no history of transcutaneous electrical nerve stimulation (TENS), acupuncture, and other conservative therapy.  The request is for radiofrequency ablation (RFA) of lumbar (L)3, L4 and L5.  The magnetic resonance imaging (MRI) official report does not comment on Modic changes at those levels, it does note degenerative changes at L4-L5 and L5-sacral (S)1 with lumbarization of S1.	

The publications to date have been company sponsored and had methodologic flaws.  There are no published data on long term complication rates.  There are other evidence- based interventions available to this patient.  This procedure is unlikely to be more beneficial than the standard approaches.

Conger et al. (3) pointed out that all of the major studies while supportive, have been funded by the company:

"There is moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion and exclusion criteria used in the published literature to date. Success of the procedure appears to be dependent on effective targeting of the Basivertebral nerve (BVN). Non-industry funded high-quality, large prospective studies are needed to confirm these findings."

Similarly, a clinical practice guideline (4) while favorable pointed out the limitations of the current literature:

1)	Industry funding is a potential source of study bias for the available data reviewed.
2)	Limited number of studies.
3)	Short-term follow up for the majority of studied patients.
4)	Unknown effect on the primary degenerative process

This procedure is not likely to be more beneficial than the standard of care.

In summary, the denial of procedure code 64628, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral and 64629, thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral and coverage for the requested treatment should be upheld. 

This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.