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

Diagnosis: Overbite.
Treatment: D8080 Comprehensive Orthodontic Treatment (Braces) and D8670 Periodic Orthodontic Treatment Visit, Pre-service.
The insurer denied the D8080 Comprehensive Orthodontic Treatment and D8670 Periodic Orthodontic Treatment Visit, Pre-service.
The denial is overturned.

The patient is a female. The request is for dental benefits for orthodontic treatment (Braces) and periodic orthodontic monthly visits.

Patient presents with skeletal Class I relationship, Class II Canines, moderate maxillary and mandibular spacing, moderately excessive overjet, deep impinging overbite with severe soft tissue damage.

The health plan denied the treatment because it states that it is not medically necessary. The provider appealed based on the conditions and diagnoses with which the patient presented.

Yes, the orthodontic therapy (Braces) and periodic orthodontic treatment visits are medically necessary.
The patient presents with a very deep overbite (greater than 50%). More than 50% of the anterior lower front teeth are covered by the upper teeth. In this case, the biting edge of the lower front teeth are biting into the gums of the upper front teeth when the patient closes their mouth. This is evident on the intra-oral photos of the upper anterior gum area.

A severe overbite like this can result in gum recession, and eventually gum disease and possible tooth loss. Difficulty with speech and chewing are also a possible consequence of this condition.

Therefore, given the above, the braces and visits are medically necessary.

As evidenced in the x-rays and the photos, the severity of the overbite and the other conditions of the patient's dentition warrants orthodontic treatment.

The long-term consequences of not treating these conditions would lead to more complications of the patient's dentition, and would thus affect the patient's overall health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea.

Treatment: Hypoglossal nerve/upper airway stimulator device.

The insurer denied coverage for hypoglossal nerve/upper air way stimulator device.

The denial is overturned. 

This is a male patient who has obstructive sleep apnea (OSA) with an Apnea Hypopnea Index (AHI) of 24.  He has used continuous positive airway pressure (CPAP) but is unable to tolerate it.  He had a sleep induced study that showed nonconcentric collapse.  He has a history of valve regurgitation, atrial fibrillation (afib) and reflux.  His initial body mass index (BMI) was 35.  He saw Ear Nose & Throat (ENT) who recommended a hypoglossal nerve stimulator (HNS).  He was denied for not fulfilling the criteria for HNS due to his elevated BMI but he said in his appeal his BMI was now 32.  His appeal letter noted that he has a "life threatening condition....his untreated sleep apnea contributed to his afib."  He is taking heart medications, Eliquis and reflux medications.  The records note he has significant fatigue.  There are journal articles included discussing HNS. 
This patient has severe OSA. He has sequelae that may be seen with severe OSA, that is, cardiac disease and afib. He has failed CPAP use. He had an OSA study showing AHI of 44. He brought his BMI down to 32 (he was denied the HNS since his BMI was 32.12). He had a drug induced sleep study showing nonconcentric collapse. He complains his OSA may be life threatening and this is reasonable relative to his cardiac disease. The criteria include moderate to severe OSA when all of the following criteria are met: 1. The patient is above a certain age; 2. AHI is between 15 and 65; 3. The patient is unable to tolerate CPAP; 4. All previous treatment measures have failed; 5. BMI is less than 32. He meets all the criteria except possibly (he could have lost more weight in the interim) the BMI but the ENT notes that there is literature that higher BMI does not exclude HNS. (To exclude a patient who fulfills all requirements and who has no good alternatives on the basis of .13 BMI would not appear to be indicated). The literature supports the efficacy of HNS and he appears to adequately, and from a medical necessity viewpoint, to fulfill the criteria for the HNS surgery.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. The hypoglossal nerve/upper airway stimulator device to treat
obstructive sleep apnea (OSA) is considered medically necessary for this patient.

The insurer's denial of coverage for a hypoglossal nerve/upper airway stimulator device to treat obstructive sleep apnea (OSA) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right wrist/forearm mass
Treatment: Follow-up Scan (magnetic resonance imaging), Pre-service
The insurer denied the Follow-up Scan (magnetic resonance imaging), Pre-service
The denial is overturned.

The patient is a male. He had a mass removed from his forearm/wrist area. His post-surgical course was non-complicated. He was evaluated by his physician on two occasions and advised to undergo magnetic resonance imaging (MRI) testing.  His pathology showed atypical lipoma.

Yes, the follow-up scan (magnetic resonance imaging) is medically necessary.
An MRI (magnetic resonance image) is of benefit if additional information assists in establishing a diagnosis and treatment.  The scientific literature describes MRI (magnetic resonance imaging) should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care. The necessity for more invasive procedures (surgical treatment) can be assessed. The performance of the MRI (magnetic resonance image) should have an impact on a patient's treatment regimen. If diagnostic tests are not clinically useful, they are not medically necessary.

The patient's records show that a mass was removed. Pathology did not show a "simple lipoma." There was atypia.  It would be important to obtain the study to see if recurrence occurred. If possible malignancy was present, ongoing monitoring would be necessary. The records showed concern. If recurrence occurred, treatment would change with more extensive reconstructive surgery.

Based upon clinical condition and Guidelines, there would be indication for additional testing. Therefore, the Follow-up Scan (magnetic resonance imaging) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Three-surface restoration tooth #14
Treatment: D2750 White Glass with High Gold Content Crown, Tooth 14, Pre-service
The insurer denied the D2750 White Glass with High Gold Content Crown, Tooth 14, Pre-service
The denial is upheld.

The patient is a female requesting a new crown for tooth #14. The x-ray presented shows the tooth having a three-surface restoration in it already. Clinical notes only say "palliative 14".

No, the proposed crown for tooth #14 is not medically necessary.
The records do not show any recurrent decay or fractures in the tooth. Also, there is no diagnostic information from the provider as to why treatment is needed.  Clinical notes only say "palliative 14".

Without an x-ray and/or photo showing decay or fracturing of the tooth, there is no need for a new crown on tooth #14.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Finger infection.
Treatment: Inpatient admission.

The insurer is denied coverage for inpatient admission.  The denial is overturned. 

This male patient has a history of chronic kidney disease, hyperaldosteronism, peptic ulcer disease, and gastrointestinal bleed who presented to the Emergency Department (ED) with complaints of right index finger pain and swelling.  The patient's vital signs on presentation included: Temperature 98.9 F (Fahrenheit), Blood Pressure 148/95, and Pulse 80, Respiratory Rate 19, and Oxygen (O2) Saturation 98% on Room Air.  The patient's laboratory results included the following: white blood cell (WBC) count 8.9, hemoglobin 12.6, hematocrit 40.5, creatinine 1.43, glucose 80, and uric acid 8.3. The patient was started empirically on intravenous (IV) antibiotics (i.e., Zosyn) and pain medications.  The patient's X-ray of right hand showed no evidence of fracture or osteomyelitis.  The patient's magnetic resonance imaging (MRI) of the hand showed extensive phlegmon distending the second proximal interphalangeal phalanx joint; possibility of osteomyelitis versus septic arthritis could not be ruled out.  Orthopedics consulted and deemed no surgical intervention was required.  Rheumatology was also consulted and unsuccessfully attempted a joint aspiration.  Infectious Diseases adjusted antibiotics.  The patient remained afebrile, hemodynamically and clinically stable.  The patient was discharged to continue antibiotics as an outpatient.       

According to documentation, the patient presented with right index finger swelling and pain suggestive of tenosynovitis infection versus a gout flare.  Although the patient was afebrile and hemodynamically stable, the patient had documented failure of outpatient management having recently been seen at another ED, sent home on pain medications.  The patient's symptoms progressed and MRI studies showed possible osteomyelitis versus septic arthritis, requiring trials of different IV antibiotics as well as colchicine.  Rheumatology attempted a joint aspiration without success.  Based on above findings, the hospital admission was medically necessary for administration of IV antibiotics, diagnostic testing, and further surgical evaluation.

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

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

Diagnosis: Cystic Fibrosis. 
Treatment: Trikafta 100 milligrams (mg)-75mg-50mg kit (84 tablets per 28 days). 

The insurer denied coverage for Trikafta 100 mg-75mg-50mg kit (84 tablets per 28 days). 
The denial is upheld. 

The patient has history of cystic fibrosis (CF).  Her Genetic mutation is W1282X and 3849+10kbCT.  The patient has had multiple exacerbations of the disease with recurrent respiratory infections.  She is currently on standard CF therapy, uses nebulizers twice daily (BID); Vest in the morning and Voltara in the evening.  The patient has had multiple courses of antibiotics including inhaled Ceftazidime; TOBI [tobramycin] and Aztreonam via Nebs [nebulization].  The patient carries a diagnosis of Bronchiectasis with acute exacerbations, Burkholderia Cepacia pneumonia, CF with gastrointestinal (GI) manifestations, Mucor infection, Burkholderia and Methicillin-resistant staphylococcus aureus (MRSA in sputum). 

As per last visit notes, the patient was on intravenous (IV) antibiotics - Meropenem.  The patient had been on Doxy prior to that.  Pulmonary function tests (PFTs) indicated an obstructive pattern, FVC [forced vital capacity] 2.74 77%, FEV1[forced expiratory volume] 1.64 53 percent (%), Ratio 60. 

Computed Tomography scan of the chest showed bronchopneumonia left upper lobe (LUL) bronchus.  There was mucoid impaction, air trapping and bronchiolitis and other chronic changes. 

The patient's medical doctor (MD) is requesting Trikafta for treatment of Cystic Fibrosis. 

This patient does not have either F508del mutation or a mutation for which Trikafta has shown clinical response. 

Use of Trikafta in this patient is not supported based on review of current literature.  It is not Food & Drug Administration (FDA) approved for the mutation this patient has.  Hence it cannot be considered medically necessary at this time.  The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for Trikafta 100 mg-75mg-50mg kit (84 tablets per 28 days) for treatment of cystic fibrosis is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who presented to the emergency department complaining of chest pain. His medical history was remarkable for hypertension, hyperlipidemia, diabetes and hepatitis B infection. His blood pressure was 139/78 mmHg with a heart rate of 84 beats/minute. His respiratory rate was 16/minute with a room air oxygen saturation of 97%. He was afebrile. His physical exam was unremarkable. An electrocardiogram showed sinus rhythm with diffuse ST segment elevation. His white blood cell count was 15,000. Both his erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated. His serum troponin level was normal. Chest X-ray showed a possible right lower lobe infiltrate. Chest computed tomography (CT) scan showed no acute pathology; there was no evidence of pericardial effusion. The patient was treated with aspirin and admitted to the hospital. 

An inpatient level of care was not medically necessary. 

This patient presented with chest pain due to acute pericarditis. He was afebrile and hemodynamically stable. His cardiac biomarkers were normal and echocardiography showed only a small anterior effusion. The medical literature indicates that inpatient admission is not necessary for the majority of patients with acute pericarditis. Indications for inpatient admission include fever > 100.4F (38C), evidence suggestive of cardiac tamponade, large pericardial effusion (an echo-free space greater than 20 millimeter (mm)), nonsteroidal anti-inflammatory drug therapy ineffective after seven days, immunosuppressed state, history of oral anticoagulant therapy, acute trauma, and elevated cardiac troponin level (suggestive of myopericarditis). This patient met none of these criteria. He could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman who presented to the hospital emergency department (ED) with upper abdominal pain. She had recently been evaluated at another hospital with similar complaints. At the time of presentation, the patient was without fever and vital signs showed a heart rate of 80/minute and blood pressure of 130/86. She was tender in the upper abdomen. The white blood cell (WBC) count was elevated at 15.2. The complete metabolic panel identified slight elevation of aspartate aminotransferase (AST) with normal alanine aminotransferase (ALT). Bilirubin was slightly elevated at 1.6. Ultrasound showed gallstones and gallbladder wall thickening.

She was initially treated with intravenous (IV) fluid and antiemetics. Surgical consultation was obtained. The patient underwent laparoscopic cholecystectomy. 

An inpatient level of care was not medically necessary in this case. This patient is a woman with no significant comorbid health issues who presented to the ED with abdominal pain. Evaluation identified gallstones and cholecystitis. She was hemodynamically stable at the time of presentation. The WBC count was elevated at presentation but trended down. An uncomplicated cholecystectomy was performed. The patient remained hemodynamically stable during the period of pre-surgical care, during surgery, and during the period of post-surgical monitoring. An observation status would have allowed for overnight monitoring, confirmation of clinical stability, cholecystectomy as performed and post-surgical monitoring.

The lower level of care would have been appropriate. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. There were no peri-operative complications or other clinical issues that mandated inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation 

Treatment: Full Hospital Admission 

The insurer denied coverage for full hospital admission. 

The denial is upheld. 

This is the case of a woman with a history of diabetes mellitus (DM), hypertension (HTN), atrial fibrillation (AF), and anemia that presented to the Emergency Department (ED) with shortness of breath and palpitations.  She reported that she was experiencing paroxysms of AF all day long.  Upon arrival, heart rate was 50 beats per minute (bpm) and blood pressure (BP) was 143/118.  Physical examination was unrevealing.  Serum blood testing revealed a white blood cell (WBC) count of 15000 and Hemoglobin of 9.  Serum lipase was mildly elevated.  Upon arrival to the hospital, she reported that palpitations had resolved.  Electrocardiogram (ECG) revealed atrial fibrillation with a controlled ventricular response.  She was monitored in the hospital and released following adjustment of diltiazem.  

The health care plan acted reasonably, with sound medical judgement and in the best interest of the patient.  This patient presented with symptomatic atrial fibrillation and was effectively treated with atrial-ventricular (AV) nodal blocking agents.  ECG revealed that heart rates were controlled while in AF upon arrival and throughout her hospital stay.  Bellew, et al studied patients presenting to the hospital with atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department.  In this study of almost 600 patients, there was no difference in outcome.  American Heart Association (AHA) guidelines note that admission to the hospital for management of atrial fibrillation in patients that achieve rate control do not require hospital admission.(2) This patient had excellent rate control and known history of anemia and no abnormalities on physical examination.  In conclusion, this patient could have been managed at a lower level of care.  Full hospital admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment and in the best interested of the patient.  

The insurer's denial of coverage for the full hospital is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Areata 

Treatment: Xeljanz (tofacitinib) 

The insurer denied coverage for Xeljanz (tofacitinib). 

The denial is upheld.  

This is the case of a male patient who has been diagnosed with alopecia areata. Upon a visit to his dermatology office, physical examination revealed: occipital scalp without hair, entire coronal scalp with many patches of hair loss and remaining hair totally white and fine, and eyebrows and eyelashes with normal growth. Xeljanz (tofacitinib citrate) 10 milligrams (mg) oral tablet, twice daily, was ordered for the patient; the indication was patchy loss of hair. 

Xeljanz is not medically necessary for the claimant's condition, alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, diphenylcyclopropenone (DPCP), calcipotriene, and anthralin. (1-11) Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata, further studies are needed to demonstrate the long term efficacy and safety of Xeljanz. It is noted that the Food and Drug Administration (FDA) released a statement in early 2019 finding increased risk of deep vein thrombosis and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10mg twice per day (BID). (1) 

The standard of care for treatment of alopecia areata would necessitate an attempt to use the above mentioned non-systemic options for the treatment of alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possible improve alopecia areata, including light therapy, squaric acid, DPCP, and anthralin. (9-11)  

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

The insurer's denial of coverage for Xeljanz (tofacitinib) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III skeletal relationship. 
Treatment: D80880 Braces, D8670 Monthly Visit x 12, Pre-service. 

The insurer denied the D80880 Braces, D8670 Monthly Visit x 12, Pre-service. 
The denial is overturned. 

The patient is a male. The request is for dental benefits for orthodontic treatment (Braces) and monthly visits, pre-service. Orthodontic records included x-rays, models, and photos. 

The patient presents with a class III skeletal relationship - hypoplastic maxilla, mild maxillary spacing, mild mandibular crowding, impacted 3rd molars, anterior crossbite with gingival attachment loss -mandibular lateral incisors. 

The health plan denied orthodontic treatment with the position that treatment is not medically necessary. The provider appealed due to the conditions with which the patient presented. 

Yes, the Braces and monthly visits are medically necessary. 

The patient's photos exhibit bi-lateral crossbites of the mandibular lateral incisors. This is where the lower mandibular incisors are in front of the upper incisors; typically the reverse is the normal alignment position. With the teeth in this un-natural position, it can affect the patient's speech and the ability to chew effectively. 

Therefore, given the above, the braces and monthly visits are medically necessary. 

Non-treatment of these conditions can bring about complications of decreased function as it relates to chewing, proper speech, and possible trauma from occlusion due to the current position of the teeth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headaches.
Treatment: Nurtec 75MG OR TBDP, Pre-service.
The insurer denied the Nurtec 75MG OR TBDP, Pre-service.
The denial is upheld.

The patient is a female with migraine headache disorder. Per pharmacy records, the patient has tried and failed rizatriptan, sumatriptan and Ubrelvy for abortive therapy. The provider is requesting Nurtec.

No, the proposed treatment with Nurtec is not medically necessary.

There is not reason the patient cannot be treated with the remaining preferred agents.  All of the preferred agents are Food and Drug Administration (FDA) approved for acute treatment of migraine headaches and are considered first line, standard of care, abortive agents (Thorlund et al.). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Nurtec relative to the preferred agents.