Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis: sinusitis.
Treatment: sinus surgery.
The insurer denied sinus surgery (CPT 31298, 31295, 31254 and 30117). 
The health plan's determination is overturned in part.  CPT codes (31298, 31295, 31254) are indicated. CPT code 30117 is not indicated.

The patient is a female with a history of recurrent sinusitis who underwent balloon sinusplasty of the paranasal sinuses and reduction of nasal swell bodies. The surgery was denied by the health plan.

The balloon sinuplasty CPT codes (31298 and 31295, 31254) are likely to be more beneficial than standard treatment because they do meet the criteria for chronic sinusitis (thickening noted on CT scan). In addition, the patient's anterior ethmoidectomy was indicated for the chronic sinus disease (noted on CT scan). However, CPT code 30117 is not likely to be more beneficial in this case. 

CPT code 31298 (CPT 31298 Nasal/sinus endoscopy, surgical, with dilation (e.g., balloon dilation); frontal and sphenoid sinus ostia) is a proven treatment for recurrent sinusitis. This procedure, along with CPT 31295 Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium e.g. Balloon dilation, transnasal or via canine fossa, is considered a standard treatment for sinusitis symptoms. CPT 30117 - treatment of the swell bodies of the septum - does not have sufficient randomized clinical trials on the efficacy of this treatment. There is not appropriate evidence in the literature that this treatment could be considered standard of care to treat nasal congestion.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain (pelvic infection)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female who presented to the emergency department (ED) with a temperature of 100 Fahrenheit and complaints of pelvic discomfort. The rest of her vital signs were stable. The patient underwent imaging by ultrasound and computed tomography (CT) showing a cyst in the right adnexa and was admitted for management of pelvic inflammatory disease (PID) including intravenous fluids, Toradol and antibiotics. 

The patient was admitted and discharged on day three. Coverage was denied because the patient did not meet criteria for inpatient level of care since she had stable vital signs, was not pregnant, did not have sepsis, and was able to tolerate oral medication and an oral diet and had not tried and failed oral antibiotics.

No, the proposed inpatient hospital admission was not medically necessary.
Inpatient level of care was not medically necessary since the patient had stable vital signs, was not pregnant, and did not have sepsis.  In addition, the patient was able to tolerate oral medication and an oral diet and had not tried and failed oral antibiotics.

Inpatient level of care in this case is not supported by peer reviewed data, it is not standard of care and it is not supported by professional organizations.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Coverage was denied because the patient did not meet criteria for inpatient level of care since as she had stable vital signs, was not pregnant, did not have sepsis, and was able to tolerate oral medication and an oral diet and had not tried and failed oral antibiotics.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion.
Treatment:  D8080 Braces and D8670 Monthly Visit (x12).

The insurer denied the  D8080 Braces and D8670 Monthly Visit (x12).  The denial is overturned.

The patient is a female with Class I malocclusion.  She has an anterior crossbites of teeth #7 and #10. There is moderate upper and lower arch crowding and a deep bite. 

The reason for the prior denial was because of a score of 21 in the Salzmann scale (Handicapping Labio-Lingual Deviation Index).

Yes, the proposed treatment is medically necessary.
The patient has anterior crossbites (teeth #7 and #10) with gingival attachment loss. This is an automatic qualifier according to the handicapping index scale.

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: Acute myeloid leukemia.
Treatment: Prevymis 480 milligram oral tablets.
The insurer denied the Prevymis 480 milligram oral tablets.
The denial is upheld.

The patient in this case is a female who has acute myeloid leukemia. She underwent allogeneic stem cell transplantation. Following transplantation, she was started on maintenance chemotherapy with decitabine.  She was started on Prevymis for prophylaxis against cytomegalovirus (CMV) reactivation.  An appeal letter states that the patient has previously been found to have cytomegalovirus (CMV) viremia.   This medication was denied because it was felt that Food and Drug Administration (FDA) and National Comprehensive Cancer Network (NCCN) guidelines did not support use of this medication beyond 100 days post-allogeneic transplant.

No, the proposed treatment with Prevymis is not medically necessary.
Letermovir (Prevymis) has been Food and Drug Administration (FDA) approved for prevention of cytomegalovirus (CMV) infection following allogeneic stem cell transplantation.  When used for prophylaxis, it is typically given for the first 100 days following transplantation.  There is no evidence showing that continued prophylaxis beyond 100 days is associated with improvements in health outcomes compared to prophylaxis up to day 100 following transplantation. There is also no clear evidence that prophylaxis is associated with improved health outcomes compared to pre-emptive therapy.  This means treatment based on identification of asymptomatic cytomegalovirus (CMV) viremia.  Given these considerations, the proposed continuation of letermovir beyond day 100 post allogeneic transplantation is not medically necessary.

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: Crowding; overbite; overjet
Treatment: D8080 Comprehensive Orthodontic Treatment
D8670 Periodic Orthodontic Visit
The insurer denied the D8080 Comprehensive Orthodontic Treatment
D8670 Periodic Orthodontic Visit
The denial is upheld

The patient is a female. The request is for dental benefits for orthodontic treatment (Braces) and monthly visits. Per the provider's dental clinical summary, the patient presents with a class I skeletal relationship, class II canines, moderate maxillary crowding, severe mandibular crowding, moderately excessive overjet, deep impinging overbite with severe soft tissue damage.

The health plan denied coverage for the request, because the patient did not score a 26, the score necessary for approval for orthodontic treatment as outlined in Handicapping Labio-Lingual Deviation (HLD) Index Report.

The provider appealed the case based on the patient's diagnosis, specifically that the patient had a deep overbite with severe soft tissue damage. Per the HLD (Handicapping Labio-Lingual Deviation) Index Report, a deep impinging overbite with soft tissue damage is an automatic qualifier for orthodontic treatment.

No, the proposed treatment of orthodontic treatment and monthly visits are not medically necessary.
The patient did not meet the score of 26 on the HLD (Handicapping Labio-Lingual Deviation) Index Report as needed for orthodontic treatment approval. However, the provider appealed based on the automatic qualifier of "deep impinging overbite with soft tissue damage."

Unfortunately, this is not substantiated in the photos and other materials submitted. Deep impinging overbite is usually when the overbite is greater than 50%, when the upper teeth come over the lower teeth such that they cover greater than half of the lower teeth.  The photos do not show this. The photos do not show soft tissue damage on the palate by the lower teeth.

Yes, the health plan acted reasonably with sound medical judgement and in the best interest of the patient.
In this case the health plan deemed that the treatment was not warranted because the provider did not demonstrate the severity of the condition as stated in the diagnosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite

Treatment: D8080 braces and D8670 comprehensive orthodontic treatment

The insurer denied coverage for D8080 braces and D8670 comprehensive orthodontic treatment

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation Index Report 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 11 points on review by internal reviewers. 

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, New York State requires, as of September 1, 2012, the use of an orthodontic index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. 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 severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index with a total of 11 points (4 points overjet, 5 points overbite, 2 points labiolingual spread).

The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient. D8080 braces and D8670 comprehensive orthodontic treatment of adolescent dentition is 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 D8080 braces and D8670 comprehensive orthodontic treatment is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Right hip closed displaced intertrochanteric fracture.
Treatment: Physical Therapy (97110).
The insurer denied coverage for Physical Therapy (97110).
The denial is modified.

This male sustained a right hip closed displaced intertrochanteric fracture after a skiing accident. He underwent right hip surgical repair. Post-operative physical therapy began thereafter.  

The physical therapy (PT) treatment notes after approximately 6 weeks of PT, provide limited quantitative or verifiable measures of improvement. However, the treatment notes document the services provided, response to treatment and significant improvement. Continuing a structured PT program for all of the time period under review was not medically necessary. For example, according to the PT note visit 24, the patient "went skiing today." He reported "not much pain when he came in for therapy." The patient no longer required structured PT after visit 24. Continued functional improvement would have been obtained via a home exercise program and gradually resuming his various recreational activities.  

Physical Therapy during the initial post-operative period, was medically necessary. Continued PT was not medically necessary.  

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

The insurer's denial of coverage for Physical Therapy (97110) is modified. Medical necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld. 

The patient is a male with a history of congestive heart failure (CHF), low ejection fraction (EF) 35-40%, hypertension (HTN), diabetes mellitus (DM), chronic kidney disease (CKD), poly substance abuse, opioid dependence on Methadone. The patient was non-compliant with his medications.

He presented to the emergency department (ED) with swelling of the lower extremities (LE), scrotal and penile swelling and anasarca. The patient had been admitted to the hospital a few days ago with the same symptoms and had signed out against medical advice (AMA). 

Vital signs (V/S) at presentation to the ED were: temperature (T)- afebrile, blood pressure (BP) 155/76, heart rate (HR) 84, respiratory rate (RR) 18, oxygen (O2) saturations 99% on room air (RA). Exam revealed anasarca. Lungs were clear. Cardiac exam was normal. There was 2+ extremity edema, scrotal and penile edema and balanitis were noted. The patient was alert and oriented X 3. 

Labs revealed: blood urea nitrogen (BUN)/ creatinine (Cr) 36/2.87, hemoglobin (Hb) 8.1, hematocrit (Hct) 24.3 Brain natriuretic peptides (BNP) >35 potassium (K). Urinalysis (UA) 3+ Protein

The patient had a chest x-ray (CXR) which was unremarkable and noted improvement of some prior infiltrates seen in the past. Computed tomography (CT) of the abdomen revealed Cholelithiasis and Nephrolithiasis with no evidence of Cholecystitis.

The patient was admitted for decompensated heart failure and started on intravenous (IV) diuretics- IV Lasix 120 milligrams (mg) 1 dose. He was also restarted on maintenance cardiac meds. 

The patient subsequently decided to leave a few hours later the same night.
Repeat V/S T 97.3 F, HR 69, RR 18, BP 158/68 and O2 saturations 100% on RA.

This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient was afebrile and hemodynamically stable. There was no hypoxia, no jugular venous distension (JVD), lungs were clear clinically and by chest x-ray and the cardiac exam was normal. 

The patient was stable to be discharged home after a period under observation with close follow - up in an outpatient setting.

The health plan acted reasonably with sound medical judgment 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: Upheld

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

The patient has a history of hypertension, hyperlipidemia, diabetes, and bipolar disorder and presented on postoperative day 1 after a percutaneous nephrolithotomy (PCNL). She complained of worsening erythema and purulent discharge from her surgical incision site. She had a low-grade fever of 100.5 degrees Fahrenheit. On presentation, she was afebrile and hemodynamically stable. Lab results showed a white blood cell (WBC) count of 29. A computed tomography (CT) scan showed possible focal pyelonephritis versus renal infarct. After admission to the inpatient service, she was admitted to the urologic service. She was noted to have cellulitis by the nephrostomy tube site. She was managed conservatively with intravenous (IV) fluids and antibiotics. She was discharged home after the percutaneous nephrostomy tube was removed. The medical necessity for an inpatient stay is under review.

No. The inpatient admission was not medically necessary.
A majority of patients who present with cellulitis/leakage/hematuria after PCNL can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status does not suggest the need for acute inpatient care. A lower level of care for this patient's clinical presentation and hospital course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowding; crossbite.
Treatment: Braces (D8080).
The insurer denied the Braces (D8080).
The denial is overturned.

The patient is a female. The request is for orthodontic treatment (braces). Per the provider's appeal summary, the patient presents with severe crowding, buccal crossbite.

The health plan is denying coverage for the claim, because the patient did not score a 26 , the score necessary on the Handicapping Labio-Lingual Deviation (HLD) Index Report to be approved for braces.

Yes, the requested orthodontic therapy (braces) is medically necessary.
As evident in the photos and x-rays, this patient presents with severe crowding and crossbites both in the anterior and the posterior. Additionally, the patient suffers from Microdeletion Syndrome, a genetic disorder involving several craniofacial abnormalities, abnormal mandible, malocclusion and tooth hypoplasia.

This degree of malocclusion can have deleterious effects on speech, the ability to chew effectively and the ability to maintain proper hygiene. Therefore, the requested braces are medically necessary.

No, the health plan did not act reasonably, with sound judgement and in the best interest of the patient.
The degree of severity of the patient's dentition and the patient's medical condition indicates the complications that can arise if the patient is not treated. Denial of the requested braces would further complicate the present and future oral health of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Humira. 
The denial is upheld.

The patient is a male with psoriasis. Body surface area affected is 60%. His face and scalp are affected. He has tried and failed clobetasol, calcipotriene, and triamcinolone. Per the pharmacy claims, methotrexate was prescribed however no medical records subsequent to this are provided. The medication under review is Humira.

The requested health treatment of Humira is not medically necessary for this patient. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines such as methotrexate covered by the patient's insurance plan are effective treatments for the management of psoriasis (1, 2).
Within the peer-reviewed literature, West et al. 2016 conducted a review of ELEVEN comparative, controlled studies that passed a Cochrane risk of bias analysis. They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques. Methotrexate is a preferred treatment, and based on data analysis, 45.2% [95% confidence interval 34.160.0] of patients achieve psoriasis area and severity index (PASI) 75 at primary endpoint, Thus, methotrexate is an effective first-line treatment for the management of psoriasis (3).
The evidence-based literature is consistent. The preferred agent methotrexate is appropriate for the treatment of the patient's psoriasis. Humira is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental restoration failure and large distal caries.
Treatment: D2740 (porcelain/ceramic crown) and D2950 (core buildups) for tooth # 29.
The insurer denied coverage for D2740 (porcelain/ceramic crown) and D2950 (core buildups) for tooth # 29.
The denial is overturned.

Based on the submitted documentation which includes copies of bitewing radiograph, entire dental treatment notes, narrative letter from the doctor and insurer correspondence, it appears that this patient presented for dental care. A failing long-standing direct placement restoration, was noted on #29. The dentist is requesting placement of a full coverage crown due to failure of the restoration and large distal caries. 

Upon review of radiograph, it supports the recommended treatment. Tooth #29 exhibits a large failing direct placement restoration with large recurrent caries on the distal aspect. There would be ample coronal structure remaining after core buildup. This tooth will then have adequate coronal structure for support of a full coverage crown and adequate residual periodontal alveolar bone height The standard of care in general dental practice would be placement of a crown which would have an excellent long-term prognosis with the recommended treatment.

Reverse denial and approve coverage for D2740 (porcelain/ceran1ic crown) and D2950 (core buildup) for tooth #29 as medically necessary as the radiographic documentation supports this service, and this service would be a standard of care in general, dental practice.

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

D2740 (porcelain/ceran1ic crown) and D2950 (core buildup) for tooth #29 on is considered medically necessary for this patient.

The insurer's denial of coverage for D2740 (porcelain/ceramic crown) and D2950 (core buildup) for tooth # 29 is overturned. Medical Necessity is substantiated.