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

Diagnosis: Overjet Overbite Anterior Crowding and Ectopic Eruption

Treatment: D8080 braces

The insurer is denied coverage for D8080 braces.

The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoranmic radiograph, montage of extraoral and intraoral clinical images, as well as copies of peer reviewed literature abstracts and insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including and overjet overbite anterior crowding and ectopic eruption and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 19 total points to support orthodontic care

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.  ln this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 19 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 19 points on the HLD index (3 points overjet, 3 points overbite, 6 points ectopic eruption, 5 points anterior crowding and 2 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note in this case, is that 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 cited below. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval. The health plan acted reasonably with sound medical judgment. The coverage for D8080 braces is not considered medically necessary for this patient.

The insurer's denial of coverage for D8080 braces is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: alcohol dependence.
Treatment: Inpatient Substance Abuse Rehabilitation Admission.
The insurer is denied coverage for Inpatient Substance Abuse Rehabilitation Admission.
The denial is overturned. 

This male patient has a history of dorsalgia and chemical use, abuse and dependence

According to the LOCADTR he met criteria for inpatient substance rehabilitation treatment as he relapsed immediately after past inpatient substance detoxification treatments and even left 2 of the 3 past treatment against medical advice(AMA). It was reported that he could not maintain any period of abstinence outside of a 24 hour inpatient setting. He was at risk for severe, complicated, and life-threatening withdrawal and also medical risks due to alcohol and crack/cocaine use daily. He reportedly lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. Without this structured and supervised therapeutic inpatient substance/alcohol rehabilitation treatment he likely would have relapsed immediately again as evidenced by past immediate relapses after past inpatient substance treatments.

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 Substance Abuse Rehabilitation Admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented with acute onset of abdominal pain, nausea, and vomiting.  She was seen at a facility and was told to follow up with her gynecologist (GYN).  She saw her gynecologist (GYN) and was sent to the emergency department.  She was evaluated.  She had blood work, urinalysis, ultrasound, and computed tomography (CT) scan.  She had an elevated white blood cell count.  She was afebrile, normotensive, without tachycardia or tachypnea.  She was admitted with the diagnosis of pelvic inflammatory disease.  She was given intravenous (IV) fluids and intravenous antibiotics.  She had an ultrasound and computed tomography (CT) scan that were both normal except for a uterine polyp.  Her urine grew out Escherichia coli.  Admission day 2, she was feeling better.  Her white blood cell count was normal.  She was discharged home with oral antibiotics.

No, the proposed inpatient admission was not medically necessary.
According to Workowski (2), most women with pelvic inflammatory disease (PID) can be safely treated in outpatient settings. 

Indications for hospitalization and parenteral antibiotics include:
1) Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain)
2) Complicated pelvic inflammatory disease (PID) with pelvic abscess (including tubo-ovarian abscess)
3) Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess
4) Inability to take oral medications due to nausea and vomiting
5) Pregnancy
6) Lack of response or tolerance to oral medications
7) Concern for non-adherence to therapy

There has been a persistent trend towards outpatient treatment of pelvic inflammatory disease (PID) with only the minority of women being hospitalized. Support for outpatient therapy for mild or moderate pelvic inflammatory disease (PID) comes from the Pelvic Inflammation Disease Evaluation Clinical Health trial (ie, PEACH trial). In that trial, 831 women with lower abdominal pain, uterine or adnexal tenderness, and mucopurulent cervicitis or untreated gonococcal or chlamydial infection were randomly assigned to inpatient therapy with intravenous cefoxitin for at least 48 hours plus doxycycline or outpatient therapy with a single intramuscular dose of cefoxitin with probenecid plus doxycycline. Short-term clinical and microbiologic outcomes and long-term reproductive outcomes (eg, ectopic pregnancy, chronic pelvic pain) were similar between the two groups.

In review of the record, the patient did not have severe disease.  She was afebrile.  She did not have an abscess.  She was able to tolerate orally.  She did not have any signs of appendicitis, ovarian torsion, or other indications for surgical intervention.  She was not pregnant.  Therefore the literature would not support that this patient would require inpatient hospitalization for management.  The admission would not follow the standard of medical care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dental problems.

Treatment: D6241 false tooth for bridge, Tooth 28; D6751 white glass with metal cap for bridge, Tooth 27; D6751 white glass with metal cap for bridge, Tooth 29; D6751 white glass with metal cap for bridge, Tooth 30; 06751 white glass with metal cap for bridge, Tooth 31 D6751 white glass with metal cap for bridge, Tooth 31.

The insurer is denied coverage for D6241 false tooth for bridge, Tooth 28; D6751 white glass with metal cap for bridge, Tooth 27; D6751 white glass with metal cap for bridge, Tooth 29; D6751 white glass with metal cap for bridge, Tooth 30; 06751 white glass with metal cap for bridge, Tooth 31 D6751 white glass with metal cap for bridge, Tooth 31.

The denial is overturned. 

This female patient has a history of dental problems

Upon review of the documentation, in particular the radiograph it is evident that the preexisting bridge was failing.  To restore function to the right mandibular dentition, in this case since the patient has pre-existing fixed bridge, replacement with a fixed prosthesis spanning #27-31site as recommended is the standard of care dental treatment in general dental practice. As the dentition is already restored with a fixed bridge prosthesis the only treatment that would be considered an appropriate for replacement of the current fixed bridge is another.

Reverse denial and approve coverage for D6241 false tooth for bridge, tooth 28; D6751 white glass with metal cap for bridge, tooth 27; D6751 white glass with metal cap for bridge, tooth 29; D6751 white glass with metal cap for bridge, tooth 30; D6751 white glass with metal cap for bridge, tooth 31 as medically necessary at this would be the standard of care dental treatment in clinical practice.

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 D6241 false tooth for bridge, Tooth 28; D6751 white glass with metal cap for bridge, Tooth 27; D6751 white glass with metal cap for bridge, Tooth 29; D6751 white glass with metal cap for bridge, Tooth 30; 06751 white glass with metal cap for bridge, Tooth 31 D6751 white glass with metal cap for bridge, Tooth 31 is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis. 
Treatment: Tymlos. 

The insurer denied coverage for Tymlos. 

The denial is upheld. 

The patient has history of osteoporosis. Her physician has prescribed Tymlos. The patient was on alendronate initially and then Forteo for years. BMD [bone mineral density] went down the first year and up the second. She is off therapy for almost few years and BMD has gone down. T-score in the left femoral neck was -2.5, a decrease over a few months. There is a history of a rib fracture, and the physician wants to give Tymlos. 

In the www.uptodate.com chapters "Parathyroid hormone[PTH]/parathyroid hormone-related protein analog for osteoporosis" and "Overview of the management of osteoporosis in postmenopausal women" it is mentioned that some clinicians use a repeat course of PTH although efficacy and safety are not established. 

The only article found addressing this issue was "Retreatment With Teriparatide One Year After the First Teriparatide Course in Patients on Continued Long-Term Alendronate by Felicia Cosman et al. They conclude that there is benefit and the treatment can be considered in patients with severe osteoporosis. Subsequent studies were not found. 

The reviewer finds no information addressing this situation. The patient already received PTH out of sequence with a bisphosphonate. The comparative benefit of repeat PTH versus using other treatment here is not clear. There are on-label alternatives to using Tymlos off-label. The long-term safety of PTH analogs given for more than 2 years is unknown. No contraindication to anti-resorptive therapy has been documented. Trial of one bisphosphonate did not work. There are other alternatives. 

As noted above, the unknown risks of repeat treatment with a PTH analog are unclear and mitigate against its use. 

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

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

Diagnosis: Dermatology. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Xeljanz. 
The health plan's determination is upheld.

The patient is a female with alopecia (capitis) totalis. She has failed intralesional Kenalog and oral prednisone. She is very depressed due to the hair loss. The subject under review is the medical necessity for the requested medication Xeljanz 10 milligrams (MG).

The health plan's determination is upheld in whole. 

The requested treatment of Xeljanz 10MG is not medically necessary for this patient's alopecia totalis. There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Xeljanz for this patient's condition as an accepted standard of practice in the United States (U.S.) prior to the conventional alternatives. There is no documentation the patient has exhausted based on the standard of care, all topical options, and that it would therefore be medically necessary to start systemic treatment with Xeljanz, which would carry a higher side effect profile.
The evidence-based literature is consistent and in line with the health plan's determination.
There is no documentation provided that would justify the patient requiring treatment with Xeljanz prior to the conventional alternatives. Therefore, Xeljanz is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis

Treatment Humira (adalimumab)

The insurer denied coverage for Humira (adalimumab) 

The denial is overturned

The patient has a past medical history of mild to moderate ulcerative colitis and has been treated with steroids and mesalamine with some improvement in symptoms but with periodic exacerbations. Stool calprotectins have varied between 100 and 6840. Her last colonoscopy with pathology demonstrating a normal terminal ileum, diffuse colitis with scattered crypt abscesses, absent granulomas and rectal sparing. Upper endoscopy has been reportedly normal. MR [magnetic resonance] enterography reportedly showed inflammation of the appendix and mid-transverse to rectosigmoid colon. She has been seen by 2 different gastroenterologists with the first prescribing methotrexate and the second suggesting treatment with Humira. Her latest weight is 34.9 kilograms and her height is 141 centimeters. 

This patient suffers from mild to moderate inflammatory bowel disease - likely ulcerative colitis (rectal sparing is atypical). She has failed first line therapy with an aminosalicylic acids (ASA) agent. In regard to the treatment options for this patient in a review of the management of mild to moderate ulcerative colitis in children from UptoDate the authors state the following:

"For patients with mild or moderate colitis, medical therapy usually is successful in achieving remission and often maintains long-term remission as well. The basic principles of medical therapy are similar to those in adults with UC [ulcerative colitis], although the chronic use of glucocorticoids in children is particularly problematic because of potential linear growth impairment and bone demineralization. Thus, aminosalicylates or glucocorticoids are used for induction, depending on the severity of presentation. The aim is to transition patients to aminosalicylate maintenance therapy. However, fewer than 50 percent of patients maintain corticosteroid-free remission on aminosalicylates alone. The remainder of patients require long-term treatment with immunomodulators or biologic agents."

For this patient with active disease by symptoms, pathology and stool inflammatory markers the best therapy at this time is biologicals. The agents suggested by the insurer are slow acting (require more prolonged steroid use), have higher toxicity and are less well studied (methotrexate). Humira is in the best interest of the patient but is more expensive (prompting the insurance denial) and may lose efficacy over time if neutralizing antibodies. Humira is medically necessary for the treatment of this child's ulcerative colitis. 

Based on the above, the medical necessity for the Humira (adalimumab for the treatment of ulcerative colitis is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Ears/Nose/Throat. 
Treatment: Surgical Services. 
The insurer denied septoplasty, rhinoplasty with major septal repair, lateral wall implant and inferior turbinate resection. 
The denial is partially overturned.

The patient is a female who was struck by a car and sustained nasal fractures and facial lacerations. She complained of difficulty breathing through her nose; Breathe right strips resulted in partial improvement. Exam revealed a deviated nasal septum to the right and irregular dorsal nasal hump and bilateral inferior turbinate hypertrophy. She has a history of allergic rhinitis and was treated with Flonase nasal spray and saline. She was seen in follow up in one month. Photo documentation demonstrated nasal valve collapse on inspiration. Septoplasty or septorhinoplasty with repair of nasal valve stenosis using Latera, and inferior turbinate reduction are the services under review.

The health plan's determination is overturned in part. 

Septorhinoplasty and inferior turbinate reduction are medically necessary. The use of Latera, a bioabsorbable implant, is not medically necessary. Septoplasty is a part of septorhinoplasty and not medically necessary.
Septorhinoplasty with septal repair is considered reconstructive and not cosmetic. It is related to the documented injury in which she incurred a nasal fracture. The patient failed a one-month trial of saline and Flonase nasal spray meeting maximal medical therapy preoperatively (Watson, 2021). Therefore, septorhinoplasty is medically necessary. Septoplasty is not indicated on its own when septorhinoplasty is performed therefore it is not considered medically necessary. Bilateral inferior turbinate hypertrophy is medically necessary. According to Zapanta (2021) in general he states, indications for inferior turbinate reduction includes subjective nasal congestion due to turbinate hypertrophy that has failed appropriate medical therapy, and this is documented in the clinicals provided. Therefore, reduction of the inferior turbinates is medically necessary.
Repair of nasal valve collapse with Latera, is not medically necessary. According to the manufacturer supporting the cartilage "may" reduce nasal airway obstruction symptoms. In a 2017 study by San Nicolo a cohort of 30, there was improvement in the Nasal Obstruction Symptom Evaluation (NOSE) score of at least one class of five or 20%. At 24 months follow up (San Nicolo, 2018) in 2018, the cohort reduced to 25, and the authors conclude that there was symptom improvement in some subjects. Based upon the peer reviewed medical literature, as there are no comparison studies with the current standard, with long term effectiveness affecting patient health outcomes. Therefore, the Latera nasal implant for the treatment of nasal vestibular collapse is not medically necessary.
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 and vomiting of 1-day duration. At the time of presentation, the patient was without fever and vital signs showed a heart rate of 63 beats/minute and blood pressure of 101/66. She was tender in the upper abdomen. The white blood cell (WBC) count was 11.0. The complete metabolic panel identified normal aspartate aminotransferase (AST), alanine aminotransferase (ALT), and Bilirubin. Ultrasound showed cholelithiasis and findings of cholecystitis.

She was initially treated with intravenous (IV) fluid and antiemetics. Surgical consultation was obtained and laparoscopic cholecystectomy was performed. Surgery was completed without complication.

The patient tolerated oral intake. She was discharged from the inpatient setting with instructions for outpatient surgical follow up.

An inpatient level of care was not medically necessary for this patient. This patient who presented to the ED with abdominal pain. Evaluation identified gallstones and findings of cholecystitis. She was hemodynamically stable at the time of presentation. The WBC count was slightly elevated at 11.0. The patient had no significant comorbid health conditions that required an inpatient designation. Laparoscopic cholecystectomy was performed without complication. The patient remained hemodynamically stable during the period of monitoring. Observation would have allowed for overnight monitoring, surgery, confirmation of clinical stability, and diet advancement.

A 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. This lower level of care would have been consistent with generally accepted standards of care. This would have allowed for surgical assessment, treatment with IV fluid and antibiotics, and arrangements for outpatient follow up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: migraine

Treatment: Ajovy autoinjector 225 milligram (mg)/1.5 AUTO INJCT 3.0

The insurer is denied coverage for Ajovy autoinjector 225 milligram (mg)/1.5 AUTO INJCT 3.0

The denial is overturned. 

This female patient has a history of migraine with aura, intractable, without status migrainosus, asthma, skin cancer, arthritis, hypothyroidism, hyperlipidemia, insomnia, and anxiety.

This case involves a patient who has been treated for chronic migraines.  The documentation indicated the patient has attempted several agents to include topiramate and amitriptyline.  The patient cannot utilize medications to include propanolol due to a history of asthma.  The patient was also utilizing Wellbutrin and citalopram and therefore venlafaxine is not appropriate.  The patient has had excellent results from prior use of the requested Ajovy and therefore switching her to Aimovig is not appropriate.

The submitted documentation indicated the patient is an appropriate candidate to utilize the requested medication due to the favorable response with use and inability to utilize other medications as well as failure of Wellbutrin and citalopram. Also, Ajovy has been shown as effective when used on a quarterly basis compared to monthly. (Lipton et al)  

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 Ajovy autoinjector 225 milligram (mg)/1.5 AUTO INJCT 3.0  is overturned.  The medical necessity is substantiated.