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

Diagnosis: Skeletal Class II, moderate maxillary and mandibular crowding, open bite, severely excessive overjet, and impacted maxillary right canine
Treatment: Braces (D8080) and periodic orthodontic treatment visit (D8670)
The insurer denied the Braces (D8080) and periodic orthodontic treatment visit (D8670).
The denial is overturned. 

The patient is a female. The request is for dental benefit services for orthodontic treatment (braces) and monthly visits.  The clinical exam summary revealed a patient with skeletal Class II, moderate maxillary and mandibular crowding, open bite, severely excessive overjet, and impacted maxillary right canine.

Yes, the proposed treatment of orthodontic therapy and monthly visits are medically necessary.

As stated in the clinical summary and supported by the patient's photos and x-rays; the patient has multiple conditions that negatively affect her masticatory function, speech and aesthetics.  This patient has an anterior open bite and excessive overjet (anterior teeth do not come together in a normal manner). This can lead to difficulty with speech because the patient is unable to form the anterior seal that is necessary for swallowing and the proper enunciation of certain letters.  Excessive overjet puts the patient at increased risk for trauma due to the protrusion of these teeth.  The patient also presents with an impacted maxillary right canine (tooth is not fully erupting into the mouth in the proper designated space).  The canine plays a major role in the functional guidance of the overall dentition.

Individually, any one of the multiple conditions this patient presented with would warrant orthodontic treatment as a corrective measure.  In this circumstance, the patient has an open bite, excessive overjet, and a maxillary impacted right canine--all of which if left untreated will have a severe long-term negative impact on the patient's ability to have normal chewing function and speech.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental problems (skeletal Class I, Class II canines, vertical growth pattern, maxillary and mandibular crowding, excessive overjet, incisor protrusion, and blocked out mandibular second molars).

Treatment: D8080 braces and D8670 monthly visit.

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is overturned. 

This patient is a male child who presented for evaluation for orthodontic care.  The orthodontist identified skeletal Class I, Class II canines, vertical growth pattern, maxillary and mandibular crowding, excessive overjet, incisor protrusion, and blocked out mandibular second molars.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 27 total points.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements.

Upon review of the submitted documentation (study models were not provided for review), it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the HLD index is utilized.  This index provides 6 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 quality for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 27 points to justify orthodontic care.  This reviewer concurs with the HLD index completed by the treating orthodontist attaining a total of 27 points on the HLD index (i.e., 4 overjet, 4 overbite, 6 ectopic eruption, 10 anterior crowding, 3 labiolingual spread,) which is above the threshold of 26 points to support orthodontic care.

The coverage for D8080 braces and D8670 monthly visit is considered medically necessary for this patient.

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 D8080 braces and D8670 monthly visit should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental problems (skeletal Class I, vertical growth pattern, maxillary and mandibular crowding, excessive overjet, left posterior crossbite, and blocked out maxillary premolar).

Treatment: Insertion of braces (comprehensive orthodontic treatment of the adolescent dentition).

The insurer denied coverage for the insertion of braces (comprehensive orthodontic treatment of the adolescent dentition).

The denial is overturned.

This patient is a female child who presented for evaluation for orthodontic care.  The orthodontist identified skeletal Class I, vertical growth pattern, maxillary and mandibular crowding, excessive overjet, left posterior crossbite, and blocked out maxillary premolar.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 29 total points.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements.  

Upon review of the submitted documentation (study models were not provided for review), it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized.  This index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the HLD index arriving at 29 points to justify orthodontic care.  This reviewer concurs with the HLD index completed by the treating orthodontist, attaining a total of 29 points on the HLD index (i.e., 3 overjet, 3 overbite, 6 ectopic eruption, 10 anterior crowding, 3 labiolingual spread, 4 posterior unilateral crossbite), which is above the threshold of 26 points; this HLD index supports orthodontic care for this patient.

The coverage for insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) is considered medically necessary for this patient.

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 insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems (skeletal Class III, normal vertical growth pattern, maxillary and mandibular crowding, and posterior and anterior crossbite).

Treatment: D8080 braces and D8670 monthly visits x 12.

The insurer denied coverage for D8080 braces and D8670 monthly visits x 12.

The denial is upheld.

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class III, normal vertical growth pattern, maxillary and mandibular crowding, and posterior and anterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 6 points on review by their 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, an HLD index is utilized. This index provides 6 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore, does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet the insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 6 points (i.e., 2 overjet, 2 overbite, 2 labiolingual spread).

The coverage for D8080 braces and D8670 monthly visits x 12 is not considered medically necessary for this patient.

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

Based on the above, the medical necessity for D8080 braces and D8670 monthly visits x 12 is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo on the face.

Treatment: Tacrolimus 0.1% ointment (Protopic).

The insurer denied coverage for Tacrolimus 0.1% ointment (Protopic).

The denial is overturned.

This is a female patient with a medical history of vitiligo on the cheek. She has used Protopic (tacrolimus) and clobetasol topical steroid.  The Protopic, Tacrolimus 0.1% ointment was not covered by her insurance.

Per Plensdorf et al. (2017), "Treatment of vitiligo depends on the distribution and extent of skin involvement, and includes topical corticosteroids and calcineurin inhibitors, ultraviolet A therapy (with or without psoralens), narrowband ultraviolet B therapy, and cosmetic coverage."

Per Guenther et al. (2019), "There is high-quality evidence supporting the effectiveness of topical calcineurin inhibitors in multiple dermatological disorders including vitiligo; psoriasis of the face, folds, and genitals; seborrheic dermatitis; chronic hand dermatitis; contact dermatitis; oral lichen planus; lichen sclerosus; morphea; and cutaneous lupus erythematosus." And as per Lee et al. (2019), "The use of [topical calcineurin inhibitors (TCIs)], both as a monotherapy and in combination with phototherapy, should be encouraged in patients with vitiligo."

The patient has what is diagnosed clinically as vitiligo on the face, which is a medical condition requiring an anti-inflammatory of moderate potency.  However, long-term topical steroid use on the face is contraindicated. Thus, the best treatment for vitiligo of the face is a non-steroid anti-inflammatory drug, such as Protopic (tacrolimus) or other calcineurin inhibitor. Literature supports that the medication, Tacrolimus 0.1% ointment (Protopic) is considered medically necessary for this patient.

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 medication Tacrolimus 0.1% ointment (Protopic) should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hypertensive Encephalopathy; Acute Kidney Injury.
Treatment:  Inpatient hospital admission.

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

This male patient has history of hypertension (HTN), 2 cerebrovascular accidents (CVA), and nicotine abuse. The patient presented to the Emergency Room (ER) with complaints of confusion for the past few months. The patient was noncompliant with his home medication regimen. In the ER, the patient's blood pressure was 203/133. The patient's computed tomography (CT) scan of the head, chest x-ray (CXR), and electrocardiogram (EKG) revealed no significant findings.   

The patient was admitted with hypertensive emergency indicated by his elevated systolic blood pressure (SBP) greater than 180 mmHg (millimeter of mercury) and diastolic blood pressure (DBP) greater than 120 mmHg with evidence of acute or worsening target organ damage. The patient's blood pressure was up to 217/156 with clinical findings of acute kidney injury noted by his elevated creatinine of 2.24 mg/dL (milligrams per deciliter). The patient also presented with altered mental status that was suspected to be due to his uncontrolled hypertension. 

Based on the review of the literature, inpatient admission was medically necessary for this patient. The patient had hypertensive encephalopathy with acute kidney injury. This patient's condition required close cardiac monitoring and administration of intravenous antihypertensive medication. The patient required adjustment of multiple blood pressure medications to stabilize his condition and control his blood pressure. This patient's clinical presentation required extended stay beyond observation status due to his worsening kidney function and need for extensive neurological workup. 

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

Based on the above, the medical necessity for inpatient hospital admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory 
Treatment: Home Health Care. 
The insurer denied increase in PCA hours to 20 per week. 
The denial is overturned in whole.

The patient is a female with a past medical history significant for anxiety, heart disease, hypertension, hyperlipidemia, insomnia, chronic pain, osteoarthritis, sciatica, gait abnormality and urinary incontinence.
The patient is requesting additional personal care service hours to be increased from 4 days a week 4 hours a day to 5 days 4 hours per day. The additional services were denied based on medical necessity.
The subject under review is the medical necessity for the additional services.

The health plan's determination is overturned in whole.

The requested services personal care aid (PCA) services: 4 hours per week, 5 days (total of 20 hours weekly) is medically necessary for this patient.
Services were denied based upon the following, patient is independent for bed mobility, personal hygiene, toilet use, and eating requires set up only. Patient requires supervision for toilet transfer. Patient has limited needs for dressing upper and lower body. Patient is able to walk independently in her apartment she does require extensive assistance for meal preparation and medications and housework.
The Uniform Assessment System (UAS) from both dates were reviewed. 
Client tasking sheet recommended PCA level 2 services 4 days a week 4 hours a day along with social day care (SDC) 3 days per week. Similar recommendations were made in previous years.
The patient is a female with a past medical history as noted above. On both evaluations it was recommended that the patient receive 4 hours a day 4 days a week. Is also recommended that the patient go to day services. However due to coronavirus, day services are not available. It is reasonable to increase hours an additional day due to the fact that these daycare services are not available secondary to the coronavirus. This would better follow the recommendations per the tasking tool.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain; End Stage Renal Disease

Treatment: Inpatient hospitalization

The insurer denied inpatient hospitalization.

The denial was upheld.   

This male patient has end stage renal disease (ESRD) on dialysis and was admitted to the hospital for chest pain. He was evaluated by Cardiology and work up did not indicate acute coronary syndrome; no ischemia work up was needed. He also had a hypotension episode with syncope which improved with holding antihypertensive medications. He was evaluated by Nephrology for ESRD and hyponatremia, which resolved with intravenous fluid bolus and oral fluid restriction. He was discharged in stable condition.

This patient was treated for hyperkalemia. He was treated with hemodialysis and his condition responded to daily dialysis. He did not have persistent severe hyperkalemia, no signs of severe volume overload or hypoxia, and no documentation of severe uremia such as encephalopathy or uremic bleeding. He had established dialysis access and did not require emergent vascular intervention. His condition could have been treated safely at a lower level of care.

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

The carrier's denial of coverage for inpatient hospitalization is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal colic; vomiting. 
Treatment: Inpatient admission. 

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

The patient is a male. He was admitted with left renal colic and vomiting. 
The patient's vitals were as follows: Temperature 99.7, respiration rate 22, blood pressure 144/92-62.  The WBC (white blood cell) count was 16,960.  The creatinine was 1.56.  CT (computed tomography) imaging demonstrated a 4 mm (millimeter) left distal ureteral calculus with hydronephrosis.  IV (intravenous) pain medications, nausea medications, IV (intravenous) antibiotics and IVF (intravenous fluids) were administered.

Later on the same day, the patient was discharged home.  His pain had improved.  He was afebrile and hemodynamically stable throughout the stay. 

No, the Inpatient admission was not medically necessary. 

An acute inpatient level of care was not medically necessary.  The patient's care could have been provided at a lower level of care.  He was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, IV (intravenous) antibiotics and IVF (intravenous fluids) followed by same day discharge in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric Pain; rule out Acute Coronary Syndrome.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld.  

This male patient had a history of hypertension, obstructive sleep apnea, morbid obesity, and bipolar disorder.  He could not provide a complete list of his home medication, but did relate use of nifedipine for hypertension in the past, current use of Abilify, and occasional use of ibuprofen.  He was brought to the emergency department (ED) by ambulance with a 3 week history of burning abdominal pain, worse with food intake, as well as exertional dyspnea and dizziness with standing up.  Initial vital signs included blood pressure (BP) 138/89, heart rate 100, temperature 97.9 F, respiratory rate 20, and oxygen saturation on room air 100%.  Body mass index (BMI) was 65.7.  Laboratory test results included white blood cell (WBC) count 8.7, hemoglobin 14.0, creatinine 0.96, normal liver function tests, brain natriuretic peptide (BNP) less than 10, lipase 20, and troponin 0.02.  He was admitted to rule out acute coronary syndrome (ACS).  Subsequent troponin was 0.00.  An electrocardiogram (EKG) revealed normal sinus rhythm with premature supraventricular complexes and was normal.  Chest x-ray and computed tomography (CT) scan of the head were also normal. Echocardiography revealed normal global left ventricular systolic function, mild left ventricular hypertrophy, and left ventricular and atrial dilatation.  Carotid Doppler examination was normal.  He was treated with hydralazine and nifedipine for subsequent elevated blood pressures (187/107-194/112), then re-started on nifedipine.  He was also treated with famotidine for likely gastroesophageal reflux disease (GERD), vitamin D for deficient level of 7.9 and atorvastatin for elevated risk factors.  He was discharged on these medications for follow-up in cardiology and outpatient medical clinics.

There is no evidence that an acute inpatient level of care was medically necessary to determine that this patient's symptoms were not related to acute coronary syndrome.

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

The medical necessity for inpatient hospital admission is not substantiated.  The carrier's denial of coverage for the inpatient hospital admission is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus
Treatment: Novolog 100U/ML VIA
The insurer denied the Novolog 100U/ML VIA.
The denial is upheld. 

The patient is a female with type 1 diabetes. She uses a Tandem insulin pump. The request for Novolog is under review.

No, the requested Novolog is not medically necessary.

This request is for Novolog. The prior request was denied as the patient has not tried generic insulin aspart. Novo Nordisk manufactures a generic insulin aspart, which is the exact same drug product, including both active and inactive ingredients, as the branded product. Novolog and generic insulin aspart are expected to be equally safe and effective in this clinical situation. 

Therefore, no, the requested Novolog is not medically necessary.