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

Diagnosis: Convulsion
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a male with HIV (human immunodeficiency virus) and depression. He initially presented to the ER (emergency room) due to auditory, visual and tactile hallucinations in the setting of drug use. He was later found to have two episodes of generalized convulsive seizures.

The patient was found to have lactic acidosis and mild rhabdomylosis. He was also noted to have agitation. He required both IV (intravenous) medications for the seizures and agitation. He was admitted to neurology and psychiatry consult and was stabilized from a seizure standpoint and was discharged the next day.

Yes, the Inpatient admission was medically necessary.
Inpatient admission was warranted. The patient had two episodes of generalized tonic-clonic seizures in the setting of altered mental status, and therefore, status epilepticus was a strong possibility and needed to be rule out with frequent neurological examination and EEG (electroencephalogram). The patient also required IV (intravenous) medications for seizures and agitation that could not have been done safely in the outpatient setting. The patient also was noted to have rhabdomyolysis and lactic acidosis, which are seen with seizures and required IV (intravenous) fluids, which would not have been possible in the outpatient setting.

Therefore, given the above, the inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Failure to admit someone with status epilepticus and not treating it can lead to significant morbidity and mortality.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertension, chronic obstructive pulmonary disease (COPD), and opioid use disorder.
Treatment: Skilled nursing facility (long term care).
The insurer denied the Skilled nursing facility (long term care).
The denial is upheld.

This patient is a male who was admitted to an acute inpatient level of care after presenting with vomiting and cholelithiasis. He has a history of hypertension, chronic obstructive pulmonary disease (COPD), and opioid use disorder.  He was treated with conservative care.  He was discharged and admitted to a skilled nursing facility (SNF) level of care.  The patient does not have skilled nursing care needs.  He performs activities of daily living (ADLs) with intermittent supervision.  He does not receive physical or occupational therapy.

No, the proposed skilled nursing facility long term custodial care is not medically necessary.
This patient with several chronic medical conditions is requesting skilled nursing facility long term (custodial) care.  Custodial care is care primarily for the purpose of assisting a patient in activities of daily living (ADLs) or in meeting personal rather than medical needs, and which is not specific treatment for an illness or injury.  It is care that cannot be expected to substantially improve a medical condition and has minimal therapeutic value.  Such care includes: assistance with walking, bathing or dressing; transfer or positioning in bed; normally self-administered medicine; meal preparation; feeding by utensil, tube or gastrotomy; oral hygiene; ordinary skin and nail care; catheter care; suctioning; using the toilet; enemas; or preparation of special diets and supervision over medical equipment or exercises or over self administration of oral medicine. This patient does not have skilled nursing care needs. This patient is able to perform activities of daily living without assistance.  His functional level is with supervision.  The requested long term skilled nursing facility care is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Myocardial SPECT Multiple Studies. 

The insurer denied Myocardial SPECT Multiple Studies. The health plan's determination is upheld. 

The patient is a female for which myocardial perfusion imaging exercise testing is under review. There was report of angina, chest pain, and shortness of breath. She reported being under a lot of stress. There was left ventricular ejection fraction (LVEF) of 40-45% reported on guideline directed medical therapy. Cardiomyopathy was noted on echocardiogram. The electrocardiogram (ECG) demonstrated a mild nonspecific T-wave abnormality. 

Myocardial SPECT Multiple Studies is not medically necessary for this patient.
This patient presented with chest pain and shortness of breath in a non acute setting. There were no baseline ECG abnormalities that would preclude accurate interpretation during treadmill testing such as a left bundle branch block, paced rhythm, digoxin therapy, pre -excitation, 1 millimeter (mm) or greater baseline ST depression, or atrial fibrillation / flutter. There was also no past submaximal treadmill test, or previous negative or nondiagnostic treadmill test, in the setting of ongoing typical angina. There was no inability to ambulate on a treadmill noted. In the setting of this case, the addition of imaging, such as SPECT, to standard treadmill testing has not been established as standard of care towards improved cardiac outcomes. Therefore, the requested testing is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces and office visits.
The insurer denied braces and office visits.
The determination is upheld.


The patient has a Class I occlusion with a 4 millimeter (mm) overbite and 5 mm overjet. He has mild maxillary and mandibular crowing. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion. At issue is the medical necessity of braces and monthly visits.

The requested treatment is not medically necessary. There is no medical reason to correct his malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) However, this patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health.
Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, anterior crowding and posterior unilateral crossbite and has recommended orthodontics. The orthodontist has completed the Handicapping Labia-Lingual Deviation (HLD) index attaining 26 total points to support orthodontic care. 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 only 9 points. The orthodontist is appealing the decision. 

Upon review of the submitted 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 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 9 total points (4 overjet, 2 overbite, 3 labiolingual spread).

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. 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.

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 monthly visit is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces.
The insurer denied Braces.
The determination is upheld.

The patient has a Class II occlusion with 3 millimeter (mm) overjet and 5 millimeter (mm) overbite. The maxillary and mandibular arches have moderate crowding. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces.

The requested service, braces, is not medically necessary. There is no medical reason to correct her malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) However, this patient presents with none of those conditions. The provided photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 3 mm overjet but research shows this amount of overjet does not affect oral health related quality of life. (2) If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 comprehensive orthodontic treatment of the adolescent dentition and D8670 periodic orthodontic treatment visit x 12
The insurer denied coverage for D8080 comprehensive orthodontic treatment of the adolescent dentition and D8670 periodic orthodontic treatment visit x 12
The denial is overturned

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 impacted maxillary canines among other findings. The orthodontist has completed the Handicapping- Labiolingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. 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 only 20 points on review by internal reviewers. The orthodontist is appealing on behalf of the patient. 

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 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 impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

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.  

The clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care. 

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

The insurer's denial of coverage for D8080 comprehensive orthodontic treatment of the adolescent dentition and D8670 periodic orthodontic treatment visit x 12 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Nutropin. 
The denial is overturned.

This is a male diagnosed with idiopathic short stature (ISS). This request is for Nutropin 0.9 milligrams (mg). As reported; he started growth hormone (GH) therapy. 
His mother's height is 151 centimeter (cm), and father's height is 173 cm and mid parental height is 168.5 cm (-1.16 standard deviation score [SDS]).
The subject under review is the medical necessity for Nutropin.

The health plan's determination is overturned. 

Nutropin is medically necessary for this patient. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4, 5, 6, 7, 8, 9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient had a pretreatment height less than or equal to -2.25 standard deviation (SD). The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The patient benefited from growth hormone. The request is consistent with generally accepted standards of medical practice and is likely to be beneficial for the patient's health. The request is therefore medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is overturned.

This is a patient who has persistent low back pain. His pain is aggravated with forward bending, lifting and other physical activities. He had tried 12 weeks of physical therapy (PT) with no improvement. He had failed to respond to pain medications and chiropractic manipulation. His pain is severe enough to interfere with functioning and quality of life. The patient denied any lower extremity pain. The physical exam (PE) is remarkable for decreased range of motion (ROM) of the lumbar spine, and pain with flexion. A magnetic resonance imaging (MRI) scan showed multilevel degenerative disc herniations with chronic endplate changes at lumbar (L) 5- sacral (S) 1. The Intracept procedure was recommended for his back pain.
At issue is whether the Intracept Procedure (Intraosseous Basivertebral Nerve Ablation) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment, Intracept procedure, is likely to be more beneficial than any standard treatment.
This patient has persistent back pain without any lower extremity pain. His persistent pain is most likely vertebrogenic from the L5-S1 degenerative endplate changes. The Intracept system was designed to treat low back pain from vertebral body by ablating basivertebral nerves. There are multiple clinical trials demonstrated the efficacy of this intervention in the treatment of vertebrogenic pain. He had failed extensive treatments including physical therapy (PT), pain medications and chiropractic manipulation. His pain is severe enough to interfere with functioning and quality of life. An MRI revealed finding of Modic changes at L5-S1 level of his lumbar spine. Further interventions are medically necessary to improve his pain and functional level. Other potential treatment options are long-term use of medications (nonsteroidal anti-inflammatory drugs (NSAIDs), opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carry significant risks and complications. Given this clinical scenario, the Intracept procedure is the appropriate next step intervention.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back Pain
Treatment: Intracept Procedure
The insurer denied the Intracept Procedure.
The determination is upheld.

The patient has with a history of chronic low back pain. The records indicate that he has been treated with physical therapy, anti-inflammatories, muscle relaxers and lumbar medial branch blocks. Magnetic resonance imaging (MRI) of the lumbar spine revealed multilevel disc displacement, listhesis and facet arthropathy. A recommendation was made for an Intracept procedure and that is under review.

No. The Intracept procedure (Intraosseous Basivertebral Nerve Ablation) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has a history of chronic low back pain. Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. The limitation of the studies performed include unavailable long-term comparative data, lack of a sham controls and short duration of follow-up.
Therefore, it is not likely to be more beneficial than any standard treatment or treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Cough
Treatment: RVP (respiratory viral panel) testing
The insurer denied coverage for RVP testing.
The denial is upheld.

The patient was seen by her medical doctor (MD) for complaints of some cough for about 3 weeks. The patient denied any other symptoms such as fever, shortness of breath (SOB), body aches, etc (Et cetera - "and so forth").

The patient's past medical history included migraine, allergic rhinitis, leiomyoma of uterus, breast cancer, osteoporosis and arthritis. Vital signs at presentation were notable for the following: afebrile, heart rate 76, oxygen (O2) saturations 97% (percent) on room air. The patient in no acute distress (NAD), HEENT [head, eyes, ears, nose, throat] exam was within normal limits (WNL). Lungs were clear.

The patient's physical exam was completely normal. Differential diagnosis was cough likely from postnasal drip. Questionable post infectious. The patient had a respiratory viral panel (RVP) ordered which came back negative. This patient was not acutely ill. No signs of any acute infection. No signs of an acute viral upper respiratory tract infection (URTI). This patient was not immunocompromised.

RVP testing was not indicated in this patient with these findings and exam described.

The risks of this testing are not increased over other testing. This testing is not likely to be more beneficial than any other testing.

The carrier's denial of respiratory viral panel (RVP) testing performed should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Cough
Treatment: RVP (respiratory viral panel) testing
The insurer denied coverage for RVP testing.
The denial is upheld.

The patient has a past medical history notable for allergic rhinitis, breast cancer, osteoporosis, migraines, uterine leiomyoma, and arthritis. She presented to her physician's office with a history of persistent cough. She was evaluated by her doctor, who ordered pertussis, coronavirus (covid), asthma testing, a chest X-ray, and rapid viral panel (RVP) testing. Covid testing was negative. 

The scientific literature does not support evidence-based improvement in health outcomes for patients undergoing rapid viral panel testing as compared to conventional standard of care for suspected viral infection.

This technology has approval from the appropriate regulatory bodies for the diagnosis in question.

Based on the clinical history and medical records provided, there was insufficient clinical documentation to indicate suspicion for acute viral respiratory disease, as the patient had a chronic cough for approximately months prior to presentation.

RVP testing is not standard of care for evaluation of chronic cough and is considered experimental and/or investigational for the clinical scenario at hand. 

There are no adverse risks associated with RVP testing over standard treatment options.

The utility of rapid viral panel testing remains a matter of ongoing clinical investigation and is currently experimental. In the clinical setting, this testing has not been demonstrated, when prospectively used, to improve morbidity and mortality. While its use has been shown to decrease antibiotic use, length of inpatient stay, and the time in isolation, general RVP testing remains unproven with regards to affecting management and outcomes for patients with chronic cough. It is not likely to be more beneficial than any other standard testing. 

The carrier's denial of respiratory viral panel (RVP) testing performed should be upheld.