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

Diagnosis: Deep Impinging Overbite, Maxillary and Mandibular Crowding. 
Treatment: D8080 Braces. 

The insurer denied coverage for D8080 braces. 

The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, 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, maxillary and mandibular crowding, and Class I occlusion, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 

Upon review of the submitted documentation, 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 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. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 21 points (5 points overjet, 3 points overbite, 10 points anterior crowding and 3 points labiolingual spread). 

Each of the 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 clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. 

The healthcare plan did act reasonably and with sound medical judgment in the best interest of the patient. 

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

Diagnosis: Urticaria.

Treatment: Xolair SOSY [solution prefilled syringe] 150 mg/ml (milligram/milliliter).

The insurer denied coverage for Xolair SOSY 150 mg/ml (milligram/milliliter).

The denial is overturned.

This patient has a history of urticaria.  The patient was most recently seen for a follow-up regarding urticaria and to receive a Xolair injection.  She indicated since starting Xolair her hives and hot spots have completely cleared up.  She has had no itching or rash.  She did however indicate approximately 1 week prior to presentation she did have some itching.  She did report her sleep has improved and her quality of life is significantly better.  She did initiate injections and continues with sertraline as well as famotidine and montelukast.  She also receives intermittent steroid injections.  Objectively, her skin was clear.  It was recommended she continue to utilize Xolair.

Xolair is an anti-IgE (Immunoglobulin) antibody approved by the United States (U.S.) Food and Drug Administration (FDA) for chronic idiopathic urticaria in adults who remain symptomatic despite H1 (treats allergy symptoms) antihistamine treatment. According to the submitted documentation this patient has had symptoms of urticaria.  She was most recently seen for a follow-up and indicated since initiation of the requested medication her hives and hotspots have cleared up.  She has had a treatment of other medications to include steroids, famotidine, montelukast, and sertraline.  Therefore, given a trial and failure of multiple other medications in addition to improvement with initiation of this medication.

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 Xolair SOSY 150 mg/ml (milligram/milliliter)
 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet greater than 9 mm (millimeter) with incompetent lips or reverse overjet greater that 3.5 mm

Treatment D8080 braces

The insurer denied coverage for D8080 braces

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, 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 excessive overjet. The orthodontist completed the Handicapping labio-lingual deviation (HLD) index as required asserting the patient exhibits the automatically qualifying condition of overjet greater than 9 mm with incompetent lips or reverse overjet greater that 3.5 mm with reported masticatory/speech difficulties to support orthodontic necessity. 

Upon review of the submitted documentation, 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 claims an automatic qualifying condition of overjet
greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying conditions is not met and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the findings of the insurer reviewer attaining a score of 14 points on the HLD index (9 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. This is confirmed by several studies. 

Each of the 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 judgement in the best interest of the patient. 

The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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

Diagnosis: Autism. 
Treatment: Additional Applied Behavior Analysis (ABA)Services; 2 Hours A Week of Direct ABA Therapy. 

The insurer denied the Additional Applied Behavior Analysis (ABA)Services; 2 Hours A Week of Direct ABA Therapy. 
The denial is overturned. 

The patient is a male child with non-verbal autism that has been receiving ABA (Applied Behavior Analysis) services for the last six years. He was most recently approved of 22 hours/week of direct services but had built up sufficient hours due to therapist vacations that he was actually receiving 24 hours/week once he was allotted a second therapist. During the time that he was receiving 24 hours/week of intervention, his behavior was basically controlled, and he was making minimal improvements. (According to his family, he only made significant improvements while receiving 40 hours/week of therapeutic intervention.) Unfortunately, the extra hours were used up quickly, leaving him with inadequate service hours per week. With the decrease in services, he began to regress and manifest new and concerning behaviors: aggression including biting others and punching his head, bowel movement accidents at school, running/elopement requiring police assistance, perseverating on the door, whining behaviors, demanding to use the bathroom, not eating at school. The documentation provided includes significant acquisition of skills while receiving 40 hours/week and significant worsening of behaviors while receiving 22 hours/week or less of ABA. 

Yes, the requested 2 hours/week of direct ABA (Applied Behavior Analysis) are medically necessary and appropriate. 

Applied Behavior Analysis is a behavioral approach with a longstanding history of application with children and adolescents on the autistic spectrum. ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan. The literature supports the utility of this method of intervention particularly for autistic children and adolescents with behavioral issues. 

This young male child has multiple concerning maladaptive behaviors as a result of his autism that have acutely worsened, along with regression of behaviors, when his service hours were decreased. He was receiving 24 hours/week despite being approved for 22 hours/week due to therapist absence/vacations, barely sufficient to keep him minimally safe in the community. Anything less than 24 hours/week places him at risk of injuring others and injuring himself, particularly because of his propensity to elope. The requested 2 hours/week additional ABA services are medically necessary and appropriate, consistent with the current literature and standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head trauma, initial encounter

Treatment: Continued inpatient rehabilitation level of care

The insurer denied coverage for continued inpatient rehabilitation level of care.

The denial is upheld.

This patient was admitted for gunshot wounds to the head, chest and left groin. He underwent a hemi-craniotomy. He was transferred to acute inpatient rehabilitation. He was readmitted to the acute hospital for repair of cranial incision dehiscence. He was transferred back to acute inpatient rehabilitation and has received physical therapy (PT), occupational therapy (OT), and speech therapy (ST) as well as psychological care.  

From a physical medicine and rehabilitation perspective as well as a reasonable degree of medical certainty, the patient could have been transferred to a lower-level care, including outpatient rehabilitation services. The clinical records clearly document the patient was at a functional level that no longer required inpatient rehabilitation level of care:

1) According to the Psychiatry Brief Progress Note, the patient was "Stable from that outlined in initial psychiatric consultation note. No acute safety concerns." 2) According to the Summary report, nursing service report indicated the patient had no limitations for mobility, was cleared to ambulate and remained "free of falls." 3) According to the physical therapy note, the patient was able to "ascend and descend 2 flights of stairs demonstrating a reciprocal LE [lower extremity] pattern without a handrail independently." 4) In occupational therapy, the patient had long since achieved independence with activities of daily living including dressing, hygiene and grooming. 5) The clinical records also indicate there were no acute medical or complicated nursing issues to support the medical necessity of inpatient rehabilitation level of care.  

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in this particular case. From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, inpatient rehabilitation level of care was not medically necessary.

The insurer's denial of coverage for continued inpatient rehabilitation level of care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes Mellitus. 
Treatment: Humalog 100/mL INJ, Pre-service. 

The insurer denied the Humalog 100/mL INJ. 
The denial is upheld. 

The patient is a male with type 1 diabetes. The request for Humalog is under review. The prior request was denied as there is an authorized generic available, made by the same company as the brand and is otherwise identical to the brand product. The attending physician is appealing this determination. Chart notes submitted document that patient is convinced that only brand Humalog works for him and is attributing weight loss to generic insulin. Addendum added to chart notes documents ER (emergency room) visits due to hyperglycemia when on insulin lispro and plan to change to brand Humalog. 

No, the requested Humalog is not medically necessary. 

There is an authorized generic lispro on formulary, which is made by the same company, Eli Lilly and Co, as the brand and is otherwise identical to the brand product with the exception of the label. This patient has had multiple emergency room visits due to hyperglycemia. Given the generic lispro and brand Humalog are identical insulins, the two are not expected to have any differences in how they lower glucose. The patient may experience hyperglycemia due to missed insulin doses or insufficient insulin doses with either generic lispro or brand Humalog. The American Diabetes Association clinical guidelines do not recommend the use of brand Humalog over generic lispro. Therefore, no, the requested Humalog is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brain Injury. 
Treatment: Acute Rehabilitation Facility Admission. 

The insurer denied the Acute Rehabilitation Facility Admission. 
The denial is upheld. 

The patient is a female with history of Motor Vehicle Accident. She sustained a Left frontal lobe Sub-Arachnoid hemorrhage with Right hemiplegia, and Right pubic ramps fracture with no surgical intervention. Her hospital stay was complicated by pneumonia with respiratory failure and development of atrial fibrillation. She required tracheostomy for ventilation and PEG (percutaneous endoscopic gastrostomy) tube feeding due to dysphagia. 

An acute IRF (inpatient rehabilitation facility) stay was denied because she cannot participate in extensive rehab due to being unresponsive and unable to follow commands. 

Prior to admission, the patient was independent, married, and living with her family. 

The patient was totally dependent for all ADLs (activities of daily living) and non-ambulatory, while also NPO (nothing by mouth) due to dysphagia and on PEG (percutaneous endoscopic gastrostomy) tube feeding. 

The health plan's reasons for prior denial were due to the patient not meeting the criteria for acute inpatient rehabilitation facility (IRF), including that the patient can participate in a minimum of 15 hours per week of intensive therapy; practical goals for specified improvement are set within an expected timeframe; they require close medical supervision by a physician; and they require skilled therapy and nursing services. The treating physician is appealing the denial because special TBI (traumatic brain injury) rehabilitation allows multiple rehabilitation modalities, i.e., PT (physical therapy), OT (occupational therapy) and SLP (speech and language pathology) within these criteria, which will be of benefit to the patient. 

No, the Acute Rehabilitation Facility Admission is not medically necessary. 

The patient has not met all the criteria for acute rehabilitation care INTERQUAL Criteria for Acute Rehabilitation in a patient with CNS/TBI (central nervous system/traumatic brain injury). She was totally dependent for all activities of ADLs (activities of daily living) and non-ambulatory while also NPO (nothing by mouth) due to dysphagia and on PEG (percutaneous endoscopic gastrostomy) tube feeding, unresponsive, non-verbal, but arousable to pain, and she also opens her eyes. She is unable to follow commands. She has tracheostomy and feeding through PEG (percutaneous endoscopic gastrostomy) tube. 

Based on not meeting the INTERQUAL requirements for acute inpatient rehabilitation, it is not medically necessary for patient to be admitted to the acute inpatient rehabilitation, as she is unarousable and unable to be alert and unable follow commands that will enable her participate effectively in every-three-hour daily rehabilitation x 5 days a week. 

The patient will be better served in a lower level of care like an Long term acute care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult female who presented to emergency department with abdominal pain.  On CT (computed tomography) scan the patient was found to have appendicitis.  She subsequently underwent a laparoscopic appendectomy. Postoperatively, the patient was allowed to advance diet as tolerated, and she was discharged home.

No, the inpatient admission was not medically necessary.

Inpatient admission is not indicated for an uncomplicated case of appendicitis, as in the case of this patient.  Given the patient's presentation and findings, treating the patient at a lower level of care would have been consistent with the standard of care in the surgical community.  A lower level of care would not have compromised the patient's health, safety, or treatment provided.  As such, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abnormal auditory perceptions, unspecified ear

Treatment: speech therapy services

The insurer is denied coverage for speech therapy services.

The denial is upheld. 

This female patient has a history of speech and language impairment.

There is insufficient data from the treating speech pathologist, to indicate that the patient presents with a diagnosed communication disorder. The therapy goals and plans were based on data from a neuropsychologist and audiologist. There were no standardized test results to compare the patient to age-matched peers. This is not the standard of care in the speech pathology community. There was insufficient data to show that the patient required outpatient speech therapy, in addition to the therapy already being provided through the school system.      

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

The carrier's denial of coverage for the speech therapy services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Crisis.

Treatment: Inpatient hospital admission.

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld. 

The patient is a has a past medical history (PMH) of sickle cell disease, avascular necrosis, and acute chest syndrome. The patient presented with sickle cell anemia and was admitted. 

According to the clinical documentation provided for review, the patient has the past medical history (PMH) of sickle cell disease, avascular necrosis, and acute chest syndrome. The patient had an uncomplicated sickle cell pain crisis. The patient had a history of avascular necrosis (AVN). The patient's computerized tomography (CT) scan of the chest did not demonstrate infiltrates. The patient was given intravenous (IV) fluid and pain medication. The patient was discharged the following day.

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

The patient with an uncomplicated acute sickle cell pain crisis, does not need acute level hospitalization on presentation. The majority of these patients will improve with standard conservative measures within 12 to 24 hours. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate. Therefore, the request for the inpatient hospital admission is not considered medically necessary for this patient.

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018).
                                                       
The insurer's denial of coverage for the inpatient hospital admission is upheld Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary and mandibular spacing, incompetent lips, excessive overjet

Treatment: D8670 periodic orthodontic treatment visit

The insurer denied coverage for D8670 periodic orthodontic treatment visit

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 maxillary and mandibular spacing, incompetent lips, excessive overjet. The orthodontist has presumably completed the Handicapping Labio-Lingual Deviation (HLD) index as required stating the patient exhibits the automatically qualifying condition of overjet greater than 9 with incompetent lips or reverse overjet greater that 3.5 rum with reported masticatory/speech difficulties to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet this required handicapping malocclusion medical necessity requirement on the HLD index on review by internal reviewers. 

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.

In this case, the treating orthodontist claims an automatic qualifying condition of overjet greater than 9 mm (millimeter) with incompetent lips or reverse overjet greater than 3.5 rum with reported masticatory/speech difficulties and deep impinging overbite with severe soft tissue damage. 

This reviewer finds that this automatically qualifying condition is met and supports comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

The healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient. D8670 periodic orthodontic treatment visit is considered medically necessary for this patient.

The insurer's denial of coverage for D8670 periodic orthodontic treatment visit is overturned. Medical necessity is substantiated.