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

Diagnosis: Anterior crossbite with gingival attachment loss

Treatment: Braces and monthly visits

The insurer denied coverage for braces and monthly visits.

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 anterior crossbite with gingival attachment loss in addition to other clinical findings. 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. 

Upon review of the submitted documentation, 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
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 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 HLD 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 clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

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

The insurer's denial of coverage for braces and monthly visits is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decompensated Cirrhosis

Treatment full admission and hospital care

The insurer denied coverage for full admission and hospital care

The denial is upheld

According to the provided medical records, the patient has a history of alcoholic cirrhosis, hypertension, high cholesterol, diabetes, Monoclonal gammopathy of undetermined significance (MGUS) with established ascites. He presented to the hospital with increasing abdominal distension and was noted to have ascites upon examination. His blood pressure was 170/92, temperature was 98.0, and his oxygen saturation was 99% (percent) on room air. Imagining revealed rib fractures to the right 8/9/10th ribs and left 9/10th ribs. His labs showed a hemoglobin of 7.9, international normalized ratio (INR) of 1.2, Partial thromboplastin time (PTT) of 36, and bilirubin of 3.2. He was monitored overnight and had continued dropping hemoglobin level.  He underwent paracentesis with removal of nine liters of fluid. The claimant was treated and when he felt better, he left the hospital against medical advice (AMA).

The health care plan acted reasonably and with sound medical judgment and in the best interest of the claimant. This patient could have been managed in a lower level of care such as observational status. This patient presented with multiple issues including rib fractures, alcohol intoxication, possibly withdrawal, and decompensated cirrhosis; none of which directly required acute level care. The patient was hemodynamically stable and not in active withdrawal, did not have significant ongoing bleeding; only having nose bleeding and was not hypoxic from his rib fracture. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would have been appropriate.      

The full admission and hospital care was not medically necessary. 

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine, 2021).                                                         

The insurer's denial of coverage for the full admission and hospital is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic Arthritis
Treatment: Xeljanz XR 11mg, Pre-service
The insurer denied the Xeljanz XR 11mg, Pre-service
The denial is overturned. 

The patient is a male with psoriasis and severe psoriatic arthritis. He failed prior treatment with methotrexate, Enbrel, Humira, Stelara, Cosentyx and Taltz. Per the attached appeal, the patient is currently doing well with Xeljanz XR (extended release).

Xeljanz XR (extended release) was denied for this patient because it was not being used in combination with a conventional DMARD (disease-modifying antirheumatic drug). The patient's provider indicates that this patient had severe liver toxicity with conventional DMARDs (disease-modifying antirheumatic drugs), including methotrexate, sulfasalazine and leflunomide, and is thus not a candidate for combination DMARD (disease-modifying antirheumatic drug) therapy with Xeljanz XR (extended release). The appeal is for Xeljanz XR (extended release) monotherapy for the treatment of severe psoriatic arthritis.

Yes, the treatment with Xeljanz XR (extended release) is medically necessary.
This patient with severe psoriatic arthritis failed prior treatment with methotrexate, Enbrel, Humira, Stelara, Cosentyx and Taltz, and is intolerant of various conventional DMARDs (disease-modifying antirheumatic drugs) (i.e., methotrexate, sulfasalazine and leflunomide) due to liver toxicity. He is presently doing well on Xeljanz XR (extended release) monotherapy. Although Xeljanz XR (extended release) is FDA (United States Food and Drug Administration)-approved for the treatment of active psoriatic arthritis when used in combination with non-biologic DMARDs (disease-modifying antirheumatic drugs), it is approved for other related conditions, such as rheumatoid arthritis, when used as monotherapy.

Furthermore, in a recent open-label, long term extension study of Xeljanz for the treatment of psoriatic arthritis, combination DMARD (disease-modifying antirheumatic drug) therapy was not required, and the safety and efficacy of Xeljanz in patients with psoriatic arthritis was consistent with the phase 3 studies.

Therefore, given the above, the requested Xeljanz XR (extended release) monotherapy for the treatment of psoriatic arthritis in this patient who failed multiple DMARD (disease-modifying antirheumatic drug) and biologic therapies and had liver toxicity with conventional DMARDs (disease-modifying antirheumatic drugs) is clinically appropriate and in accordance with standard of care in the rheumatology community, and thus is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aortic Stenosis. 
Treatment: Heart valve surgery and full hospital admission (33361, 33362, 35226). 

The insurer denied the Heart valve surgery and full hospital admission (33361, 33362, 35226). 

The denial is overturned. 

The patient is a male with severe aortic stenosis who is being considered for a TAVR (transcatheter aortic valve replacement). 

Yes, the requested Heart valve surgery and full hospital admission (33361, 33362, 35226) is medically necessary. 

There is adequate peer-reviewed literature to support the use of TAVR (transcatheter aortic valve replacement) in low risk patients with severe aortic stenosis. 

TAVR (transcatheter aortic valve replacement) is associated with a lower mortality and morbidity compared to open surgery.  In the studies referenced below, the median age was 73, and a particular age restriction was not part of the study design. 

Therefore, in this patient who meets criteria for aortic valve replacement, TAVR (transcatheter aortic valve replacement) would be clinically appropriate and standard. It can be performed with a shorter hospital stay and complication rate than an open operation. It would therefore be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma	

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

The patient has a history asthma, gastroesophageal reflux disease (GERD), and Methadone Dependence. They presented to the emergency department (ED) with complaints of shortness of breath (SOB) and some productive cough with whitish sputum. The patient was noted to be using some accessory muscles. The patient was awake and alert. As per the physical exam the patient was in no acute distress. There was some decreased air entry noted along with wheezing and positive rales. Laboratory studies revealed the white blood count was 9.7 the hemoglobin was 8.4 and the hematocrit was 28. Electrolytes were within normal limits.  A chest X ray revealed no signs of pneumonia. Have the patient had a peak expiratory flow (PEF) which was reported to be 100. The patient was treated with intravenous (IV) steroids, bronchodilators (BD), Magnesium and antibiotics.

As per the history and physical the patient was in no acute distress with expiratory wheezing noted. As per the note, the patient was awake and alert heart rate was 84, blood pressure  was 138/60, respiratory rate was twenty, oxygen saturation was 97% (percent) on room air and arterial blood gases were 7.38/47/94/28%.

The patient was continued on treatment with steroids bronchodilators and antibiotics the patient remained stable after admission the patient signs out against medical advice a few hours later.

This patient was in the hospital for under 24 hrs. This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. Patient could be in Observation status for up to 48 hours.

This patient remained stable after admission. The patient was not hypoxic. Oxygen saturation was 97% on room air. There were no signs of pneumonia on chest X ray. 

This patient was stable to have been discharged home after a period under observation. they could have been discharged on oral steroids bronchodilators and oral antibiotics if clinically needed.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infected tooth
Treatment: D2750 White Glass with High Gold Content Crown, Tooth #19
The insurer denied the D2750 White Glass with High Gold Content Crown, Tooth #19
The denial is upheld.

The patient is a female having pain to chewing on tooth #19. Tooth #19 has had a root canal procedure done to it and has an existing crown. The patient claims the crown has "worn down" to the point that it cannot be used to chew food properly and therefore needs replacement.
The patient is also requesting an implant to replace tooth #31.

No, the requested health service is not medically necessary.
Tooth #31 is still in the patient's mouth. It has a one surface amalgam restoration in it and is evidenced to be healthy. It does not need to be removed and replaced with an implant.

X-rays provided for tooth #19 show severe radiolucency (infection) around the mesial root. X-ray also shows radiolucency (infection) between the roots. These infected areas possible suggest the tooth has a fracture somewhere in the root. Before a new crown can be placed, an endodontic (root canal) evaluation is needed to see if the tooth can be treated, or if it needs to be extracted.

Regarding tooth #19, until the infection can be treated by redoing the root canal procedure, this tooth is not a candidate for a new crown. If the tooth cannot be treated to remove the infection, it will need to be extracted. If the tooth is deemed to have a fracture, there is no choice but to extract it.

Therefore, given the above, the requested health service is not medically necessary.

No crown is indicated for now for tooth #19, until the tooth is treated and the infection is cleared up. Then a new crown would be warranted.  The implant for tooth #31 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: spinal stenosis, myelofibrosis, ulcerative colitis, Alzheimer's disease, atrial fibrillation and coronary artery disease
Treatment: Increase Personal Care Services 24 Hour(s) A Day 7 Day(s) A Week (split shift), Total 168 Hours Total
The insurer denied the Increase Personal Care Services 24 Hour(s) A Day 7 Day(s) A Week (split shift), Total 168 Hours Total
The denial is overturned. 

The patient is a female with a history of spinal stenosis, myelofibrosis, ulcerative colitis, Alzheimer's disease, atrial fibrillation and coronary artery disease. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 168 hours/week Personal Care Services to offer increased ADL (activities of daily living) support.

Yes, the requested Personal Care Service 24 hours/day, 7 days/week, split-shift, 168 hours/week is deemed medically necessary.
This is a female with a history of with a history of spinal stenosis, myelofibrosis, ulcerative colitis, Alzheimer's disease, atrial fibrillation and coronary artery disease. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).

Although an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and noted that the currently approved plan of 84 hours/week Personal Care Services is sufficient to meet the patient's current needs; the patient's provider relates that this reduced schedule prevents the patient from being turned in bed/repositioned every two hours throughout the night as needed to prevent bedsores/pressure ulcers. This is especially important given her prior history of sacral pressure ulcers.

Hence, provision of 168 hours/week Personal Care Services can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 168 hours/week Personal Care Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male. He has a past medical history significant for congestive heart failure, sleep apnea, atrial fibrillation, status post prior multiple ablations. He presented to the ER (emergency room) for complaints of chest pain and palpitations, as well as leg edema and orthopnea.

The patient had significant tachycardia, with HR (heart rate) of 134 bpm (beats per minute) on admission, and ECG (electrocardiogram) revealed atrial flutter. His cardiac troponin was elevated at 0.4. Pro-BNP (brain natriuretic peptide) was severely elevated at 1990. His renal function was abnormal with creatinine of 1.94.

The patient was admitted for management of atrial arrhythmia, CHF (congestive heart failure) and type 2 NSTEMI (non-ST elevation myocardial infarction). The patient was treated with intravenous and PO (oral) diltiazem and started on IV (intravenous) diuretic. His TSH (thyroid stimulating hormone) was found to be severely elevated, and he was treated with levothyroxin supplementation. His renal function was monitored with diuresis. His heart rate was controlled with calcium channel blocker. The patient was subsequently discharged with a plan for outpatient follow-up for possible cardioversion.

Yes, the Inpatient admission was medically necessary.

The patient presented with recurrent atrial arrhythmia, uncontrolled heart rate and signs of end-organ damage, Type 2 non-ST elevation myocardial infarction, heart failure. The course was further complicated by renal dysfunction. This patient with multiple co-morbidities, who presented with CHF (congestive heart failure) exacerbation was appropriately treated with IV (intravenous) diuresis and rate control. He required close monitoring of his CHF (congestive heart failure) and renal function, given the underlying kidney disease, as well as telemetry monitoring for medical control of his arrhythmia. Given this presentation, acute CHF (congestive heart failure), Type 2 MI (myocardial infarction), atrial arrhythmia, as well as multiple risk factors and co-morbid conditions, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neuropathy

Treatment: code 64575, incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) for the treatment of neuropathy

The insurer denied coverage for code 64575, incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) for the treatment of neuropathy

The denial is upheld.

This gentleman has left ankle pain, weakness, difficulty walking and neuropathy, status post COVID (coronavirus) infection. The patient was evaluated. Documented treatments included Transcutaneous electrical nerve stimulation (TENS), acupuncture, physical therapy, Tylenol, Cymbalta, Lyrica and Tramadol. He was noted to have left peroneal neuropathy and to be using an ankle-foot orthosis for foot drop. Treatment with the Bioness StimRouter, one lead, left peroneal nerve, posterior thigh was planned. The patient presented for Stimwave spinal cord stimulator implant surveillance and injections, performed by Rehabilitation and Physical Medicine and Pain Management.

Wilson et al (1) conducted a review of and concluded: "Peripheral nerve stimulation has been studied in musculoskeletal pain syndromes, neuropathic pain syndromes, craniofacial pain, and in acute post-operative pain. This pain-relieving treatment is a promising treatment though many applications have not yet been well studied."

Similarly, Deer et al (2) have concluded: "The greatest need to further improve this biolelectronic therapy is in researching outcomes to help us better understand proper use and patient selection. This review identifies principles that a practitioner needs to address prior to implanting a peripheral nerve stimulation (PNS) system in a patient. Best use of image guidance, selection of neural target, optimizing stimulation parameters, understanding trialing benefits and specific techniques are critical for the success of PNS outcomes in the clinical setting."

This is a promising technology, but it is not yet supported as standard of care in the literature. It's use here is not medically necessary. The health plan acted reasonably in the best interest of the patient.

Based on the above, the medical necessity for the code 64575, incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) for the treatment of neuropathy is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impacted maxillary left canine.
Treatment: Braces And Monthly Visit, Pre-service.
The insurer denied the Braces And Monthly Visit, Pre-service.
The denial is upheld.

The patient is a male. The request is for dental benefits for orthodontic treatment (Braces) and monthly visits.

Orthodontic records were made, including x-rays, photos, and clinical evaluation performed.

The patient presents with skeletal class I relationship, mild maxillary and mandibular spacing, open bite, slightly excessive overjet, impacted maxillary left canine, and over-retained primary canine.

The health plan denied the claim, because the patient did not score a 26, the necessary score to be approved for braces per the Handicapping Labio-Lingual deviation (HLD) Index report.

The provider appeal the case because of the impacted maxillary left canine.

No, the  Braces and monthly visits are not medically necessary.
The provider highlighted that the reviewer did not consider the impacted maxillary left canine; the records submitted does not support that there is an impacted maxillary left canine. This impacted canine is not evident in the x-rays submitted.

Therefore, the braces and monthly visits are not medically necessary.

The main diagnoses that the provider highlighted (impacted canine) is not evident and supported by the x-ray records submitted; therefore orthodontic treatment to correct this issue is not warranted.