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

Diagnosis: Dental Problems
Treatment: Dental/Orthodontic Procedure
The health plan denied the treatment of braces as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient in question is presenting with a skeletal Class I malocclusion with maxillary and mandibular crowding. She is missing teeth 4, 13, and 21. She has a 4 millimeter (mm) anterior open bite. She is treatment planned for 24-30 months of orthodontics including extraction of A, J, K, T, and 29 to address the open bite, but the treatment was denied due to lack of medical necessity. The family has appealed this ruling. 

Orthodontic treatment is medically necessary for this patient.
Anterior open bite patients are among the most difficult patients to treat.[1] One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite.[2] Additionally, orthodontic treatment is medically necessary for this patient due to the fact that this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis Flare

Treatment: Orencia ClickJect 125 milligrams per milliliter (mg/mL) SC (subcutaneous) SOAJ (solution auto-injector).

The insurer denied coverage for Orencia ClickJect 125mg/mL SC SOAJ

The denial is overturned

The patient is a female with a past medical history of rheumatoid arthritis (RA). The patient had an office visit with her Rheumatologist. Per the visit notes, the patient presented with severe RA flare and failure of Tumor necrosis factor (TNF) therapy. She is being followed by gastrointestinal (GI) for liver abnormalities. The patient was on prednisone. She had weight gain and sleep issues on 40 mg of prednisone. The plan was to taper prednisone, stop Humira, and start Orencia. Rheumatologist is requesting coverage of Orencia ClickJect 125 mg/mL for treatment of the patient's RA. 

The insurer has denied coverage for Orencia ClickJect 125mg/mL SC SOAJ as not medically necessary. In their Final Adverse Determination letter, the insurer states that the patient does not meet criteria for coverage because she has not taken or had a poor response to medications on the preferred drug list. The insurer states the patient's doctor should consider using Xeljanz and Xeljanz extended-release (XR). 

Rheumatologist is appealing the decision. The appeal letter states that the patient was having a severe rheumatoid arthritis flare and failure of her Tumor necrosis factor (TNF) therapy. She has had abnormal liver function tests (LFTs). 

The Food and Drug Administration (FDA)-labeling for Orencia and Xeljanz were reviewed, as was the www.uptodate.com chapter "Treatment of rheumatoid arthritis in adults resistant to initial biologic DMARD [disease-modifying antirheumatic drugs] therapy." 

There is no recommendation to monitor LFTs in Orencia, and liver toxicity has not been a feature of studies or experience. On the other hand, patients on Xeljanz have a higher incidence of LFT abnormalities, and routine monitoring of LFTs is recommended (it is not clear how much of the toxicity is due to concomitant methotrexate).

Given the problems with abnormal LFTs, Orencia is less likely to cause confusion/toxicity. 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 Orencia ClickJect 125mg/mL SC SOAJ is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation
Treatment: Inpatient hospital
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is a male with history of appendectomy complicated by postoperative pleural effusions and Clostridium Difficile colitis who presented with 2 days of abdominal pain. He reports since his surgery he has had mild abdominal pain on and off which became constant 2 days prior to presentation. The pain is located in the left lower quadrant and is rated 8/10 at its worst. He describes the pain as sharp and non-radiating. Standing up and walking around exacerbated his symptoms. The patient describes associated nausea but has not vomited. He has a history of constipation and at this time he has not had a bowel movement for 3 days. He was admitted for pain control for abdominal pain and workup for infectious versus inflammatory etiology for his symptoms.

No. The Inpatient Hospital Admission was not medically necessary for this patient. This patient presented with abdominal pain and reports of constipation. His pain was 8/10 that improved with intravenous (IV) Morphine in the emergency room (ER). He had laboratory studies done as well as an abdominal CT (computed tomography). He was afebrile, had stable vital signs, no elevated inflammatory markers, no rebound tenderness or guarding on exam. His CT scan did not reveal any surgical emergency or signs or intestinal perforation or obstruction. GI (Gastrointestinal) was consulted and they felt his symptoms were most consistent with constipation. He did not require inpatient level of care to manage his constipation. He did not have significant stool burden described on CT scan that would need inpatient level of care to manage. He responded well to clean out, his pain resolved, and he was discharged the following day after admission. His illness was not severe enough to require increased intensity of services that would qualify for inpatient admission. He did not appear to have a surgical abdomen at the outset, nor did he show signs of impending deterioration. No highly technical or skilled care was ordered upon admission. The Inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis.
Treatment: Prolia 60mg/ml (milligrams/milliliter) SC SOSY, Pre-service.

The insurer denied Prolia 60mg/ml SC SOSY, Pre-service.  The denial is overturned. 

This is a female with osteoporosis treated with Prolia. Her T-score was -4.1 in the L (lumbar) 1-L4 spine. She had osteonecrosis of the jaw related to alendronate.  She has tried and failed Evista. The request for Prolia is under review.

Yes, the proposed Prolia is medically necessary.

The preferred alternatives are alendronate, ibandronate, and zoledronic acid. The prior request for Prolia was denied as the appeal indicates that patient has experienced osteonecrosis of the jaw due to alendronate, but this was not supported by the submitted clinical documentation.  This patient is at very high risk of fragility fractures given her very low T-score of -4.1. Prolia has been shown to be superior to oral bisphosphonates at 12 months for effect on bone mineral density at the lumbar spine [1] and in a second study treatment with Prolia resulted in greater bone mineral density at all measured skeletal sites and greater inhibitor of bone remodeling as compared intravenous bisphosphonates [2]. Without Prolia, this patient will continue to be at high risk of a fragility fracture. Therefore, given this patient is at high risk for fractures, the requested Prolia is medically necessary, and bisphosphonates are not an appropriate alternative therapy in this patient with high risk for fracture.

The requested Prolia is medically necessary, and the denial was not appropriate.
Appeal type: Medical necessity
Decision: Upheld

Dental
Dental/orthodontic treatment

Diagnosis: maxillary and mandibular crowding.
Treatment: Braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is upheld. 

Braces and Monthly Visits are not medically necessary for the patient at this time. He is in the process of losing his remaining primary teeth as they are replaced with permanent teeth. Research indicates the following risk factors for impacted canines in patients over 10 years of age:
1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does not have this, as shown in the panoramic radiograph.)
2) The canines cannot be palpated and occlusal development is advanced (occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption.)
3) The lateral incisor is proclined and tipped distally (Tooth 7 is rotated, but so is tooth 10, and tooth 11 is erupted. Tooth 7 is not tipped distally)
4) On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor. (The incisal tip is near the root of #7 on the radiograph but it is not overlapping #7 on the panoramic radiograph provided.)
The patient does have maxillary and mandibular crowding and treatment may be indicated in the future. However, the patient does not exhibit any of the criteria to suspect #6 is, in fact, impacted. For this reason, Braces and Monthly Visits are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Insomnia
Treatment: Xyrem
The insurer denied Xyrem. The health plan's determination is upheld.

The patient is a female with a history of obstructive sleep apnea (OSA), fatigue and excessive daytime sleepiness. The patient had previously been under the care of a pediatric sleep medicine provider. The patient's prior complaints had involved "persistent hypersomnia, mostly in the mornings, hypnagogic jerks and confusional arousals". Coverage of Xyrem (sodium oxybate) is under review. 

Xyrem is not medically necessary for this patient. The use of Xyrem is not supported by any current clinical practice guidelines for use in idiopathic hypersomnia. The evidence published to date suggesting a role for the use of Xyrem in hypersomnia is limited to case reports/series. It is also known that Xyrem is effective given sleep architecture changes unique to narcolepsy (sleep architecture in narcolepsy is also different from that seen in idiopathic hypersomnia). Thus, the findings of efficacy of Xyrem in narcolepsy cannot be extrapolated to create predictions on the drug's utility in idiopathic hypersomnia. Ultimately, conclusions cannot be drawn from such reports as they are not considered to be reliable evidence given the high grade of bias (in that often only favorable findings are published).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Palpitations. 
Treatment: Inpatient admission. 

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

The patient is a female. She has a past medical history significant for asthma, cholecystectomy, and episodes of paroxysmal SVT (supraventricular tachycardia). She presented to the ER (emergency room) via EMS (emergency medical services) for an episode of SVT (supraventricular tachycardia) with heart rate of 160, which converted to normal sinus rhythm with vagal maneuvers. 

The patient's ECG (electrocardiogram) in the ER (emergency room) revealed normal sinus rhythm at 72 BPM (beats per minute). While in the hospital, patient had several episodes of SVT (supraventricular tachycardia), which resolved with vagal maneuvers as well. The patient was admitted for SVT (supraventricular tachycardia). 2D (two-dimensional) echocardiogram revealed preserved LV (left ventricle) function. She was seen in consultation by cardiology and was recommended to start a low dose metoprolol. The patient was discharged home the next day with a plan for outpatient cardiology follow-up. 

No, the inpatient admission was not medically necessary. 

The patient presented for evaluation of palpitations. She was diagnosed with paroxysmal SVT (supraventricular tachycardia), which responded to vagal maneuvers. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), ventricular arrhythmia or hemodynamic instability. There was no plan for urgent inpatient ablation or EP (electrophysiology) study.  Echocardiogram was normal. The patient was started on oral beta-blocker and discharged. There was no plan for urgent inpatient ablation or EP (electrophysiology) study. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Tepezza. 
The denial is upheld.

The patient is a nonsmoking male with a history hyperthyroidism and status post radiation (unclear if radioactive iodine). He presented with itchy dry eyes and inferior scleral show. Per the clinical notes submitted, the patient has vision of 20/15 both eyes (OU), with normal intraocular pressures in upgaze, normal hertel exophthalmometry readings, full visual fields to confrontation, normal color vision and illegible findings on "medial gaze OU". A head computed tomography (CT) reportedly showed medial and inferior rectus thickening OU. The patient has a reported history of peptic ulcer disease, though is not currently treated. His provider is recommending Tepezza/teprotumumab to treat his active thyroid eye disease. The subject under review is the medical necessity for Tepezza.

The health plan's determination is upheld.

Tepezza is Food and Drug Administration (FDA) approved to treat thyroid eye disease (TED) without reference to disease severity or clinical activity. This has led some clinicians to use teprotumumab in the chronic, noninflammatory phase of the disease. However, the industry-sponsored, placebo-controlled randomized studies, showed efficacy of the agent versus placebo in proptosis reduction, reduction of the clinical activity score (CAS), and reduction of diplopia. Patients enrolled were in the inflammatory phase of the disease (less than [<] 9 months of disease duration) and had moderate-to-severe disease with a clinical activity score of 4 or more. It is unclear how long this patient has been in the active phase of TED. The duration of his symptoms prior to that is not established. Further, the patient may have active TED, but his submitted proptosis measurements are within the normal range which is typically considered < 20 for Caucasian men, and his optic nerve function is intact with normal vision, normal reported fields, normal color vision, no afferent pupillary defect and normal intraocular pressures. There has not been a non-inferiority clinical trial that compares Tepezza to intravenous (IV) methylprednisolone, the current mainstay of therapy. Finally, side effects including hearing loss, cognitive decline and hyperglycemia have all been reported. Therefore, a trial of IV steroid is not unreasonable prior to using Tepezza in this patient.
Tepezza is not medically necessary at this point. It is reasonable to consider IV solu-medrol or dexamethasone as a first line treatment in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment: White glass with metal crown, tooth 30. 

The insurer denied the white glass with metal crown, tooth 30. 
The determination is overturned. 

The patient presented for evaluation and treatment of tooth number (#) 30. Provided for review are previous letters of appeal and denial, full mouth radiographic images from an unknown date, and one page of American Dental Association (ADA) claim forms. Previous denials have been on the basis that the tooth has an inadequate fill on tooth #30 which has received a root canal which they have determined has not gone to the apex of the canals. At issue is the medical necessity of the treatment of (2751) porcelain fused to metal crown for tooth #30. 

The requested service/treatment of white glass with metal crown for tooth #30 is medically necessary for this patient. Although, the argument that the root canal therapy on tooth #30 is incomplete as it does not end at the tip of the root, not all nerves exit exactly from the tip of the root and all root canals are completed with the intention of removing only the most necessary affected tooth structure from the canals and to wherever the nerve happens to exit, not just the apex of the root. Further, beyond the acceptable variation in the exit point and thus the fill of the root canal, the tooth itself is in definite need of a crown as it has an entire cusp missing as well as tooth structure that is missing to the extent that a direct filling cannot be used. 

Therefore, the treatment of (2751) porcelain fused to metal crown for tooth #30 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment: Braces and Adjustments for Braces. 

The insurer denied the Braces and Adjustments for Braces. 
The determination is overturned. 

The patient presented with a skeletal Class I malocclusion with maxillary and mandibular crowding. She had an anterior open bite. She was treatment planned for orthodontics to address the open bite, but the treatment was denied due to a lack of medical necessity. At issue is the medical necessity of braces and adjustments for braces. 

The requested services are medically necessary. 

Patients with an anterior open bite patients are among the most difficult patients to treat. (1) One side effect of an anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. (2) Orthodontic treatment is medically necessary for this patient due to the side effect described above (1), and the fact that this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital stay. 
The denial is upheld. 

The patient is a male with a past medical history significant for hypertension, hyperlipidemia, and anxiety who presented to the hospital with complaints of acute onset of right knee pain. It was reported that the patient recently underwent arthroscopy. 

Upon evaluation in the hospital, the patient underwent a lower extremity venous doppler ultrasound, which was negative for deep vein thrombosis (DVT). Computed tomography (CT) scan of the knee demonstrated trace/small amount of joint effusion. The inflammatory markers were within normal limits. The admitting physician stated that the diagnosis of a septic joint was unlikely. The admitting physician suggested that the patient most likely had a small joint effusion related to a recent surgical intervention. 

In the hospital, the patient was seen by physical and occupational therapy who recommended outpatient physical therapy (PT). 
It was also mentioned that the patient had experienced episodes of bright red blood per rectum, however, his hemoglobin remained stable at 15. Because of rectal bleeding, the treatment with Naproxen was discontinued and the patient was started on proton pump inhibitors. 
It was suggested that the bright red blood per rectum could be related to constipation and hemorrhoids. The patient was recommended follow-up with a gastroenterologist as an outpatient. 

The subject under review is the medical necessity for the inpatient stay. 

The inpatient hospital stay was not medically necessary. 

There was no evidence of fracture or dislocation in the joint requiring intervention. There was no evidence of infection in the joint necessitating initiation of treatment with antibiotics. According to the medical records, the patient had no severe crystal arthropathy or myopathy requiring treatment at the acute inpatient level of care. There was no mention of severe rheumatological disease, including vasculitis, or rhabdomyolysis. 

The rectal bleeding was mild and self-limited. It did not require any interventions justifying admission at the acute inpatient level of care. 
There was no compelling clinical reason why the patient could not have safely and appropriately received care at a lower level of care status. 
Overall, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class I, maxillary and mandibular crowding, overjet, and impacted left maxillary canine.

Treatment D8080 braces and D8670 monthly visit x (times) 12.

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

The denial is upheld.

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 skeletal Class I, maxillary and mandibular crowding, overjet, and impacted left maxillary canine. The orthodontist has completed the Handicapping Labio-Lingual 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 6 points on review by 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 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 not met and does not support comprehensive orthodontic care. This reviewer concurs with the findings of the insurer of attaining 6 points on the HLD index (2 points overjet, 2 points overbite, 2 points 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 denial should be upheld as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit x 12 is upheld. Medical necessity is not substantiated.