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

Diagnosis: Dental Problems (skeletal Class II, vertical growth pattern, Class II canines, maxillary and mandibular crowding, excessive overjet and anterior crossbite (mandibular right canine). 

Treatment: D8080 braces and D8670 monthly visit x 12. 

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

The denial is upheld. 

This is a male patient who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II, vertical growth pattern, Class II canines, maxillary and mandibular crowding, excessive overjet and anterior crossbite (mandibular right canine). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. It seems that the orthodontist may have also completed the HLD index with attaining a point value of 18, although this document, if completed, is not provided for review. The insurer has denied coverage for orthodontic treatment as not medically
necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 15 points on review by their 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, the HLD index is utilized. This index provides 6 specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to quality for orthodontic care, a total score of 26 points is necessary. In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 15 points (3 overjet, 2 overbite, 10 anterior crowding). 

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

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

The medical necessity for D8080 braces and D8670 monthly visit x 12 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite.
Treatment: Braces.
The insurer denied the braces. 
The denial is upheld. 

The patient is a female.  The request is for dental benefit services for orthodontic treatment (braces).  Clinical exam summary revealed a patient who presented with skeletal Class I, normal vertical growth, Class II canine relationship, mild maxillary and mandibular spacing, and an anterior crossbite with gingival attachment loss (mandibular left canine).

No, the proposed treatment with braces is not medically necessary.

The orthodontic treatment is not medically necessary because the patient's photos and x-rays do not show an anterior crossbite (maxillary anterior tooth/teeth would be positioned lingual to their original eruption position).  In addition to the severity of the cross-bite not being supported, details of the approximate amount of gingival attachment loss are not indicated in the clinical summary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated blood pressure.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a female patient who had a Cesarean section (C-section) delivery complicated by a postoperative wound infection, who presented to the Emergency Department (ED) 2 weeks later with complaints of elevated blood pressure and migraine. Blood pressure on admission in the ED was 170-180/90-100. She was admitted with a diagnosis of preeclampsia. Because of bradycardia, a Cardiology consult was obtained. The patient's headache responded to Reglan and Benadryl in the ED. A Computed Tomography scan of the patient's head was normal. Echocardiogram was normal. She received 24 hours of magnesium sulfate. Her blood pressure was well controlled with Procardia. She was seen by Infectious Disease because of her wound infection. 

This patient presented 2 weeks after delivery with an elevated blood pressure. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than 2 days but less than 6 weeks after delivery. 

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman. This patient had an elevated blood pressure, no protein in the urine and no elevated liver function tests (LFT) and no end organ dysfunction. This patient did not have a diagnosis of preeclampsia. She had significant elevation in her blood pressure. Ideally this patient would have been observed in the ED. Once her blood pressure was controlled, the patient could have been discharged home on home blood pressure monitoring and to return if any worsening of her blood pressure. Both the Cardiology consult and Infectious Disease consult did not require hospital admission.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission was not medically necessary. 

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

Diagnosis: Sublingual mass. 
Treatment: Inpatient admission. 

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

The patient is a female with a sublingual mass measuring 5.87 centimeters (cm) in greatest dimension, present for three years, excised earlier this year. The patient had a hospital admission. Vital signs were temperature (T) 37.2, heart rate (HR) 92, blood pressure (BP) 133/71, respiratory rate (RR) 22, and oxygen saturation (SpO2) 100%. She tolerated diet. Her pain was controlled. She was discharged the following day. She had no preoperative complications. She had no active interventions postoperatively. 

No, the proposed treatment, inpatient admission, was not medically necessary. 

Care could have been delivered at a lower level of intensity than acute inpatient. 

The patient had uncomplicated excision of sublingual mass. She had no complications or active interventions following the surgery. The patient could have been managed at a lower level of intensity than acute inpatient care. The plan acted reasonably to deny coverage for acute inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal muscular atrophy.
Treatment: Ongoing home health visits for physical therapy.
The insurer denied coverage for ongoing home health visits for physical therapy.
The denial is overturned. 

This is a female patient diagnosed with spinal muscular atrophy. The patient was being treated with the medication Evrysdi and was receiving nebulizer treatments every 6 hours. The patient also underwent treatment with a vest and Cough Assist device. The patient was utilizing a Bilevel Positive Airway Pressure (BiPAP) machine at nighttime.  The patient was receiving disease-targeted therapy for strength and function. The care plan indicated the patient was to continue physical therapy (PT) for spinal muscular atrophy.  The reason for home care was to reduce the risk for prehospitalization.

As per the patient's medical record, this patient has progressive weakness due to spinal muscular atrophy (2 copies of survival of motor neuron-2(SMN2)). As per a PT note (home PT visit #2), the patient has decreased ability to maintain full active range of movement (ROM) for 20 repetitions (reps) with the majority of exercises, potentially due to decrease in PT frequency. The patient requires continued skilled PT services to address frequent tonal changes effecting ROM and active control of tone for movement. To discontinue PT at this time would negatively impact the patient's ROM and active control increasing difficulty of positioning and transfers on caregivers. Functionally, the patient is max A for bed mobility, rolling, and transfers. The patient has 2/5 hip flexion and poor lower extremity control. Due to her spasticity and poor mobility, the patient is at increased risk of pressure injury. As per recent published guidelines, "Since the original consensus statement paper there has been increasing evidence that a proactive approach, including regular sessions of physical therapy (PT) may influence trajectories of progression". The patient is on the newest Food and Drug Administration (FDA)-approved therapy to treat patients with spinal muscular atrophy, such as this patient, and in order to maximize the benefit to her strength and function. Thus, the continued home health visits for physical therapy is considered medically necessary.

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

Based on the above, the medical necessity for ongoing home health visits for physical therapy is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Problems (skeletal Class I, vertical growth pattern, Class II canines, maxillary and mandibular crowding, and anterior crossbite (mandibular right canine)). 
Treatment:  Braces.

The insurer denied coverage for braces.  The denial is upheld. 

This patient is a female child, who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, vertical growth pattern, Class II canines, maxillary and mandibular crowding, and anterior crossbite (mandibular right canine).  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 13 points on review by their 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, the HLD index is utilized.  This index provides 6 specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system, if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is not met, as there is no evidence of gingival attachment loss or gingival recession; therefore, the evidence does not support comprehensive orthodontic care using this criterion.  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 13 points (3 overjet, 3 overbite, 5 anterior crowding, and 2 labio-lingual 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.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

Coverage for braces is not considered medically necessary for this patient.

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

Diagnosis:  Multiple Sclerosis.
Treatment:  Zeposia.

The insurer denied Zeposia.  The health plan's determination is overturned. 

The patient is female, who has been diagnosed clinically and radiographically with relapsing remitting multiple sclerosis.

The patient presented with decreased dexterity and tightness in her left hand, and leg numbness, weakness and left-sided dysesthesias.  She was admitted to the hospital for intravenous solumedrol.  The steroid helped with the sensation of tightness and pain in her fingers, but there was no improvement in the numbness.  She was discharged home on a tapering course of oral steroid.

Zeposia is medically necessary for this patient.  Multiple sclerosis (MS) is a chronic autoimmune neurodegenerative disease affecting the central nervous system. It involves inflammation, demyelination, neuronal and oligodendrocyte loss, disruption of the blood-brain barrier.  Debilitating symptoms of the disease include fatigue, depressive symptoms and cognitive impairment. MS may present as a clinically isolated syndrome, relapsing MS (RMS), secondary progressive MS or primary progressive MS.  RMS, the most prevalent type of MS, is characterized by episodes of relapses followed by a remission period.  Multiple sclerosis at present has no cure, but treatment options exist. 

The clinical efficacy, safety and tolerability of ozanimod for the treatment of patients with RMS have been demonstrated in the Phase III RADIANCE and SUNBEAM clinical trials. 

The comparative efficacy of ozanimod and fingolimod in the treatment of RMS has not yet been fully characterized with a formal head to head clinical trial. 

With regard to whether there is an increased risk of more serious Covid19 infection with Gilenya (fingolimod) compared with Zeposia (ozanimod), data are limited. 

With regards to Zeposia not being approved for use in children, it is noted that the patient is adult-sized and receives adult doses of other medications.  Drugs are frequently used on an off-label basis in pediatrics.  The American Academy of Pediatrics notes: "The absence of labeling for a specific age group or for a specific disorder does not necessarily mean that the drug's use is improper for that age or disorder.  Rather, it only means that the evidence required by law to allow inclusion in the label has not been approved by the FDA [Food and Drug Administration].  Additionally, in no way does a lack of labeling signify that therapy is unsupported by clinical experience or data in children.  Instead, it specifically means that evidence for drug efficacy and safety in the pediatric population has not been submitted to FDA for review or has not met the regulatory standards of 'substantial evidence' for FDA approval."

In summary, there appears an advantage to the use of Zeposia (ozanimod) compared with Gilenya (fingolimod) in terms of a lower incidence of adverse events.  It has not been demonstrated that there is an advantage to using Zeposia with regards to its efficacy in disease modulation.  It is unknown whether the drugs differ in posing an increased risk for serious infection in Covid19.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorder. 
Pharmacy/Prescription Drugs. 

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent. 

The insurer denied Dupixent. 
The health plan's determination is upheld. 

The patient is a female with moderate to severe atopic dermatitis affecting the groin area, bilateral upper arms, and trunk. The patient has tried and failed topical mometasone, fluocinonide, hydrocortisone, clobetasol, triamcinolone, clotrimazole, Eucrisa, and Protopic, as well as phototherapy. 

Health plan coverage of Dupixent is under review for medical necessity. 

Dupixent is not medically necessary. The patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line oral medications such as Methotrexate, Azathioprine, or Cyclosporine that are used for moderate to severe atopic dermatitis. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with modern dermatology literature, the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: acute cholecystitis; s/p (status post) laparoscopic cholecystectomy
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient was a woman. Her medical history included symptomatic gallstones for which she was scheduled to undergo elective, outpatient laparoscopic cholecystectomy. However she presented to an emergency room with progressively worsening right-upper-quadrant abdominal pain, nausea, and vomiting. Her vitals were temperature 36.6, pulse 84, blood pressure 132/85, respirations 18, oxygenation 99%. Serum laboratories demonstrated a white-blood-cell count of 10. Abdominal ultrasound was consistent with acute cholecystitis. 

The patient was admitted at an acute inpatient level-of-care with a diagnosis of acute cholecystitis. She underwent laparoscopic cholecystectomy with intra-operative cholangiogram. Surgery and recovery were uncomplicated. The patient was discharged home in good and stable condition with prescriptions for oral analgesics and outpatient surgical follow-up. 

The proposed treatment -- admission at an acute inpatient level of care was not medically necessary. 

Guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons [SAGES] are clear: "Patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery". Therefore, in the absence of significant co-morbidities, physiologic derangements, or clinical instability, there was no evidence of medically necessity for admission at an acute inpatient level of care. This patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: History of glaucoma, coronary artery disease,
anxiety disorder, dementia, depression and stroke
Treatment: Increase Personal Care Services, 24 hours, seven days a week (split-shift)
The insurer denied the Increase Personal Care Services, 24 hours, seven days a week (split-shift).
The denial is upheld. 

The patient is a female with a history of glaucoma, coronary artery disease, anxiety disorder, dementia, depression and stroke. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of 24 hours, seven days a week (split-shift), Personal Assistance Services to offer increased activities of daily living (ADL) support.

No, proposed treatment of 24 hours, seven days a week (split-shift), Personal Assistance Services is not deemed medically necessary.

This patient is a female with a history of glaucoma, coronary artery disease, anxiety disorder, dementia, depression and stroke. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

However, an in-home assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and revealed that the currently approved plan of 84 hours per week Personal Assistance Services is sufficient to meet the patient's current needs. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment of 24 hours, seven days a week (split-shift), Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal class I, vertical growth pattern, class II canines, maxillary and mandibular crowding, and anterior crossbite (mandibular right canine)).

Treatment: D8080 braces and D8670 monthly visits x 12

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

The denial is upheld. 

This is a female patient who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal class I, vertical growth pattern, class II canines, maxillary and mandibular crowding, and anterior crossbite (mandibular right canine). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 23 points on 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, the 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 not met as there is no evidence of gingival attachment loss or gingival recession and therefore, does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet the insurer's and plan's criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 23 points (i.e., 4 for overjet, 4 for overbite, 10 for anterior crowding, and 5 for labio-lingual spread).

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

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

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