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

Diagnosis: Malocclusion

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 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 26 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 13 and 15 points by internal independent reviewers. 

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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 15 points on the HLD index (7 overjet, 5 overbite, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. 

Regarding the validity of the Handicapping Labio-Lingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for D8080 braces and D8670 monthly visit x 12 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral vascular disease. 
Treatment: Vascular Surgery (current procedural terminology (CPT) 37228, 37224, 37226, 37220). 
The insurer denied Vascular Surgery (current procedural terminology (CPT) 37228, 37224, 37226, 37220). 
The health plan's determination is overturned. 

The patient is a woman with abdominal aortic aneurysm, claudication, and peripheral vascular disease who was seen for claudication. The patient complained of short distance claudication. The patient was noted to have warm bilateral lower extremities. ABI (ankle brachial index) of the left leg was 0.71 and the right leg was 0.65. The patient was diagnosed with lower extremity claudication. 
A computed tomography angiography (CTA) of the abdomen aorta with runoff was ordered. The CTA of the abdominal aorta with runoff was performed and demonstrated severe atheromatous disease with infrarenal aortic occlusion with diffusely attenuated bilateral iliac arteries. 

The requested Vascular Surgery (CPT 37228, 37224, 37226, 37220) is medically necessary for this patient. The patient has bilateral lower extremity claudication requiring treatment. The recommended treatment is medically necessary and is the standard of care for the treatment of claudication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dementia
Treatment: Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hours per Day (Split Shift)
The insurer denied Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hours per Day (Split Shift).
The health plan's determination is upheld.

The patient is a female with medical history notable for dementia, incontinence, and chronic pain. The patient is currently receiving 24-hour LPN (licensed practical nurse) care. The patient and her care team requested Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hours per Day (Split Shift).

The requested Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hours per Day (Split Shift) is not medically necessary for this patient.
The patient is currently approved for 24-Hour per day split shift LPN services. There is insufficient evidence that the patient would require additional assistance beyond the LPN. The patient's healthcare team argues that it is not possible to perform skilled nursing and personal care tasks simultaneously. Although the patient requires 24-hour per day personal care, the care is not typically being provided continuously but just needs to be available in the event of unscheduled needs. There is insufficient documentation that a split shift LPN would have inadequate time to address all of the patient's care needs. Therefore, the request to have a 24-hour split shift personal care aide in addition to a 24-hour split shift licensed practical nurse is not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: thyroid nodule
Treatment: Gene Expression (Lab Work) 
The insurer denied Gene Expression (Lab Work) 
The health plan's determination is overturned. 

The patient is a female who underwent a thyroid ultrasound showing multiple thyroid nodules but a solid and cystic nodule in the lower pole of the left lobe of the thyroid gland which met criteria for fine needle aspiration (FNA) (TIRAD 5) with size of 2.0 centimeter (cm). The patient underwent FNA with pathology stating "although there are benign features including colloid, there is an insufficient quantity of groups of follicular cells (less than (<) 6 groups composed of at least 10 cells each) with interpretive diagnosis of unsatisfactory for adequate cytologic evaluation". The patient underwent another FNA with pathology report stating "cellular specimen consisting of follicular-derived cells in syncytial and microacinar arrangements with crowding and mild nuclear atypia. The findings are those of an adenomatous lesion as seen in cellular hyperplastic nodules or follicular epithelial derived neoplasms".

Gene Expression (Lab Work) was medically necessary for this patient.
The patient's pathology report from the second fine needle aspiration (FNA) was reported as cellular hyperplastic nodule or follicular epithelial derived neoplasm. Gene expression classifiers in FNA of the thyroid are considered medically appropriate when surgical decision will be based on test results for thyroid nodules with cytological diagnosis of atypia of undetermined significance/follicular lesion or either undetermined significance on FNA, which was the case with this patient' pathology. The patient's nodule was greater than (>)1.0 centimeter (cm) and there was no clinical suspicion of malignancy based on provider judgment and ultrasound and there were no compressive manifestations. The patient's clinical scenario and pathology of her thyroid nodule FNA met criteria for gene expression lab work. In addition, the most up to date literature regarding recommendations for evaluation of thyroid nodules with uncertain pathology recommend gene expression lab work as the next step in evaluation. In summary, Gene Expression (lab work) is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and Monthly Visit
The insurer denied: Braces and Monthly Visit
The denial is overturned.

The patient is an adult male. The request is for orthodontic benefits. He has a Class II canine malocclusion with severe upper and lower crowding. The health plan denied coverage of 
the request due to the patient scoring 19 points on the handicapping index scale. The denial is being appealed.

The Braces and Monthly Visit are medically necessary.

The patient's upper left and right permanent canines (teeth #[number]s 6 and 11) are blocked out. This means there is not enough room for them to erupt normally in the dental arch, and they are growing out into the lip area. Without these critical teeth being in their proper positions, there can be no "canine guidance." This is when, during the chewing cycle, the lower canines glide up along the insides of the upper canines in a coordinated fashion. This allows the back teeth to "disarticulate" or open up the bite. Without canine guidance, the back teeth do not open up and will bang into each other in a traumatic fashion. Over time, fractures and/or loosening of these teeth can happen. Teeth #6 and #11 need to be placed in their correct position, and orthodontic treatment is needed to do this. This case has medical necessity. The monthly visits are needed to make sure the orthodontic treatment is progressing properly.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental issues
Treatment:  Full Braces and Monthly Brace Adjustment Visit.

The insurer denied Full Braces and Monthly Brace Adjustment Visit.  The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion with a 3-millimeter (mm) overjet and 4 mm overbite. She has minor maxillary and mandibular crowding. She is treatment planned for Full Braces and Monthly Brace Adjustment Visit to correct her malocclusion. This is under review.

Full Braces and Monthly Brace Adjustment Visit are not medically necessary for this patient.
There is no medical reason to correct her malocclusion with braces. While the patient has crowded teeth, there is no posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. This patient has a Class I occlusion, and masticatory efficiency is highest in patients with a Class I occlusion. The patient's overjet is slightly more than ideal, but her overjet would not affect oral health related quality of life, unless it was greater than 6mm. If her teeth were aligned, it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 Monthly visit

The insurer denied coverage for D8080 braces and D8670 Monthly visit.  The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, among other findings and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 16 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 16 points 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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 16 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 16 points on the HLD index (3 overjet, increased overbite, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note is in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

Regarding the validity of the Handicapping Labio-Lingual Deviation Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 braces and D8670 Monthly visit is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac Arrest.
Treatment: Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

The patient is a male with a history of diabetes and alcohol abuse who quit drinking on his own 5 days prior. He was found down by emergency medical services in asystole, and the return of spontaneous circulation was achieved after cardiopulmonary resuscitation (CPR). The patient was intubated. He was brought to the emergency room. He was hypotensive and started on levophed and given sedation. He was admitted and brought to the intensive care unit (ICU). He suffered an anoxic brain injury and was unable to wean from the ventilator, so he had a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placed. He was able to decannulate. He suffered from contractures limiting mobility. He ate a mechanical soft diet with assistance. Per review of the chart, the patient was appropriate for discharge to a Skilled Nursing Facility (SNF) per chart notes. He was not able to be placed secondary to legal and financial reasons for a prolonged period per case management notes. He remained hospitalized. At issue is the medical necessity of continued inpatient hospital stay.

The requested service of continued inpatient treatment was not medically necessary for the patient. The patient was appropriate for discharge from the hospital. He was medically appropriate for transition from inpatient at that time, as he did not require continued hospitalization for medical treatment or for medically required inpatient diagnostic study [1]. Further, a delayed discharge from hospital to home or another setting can lead to poorer patient outcomes. Further delayed discharge results in over testing for acute conditions and under management of chronic diseases; as such, this practice does not benefit the patient [2,3]. Transition from the hospital to a SNF was delayed for this patient secondary to insurance reasons related to legal reasons, per documentation in case management notes. The patient's needs were chronic at this point and do not meet the definition of inpatient care management [1].
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes
Treatment: Formulary exception for Tradjenta
The insurer denied: Formulary exception for Tradjenta
The denial is upheld.

The patient is an adult male diagnosed with T2DM (type 2 diabetes mellitus). This request is for Tradjenta. As reported, he is on Tradjenta 5 milligrams for over 10 years, along with metformin 1000 milligrams, and his diabetes has been controlled. As per the recent visit note; he is on Jardiance and metformin. His A1C (glycated hemoglobin) 4 months ago was 6.8 %.

The health plan should not cover the Formulary exception for Tradjenta.

The formulary alternative is Januvia. Januvia is not documented to have been ineffective for this patient, nor is it reasonably expected to be ineffective. The formulary alternative is reasonably expected to be as effective as the requested non-formulary, as described below. The formulary alternative is not reasonably expected to have adverse effects on this patient.
There are no studies showing superiority of one DPPIV (Dipeptidyl Peptidase-4) inhibitor (1-3) over another including linagliptin (Tradjenta), saxagliptin (onglyza), vidagliptin (galvus), alogliptin (Nesina) or sitagliptin (Januvia) (4-7). There are no studies showing superiority of the requested medication over the formulary alternatives. The patient can try the formulary alternative option, Januvia. The request does not meet the 
standard of care, and therefore should not be covered by the health plan.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hemochromatosis, Beta Thalassemia
Treatment: Deferasirox to treat hemochromatosis
The insurer denied coverage for deferasirox to treat hemochromatosis.
The denial is upheld.

This is a patient who is diagnosed with Beta Thalassemia Major and was being transfused every two weeks and was receiving Jadenu and Ferriprox for the past several years. The patient successfully reached a ferritin of 248, but now had "a lapse in therapy due to a denial" and most recently the patient's ferritin was 5,122 nanograms per milliliter (ng/ml). The treating provider requested therapy with deferasirox, which is under review. 

The request was denied. As noted in the Notice of Final Adverse Determination letter from the plan, the plan only covers this drug when the patient meets one of these options: A) They have tried other drugs the plan covers (preferred drugs), and they did not work well, or B) The doctor gives us a medical reason the patient cannot take those other drugs. For this patient's plan, they may need to try up to three preferred drugs. The preferred drugs for the patient's plan are: deferiprone and Ferriprox. 

"The iron status of routinely transfused patients must be monitored. Clinical signs of iron overload and serial serum ferritin remain the most reliable method to evaluate iron overload. Iron chelation therapy is generally started after patients have received 10 to 20 transfusions or have serum ferritin levels more than 1000 ng/ml. Other nutritional sequelae of thalassemia include relative folate deficiency, calcium depletion, and vitamin C deficiency. Symptomatic hypersplenism is common in thalassemia intermedia and major and may be treated with splenectomy. Post-splenectomy patients have an increased susceptibility to blood-borne infections with encapsulated bacteria and should receive appropriate immunizations." (Needs, T., Gonzalez-Mosquera, L. F., & Lynch, D. T. 2023)                                                       

The formulary drugs are not likely to cause the patient an adverse reaction. The patient has been using Jadenu and Ferriprox, without incident.      

The formulary drugs have not been ineffective, based on the patient's clinical history. There was no evidence of that. It appears that if not for a lapse in therapy, these alternatives would have continued to work. They can be reinstated.     

There is no evidence/support in the medical literature that the requested drug, deferasirox, is more effective than formulary alternatives. 

Additionally, there was no clinical information showing the patient has tried and failed or has a contraindication to the plan's formulary options, deferiprone and Ferriprox, which are also appropriate for the management of the patient's condition. Therefore, the request cannot be approved at this time.

The carrier's denial of a request for a formulary exception for deferasirox for use in the treatment of hemochromatosis is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Venolymphatic vascular malformation
Treatment: Radiology sclerotherapy (ambulatory surgery - outpatient services [37241 x 1])
The insurer denied radiology sclerotherapy (ambulatory surgery - outpatient services [37241 x 1]).
The denial is overturned.

The patient is a school-aged male with a right cheek venolymphatic malformation (VLM). The request is for sclerotherapy.

The requested health service is medically necessary.

Lymphatic malformations are difficult to treat. Surgery has been the standard of care in the past, but surgery has a high risk of lymphatic malformation recurrence and has the additional need for significant patient recuperation. Many peer reviewed articles demonstrate sclerotherapy to have a high success rate as primary treatment of lymphatic malformations. Today's standard of care for lymphatic malformations is sclerotherapy. A review and meta-analysis paper by Sun in 2023 states that sclerotherapy is safe. A systematic review paper by Maria in 2020 states that "percutaneous sclerotherapy is a safe and effective modality for treatment of LMs of the head, neck, and face." A systematic review paper by Shoji in 2020 states that sclerotherapy is safe and effective.