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

Diagnosis: Incisal caries on teeth 8 and 9

Treatment: Porcelain veneers

The insurer denied coverage for Porcelain veneers.

The denial is upheld.
 

Upon review of the submitted documentation which includes copies of full mouth series radiographs in addition to intraoral clinical photographic images, narrative letters from the treating dentist and insurer correspondence it appears that this patient presented with craze lines and incisal caries on teeth 8 and 9. Labial veneer restorations were recommended to improve cosmetics and function. The insurer has denied coverage of the labial veneers stating that these services are considered to be elective/ cosmetic and based on submitted documentation there is insufficient loss of tooth structure due to decay or fracture or other clinical findings that would necessitate veneer placement. The patient is appealing.

Although labial veneers will address the cosmetic issues associated with these incisors, peer-reviewed literature as referenced below suggests a more conservative approach with composite resin restorations is an appropriate treatment modality. This more conservative restorative option would be successful in addressing the patient's chief complaint and address both the cosmetics and functional issues at hand. As a direct composite restoration would be an appropriate alternative treatment option, the labial veneers are deemed not medically necessary. 

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

Based on the above, the insurer's denial must be upheld. The medical necessity for labial veneers on teeth 8 and 9 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial flutter
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is an adult male that was sent to the hospital via ambulance after he was noted to have atrial flutter during a routine outpatient cardiology follow up appointment. He was noted to have atrial flutter on electrocardiogram. The patient reported palpitations and lightheadedness earlier that morning but noted no symptoms while in the office while in atrial flutter. Past medical history was significant for recent pericarditis, pericardial effusion, and hypertension. Upon arrival, vital signs were stable, blood pressure 146/97 mmHg (millimeters of mercury), and pulse 101 beats per minute. Physical exam revealed a regular pulse and no abnormalities. 12 lead electrocardiogram revealed sinus rhythm at 90 beats per minute without ST or T (cardiac rhythm) wave abnormalities. Serum blood testing revealed no significant abnormalities. Both troponin and B-type Natriuretic peptide (BNP) were normal. White blood cell (WBC) count was 8.5. Point of care ultrasound demonstrated a moderate pericardial effusion. No findings suggestive of tamponade noted. He remained in sinus rhythm and was discharged the next day on colchicine.

As per Up to Date, "High-risk patients with acute pericarditis (algorithm 1) should be admitted to the hospital in order to initiate appropriate therapy and expedite a thorough initial evaluation. Conversely, patients with uncomplicated (i.e. [that is], low-risk) acute pericarditis can usually be evaluated and sent home, with outpatient follow-up to assess the efficacy of treatment." This patient did not manifest any high-risk findings to require acute inpatient management. He could have been observed and discharged for continued outpatient management.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for: Inpatient admission

The denial is: Upheld

The patient presented with abdominal pain, nausea, and diarrhea. The patient was afebrile and the vital signs were stable. It was felt that the symptoms were related to food that was spoiled. There were no peritoneal signs. A computed tomography (CT) scan showed cholelithiasis and hepatic steatosis. The patient was diagnosed with gastroenteritis and treated with Cipro and Flagyl. A gastrointestinal (GI) polymerase chain reaction  (PCR) panel was negative. The symptoms improved and the patient was able to tolerate a diet. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-170 for gastroenteritis. Clinical indications for admission include having a suspected severe infection, peritoneal signs, hemodynamic instability, severe vomiting that is not responsive to antiemetics, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had gastroenteritis. IV hydration, antiemetics, and stool testing could have been done in the Emergency Room (ER) with observation care. Afterwards, the patient could have been discharged on a course of oral antibiotics. The patient did not meet MCG criteria for admission for gastroenteritis. 

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 inpatient hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: periodontal pocketing

Treatment: deep gum and root cleaning.

The insurer denied coverage for deep gum and root cleaning.

The denial is upheld.



Based on the submitted documentation which includes copies of periodontal charting, panoramic radiograph and insurer correspondence, it appears that this patient presented for evaluation for dental services and periodontal therapy. The dentist reported periodontal chartings indicating 2-5 millimeter (mm) generalized periodontal pocketing. The recommended treatment was scaling and root planning of all four quadrants. The insurer has denied the service as the information provided does not show evidence of moderate to severe periodontal disease or other clinical or radiographic criteria to justify the services such as bone loss and therefore does not meet clinical criteria to support scaling and root planning. The patient is appealing.

Upon review of the submitted documentation, both the radiographs and periodontal probing depths there is minimal if any loss of alveolar bone height affecting these teeth. The 5 mm increased pocket depths likely represent pseudo pocketing due to superficial calculus accumulation and poor oral hygiene. There is minimal significant periodontal probing with no periodontal probing over 5 mm depth. The insurer has correctly applied the clinical criteria in denying scaling and root planning services.

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 deep gum and root cleaning, All Quadrants is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Gynecological
Surgical procedure

Diagnosis: Uterine fibroids
Treatment: Radiofrequency Ablation Procedure 
The insurer denied Radiofrequency Ablation Procedure. The health plan's determination is upheld. 

The patient is a female with heavy menstrual bleeding with cramping. She has failed a progesterone intrauterine device (IUD), Myfembree and Aygestin. Pelvic ultrasound showed a multi-fibroid uterus. She would like to use transcervical ultrasound guided radiofrequency ablation.

The requested Radiofrequency Ablation Procedure is not medically necessary for this patient.
A systematic review of prospective studies for treatment of uterine fibroids with radiofrequency ablation (RFA) has been completed. The authors concluded that RFA of uterine fibroids significantly reduced fibroid volume, provided significant durable improvements in fibroid-related quality of life (QOL), and was associated with favorable re-intervention rates. However, there were several drawbacks pertaining to the quality of the included studies that may influence conclusions. First, there was less precision in the RFA results following 12 months of follow-up since fewer studies reported longer term data. Second, the number of included studies was insufficient to perform statistical comparisons among RFA delivery approaches for several outcomes. Third, it was not possible to determine from this analysis whether RFA efficacy was influenced by fibroid type or volume due to concerns of aggregation bias whereby real associations observed at the patient level. Finally, these researchers planned to report the frequency of complications in this meta-analysis; however, complication reporting was highly inconsistent and inadequate such that any attempts at reporting these data would have led to inaccurate and misleading results. These investigators stated that authors of future RFA studies are encouraged to provide detailed definitions of complications and a complete listing of reported complications during follow-up, with further specification of event seriousness and relationship to the RFA procedure.
Therefore, the procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with uncomplicated acute appendicitis. She was afebrile at the time of presentation. Her white blood cell (WBC) count was 8. Computed tomography (CT) showed acute appendicitis with no definite abscess. The patient was admitted and underwent uncomplicated laparoscopic appendectomy. She was discharged the next day.

The proposed treatment was not medically necessary.

This patient underwent uncomplicated laparoscopic appendectomy. She was nontoxic and afebrile at the time of admission. Her white blood cell count was normal at admission. She was discharged the next day and did not demonstrate any other signs of needing to be in at the inpatient level for her diagnosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea, vomiting, and abdominal pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This patient is an adult male who presented for nausea, vomiting, and abdominal pain for eight days. His white blood cell count was 11.3; sodium was 123, chloride was 88, and lactic acid was 4.3. The patient was found to have a pancreatic mass on computed tomography (CT) scan measuring 1.9 centimeters. In the emergency department, the patient received intravenous fluids, morphine, and potassium supplementation.  The patient was admitted to inpatient care and received intravenous hydration. Magnetic resonance imaging (MRI) showed a 1.9 centimeter cluster of cysts and fatty liver. Ferritin was 1700 and hemochromatosis was considered. On day #2, intravenous hydration was continued. Renal was consulted and noted the very rapid response of the sodium (improved to 131). Intravenous fluids were recommended (500 cubic centimeters [cc] of dextrose five percent [D5] water to reverse the rapid overcorrection). Gastroenterology was consulted for the pancreatic mass and recommended outpatient endoscopic ultrasound. On day #3, the patient's sodium level was 132. A cardiac echocardiogram was normal. The patient was able to tolerate oral intake. On day #4, the patient was feeling better and was tolerating diet. His sodium was 134. Hematology was consulted to address possible hemochromatosis. Repeat magnetic resonance imaging with iron quantification was recommended. The notes indicated that discharge was anticipated the next day after physical therapy evaluation. On day #5, the patient could tolerate diet without pain and was discharged.

The proposed treatment was medically necessary.

As the patient had electrolyte imbalance, specifically the hyponatremia of 123 that required close monitoring and slow correction (avoiding overcorrection to prevent osmotic demyelination syndrome), inpatient admission was medically necessary. Additionally, the patient required pain control, slow advancement of diet, and workup of the pancreatic mass. Therefore, the proposed treatment was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive urgency

Treatment: Inpatient admission

The insurer denied coverage for: Inpatient admission.

The denial is: Upheld

Asked to review the case of an adult gentleman that presented to the hospital with complaints of left sided sharp chest pain. Past medical history was significant for hypertension (HTN). The patient reported that he had not taken his antihypertensive medication for two months. On arrival to the hospital blood pressure (BP) was elevated: 221/124 mmHg (millimeters of mercury) and pulse was 98 bpm (beats per minute). Physical exam revealed bilateral pedal edema. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm with LVH (left ventricular hypertrophy) with expected ST/T wave abnormalities. Serum blood testing revealed no significant abnormality. The patient was treated with labetalol and losartan and admitted to the hospital. BP remained elevated and hydrochlorothiazide was added to the medical regimen. Echocardiogram demonstrated concentric left ventricular hypertrophy with a left ventricular ejection fraction (LVEF) of 76%. Ultimately blood pressure was controlled, and the patient was discharged and scheduled for outpatient cardiology follow-up. 

Hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1) This patient presented with a systolic BP of 221mmHg. The patient reported chest pain and headache but did not have any evidence of target organ damage on serum blood testing. He was diagnosed with hypertensive urgency.  Admission to the hospital for aggressive blood pressure management was not necessary.

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit (x12)

The insurer denied coverage for D8080 braces and D8670 monthly visit (x12.)

The denial is overturned.

 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crossbite among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (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. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 19 points by internal reviewers when 26 points are required for approval. 

Upon review of the submitted documentation (study models were not provided for review) 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, New York State requires 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 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 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. 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 overturned. The health care plan did not 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 (x12) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: infectious disease or bacterial vaginosis
Treatment: vaginal panel
The insurer denied coverage for vaginal panel.
The denial is upheld.

The insurer has denied coverage for the vaginal panel as not medically necessary. In a Final Adverse Determination letter, they stated that the doctor thought the patient had a vaginal infection. The panel of tests is still being investigated in the diagnosis and treatment of women with symptoms of vaginitis. The requested service is denied based on the policy Genitourinary Pathogen Nucleic Acid Detection Testing; 2022T0608G. 
The patient is appealing. In the member service request form, the patient stated that her symptoms were a potential indicator for an infectious disease or bacterial vaginosis.

Diagnosis of vaginitis is based on clinical symptoms, pH (acid/base balance) of the vaginal fluid and microscopic examination of the discharge. Ideally, a diagnosis of bacterial vaginosis is made if 3 out of 4 of "Amsel's criteria" are met: A strong fishy odor on adding alkali to vaginal fluid (positive amine test); Clue cells (vaginal epithelial cells heavily coated with bacilli) on microscopy; Thin, white, homogenous discharge; Vaginal pH greater than 4.5. 
Microscopic examination may also reveal motile trichomonads or candida hyphae. The presence of Gardnerella vaginalis on culture cannot be used to diagnose bacterial vaginosis, since it is present in approximately 50% (percent) of healthy women. Culture of trichomonas and candida may be helpful if clinical symptoms are suggestive, and microscopy is negative. Mixed infections are also common, with trichomonas, candida or both coexisting with bacterial vaginosis. Deoxyribonucleic acid (DNA) probes have been developed to directly detect the presence of candida, trichomonas and Gardnerella.  

According to American College of Obstetricians and Gynecologists (ACOG), microscopy is the first line for diagnosing vulvovaginal candidiasis and trichomoniasis. The Centers for Disease Control and Prevention (CDC) also recommend the gram stain as the gold standard for diagnosis of vaginal infections and recommends use of Amsel's criteria if a gram stain is not available. The CDC states that the DNA probes "have acceptable performance characteristics" compared to the gram stain but make no recommendation for their use. There are no high-grade evidence-based peer reviewed studies published in the medical literature to support the efficacy of the technology which consists of: a. Meta-analyses of randomized trials; or b. Randomized controlled trials.

The testing done was not medically necessary. Adequate history, physical examination and office microscopy should rule out the presence of these infections.

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 the vaginal panel is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crohn's Disease.
Treatment:  Inflectra (Q5103 Infliximab-dyyb).

The insurer denied coverage for Inflectra (Q5103 Infliximab-dyyb).  The denial is overturned.

The patient has been diagnosed with Crohn's disease. Recently, the patient had anemia, low albumin, weight loss, and markedly elevated fecal calprotectin. A magnetic resonance elastography (MRE) showed disease in the right colon with wall thickening and stricture. A colonoscopy showed active colitis. The patient received their first dose of lnflectra while in the hospital. It is felt that this patient has very aggressive Crohn's disease and needs to continue with infliximab. 

The American Gastroenterological Association has published Clinical Practice Guidelines for the Medical Management of Moderate to Severe Luminal and Perianal Fistulizing Crohn's Disease (Gastroenterology 2021; 160:2496-2508.) There is a strong recommendation to give anti-TNF (tumor necrosis factor) drugs for induction and maintenance of remission. There is no recommendation that the patient needs to have failed steroids or have tried another systemic therapy. 

This patient has moderate to severe Crohn's disease and requires biologic therapy. Giving infliximab is a recommendation that is advised by both the American Gastroenterological Association and the American College of Gastroenterology. 

The health care plan did not act in the best interest of the patient. lnfliximab is a medically necessary treatment. The denial is reversed.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Inflectra (Q5103 Infliximab-dyyb) injections is substantiated.