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

Diagnosis: Dental Problem/ Teeth Spacing Problem. 
Treatment: Dental/ Orthodontic Procedure. 

The health plan denied the requested dental treatment plan as not medically necessary. 
The health plan's determination is upheld. 

The patient is a female with mild maxillary and severe mandibular crowding. #27 has erupted labial within the arch due to lack of space. The patient has a class I occlusion with 6 mm (millimeter) overjet and 5 mm overbite. 

The patient is treatment planned for 30-36 months of orthodontics to align the teeth and correct the bite, but the plan was denied due to lack of medical necessity. 

I uphold in whole, the health plan's denial of medical necessity. 

While the patient has crowded teeth, there is not anterior or 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. [2] The 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. [3] 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, treatment is not medically necessary. 

#27 is crowded but it has erupted successfully. There are no indications of gingival recession or pathology from the tooth position of #27. It is not as if the tooth was so crowded it was prevented from erupting, which left untreated it could damage the roots of other permanent teeth [1] leading to more invasive and expensive procedures than orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces, Monthly visit
The insurer denied Braces, Monthly visit.
The determination is upheld.

The patient has a Class I occlusion with a 5 millimeter (mm) overbite and 3 mm overjet. He has minor crowding. He is treatment planned for orthodontics to correct his malocclusion. At issue is the medical necessity of braces and monthly visit.

The patient has minor crowding. His overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. The patient's mother states he constantly bleeds from his gums. This would most likely be due to plaque-induced gingivitis. However, it could be indicative of a more significant systemic problem and should be investigated. (1)

There is no medical reason to correct his malocclusion with braces. While the patient has minor crowding, there is no anterior or 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. (2) However, this patient presents with none of those conditions. Aligning his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (3) The patient's overjet is slightly more than ideal but his overjet would not affect oral health related quality of life unless it was greater than 6 mm. (4) If his teeth were aligned, it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health.
Therefore, the orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right sided weakness.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a prior history of a stroke and a seizure disorder who presented to the hospital with slight right sided weakness. The formal neurologic examination indicated 5-/5 on the right side of the body. A magnetic resonance imaging (MRI) scan of the brain was performed that did not show any evidence of an acute stroke. There was suggestion of chronic ischemic disease versus demyelination. No further inpatient work up was performed regarding the results of the MRI. The patient underwent an electroencephalogram (EEG) that showed epileptiform changes. The patient was diagnosed with a partial focal seizure. The patient's Keppra was increased from 500 milligrams (mg) twice daily to 1000 mg twice daily. Outpatient follow up was arranged. Despite that the hospitalist indicated that the patient had a prior history of stroke, he was not on aspirin or a statin and these medications were also started on discharge.

The acute inpatient hospitalization was not medically necessary. The patient was admitted to the hospital for evaluation of right sided weakness. An MRI of the brain was performed that showed no acute ischemia. In other words, the patient did not have a stroke. Medical documentation indicates a possible transient ischemic attack; however, this diagnosis is also unlikely as the symptoms persisted for more than 24 hours. The neurologic disability was extremely mild given that the neurologist noted 5-/5 strength on the right side of the body.
The patient was diagnosed with a partial seizure. He had a pre-existing diagnosis of seizure and was already treated with Keppra. The only medical intervention was to increase the dose of Keppra from 500 mg twice daily to 1000 mg twice daily. He did not have persistent seizures that were not controlled with observation care or a new seizure type noted.
As such, the care provided was not consistent with an inpatient admission. Neither the diagnosis of transient ischemic attack or breakthrough seizure require acute inpatient admission. Both of these diagnoses are consistent with an observation stay as the standard of care in the United States. No special or extenuating circumstances were identified for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Humira 80 mg
The health plan denied the Humira 80 mg.
The determination is overturned.

The patient has ulcerative colitis. She failed Asacol, Colace, and Rowasa enemas. She has required budesonide, and has been unable to taper prednisone. The Humira was increased to 40 milligrams (mg) weekly due to ongoing frequent bowel movements. She had the onset of left lower quadrant abdominal pain, hematochezia, and bowel incontinence. A colonoscopy showed pancolitis (Mayo 2). Her Humira trough level on Humira 40 mg weekly was 1.43 micrograms per milliliter (ug/mL). The coverage is requested for Humira 80 milligrams (mg) weekly for the treatment of ulcerative colitis.
The requested Humira is medically necessary. The patient has ulcerative colitis with ongoing symptoms and corticosteroid dependence, which is consistent with uncontrolled disease, and a documented low Humira level on the current Humira dose of 40 mg weekly [1]. In the high-quality ULTRA 2 [ulcerative colitis long-term remission and maintenance with adalimumab 2] trial used for Food and Drug Administration (FDA) approval; it was part of the protocol to increase the Humira dose if the response was not adequate on Humira 40 mg every 2 weeks [2]. The trial advanced nonresponders at week 8 to weekly therapy as well as week-8 responders - both groups contained a fraction that responded to dosing frequency increase. In the ULTRA 3 trial, weekly Humira was started for inadequate response, or for flare [3]. In a subset analysis of ULTRA 2 patients, those on weekly therapy had week-52 response rate of 25% after failing therapy given every 2 weeks [4].
Also, the American Gastroenterological Association guidelines for management of ulcerative colitis state that when there is loss of response to anti- tumor necrosis factor (TNF) medication with a subtherapeutic drug level (as in this case), the recommendation is to increase the drug dose [5,6]. Continuation of Humira 40 mg every week or changing to a different medication may result in disease flare, disease complications, hospitalization, or dysplasia (which increases the risk for colorectal cancer), and insufficient disease control due to insufficient drug dosing can increase these risks [7]. Therefore, in this case, extenuating circumstances support the request for Humira 80 mg every 7 days.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Other-Dysphasia.
Treatment: Inpatient Hospital Stay.

The health plan denied the inpatient hospital stay.  The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history significant for esophagogastric junction outflow obstruction/jackhammer, who underwent Botox injection and dilation procedures and who presented to the hospital  with severe dysphasia. It was reported that at the time of admission the patient only tolerated a liquid diet. It was reported that he had lost approximately 20 pounds over the course of one year.

In the hospital, the patient was seen by a gastrointestinal (GI) specialist who performed per oral endoscopic myotomy (POEM) procedure. The procedure was uncomplicated. Following the procedure, the patient was admitted for observation. Right after the procedure, the patient was kept nothing by mouth (NPO) but then started on a liquid diet including medications and sips of water. He received treatment with proton pump inhibitors. He initially received intravenous (IV) Unasyn but subsequently was transitioned to Augmentin. Since the patient's clinical condition improved, he was discharged from the hospital.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. The review of the medical records clearly demonstrated that the patient's dysphasia was not associated with severe dehydration or electrolyte abnormalities. There was no evidence of hemodynamic instability. There was no evidence that the patient had a complete esophageal obstruction. Even though the patient was spitting after the consumption of liquids, he was still able to maintain oral hydration. There was no evidence that the patient required a parenteral nutrition regimen. The procedure performed during the hospital stay was elective and not emergent.

Taking into consideration all these facts, admission for observation at a lower level of care following the procedure was the most appropriate, to ensure adequate pain control and the patient's ability to tolerate oral intake. Following the procedure, this patient remained in stable clinical condition and did not require administration of intravenous antibiotics, pain medications, or intravenous hydration that was beyond the scope of a lower level of care.

Milliman Care Guidelines (MCG) Health Inpatient & Surgical Care 24th Edition criteria Esophageal Disease were attached to the chart and carefully reviewed. There was no evidence that these criteria were applicable in this clinical case to justify admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet, overbite, ectopic eruption. 
Treatment: D8080 braces and D8670 monthly visit (x [times]12). 

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 overjet, overbite, ectopic eruption, and anterior crowding.  The orthodontist as completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 28 total points. 

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, a Handicapping Labiolingual Deviation 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 completes the second portion of the index arriving at 28 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 28 points on the HLD index which is above the threshold of 26 points to support 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. 

Reverse denial as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval. 

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

The coverage of D8080 braces and D8670 monthly visits x 12 is considered medically necessary for this patient. 

The insurer's denial of coverage for D8080 braces and D8670 monthly visit (x12) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite. 
Treatment:  D8080 Braces and D8670 Monthly Visit (x12). 

The insurer denied the  D8080 Braces and D8670 Monthly Visit (x12). 
The denial is overturned. 

The patient is a male. The request is for braces and monthly visits. Per the provider's clinical summary, the patient presents with a skeletal class III relationship, moderate maxillary crowding, mild mandibular crowding, anterior crossbite with gingival attachment loss (mandibular right canine). 

The health plan denied the claim, because the patient did not score a 26, the score needed to be approved for orthodontic treatment. 

The provider appealed the claim because of the anterior crossbite. 

Yes, the braces and monthly visits are medically necessary. 

As demonstrated in the x-rays and photos, and as stated in the dental clinical summary, the patient presents with moderate crowding. The patient also has anterior crossbite with gingival attachment loss mandibular right canine. 

The presence of the crowding and crossbite can affect the ability for the patient to chew food properly and speak properly. It can also impact the ability to maintain proper hygiene and can lead to gingivitis/inflammation and gum disease. 

Therefore, given the above, the braces and monthly visits are medically necessary. 

No, the health plan did not act reasonably, with sound medical judgement and in the best interest of the patient. 
If these conditions as seen in the patient are left untreated, the complications of decreased proper function as it relates to chewing, speech and compromised oral hygiene can only lead to more dental problems in the future.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.

Treatment braces (comprehensive orthodontic treatment).

The insurer denied coverage for braces (comprehensive orthodontic treatment).

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to and anterior crossbite with gingival attachment loss skeletal Class I, along other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. 

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, a Handicapping Labiolingual Deviation 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 criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 8 points (1 overjet, 1 overbite, 4 posterior unilateral crossbite, 2 labiolingual spread).

The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the braces (comprehensive orthodontic treatment) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite with gingival attachment loss,

Treatment: D8080 braces and D8670 monthly visit (x ([times] 12),

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

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss (mandibular canines), among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity.

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, a Handicapping Labio-Lingual Deviation 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 criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer, attaining 21 points (4 overjet, 3 overbite, 10 anterior crowding, 4 labiolingual spread).

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

Based on the above, the medical necessity for the D8080 braces and D8670 monthly visit (x [times] 12) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Impinging Overbite with Severe Soft Tissue Damage

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, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labiolingual Deviation (HDL) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 

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 a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualifying 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 deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care 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 19 points (6 points overjet, 6 points overbite, 5 points anterior crowding and 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. 

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

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

Diagnosis: Parkinson's Disease.
Treatment: Neupro 4mg/24hr TD PT24.
The insurer denied the Neupro 4mg/24hr TD PT24.
The denial is upheld.

The patient is a female with Parkinson's disease (PD). She is currently treated with Neupro and Rytary. The provider indicated the patient has tried and failed ropinirole, ropinirole extended release (ER) and rasagiline. The provider is requesting continuation of Neupro. This was denied coverage as the patient has not tried all of the preferred agents.

No, the proposed treatment is not medically necessary.
There is no reason the patient cannot be treated with pramipexole. This medication is Food and Drug Administration (FDA) approved for the patient's condition (Zesiewicz; Poewe et al.). There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Neupro relative to the preferred pramipexole.