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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay.
The denial is overturned.

The patient is a male who presented after repair of a labral tear of the left hip, with complications including post operative non-epileptic seizures and spasticity. The patient underwent surgery for a labral repair, post-operatively he had an episode of whole body shaking with both eyes rolling to the right side for 10-20 seconds. He then became unresponsive. He received midazolam at that time and seemed to return to baseline, but then had several additional episodes. He subsequently had increased muscle tone as well as significant pain in the left leg, with inability to ambulate. He was therefore transferred to the inpatient unit for further care. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

The inpatient stay was medically necessary. This is a patient with a history of functional neurological disorder who presented following a labrum repair with non-epileptic seizures, spasticity, and pain. He required inpatient care for close monitoring and ongoing evaluation, pain control, medication adjustment, and extensive physical and occupational therapy. After stabilization he required ongoing rehabilitation for functional support and care as he continued to have imbalance, deconditioning, and decreased functional mobility and transitions.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 25th edition; Hip Arthroscopy; hospitalization is indicated for complications of the procedure or failure to achieve discharge status criteria.
This patient could not be safely discharged prior to clinical optimization and required ongoing skilled nursing care as well as intensive therapy in order to achieve age-appropriate activities of daily living. His ongoing inpatient hospitalization was required until safe discharge to approved inpatient rehabilitation services could be achieved. Discharge criteria include the ability to perform activities of daily living as appropriate, with activity level acceptable for next level of care. This patient continued to require comprehensive inpatient rehabilitation services, which necessitated ongoing care and services in the hospital pending a safe transfer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I malocclusion
Treatment: Braces/monthly visit
The insurer denied Braces and Monthly Visit x 12. The health plan's determination is upheld. 

The patient in question is a female with a diagnosis of Class I malocclusion, 4-millimeter (mm) overjet and 3 mm overbite. The upper and lower arches are both have mild spacing. She is treatment planned for 24-30 months of orthodontics (Braces) to correct her malocclusion. 

Braces and Monthly Visit x 12 are not medically necessary for this patient.
The patient has appropriate overbite and overjet. There is spacing, but that alone does not rise to the threshold of medical necessity. The photos do not support a diagnosis of a crossbite of tooth 27 with tooth 6 or 7, and the gingival margin of 27 appears to be the same as tooth 22 (the contralateral canine). There does not appear to be attachment loss. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. The diagnosis states the patient has a skeletal Class I relationship which is the most efficient jaw relationship for mastication. If her teeth were aligned, it would provide an aesthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, braces are not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Myelodysplastic Syndrome
Treatment: Formulary exception for Posaconazole Delayed-Release Tablet,  Pre-service

The insurer denied the Formulary exception for Posaconazole Delayed-Release Tablet,  Pre-service.
The denial is upheld.

The patient in this case is a man. He was diagnosed with myelodysplastic syndrome and was started on treatment with azacitidine.  Posaconazole was used for anti-fungal prophylaxis.


No, the health plan should not cover the Formulary exception for Posaconazole.
There is no data showing that use of posaconazole can improve health outcomes in comparison to the formulary alternatives for patients with myelodysplastic syndrome being treated with azacitdine.  The most important fungal pathogen in such patients is candida, which can be addressed with fluconazole.  For patients who will have ongoing severe neutropenia use of another agent is potentially appropriate, but there is no data showing that posaconazole is safer and more effective than voriconazole for such patients.  Therefore, the health plan should not cover the formulary exception for posaconaozle.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pseudotumor Cerebri.
Treatment inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

The patient was admitted to the emergency department regarding papilledema. The patient went to the eye doctor for routine visit and was found to have bilateral papilledema on examination. There were reports of frontal headaches for the months for which she utilized ibuprofen with some relief. The patient was admitted for concerns of pseudotumor cerebri. Computed Tomography (CT) of the brain revealed no acute intracranial pathology. Right sphenoid sinus disease was noted. The patient was discharged.

The workup of bilateral papilledema is not a medical emergency and can be safely worked up on an outpatient basis. Imaging studies with a CT of the brain and/or a magnetic resonance imaging (MRI) of the brain could be performed on an outpatient basis. Lumbar puncture, which is commonly performed in the workup of papilledema, can be performed on an outpatient basis. In this case, the diagnostic studies and overall, the medical management could have been performed in the emergency department (ED) or an at an outpatient basis. Care provided did not warrant inpatient admission. Therefore, the entire inpatient admission was not medically necessary.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 periodic orthodontic visits

The insurer denied coverage for D8080 braces and D8670 periodic orthodontic visits

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss (mandibular left canine) in addition to other clinical findings. The orthodontist has completed the Handicapping Labiolingual Index (HLD) 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. 

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, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of 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 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. This is confirmed by several studies referenced below.

Each of the peer-reviewed articles conclude that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

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

Braces and periodic orthodontic visits are medically necessary for this patient.

The insurer's denial of coverage for D8080 braces and D8670 periodic orthodontic visits is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: D8080 braces and D8670 monthly visits (x12).

The insurer denied coverage for D8080 braces and D8670 monthly visits (x12).
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 

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 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 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 using this criterion. In this case, the clinical circumstance does not 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.  This is confirmed by several studies as referenced below.

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.

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

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visits (x12) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing teeth.
Treatment: D6010 Implant Placement, Tooth, 7, 8, 18, 19, 29, 30.
The insurer denied the D6010 Implant Placement, Tooth, 7, 8, 18, 19, 29, 30.
The denial is upheld.

The patient is a female. This patient is under the care of a dentist. The patient is missing many teeth. The dentist and patient have developed a treatment plan to replace many missing teeth to include 7, 8, 18, 19, 29, and 30 with dental implants.

This request was denied by the health plan as not medically necessary due to no discussion about any other options. This denial was appealed.

No, at this time, the request is not medically necessary.
The records as submitted do not support the requested treatment.  Further, there is no evidence that any other treatment plans have been proposed.

Yes, based on the information provided, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fractured tooth.
Treatment: D2740 Porcelain Crown, Tooth 15.
The insurer denied the D2740 Porcelain Crown, Tooth 15.
The denial is overturned.

The patient is a female. The request is for dental benefits for a porcelain crown on tooth # 15.

Per the Provider's clinical findings, the patient presents with tooth #15 with a fracture and a large amalgam filling. The treatment plan is to restore tooth with a crown.

Health plan denied coverage of the claim as not medically necessary, as they posit that the tooth is not evidenced to have decay or injury.

The denial was appealed by the patient appealed because of the nature of the condition of the tooth and the diagnosis.

Yes , the requested crown on tooth #15 is medically necessary.
X-rays show that the patient has a large filling on tooth #15 that runs almost the entire length of the tooth mesio-distally (front-back), and the filling is evidenced to cover greater than 65 percent of the tooth. Additionally, per the provider's reports, there is a fracture on that tooth. Therefore, the recommendation of a crown is the best treatment option given these circumstances.

A crown would not only restore function but also provide the best protection from future fracture and provide the best prognosis for the longevity of this tooth.

No, the health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.
If the optimal treatment of a crown is not utilized in this case, the tooth will be prone to further fracture and deterioration. 

This would not serve the best long term interest of the patient's dentition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Back Pain. 
Treatment: Intraosseous Destruction Lumbar/sacrum. 

The insurer denied coverage for intraosseous destruction lumbar/sacrum. 

The denial is upheld. 

This patient has a with a history of gastroesophageal reflux disease (GERD), headaches, Rocky Mountain spotted fever, Lyme disease, and lupus. He presented to the Pain Management physician's office for the evaluation of chronic back pain from lumbar spine disease. Magnetic resonance imaging (MRI) revealed degenerative (Modic) changes at L (lumbar) 5-S (sacral) 1 including herniation contacting the S1 nerve root.  The request is for RFA [radiofrequency ablation] of basivertebral nerves at L5 and S1. 

Fischgrund and colleagues (1) published a double-blind, sham-controlled RCT (random control trial) evaluating the Intracept system and RF [radiofrequency] ablation of the Basivertebral nerve for the treatment of chronic low back pain. A total of 225 participants with chronic (>= [greater than or equal to] 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n=78) or treatment (n=147) intervention. In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85Celsius for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Owestry disability index (ODI) of 30 points (on 100 point scale) and a minimum VAS [visual analogy scale] of 4 cm [centimeters] (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13% [percent]) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance. 

The publications to date have been company sponsored and had methodology flaws.  There is no published data on long term complication rates.  UptoDate (3) has evaluated this procedure and concluded that it is unproven. 

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 intraosseous destruction lumbar/sacrum is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Advanced Imaging. 
The insurer denied positron emission tomography/computed tomography (PET/CT). 
The denial is upheld.

The patient is a female with Federation of Gynecology and Obstetrics, (FIGO) Stage III ovarian cancer status/post (s/p) debulking surgery. She has completed adjuvant chemotherapy and is on Zejula maintenance therapy. She underwent surveillance imaging by positron emission tomography (PET)/computed tomography (CT). The subject under review is the medical necessity for the imaging.

The health plan's determination is upheld.   

The requested positron emission tomography and computed tomography is not medically necessary for this patient. There are no data to show that use of PET/CT imaging as performed in this case is superior or that it improves outcomes or survival in patients with ovarian cancer. It is not supported by peer reviewed literature, it is not the standard of care, and it is not supported by professional organizations and thus, it is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with new onset atrial fibrillation.

The patient's initial RVR (rapid ventricular response) was to 150s. She was treated with IV (intravenous) Cardiazam, IVF (intravenous fluids) and PO (oral) medications. Her rate decreased, and an echo showed depressed LV (left ventricle) function (EF [ejection fraction] 35 to 40% [percent]).

The patient denied chest pain, shortness of breath, palpitations or edema. Her BP (blood pressure) was 143/98. There was no documentation of hypotension. There was no evidence of ischemia. There was no hemodynamic instability documented.

The patient was discharged on anti-coagulation therapy, beta blockers, ARB (angiotensin II receptor blocker), and a low dose diuretic.

No, the inpatient admission was not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

In this case, the patient presented with new onset atrial fibrillation which was nearly asymptomatic. While there was a rapid ventricular response, it was well-tolerated. In fact, the patient was hypertensive when first seen and the rate was highest. She was never hemodynamically compromised. There was no evidence of ischemia. All medications that were given would have been appropriate in a lower level of care. There was no "complex" care that required an inpatient level of care in this patient's care. This patient had no evidence of ACS (acute coronary syndrome). While there was always a potential for an adverse event, one did not happen, and no actual treatment was added.

The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care that was provided was telemetry, PO (oral) and IV (intravenous) medications, and tests that are frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no discussion of what care provided was not able to be done in a lower level of care.

All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urosepsis.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is a male with a history of coronary artery disease (CAD) status post stenting, hypertension, benign prostatic hyperplasia (BPH), prostate cancer status post robotic assisted radical prostatectomy. The patient was transferred to the emergency department (ED) for evaluation of fever, shortness of breath, and urinary tract infection. He was admitted for urosepsis treatment and Urology/ Nephrology were consulted. Urine culture was positive, blood culture was negative. The patient improved on intravenous (IV) antibiotics and was discharged to subacute rehabilitation. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. They noted the patient's treatment was with antibiotics, supportive care, and medication optimization. The exam showed no acute distress. 

The patient fails to meet InterQual: Acute Adult Infection: Pyelonephritis criteria for acute admission. Criteria include absolute neutrophil count (ANC) <500, ...immunocompromised, mental status change, history of ureteral stent, urinary tract, obstruction, etc.

The patient fails to meet MCG (Milliman Care Guidelines) Health (25th) UTI-RRG criteria. He fails to meet clinical indications for admission to inpatient care include hemodynamic instability, altered mental status, immunocompromised status, persistence or worsening of clinical findings despite observation care.

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

The inpatient hospital admission is not considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.