Persius/imr-appeals huggingface dataset:
Diagnosis: Class I Occlusion
Treatment: Braces

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

The patient in question is a male with a Class I occlusion with 5 millimeter (mm) overbite and 3mm overjet. He has moderate maxillary and mandibular crowing. He is treatment planned for orthodontics (braces) to correct his malocclusion. 

There is no medical reason to correct this patient's malocclusion with braces. While the patient has 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. 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. 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. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Braces are not medically necessary.
Diagnosis: Status Post 2 Kidney Transplants. 
Treatment: Egg Retrieval with Fertilization of the Eggs. 

The insurer denied Egg Retrieval with Fertilization of the Eggs.  The denial is upheld.

The patient is a gravida 1, para 0, elective abortion (EAB) 1 female with a history of focal glomerulosclerosis, which has resulted in kidney failure necessitating a kidney transplant. She has had two kidney transplants. She is currently on multiple immunosuppressive medications that would need to be reduced, stopped, or switched in order for the patient to attempt pregnancy, and doing so could endanger her transplant. An evaluation from her nephrologist and a maternal-fetal medicine physician all state that they discourage the patient from conceiving and attempting to carry a pregnancy on her own due to significant health risks. These risks include renal transplant rejection, pre-eclampsia, eclampsia, fetal growth retardation and further worsening of her renal function. She also is an insulin dependent diabetic and has hypertension. She has had loop electrosurgical excision procedure (LEEP) procedure for cervical dysplasia. There are no records or testing showing the patient's fertility potential or any studies detailing evidence of her fertility status. No semen analysis was given.

The patient is requesting in vitro fertilization (IVF) which requires ovarian stimulation, egg retrieval, fertilization of oocytes to create embryos and freezing of embryos for future use. It is her intent to use a gestational surrogate to carry the pregnancy due to her multiple medical issues that make her carrying the pregnancy a significant potential risk to her health and well-being.

The request for services have been denied as the patient does not meet criteria for the use of IVF treatment. 

The health plan's determination is upheld.

The requested egg retrieval with fertilization of the eggs is not medically necessary for this patient.

There have been no studies to determine the patient's fertility status. Given her age, she may not meet criteria for starting fertility treatment. There is no evaluation of her partner to determine if there are any infertility issues. The patient does not meet standard criteria for IVF treatment.

Based on the standard of care, it is reasonable to consider IVF for this patient due to her medical condition (chronic renal failure with renal transplant).  However, there was no evidence presented to show what her fertility potential is and/or any information on her reproductive history.  Without fully evaluating this patient to even see if she is a candidate for infertility treatment, one cannot approve aggressive treatment.  Standard of care requires that a patient and her partner have an initial work-up to look for all potential infertility issues.  None of this was done.  Therefore, this patient does not meet standard criteria for IVF.
Diagnosis: Chronic Migraine. 
Treatment: Botox Injection. 

The insurer denied the Botox injection. 
The determination is upheld. 

The patient has chronic migraine and has tried and failed antihypertensive drugs and antidepressant drugs. Botox was denied because there was not documentation of certain headache features. The provider appealed the determination. 
At issue is the medical necessity of a Botox injection. 

The requested health service/treatment of Botox Injection is not medically necessary for this patient. While Botox is Food and Drug Administration (FDA) approved for the prevention of chronic migraine, the submitted documentation does not show that the patient has undergone an adequate trial of preventative agents. The documentation indicates that the member has tried and failed antidepressants and antihypertensive agents. Not all hypertensive agents or antidepressants are effective for prevention of migraine. There is no specification of what drugs were tried and failed or the duration of therapy. 

Additionally, there is documentation that the patient has a headache on 15 days of the month. Chronic migraine is defined as 15 or more headache days per month with 8 or more of those days meeting migraine criteria for at least 3 months. There is inadequate documentation of chronic migraine.
Diagnosis: Post-tonsillectomy bleed
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of a tonsil bleed. She had a tonsillectomy and adenoidectomy several days prior to presentation (unclear per the records provided). She presented to the emergency department (ED) with a tonsil bleed.
She was noted to be hemodynamically stable and was tolerating oral intake well. She was admitted to the hospital. She had no recurrent bleeding. She was discharged the next day.
At issue is the medical necessity of an inpatient stay.
An inpatient stay was not medically necessary for this patient.
The patient had a post-tonsillectomy bleed. It is considered standard of care to admit a young child for observation when there is evidence of bleeding because children have overall low blood volumes and excessive bleeding can lead to significant medical complications. Based on the clinical documents the child was not actively bleeding, had normal vital signs and was in no cardiopulmonary distress. It would be considered clinically appropriate and standard of care to observe the child overnight. However, the care could have been provided at a lower level than inpatient.
Diagnosis: Dental Problems/Other/ Class I Occlusion
Treatment: Dental/Orthodontic Procedure
The health plan denied the requested dental treatment plan. 
The health plan's determination is upheld.

The patient is a female with a Class I occlusion. She has severe mandibular crowding and moderate maxillary crowding, moderate overjet, and moderate overbite. The subject to be determined is the medical necessity for braces and monthly visits.

The health plan's determination of medical necessity is upheld, in whole.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 11 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, braces and monthly visits are not medically necessary for this case.
Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent 300MG/2ML SOSY. 

The insurer denied the Dupixent 300MG/2ML SOSY. 
The denial is upheld. 

The patient is a male with atopic dermatitis to the face, extremities and neck, treated with topical steroids, systemic steroids, Eucrisa, Opzelura, and tacrolimus. His provider is requesting Dupixent. The health plan denied coverage, as the patient is under the appropriate age. 

No, the requested Dupixent is not medically necessary. 

This patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis. The documentation does not support aggressive topical measures with emollients and wet-to-dry wraps, bleach baths, and phototherapy, which are considered first and second line therapies for eczema. Systemics such as cyclosporine can also be used in atopic dermatitis. 

According to the recommendations provided by Simpson et al, steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy. 

Dupixent is not appropriate or medically necessary for this patient. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Diagnosis: Trauma/Injuries/Spinal Cord Injury
Treatment: Skilled Nursing Facility/Custodial Care
The health plan denied the requested continued long term custodial care as not medically necessary.
The health plan's determination is upheld.

The patient is a male admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T (thoracic) 9 - L (lumbar) 1 posterior fusion, then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating, but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory, requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition via an oral diet, did not have an active complex comorbidity that needed treatment, and was participating in physical therapy.

At issue is the medical necessity for continued long-term custodial services.

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

No, the requested health service/treatment of continued long-term custodial services is not medically necessary for this patient.

The long-term custodial services would not be medically necessary, based on the clinical documentation reviewed. This patient was admitted after a motor vehicle accident resulting in a splenic laceration, rib fractures and spinal injuries requiring T9 - L1 posterior fusion then complicated by an abscess requiring drainage and then was status post a fall, which required decompression of T8 - T11. He was then admitted for rehabilitation services. Per the most current clinical notes, the patient is independent with eating but requires assistance with bathing, dressing, personal hygiene, toileting and is non-ambulatory requiring a wheelchair for locomotion. The patient was afebrile, hemodynamically stable, alert/awake/oriented, he was not in any respiratory distress, continued nutrition was via an oral diet, he did not have an active complex comorbidity that needed treatment, and he was participating in physical therapy. All of the above requirements did not require frequent nursing care > (greater than) 6.5 hours per day, daily physician assessments, or by themselves requiring facility-based treatment. The patient can undergo custodial care at home with physical therapy services as an outpatient. Therefore, the requested health service/treatment of continued long-term custodial services is not medically necessary for this patient.
Diagnosis: Coronary Artery Disease

Treatment: evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)

The insurer denied coverage for evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick)

The denial is overturned.

This case of a woman with a history of aortic stenosis, coronary artery disease, stroke, hypertension, psoriasis, gout and hypercholesterolemia. She was prescribed Repatha after LDL (low-density lipoprotein) cholesterol remained elevated despite high intensity statin (rosuvastatin 40mg (milligrams) daily) and ezetimibe 10 mg daily therapies.  Lipid panel revealed LDL cholesterol of 90mg/dl (milligrams per deciliter).  The patient has documented coronary artery disease with significant coronary artery stenosis that required stent placement.  The patient's physician submitted documentation demonstrating that the patient has been treated with high intensity statin and ezetimibe.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. This patient is already treated with high intensity statin therapy and ezetimibe.  She suffers from atherosclerotic coronary artery and has a history of stroke.  Addition of a non-statin agent such Evolocumab in this setting has been associated with significant event rate reduction regardless of serum LDL level. (Reference 1, 2). Current American Heart Association and American College of Cardiology guidelines recommend addition of PCSK-9 (Proprotein convertase subtilisin/kexin type 9_ inhibitor therapy to maximally tolerated statin therapy in patients at high risk for future ASCVD events including those with multivessel disease. (Reference 1,2,3).  Such patients are given a class I indication for treatment with non-statin therapy such as evolocumab when LDL-C levels are greater than 55mg/dl. (Reference 3) In conclusion, the proposed treatment (evolocumab) is medically necessary.

The insurer's denial of coverage for the evolocumab 140 milligrams/milliliter (mg/ml) subcutaneous (SC) pen injector (Repatha Sureclick) is overturned. Medical Necessity is substantiated.
Diagnosis: Malocclusion. 
Treatment: Comprehensive Orthodontic Treatment. 

The insurer denied coverage for 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, 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 Labia-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. This reviewer concurs with the HLD index of the insurer with a total of 10 points (4 points overjet, 4 points overbites, 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 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. 

Uphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. 

The insurer's denial of coverage for the comprehensive orthodontic treatment is upheld. Medical Necessity is not substantiated.
Diagnosis: Hypertension, hypothyroid, dementia, history of 2 strokes

Treatment   Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week  

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day 7   days per week (split shift)- for a total of 168 hours per week  

The denial is overturned 

The patient is a woman with multiple medical problems including hypertension, hypothyroid and dementia.  She also has a history of 2 strokes.  The insurer approved Personal Care Aide (PCA) of 11 hours/week, 7 days/week for a total of 77 hours/week.  Under review is the request for PCA Level 2: 12 hours/day-7days/week (split shift)- for a total of 168 hours/week.

According to the Uniform Assessment System (UAS) report , the patient has significant cognitive deficits.  Cognitive skills are described as "severely impaired." She is oriented only to person and does not recognize caregivers or family members.  The patient is totally dependent for activities of daily living tasks that include personal hygiene, dressing and toilet use.  She is incontinent of bowel and bladder.  The patient is also totally dependent for bed mobility and is non-ambulatory.  She is bed bound, unable to feed or reposition herself.   The patient's severe dementia and progressive functional declined after a nearly 2-month hospitalization due to another stroke, this supports the medical necessity of personal care assistance (PCA) 24hours per day, 7 days per week split shift, to allow her to resume living safely at home.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  

The requested increase Personal Care Aide (PCA) Level 2: 12 hours per day-7days per week (split shift)- for a total of 168 hours per week is medically necessary for this patient.  

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

The insurer's denial of coverage for Personal Care Aide (PCA) Level 2: 12 hours per day-7days per week (split shift)- for a total of 168 hours per week is overturned. Medical Necessity is substantiated.
Diagnosis: Allergic reaction.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient has a past medical history (PMH) of asthma and was admitted with complaints of (c/o) a possible allergic reaction to peanut oil and tongue and lip swelling. Vital signs were notable for peripheral capillary oxygen saturation (SpO2) of 99%. The physical exam was notable for no acute distress, angioedema of the tongue, no pulmonary retractions, labored breathing, or expiratory stridor, and able to speak in full sentences without difficulty and able to handle secretions. Lab work was unremarkable. The patient was diagnosed with anaphylaxis and treated with intravenous (IV) fluid, antihistamines, IV steroids, intramuscular (IM) epinephrine times (x) 2, and a nebulizer. Of note, the patient's symptoms improved upon arrival to the emergency department (ED), and improved after initial treatment in the ED. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient with a recent history of an urticarial rash presented to the ED with c/o possible allergic reaction to peanut oil and tongue and lip swelling. There was no actual or impending airway compromise, unstable vital signs, hypoxia, respiratory distress or respiratory failure, progression of allergic reaction/angioedema while undergoing treatment, hypotension, acute coronary syndrome (ACS), hoarseness or need for IV vasopressors. Overall, this stable patient was treated with IV steroids, IM epinephrine, and antihistamines, and responded to the treatment in the ED, and these interventions could have been safely provided at a lower level of care than inpatient.
Diagnosis: Plantar fasciitis. 
Treatment: Custom Shoe Inserts (L3000 x2). 

The insurer denied coverage for Custom Shoe Inserts (L3000 x2). 

The denial is overturned. 

The patient is a female with long history of foot and ankle pain. There is a history of ankle sprain, metatarsalgia, painful calluses, bunions, and plantar fasciitis. The patient has tried good supportive shoes and compression socks to no avail, along with over-the-counter pain medications and continues to have arch pain. Furthermore, the notes outline that the deformity of the foot was such that even with the use of a prefabricated orthotic there was complete collapse of the arch.  As such, custom orthotics were recommended. 
 
A review of the literature reveals that while there is a vast amount of research with regard to conservative therapy for plantar fasciitis, there is no optimal answer when it comes to specific orthotic therapy for plantar fasciitis. While some patients may benefit from over-the-counter orthotics, others may get no better without the use of custom orthotics. In the case of this patient, it is clear from the medical records made available that the prefabricated orthotics made little difference and the patient needs a good custom orthotic to help with her plantar fasciitis by providing her more support. Given the available literature on this topic and this patients history, in this reviewer's expert opinion it is best that the orthotics are approved, so that the patient can get the treatment she needs to resolve her plantar fasciitis. 

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

The insurer's denial of coverage for Custom Shoe Inserts (L3000 x2) is overturned. Medical Necessity is substantiated.