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

Diagnosis: Orthopedic/Musculoskeletal/Other/Avascular Necrosis. 
treatment: Inpatient Hospital. 

The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned. 

This case describes a male patient with a history of alcohol abuse and avascular necrosis of the left hip. The records document that he had progressive, function limiting hip pain secondary to the avascular necrosis and failed conservative treatment. The patient opted to undergo elective total hip replacement surgery. The surgery was successful, but the patient had 900 cc of blood loss and required a transfusion of two units of packed red blood cells intra-operatively and had a hypotensive episode after the operation. The patient received an additional unit of blood on post-operative day #1. The patient was stabilized and participated in supervised physical therapy. He was deemed stable for discharge. 

The issue in this case is the medical necessity of the inpatient admission. 

I overturn, in whole, the health plan's determination of medical necessity in this case. 

This determination is based upon the provided documentation in the medical records and recommendations of the current peer-reviewed literature. First, the records in this case document that the patient had significant blood loss during the operation and required two units of blood to be transfused intra-operatively. The patient also had significant a hypotensive episode after surgery with a blood pressure of 76/44 millimeters of mercury (mmHg). A fluid bolus was administered, and the patient's blood pressure normalized. The patient's post-operative hemoglobin was 7.3, so an additional unit of blood was given on post-operative day #2. The hemoglobin improved to 9.6 on post-operative day #3 and he was deemed stable for discharge. Based upon this documentation in the records, the inpatient hospital admission was medically necessary to medically stabilize this patient after total hip replacement surgery. The current, peer-reviewed literature supports inpatient admission, given the circumstances documented in this patient's records after the operation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Breast Cancer.
Treatment: Bioimpedance spectroscopy. 
The insurer denied Bioimpedance spectroscopy.
The determination is overturned.


The patient has a significant past medical history of right sided ductal carcinoma in situ (DCIS) treated with breast conservation surgery, radiation and anti-estrogen therapy. She subsequently developed left breast invasive ductal carcinoma requiring a left breast lumpectomy and sentinel lymph node biopsy. At the time of surgery 4 sentinel nodes and one palpable node was removed for a total of 5 nodes. The operative report and full pathology report were not included in the documentation. She also underwent adjuvant radiation treatment to the left breast. At issue is whether bioimpedance spectroscopy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Given that the patient underwent sentinel node biopsy and 5 nodes were removed she is at significantly higher risk of lymphedema than if less than 5 nodes were removed. She also has a history of contralateral breast surgery and radiation and as such is at risk of bilateral lymphedema although  the contralateral side is less. Bilateral lymphedema is a debilitating condition so close monitoring of at least the arm at most at risk of developing lymphedema is prudent. Studies have shown that the use of bioimpedence spectroscopy is superior to tape measurement for the early detection of lymphedema.
The treatment of lymphedema is improved significantly by early detection. The superior test for this is bioimpedance spectroscopy. Studies have shown that the early detection of lymphedema has significant cost savings in terms of future patient care. In this patient, she was at higher risk for lymphedema and should be monitored closely.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Breast Cancer.
Treatment: Bioimpedance spectroscopy.
The insurer denied Bioimpedance spectroscopy.
The determination is upheld. 

This is a patient with a history of right breast ductal carcinoma in situ diagnosed and treated with breast conserving surgery, radiation therapy and several years of endocrine therapy with tamoxifen. She was diagnosed with a tumor (T) 1a nodes (N) 0 stage I a invasive ductal carcinoma of the left breast for which she completed breast conserving surgery, sentinel lymph node biopsy (0/4 lymph nodes involved with metastatic carcinoma) and, she was beginning adjuvant radiation therapy. A request was made for bioimpedance spectroscopy (BIS) for monitoring for the development of subclinical lymphedema.
At issue is whether the bioimpedance spectroscopy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service, bioimpedance spectroscopy (BIS), is not likely to be more beneficial than any standard treatment for the patient's condition.
The patient has a history of bilateral, metachronous breast cancer. Her cancer on the right side, diagnosed and treated, was non-invasive and was treated with breast conserving surgery, adjuvant radiation therapy and endocrine therapy. She was subsequently diagnosed with a small invasive cancer on the left side that was treated with breast conserving surgery and sentinel lymph node biopsy, and thus far radiation therapy.
She did not have any axillary intervention on the right side. On the left side, she underwent a sentinel lymph node biopsy with the removal of four benign lymph nodes. She did not undergo full axillary lymph node dissection or comprehensive nodal radiation. Her risk of lymphedema is, therefore, quite low.
The studies evaluating the efficacy of BIS for detection of subclinical lymphedema were performed on patients at high risk for lymphedema, specifically those who had comprehensive nodal radiation or complete lymphadenectomy. These studies have not evaluated the efficacy of BIS in the setting of patients who underwent sentinel lymph node biopsy alone with fewer than 6 lymph nodes removed.
In patients with a high risk of developing lymphedema, bioimpedance spectroscopy has been shown to be clinically useful in identifying patients with subclinical lymphedema so as to initiate early intervention which decreases the incidence of progression of lymphedema, however, in this patient's case, bioimpedance spectroscopy is not likely to be more beneficial than any standard treatment for the patient's condition. Her risk of lymphedema is quite low.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Breast Cancer.
Treatment: Bioimpedance spectroscopy.
The insurer denied Bioimpedance spectroscopy.
The determination is overturned.

The patient has a history of right breast ductal carcinoma in situ (DCIS)  status post lumpectomy (LPX), radiation therapy (XRT) and several years of Tamoxifen now with newly diagnosed invasive ductal carcinoma status/post (s/p) partial mastectomy (PMX) followed by XRT. Bioimpedance spectroscopy is under review.

The proposed health service or treatment, bioimpedance spectroscopy, is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Bioimpedence spectroscopy is more beneficial and more accurate in determining baseline and subclinical lymphedema. This particular patient with a history of breast cancer twice is at a higher risk of developing lymphedema, therefore, recognizing subclinical lymphedema with sophisticated measurements based on the electrical flow through the extremity would provide a more accurate assessment and allow the provider to initiate measures at an earlier stage to help maintain and prevent debilitating lymphedema. There is no proven treatment for lymphedema; the only way to treat it is by identifying it early. The American Society of Breast Surgeons, American Cancer Society indicate prevention and early detection and the initiation of therapy such as compression sleeves, massage therapy at the earliest signs of lymphedema. The issue is how to identify accurately the early signs of lymphedema; the simple tape measurements of an extremity are not sensitive enough, therefore, techniques like bioimpedence are highly utilized in the clinical setting in high-risk patients such as this particular patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis

Treatment: Dupixent

The insurer denied coverage for Dupixent.

The denial is overturned. 

The patient has a diagnosis of atopic dermatitis.  The patient has failed therapy with topical steroids, as well tacrolimus, and Opezelura 1.5% (percent) cream.  The patient has also failed therapy with oral prednisone.  The requested medication is Dupixent.  

The patient has a diagnosis of severe atopic dermatitis, which would be amenable to systemic therapy.  Due to the underlying anemia, methotrexate and azathioprine would not be ideal therapeutic options.  The patient's history is also complicated by the underlying hidradenitis suppurativa requiring systemic therapy with doxycycline.  Given the history of asthma and atopic dermatitis, Dupixent, which is FDA (Food and Drug Administration) approved for both, would appear to be the better treatment option for this patient.  As such, the use of Dupixent for the treatment of severe atopic dermatitis is medically necessary based on the clinical scenario and the documentation provided.    

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

The insurer's denial of coverage for Formulary Exception for Dupixent is overturned.  Medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gastroparesis. 
Treatment: Motegrity. 

The insurer denied Motegrity. The health plan's determination  is overturned. 

The patient is a female with gastroparesis. She had tardive dyskinesia with metoclopramide. She had diarrhea with lubiprostone and linaclotide. She has had improvement in symptoms and weight on Motegrity 2 milligrams (mg) daily. The coverage is requested for Motegrity 2 mg daily for the treatment of gastroparesis. 

A formulary exception is indicated for this patient. 

The patient has attempted first-line therapy (according to the most recent American College of Gastroenterology guidelines) for the treatment of gastroparesis with metoclopramide but had a severe adverse effect. Motegrity has demonstrated greater efficacy than placebo for the treatment of gastroparesis in a crossover study, with improvement in symptoms. The formulary alternatives may be effective for the treatment of constipation but are not supported for the treatment of gastroparesis. In this patient with improvement in symptoms on Motegrity, the request to continue Motegrity is supported.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Paroxysmal Atrial Fibrillation. 
Treatment: Eliquis. 

The insurer denied the Eliquis. 
The determination is overturned. 

The patient has a history of paroxysmal atrial fibrillation, prior ablations, nonobstructive coronary artery disease (CAD), dyslipidemia, obstructive sleep apnea (OSA), and sick sinus syndrome. The patient has been doing well anticoagulated with apixaban and records show she did not tolerate Xarelto in the past due to bleeding complications. The patient's health plan has denied authorization for apixaban as it does not meet established criteria demonstrating failure, intolerance and or contraindication to the alternative formulary anticoagulants, Warfarin and Xarelto. At issue is whether the formulary drug (Warfarin, Xarelto) will be or has been ineffective, would not be as effective as the non-formulary drug (Eliquis), or would have adverse effects. 

The formulary drugs Warfarin and Xarelto would not be medically appropriate for anticoagulation and prevention of stroke for this patient for the following reasons. Records indicate the patient has already tried and failed the formulary anticoagulant Xarelto due to significant bleeding in the past. Therefore, treating this patient once again with Xarelto would be medically inappropriate and unsafe. In addition, the other formulary anticoagulant, Warfarin, would be medically inappropriate for this patient because of its inferior safety profile compared to apixaban due to its higher risk of serious bleeding which is supported by peer-reviewed published medical literature and expert consensus guidelines on anticoagulation management for patients with atrial fibrillation (1-3).
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Central Nervous System. 
Treatment: Pharmacy/prescription drug. 

The insurer denied Horizant. The health plan's determination is overturned. 

The patient is a female with a history of restless leg syndrome. The records indicate that she has been treated with Mirapex and Gabapentin for restless leg syndrome which were ineffective at maximum doses. The treating provider documented that the patient was using samples of Horizant for more than 2 weeks and has had major benefit. The use of the non-formulary Horizant is the subject under review. 

In this case it was clearly documented by the physician's assistant that the patient has tried and failed the formulary drug Gabapentin. The health plan states that Horizant was denied because there is no documentation of "failure of all the formulary alternatives.... Formulary alternatives are Gabapentin, Gralise." However as described above the patient did fail Gabapentin. Gabapentin ER [extended-release] (Gralise) is an analog of gamma-aminobutyric acid (GABA) that has GABA agonist activity hence the same mechanism of action as Gabapentin. Gabapentin enacarbil ER (Horizant) is an extended-release formulation of gabapentin enacarbil, a prodrug of gabapentin. It is efficacious in restless legs syndrome (RLS) and postherpetic neuralgia (PHN). 
Clinical trials have evaluated gabapentin enacarbil for safety and efficacy in treating moderate-to-severe RLS symptoms for up to 64 weeks. It offers a pharmacokinetic advantage over gabapentin by having improved absorption and a longer duration of action. The Food and Drug Administration (FDA) approval of Horizant for RLS was based on two 12-week clinical studies in approximately 400 adults with RLS. The subjects were required to have a total score of greater than or equal to (>=)15 on the International Restless Legs Syndrome (IRLS) Rating Scale at baseline. In Study 1 the subjects received the 1,200 milligrams (mg) of Horizant, or placebo taken once daily at about 5 PM with food. In Study 2 the subjects received 600 mg of Horizant, 1,200 mg of Horizant or placebo taken once daily at about 5 PM with food. Efficacy was evaluated using the IRLS Rating Scale and Clinical Global Impression of Improvement (CGI-I) score. Statistically significant differences (probability [P) less than [<] 0.05) between the treatment groups receiving 600 and 1,200 mg of Horizant and the group receiving placebo were observed at Week 12 for both the mean change from baseline in the IRLS Scale total score and the proportion of responders (much improved) or (very much improved) on the CGI-I Scale. 

There is documentation of a failed formulary drug and Horizant has been proven to provide relief of restless leg syndrome.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD (chronic obstructive pulmonary disease).
Treatment: High Frequency Chest Wall Compression Device.
The insurer denied the High Frequency Chest Wall Compression Device.
The denial is overturned.

The patient is a male with COPD (chronic obstructive pulmonary disease). He is being treated with Stiolto Respimat and High Frequency Chest Wall Compression Device to improve pulmonary secretion clearance. The continued use of the High Frequency Chest Wall Compression Device was denied by the health plan due to lack of clinical documentation of positive outcomes. This denial is being appealed.

Yes, the High Frequency Chest Wall Compression Device is medically necessary.
This patient with COPD (chronic obstructive pulmonary disease) is being treated with Stiolto Respimat and High Frequency Chest Wall Compression Device to improve pulmonary secretion clearance. The clinical documentation provided shows that patient's pulmonary secretion clearance has improved with the device. The patient has less cough, sputum and better breathing. The continued use of the device is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Food Impaction. 
Treatment: Inpatient Hospital Stay. 

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

The patient has a medical history of diabetes mellitus type II, hypertension, hyperlipidemia, asthma, and sleep apnea. She presented to the emergency department with a food impaction. She was eating soup, and a bone got stuck in her throat, resulting in pain on swallowing and deep breaths. Vital signs were notable for rapid pulse of 103 beats/minute and elevated blood pressure of 156/92 millimeters of mercury (mmHg). The physical examination was notable for oropharynx without swelling, erythema, abrasion, laceration, bleeding, or excess salivation; there was mild tenderness to palpation at the base of the anterior neck. 

Lab results showed elevated white blood cell count of 11.3. A computed tomography scan of the neck showed a 3-centimeter (cm) bone lodged in the proximal esophagus without evidence of perforation. She was treated with intravenous fluids and oral lidocaine solution. She was made nil per os. She was comfortable, with mild sore throat upon swallowing. An esophagogastroduodenoscopy was performed with bone removal from the esophagus and duodenum; the stomach appeared normal. The recommendation was to maintain nil per os, and then start liquid after 2 to 4 hours, advance diet as tolerated, Carafate suspension for 10 days, pantoprazole 40 milligrams (mg) twice daily intravenously while inpatient and then orally for 4 weeks, and outpatient endoscopy to evaluate for eosinophilic esophagitis. She had a severe headache and vomiting. Tylenol was not effective. She was treated with intravenous magnesium, and intravenous pantoprazole was changed to famotidine. Her throat pain and headache had significantly diminished, and she had no nausea or vomiting. She was discharged, with a plan for Primary Care follow-up. 

At issue is the medical necessity for the inpatient level of care. 

The inpatient level of care is not medically in this case. The most recent available American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the management of foreign body recommend emergent endoscopy for sharp-pointed objects in the esophagus, which was performed with successful foreign body removal [1]. Surgical intervention was not utilized, and there was no evidence of complications such as perforation or mediastinitis which would warrant the inpatient level of care [1-4]. Although she had a severe headache and vomiting for a day, this resolved with change in medications and observation; conservative management was appropriate and effective [5,6]. The care provided, including monitoring, imaging, endoscopy, and intravenous acid suppression therapy, could have been performed without the inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Durable Medical Equipment (DME)(including Wearable Defibrillators). 
The insurer denied a Zoll LifeVest. 
The denial was overturned.

This male was admitted to the hospital with congestive heart failure and a non-ST segment elevation myocardial infarction. Coronary angiography showed multi-vessel disease and a left ventricular ejection fraction (LVEF) of 10%. The patient underwent a three-vessel coronary artery bypass graft surgery. An echocardiogram showed a left ventricular ejection fraction of 20% (percent).  Guideline directed medical therapy for heart failure was prescribed.
At hospital discharge, the patient was prescribed a LifeVest wearable cardioverter defibrillator (WCD). An echocardiogram showed an LVEF of 25-30%. His lisinopril dose was increased; his metoprolol dose was decreased due to side effects. A multigated acquisition (MUGA) scan showed an LVEF of 40%. Use of the WCD was discontinued.
At issue is whether the Zoll LifeVest is likely to be more beneficial than any standard treatment.

The health plan's determination is overturned in whole.

The proposed health treatment of Zoll LifeVest was likely to be more beneficial than any standard treatment for the patient's condition.
Sudden arrhythmic death is common in the early post-myocardial infarction period, especially in the first 30 days. The risk is highest in patients with heart failure, left ventricular dysfunction, or both. Accordingly, there has been considerable interest in interventions that might modify this risk. The DINAMIT trial (Defibrillators in Acute Myocardial Infarction Trial) was a randomized multicenter, prospective study designed to assess the impact of implantable cardioverter defibrillator (ICD) implantation, in addition to optimal medical therapy (OMT) versus (vs) OMT alone on all-cause mortality in high-risk patients within 40 days after myocardial infarction (MI). However, there was no significant difference in all-cause mortality between the two groups. 
Moreover, given the possibility that systolic function might improve if the patient undergoes revascularization, a waiting period of 90 days post-revascularization is recommended. If, at the end of that 90-day period, the LVEF remains less than or equal to 35%, ICD implantation is then recommended. The efficacy of the WCD in terminating serious ventricular arrhythmias compares favorably to that of the implanted device. In one large retrospective study of patients with left ventricular ejection fractions, the WCD compared favorably to the ICD.
Therefore, the Zoll LifeVest was likely to be more beneficial than any standard treatment for the patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post hepatic and renal transplant surgery
Treatment: Private Duty Nursing (with a licensed practical nurse) For  A Total of 66 Hours
The insurer denied the Private Duty Nursing (with a licensed practical nurse) For  A Total of 66 Hours
The denial is overturned

The patient is a child with known post hepatic and renal transplant surgery. The patient has g-tube feed requirements. The feed preparations are rather specific considering the medical needs of the patient, as the patient has metabolic syndrome, methylmalonic acidemia. The patient has a special diet for their specific nutritional needs in relation to proteins, fats and minerals and vitamins. The patient's mother works and cannot stay with the child as she works.

Yes, the requested private duty nursing 66 hours/week is medically necessary.
Due to the specific feeding requirements of the patient caused by the known underlying medical pathology and the hepatic and renal transplants, the patient is at higher risk for severe metabolic  imbalance and needs for hospitalizations, including ICU (intensive care unit) level admissions, if appropriate care is not given. Because of these specific feeding and medical requirements and the severe negative outcomes for the patient if those needs are not given, it is medically necessary for the patient to receive care from a trained medical professional. Therefore termination of coverage for this care is not appropriate. The private duty nursing 66 hours/week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient needs trained medical care from a medical professional due to their specific needs.