Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD
Issue under review: LINX procedure
The health plan denied LINX procedure.

Determination:
The health plan's denial is upheld.

The patient is an adult female with BMI (body mass index) 36.73 (progress note) with long standing GERD (gastroesophageal reflux disease) despite medication. 24-hour pH study revealed an elevated DeMeester score consistent with GERD. EGD (esophagogastroduodenoscopy) revealed mild esophagitis, no hiatal hernia. Manometry was normal.

This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX, an FDA-approved treatment for GERD, is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. 

There are a few exclusions to LINX treatment including: age at least 18 years of age, no history of prior gastric or bariatric surgery, Barrett's esophagus with dysplasia and BMI > 35 kg/m2. This patient has a clinical exclusion to the treatment, which is a BMI of >35 kg/m2. Given that this patient has a BMI that is > 36 kg/m2, the requested LINX treatment is not considered medically appropriate, as the patient documents a clinical exclusion to the treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD
Issue under review: LINX procedure
The health plan denied LINX procedure.

Determination:
The health plan's denial is overturned.

The patient is an adult female. She was seen by her surgeon for Linx discussion due to reflux.  She was on omeprazole 20mg PO (by mouth) daily.  The diagnostic testing was performed as follows:

pH monitoring-DeMeester Score 33.6. 

EGD (esophagogastroduodenoscopy): Hill grade II valve.  Bravo placed.  Mild esophagitis. Duodenitis confirmed with biopsy. H. pylori negative. 

High Resolution Esophageal Motility study: Normal pressure clearance, some fragmentation but normal propagation, not spastic.  Reasonable for Linx.

History of prior EGD with Barrett's without dysplasia. 

This patient suffers from GERD (gastroesophageal reflux disease) causing esophagitis and Barrett's esophagus. Even with PPI (proton pump inhibitors), there is refluxing gastric contents. Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  Linx is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA.  There is published data on patients who have had the device for six years, showing a very low complication rate and a high resolution of GERD.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria 
Treatment: Sex reassignment mastectomy with masculine chest reconstruction 

The insurer denied the sex reassignment mastectomy with masculine chest reconstruction. The denial is overturned. 

The proposed sex reassignment mastectomy with masculine chest reconstruction is medically necessary. 

This transgender female to male has been binding breasts for years. Gender confirming top surgery is planned. 

Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" Seventh Edition guidelines: Criteria for Breast/Chest Surgery (One Referral)
Criteria for mastectomy and creation of a male chest in female to male (FtM) patients: 
1) Persistent, well-documented gender dysphoria; 2) Capacity to make a fully informed decision and to consent for treatment; 3) Age of majority in a given country (if younger, follow the standard of care (SOC) for children and adolescents); 4) If significant medical or mental health concerns are present, they must be reasonably well controlled. 

Hormone therapy is not a prerequisite. 

The patient meets these guidelines. He has well documented gender dysphoria and has the capacity to make an informed decision. He is the age of majority. He does not have significant mental health concerns. Two mental health professionals have recommended the mastectomies. Therefore, the proposed treatment is medically necessary. 

The patient meets national guidelines for transgender top surgery.
Appeal type: Medical necessity
Decision: Overturned

DX: Central Nervous System /Neuromuscular Disorder
TREATMENT: Home Health Care
DENIED: 112 hours/week consumer directed personal assistance services
THE DENIAL WAS: OVERTURNED

The patient is a female with past medical history of Parkinson's disease, dementia, diabetes mellitus type 2, hypertension, osteoarthritis, anemia, hyperlipidemia, anxiety, depression, chronic fatigue and gastroesophageal reflux disease (GERD) who had been previously assigned personal care assistance (PCA) service hours 8 hours/day, 7 days/week to total 56 hours/week. The patient lives alone. The patient's neighbor and daughter were covering the other 16 hours of care for the patient. There was a request for an increase in PCA hours to 12 hours/day, 7 days/week to total 84 hours/week.

The patient had a Uniform Assessment System-New York Comprehensive Community Assessment Report completed. The patient had worsening of her assistance needs compared to previous assessment for tasks of meal preparation, ordinary housework, managing finances, managing medications, phone use, shopping, equipment management, bathing, personal hygiene, dressing upper/lower extremities, bed mobility and eating. The patient's needs remained the same for walking, locomotion, transportation, transfer toilet and improved for toilet use. The patient was noted to be moderately cognitively impaired at most recent assessment and previously mildly cognitively impaired on prior assessment. The patient is treated with basal insulin as well as short acting insulin at meals. The patient requires a medication given at bedtime. The patient was instructed to check blood pressures daily. Final adverse determination was made to not increase PCA service hours.

The health plan's determination is overturned.

The requested service of consumer directed personal assistance services - 112 hours per week are medically necessary for this patient.
The patient has had a change in her clinical status with worsening Parkinson's and worsening dementia requiring help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). This increase in hours per day for PCA services is not for supervision or companionship. The patient needs to be directed to check blood sugars, administer insulin, check blood pressure and take evening medication. The patient requires monitoring and cognitive prompting to assure safe completion of multiple ADL's and IADL's. The patient does not have an informal helper for the total hours outside of currently assigned PCA service hours. The patient has documented worsening of her dementia with inability to complete MMSE or verbalize goals.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Aspiration pneumonia 
Treatment: Inpatient hospital admission 

The insurer denied coverage for inpatient hospital admission. The denial is upheld. 

This patient is a female with a history of Down's syndrome, developmental delay and an atrial septal defect (ASD). The child had surgery to place tubes in the ears for chronic otitis media and to remove the tonsils and adenoids because of sleep apnea and was hospitalized in the Pediatric Intensive Care Unit (PICU) in the post-operative period. The patient was given a follow up appointment with a pediatric pulmonologist following discharge. When the patient went to the scheduled appointment, the patient had been sick for four days with a cough. There was fever for a day or two which resolved two days prior to being seen by the outpatient pulmonologist. The pulmonologist evaluated the child and noted a pulse oximeter reading of 94% and sent the child to the Emergency Room (ER) for admission for possible aspiration pneumonia. 

In the ER, the child was not noted to be in any respiratory distress. On patient's physical examination, there were mild crackles audible on the right side of the lung. The patient's chest x-ray indicated some increased areas of atelectasis and interstitial markings but no change from the previous chest x-ray obtained during the recent hospitalization in the postoperative period. The patient's white blood cell (WBC) count was not elevated and serum electrolytes were normal. The child was not dehydrated and there was no requirement for oxygen supplementation. Based on the concern for aspiration pneumonia, the decision was made to admit the child to the hospital for antibiotic therapy. 

The patient with Down's syndrome had been hospitalized for an extended period in the post-operative period for feeding issues. Although the patient had a cough for four days, there was no acute deterioration in the patient's respiratory status and the patient was not in respiratory distress or in need of oxygen supplementation. Based on the review of the literature, hospitalization for supportive care and monitoring is usually indicated for infants and young children with toxic appearance, poor feeding, lethargy, and dehydrations, moderate to severe respiratory distress, and apnea hyoxemia with or without hypercapnia (arterial or capillary carbon dioxide tension >45 mmHg). 

The patient could have been safely discharged home on oral antibiotics with a diagnosis of pneumonia and an appropriate outpatient evaluation for the risk for aspiration. The acute hospitalization was not medically necessary. 

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

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post anterior cruciate ligament (ACL) reconstruction

Treatment: (L1845) Knee orthosis

The insurer denied coverage for (L1845) Knee orthosis. The denial is upheld 

This patient is a male who underwent an anterior cruciate ligament (ACL) reconstruction. This patient's post-surgical course was non-complicated. The patient was reported to be doing well and was able to twist and pivot. The patient reported feeling confident returning to sports. The patient was taking no medications and was running. The patient was sized for an ACL brace. 
The scientific literature does not demonstrate the benefit of ACL bracing after surgery. Clinicians have once believed that braces improve the outcome of ACL reconstruction by improving extension, decreasing pain and graft strain, and providing protection from excessive force. However, several randomized controlled trials (RCTs) have been performed to address these issues. This study represents a systematic review of the Level I evidence (12 RCTs) to determine if appropriate evidence exists to support brace use. Based on this systematic review with meta-analysis of 12 randomized controlled studies, there was no difference in patient outcome with or without bracing. Studies have provided evidence that postoperative bracing did not protect against re-injury, decrease pain, or improve stability. 
In this case, the medical record described a satisfactory post-surgical course for this patient. The patient did not have evidence of knee instability that required brace support. The patient was able to return to full activity, and there was no extenuating circumstance that this patient's condition warranted the need of a brace. 
The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for (L1845) Knee orthosis is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis.
Treatment: Inpatient hospitalization.

The insurer denied coverage for inpatient hospitalization.  The denial is reversed. 

This patient is a male with history of heroin use, type 1 diabetic ketoacidosis (DKA) noncompliance with insulin, who presented to the Emergency Department (ED) with complaints of nausea and vomiting.  In the ED, the patient's workup was remarkable for blood glucose of 775, bicarb of 13 and large acetone and 4 plus ketones in the urine.  The patient was treated with intravenous (IV) fluids and IV insulin.  By  that night blood glucose was 301.  The patient remained on IV insulin and was transitioned to subcutaneous (SQ) injection.  The patient left against medical advice (AMA) at that time.  The patient's hemoglobin A1c was 12.9%.  On admission, the patient's vitals showed blood pressure of 125/70 and heart rate of 110.  The patient's blood pH was 7.33.

According to Gosmanov, et al. (2018), "Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus.  Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management are keys to the successful resolution of DKA and HHS.  Critical components of the hyperglycemic crises management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis."  Fayfman, Pasquel, & Umpierrez (2017) also supports that the "mainstays of treatment in both DKA and HHS are aggressive rehydration, insulin therapy, electrolyte replacement, and discovery and treatment of underlying precipitating events."     

Based on the review of the medical record, the patient met the clinical criteria for diabetic ketoacidosis (DKA).  Although the patient was hemodynamically stable other than for the patient's tachycardia of 110, the patient's history of drug use and admitted history of non-compliance with insulin put the patient at high risk of complications associated with this patient's DKA.  Based on the review of the medical literature, this patient's clinical circumstance met the extenuating criteria for warranting inpatient admission and care.  Therefore, the inpatient hospitalization was medically necessary for this patient.  
                                                
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for inpatient hospitalization is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Moderate To Severe Chronic Plaque Psoriasis
Treatment: Otezla
The insurer denied Otezla.  
The denial is overturned.

The treatment with Otezla is medically necessary.

The patient is a male with psoriasis for whom Otezla is requested. He has involvement of the face and genitals that greatly impacts his quality of life. He is using topical steroids and calcipotriene. He is also receiving allergy shots.
Due to involvement of sensitive area, phototherapy is not appropriate. Due to the current COVID-19 pandemic, use of immunosuppressants is contraindicated where other options are available. Acitretin has not been shown to have good efficacy for facial or genital psoriasis, which is heavily impacting the patient. Otezla does not suppress the immune system and is thus the drug of choice for this patient at this time.

The pharmacy management drug policy requires:
Must have moderate to severe chronic plaque psoriasis that involves at least 10% of the body surface area. Consideration will be given to those who have severe disease of the hands or feet or other areas causing disruption in normal activities, but have less than 10% body surface area involvement AND
1) Member must be a candidate for systemic therapy (i.e. acitretin, methotrexate, or cyclosporine therapy) AND had a trial period of at least three months or had developed serious side effects or have a contraindication (medical reason to avoid the drug) to the above-mentioned agents
2) If systemic therapy is contraindicated, then one of the following must be attempted for   reasonable period of time (at least three months):

a) UVB in combination with a topical therapy such as coal tar, steroids or tazarotene
OR
b) PUVA (psoralen and ultraviolet A) in combination with topical corticosteroids OR
c) Medium/High potency topical steroids in combination with anthralin, calcipotriene, or tazarotene

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  (Celgene, 2015)  Otezla is an oral small molecule inhibitor of phosphodiesterase IV (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene, 2016)  The patient has moderate to severe psoriasis for which therapy with Otezla is appropriate and medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Diabetes mellitus with hyperglycemia 
Treatment: Formulary exception for Apidra 
The health plan should cover the Formulary exception for Apidra. 

This patient is a female with type 1 diabetes on insulin pump therapy. She has tried Novolog and Humalog, which resulted in erratic glucose control with wide swings in glucose. Her A1C (glycated hemoglobin) has improved from >9% to 6.4% on Apidra. The request for continuation of Apidra is under review. 

This patient has tried and failed Novolog (aspart insulin). Fiasp is a form of aspart insulin. Given this patient is stable on Apidra, and she had significant glycemic variability with aspart insulin in the past, it is not appropriate to transition her to Fiasp given the risk of hypoglycemia and hyperglycemia. Hypoglycemia can cause seizures and be life-threatening. Hyperglycemia can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the health plan should cover the Formulary exception for Apidra.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of chronic obstructive pulmonary disease (COPD), pulmonary nodules, seasonal allergies, cervical intraepithelial neoplasm grade 2 (CIN2) status/post (s/p) hysterectomy, degenerative joint disease (DJD), cervical spine and lumbar spine spondylosis, and greater trochanteric bursitis and presented to the emergency department (ED) with complaints of dizziness for 3 days and shortness of breath that began 1 day prior. The patient also complained of low back pain.
The patient's vital signs revealed a temperature of 98.0 degrees Fahrenheit, a pulse of 58, a respiratory rate of 20, a blood pressure (BP) of 118/72, and a pulse oximetry of 99%. The physical examination showed mild cervical paraspinal tenderness and motor strength 4/5 on the left throughout. An electrocardiogram (EKG) was performed at the clinic earlier which showed bradycardia with a pulse of 44 beats per minute. The EKG in the ED showed sinus bradycardia with pulse of 57. A brain computed tomography (CT) scan was completed and was negative for acute disease. The patient was admitted for symptomatic bradycardia and dizziness. A brain magnetic resonance imaging (MRI) scan was also completed and was unremarkable. The patient was seen by neurology and was recommended to take Meclizine. She was also seen by a physiatrist who recommended outpatient physical therapy. 
At issue is the medical necessity of the inpatient admission.

The health plan's determination is upheld in whole. The requested health service/treatment of an inpatient stay was not medically necessary for this patient. This patient was hemodynamically stable with no documentation of falls or gait instability. The treatment with oral Meclizine could have been initiated at a lower level of care. The laboratory and imaging findings did not reveal any significant issues that would require an inpatient admission. The patient did not require intravenous medications and there was no evidence of a new onset severe neurological symptom with significant physical examination findings. The bradycardia could have been monitored at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders
Inpatient Hospital

This case involves a man with a history of drug abuse, including intravenous (IV) cocaine use, and opiate use, who presented to the emergency department with right arm pain and swelling. The patient reported the pain started in the right forearm three days before presentation, non-radiating and sharp, and not relieved with any interventions at home. He had injected some cocaine in both forearms but was unable to quantify the amount that he injected. He denied chest pain, shortness of breath, or abdominal pain. One month before this presentation, the patient was treated in the hospital for cellulitis with doxycycline. The patient reported no drug allergies. The inpatient stay is under review. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient presents to the hospital with injection site cellulitis, with a negative abscess on imaging. He is hemodynamically stable, without alteration of mental status. Although the patient has a prior history of infections, this is a new infection. There is no clear evidence of a limb-threatening infection. This was ruled out by imaging, and expert surgical opinion within 24 hours of admission. There is no evidence of a rapidly progressing disease. The patient did not have a thrombotic event, nor did he have bacteremia nor endocarditis. Imaging studies showed no evidence of necrotizing soft tissue infection, such as the presence of gas in the tissue. He did not need surgical incision and drainage. There is no report of severe pain; and the patient was treated with oral nonsteroidal anti-inflammatory medications. There is no evidence of compartment syndrome. As a result, there are no clinical indications for admission to inpatient care. This presentation can be handled at a lower level of care with subsequent transition to outpatient treatment. In fact, within 24 hours of hospitalization, the patient was transitioned to an oral antibiotic regimen. In conclusion, a lower level of care is appropriate.