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

Diagnosis: Varicose Veins.
Treatment: Vein Procedures.
The insurer denied the Vein Procedures.
The denial is overturned.

The patient, a female, presents with leg symptoms consistent with venous insufficiency. She has failed a trial of compression therapy. Exam shows a cluster of varicose veins on the left leg. Duplex does not show axial (truncal) reflux, but it shows multiple varicose vein clusters. The provider has recommended phlebectomy. 

Yes, the proposed vein procedures are medically necessary.

The patient presents with leg symptoms consistent with venous insufficiency. She has failed a trial of compression therapy. Exam shows a cluster of varicose veins on the left leg. Duplex does not show axial (truncal) reflux, but it shows multiple varicose vein clusters. The provider has recommended phlebectomy.

In order to evaluate the medical necessity of the service, widely accepted standards [1-3] have been applied. Under these standards, phlebectomy is appropriate when:

1) There is no axial saphenous reflux, or any associated axial reflux has been treated. If axial reflux has been treated, a sufficient waiting period (usually four to six weeks minimum) should elapse to allow for evaluation of the patient's residual leg symptoms.
2) The patient has symptoms of venous insufficiency severe enough to interfere with normal function.
3) The patient's varicose veins are large enough to account for the symptoms.
4) The patient has failed a trial of medical grade compression stockings.

Requirement (1) has been met. The patient's venous reflux study does not show clinically significant axial reflux.

Requirement (2) has been met. The office notes describe symptoms of leg pain severe enough to affect the patient's work. She needs to stand for long stretches of time because she works as a nurse's aide and as a waitress.

Requirement (3) has been met. The physician has documented moderate to large left leg varicose veins. Varicose veins of this type are a reasonable explanation for the patient's symptoms.

Requirement (4) has been met. The office note states that the patient has been using compression stockings regularly with no relief of symptoms.

Therefore, in summary, the patient meets published, well accepted criteria for performance of phlebectomy.

Coverage was denied on the basis that the patient does not have reflux. It is true that the duplex shows no evidence of axial reflux. However, the very presence of varicose veins clusters means that the patient has branch (non-axial) reflux. This is the pathophysiologic situation in which phlebectomy (without axial ablation) can be considered in a symptomatic patient [2]. 

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: Vertigo. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is an adult patient who presented to the hospital complaining of dizziness and vomiting. The patient's dizziness worsened with changes in position. The past medical history was significant for hypertension and paroxysmal atrial fibrillation. Upon arrival to the hospital, the vital signs were stable (blood pressure 184/81, pulse 66). The physical exam was within normal limits. A 12-lead electrocardiogram revealed normal sinus rhythm without ST (interval on EKG [electrocardiogram]) or T (interval on EKG) wave abnormalities. Serum blood testing revealed no significant abnormalities. A CT (computed tomography) angiogram of the head demonstrated atherosclerosis and mild to moderate stenosis of the left intracranial vertebral artery. The patient was treated with meclizine and admitted to the hospital for observation and treatment. A Neurology consultant evaluated the patient and concluded that the patient's symptoms were due to positional vertigo. The patient was discharged the following day. 

According to the European Society of Cardiology syncope guidelines, this patient was low risk for future morbidity and mortality (Reference 1). In a study of individuals presenting to the emergency room with dizziness, near syncope and syncope, patients that were low risk for cardiac events (no acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2).

This patient presented with dizziness. No significant cardiac findings were noted on serum blood testing or electrocardiogram. The head CT revealed mild to moderate atherosclerosis without occlusion or acute cerebrovascular accident (CVA). The patient was diagnosed with vertigo and was treated with meclizine. She was discharged one day after presentation. 

This patient was low risk and was diagnosed with positional vertigo. In conclusion, acute inpatient admission was not medically necessary. 

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

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

Diagnosis:  Chronic Constipation

Treatment: Linzess CAPS (capsules) 290 micrograms (mcg)

The insurer denied coverage for Linzess CAPS 290 micrograms (mcg)

The denial is overturned

The patient has had constipation, bloating, and lower abdominal pain. She was previously treated with Linzess 145 micrograms (mcg). She has also received Trulance, Amitiza, Miralax, and Senna. She has been treated with Linzess 290 mcg for over a year and her symptoms have improved.

UpToDate article titled "Management of Chronic Constipation in Adults" discusses linaclotide. It states that in two large phase 3 trials of patients with chronic constipation, the linaclotide treated groups (both 145 mcg and 290 mcg) had significantly higher rates of three or more complete spontaneous bowel movements (CSBM) per week and an increase in one or more CSBMs from baseline during at least 9 out of 12 weeks as compared with placebo.

UpToDate article titled "Treatment of Irritable Bowel Syndrome in Adults" states that in patients with IBS [irritable bowel syndrome] with constipation (IBS-C) who have failed a trial of soluble fiber, we suggest polyethylene glycol (PEG). We treat patients with persistent constipation despite treatment with PEG with lubiprostone, linaclotide, or plecanatide.

The Federal Drug Administration (FDA) has approved prescribing information for Linzess. For patients with irritable bowel syndrome with constipation, the recommended dosage of Linzess is 290 mcg daily. This patient has symptoms that are consistent with IBS-C. She has constipation, bloating and lower abdominal pain. The 290 mcg of Linzess is the advised dose for IBS-C. In addition, UpToDate reports that two large studies have shown that patients with chronic constipation had better bowel movements with Linzess 290 mcg as compared to a placebo. This patient has been on multiple regimens including Linzess 145 mcg. She did not respond sufficiently to that dose, but her symptoms are much improved on the Linzess 290 mcg. Linzess 290 mcg has been shown to be useful for both constipation and IBS-C. It is a medically necessary treatment. The insurance company did not act reasonably or with sound medical judgement.

The insurer's denial of coverage for Linzess CAPS 290 micrograms is overturned.  
Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Edarbi (azilsartan) 80mg tablet 
The insurer denied Edarbi (azilsartan) 80mg tablet. 
The denial is overturned. 

The patient is a male with hypertension. The patient is taking Edarbi 80 milligrams (mg) tablet. It has been effective and has been well tolerated. He tried and failed 3 other angiotensin receptor blockers (ARBs) including candesartan, losartan, and telmisartan. The patient requested continuation of Edarbi 80mg daily.

At issue is the medical necessity of Edarbi 80mg tablet (azilsartan).

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

The requested health service/treatment of Edarbi 80mg tablet (azilsartan) is medically necessary for this patient.

The patient has hypertension and requires therapy. The patient has tried and failed three ARBs on the plan formulary. As such, the patient has met plan criteria for using a non-formulary drug. The patient was started on Edarbi four months ago and the medication has been effective in controlling the patient's blood pressure without adverse effects. In view of failing three other ARBs, it is reasonable to continue Edarbi to maintain blood pressure control without side effects and control hypertension with a medication that has been well tolerated.

Therefore, the requested health service/treatment of Edarbi 80mg tablet (azilsartan) is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Areata. 
Treatment: Xeljanz. 

The insurer denied the Xeljanz. 
The determination is upheld. 

The patient has alopecia areata (AA). She has lost over 50% of the hair across her scalp. She has failed steroid injections. The medication under review is Xeljanz. 

The requested health service/treatment of Xeljanz is not medically necessary for this patient. 

There are no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Xeljanz for this patient's condition as an accepted standard of practice in the United States (US) prior to the standard of care treatments. There is no documentation the patient has exhausted all topical options, and that it would therefore be medically necessary to start systemic treatment with Xeljanz, which would carry a higher side effect profile. 
Chiang et al writes their 2015 study findings: that for diphenylcyclopropenone (DPCP) "treatment success, defined as 50% terminal hair regrowth, was reached in 71% of alopecia totalis patients and in 56% of alopecia universalis patients" (1). Topical squaric acid dibutylester is a sensitizing agent which is also used for the treatment of alopecia areata, and has been shown to be effective in several studies (2). Based on the documentation provided, the patient has not tried and failed all topical therapies available. These topical medications, which have been shown to be effective for the patient's condition, should be tried and failed prior to initiating Xeljanz. Within the peer-reviewed literature, Anuset et al 2016 writes "methotrexate (MTX) combined with low- to moderate-dose OC may be an efficient and well-tolerated treatment for severe AA." Thus, methotrexate and corticosteroids are an effective first-line treatment for the management of severe alopecia (4). 
Additionally, according to Phan et al "Methotrexate for alopecia areata: A systematic review and meta-analysis," published in the Journal of the American Academy of Dermatology early 2019, "Methotrexate has reasonable effectiveness in patients with severe AA...Combination treatment results in a higher complete response rate than methotrexate stand-alone treatment...Methotrexate is an effective monotherapy or adjunct therapy in combination with corticosteroids in the treatment of severe AA" (5). 
Conventional agents are appropriate agents for the treatment of the patient's alopecia. 
It is noted that the patient has tried and failed intralesional steroids. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Xeljanz prior to the standard of care treatment. 

Therefore, the Xeljanz is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility/falls
Treatment: Personal Care Aide
The insurer denied Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split Shift). The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, dementia, glaucoma, urinary incontinence and occasional bowel incontinence who had been assigned PCA (personal care aide) services based on an assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication and phone use. With tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, and toilet transfer, the patient was assessed at extensive assistance while limited assistance with tasks of toilet use and bed mobility. The patient was assessed at supervision only with task of eating. The patient had a recent fall and was hospitalized and diagnosed with multiple rib fractures and subsequently transferred to rehabilitation. 

Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split Shift) is medically necessary for this patient.
There is documentation of worsening cognitive and functional status with a fall resulting in multiple rib fractures requiring Skilled Nursing Facility (SNF) stay. The recent assessment tool performed documents an increased need for assistance with tasks of stairs, transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. There is also documentation from the patient's PCP of need for overnight PCA services to assist the patient with ADLs and Instrumental activities of daily living (IADL). There are overnight care logs indicating the patient requires assistance with ADLs at least every 2 hours which would not allow a PCA at least 5 hours of uninterrupted sleep. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 168 hours/week (split shift) are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tinnitus.
Treatment: Binaural hearing aids (code V5261) Durable Medical Equipment (V5261 x 1 and V5160 x 1).

The insurer denied coverage for binaural hearing aids (code V5261) Durable Medical Equipment (V5261 x 1 and V5160 x 1).
The denial is upheld.

This patient has a history of hearing loss and tinnitus. She states that her reasons for wanting hearing aides are:

1.	They help with augmenting the reception of and perception of external noise - masks the sound of tinnitus,
2.	Helps brain focus on outside, ambient noise. 
3.	With loud tinnitus it's impossible to participate in regular social & communicative activities: Follow a conversation, talk on phone, watch TV - hearing aids help with the external volume of the activities"

The two audiograms are similar and show a high frequency loss in both ears commencing at 6000 Hz (hertz). Her speech discrimination is 100% (percent) bilaterally at a normal intensity. The pure tone thresholds are normal at 18 dB (decibels) hearing levels in both ears. There is no information concerning the evaluation of the type of tinnitus she is complaining about nor whether other interventions have been carried out. 

The peer reviewed literature 1-4 all recommend tinnitus evaluation and the trial of various interventions. The efficacy in the use of bilateral hearing aids in a patient with minimal hearing loss and tinnitus, such as the case of the patient, has not been established. 

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

There was no evidence that the bilateral hearing aids would be efficacious in caring for her tinnitus.  

The peer reviewed literature 1-4 notes that the is no proven efficacy for the use of binaural hearing aids in a patient with minimal hearing loss as is the condition for the patient. 

The denial should be upheld as the patient complaint concerning her tinnitus did not fulfill the criteria of Durable Medical Equipment, Orthotics, Prosthetics, and Supplies- Procedure Codes and Coverage Guidelines and there is no evidence of efficacy of binaural hearing aids for tinnitus in a patient with minimal hearing loss as is the case for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, chronic obstructive pulmonary disease, dementia, breast cancer

Treatment: personal care worker (PCW) service, 7 days per week, 24 hours per day, continuous care by more than one person

The insurer denied coverage for personal care worker (PCW) service, 7 days per week, 24 hours per day, continuous care by more than one person.

The denial is overturned.

This patient of advanced age has a prior history of acute limb ischemia, congestive heart failure, chronic obstructive pulmonary disease, dementia, breast cancer, and left lower extremity embolectomy.  The documentation indicated she is dependent on others for her daily living activities.  Her health status has been rapidly deteriorating as she suffers from multiple medical conditions.  The physician indicated her conditions lead to severe limitations of functional cognitive abilities.  She does need assistance due to the need for repositioning every 2 hours as she is bedridden.  Additional documentation does indicate she was recently discharged after undergoing the embolectomy to the left lower limb.  She is bedbound and at risk for falls.  She does utilize briefs and is oriented to self.  She is hearing impaired.  She does live alone and has a daughter who will visit.  She does have a home health aide 24 hours a day.

The documentation does indicate she relies on others for activities of daily living.  The documentation does indicate she lives alone and has been cared for by a home health aide.  The documentation indicated the patient does have multiple medical conditions that do include cognitive decline leading to severe limitation.  Therefore, it would be prudent to continue the above treatment given her significant deficits.  As such, the prior determination is overturned.

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 worker (PCW) service, 7 days per week, 24 hours per day, continuous care by more than one person is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident with left hemi-plegia, legally blind and impaired cognition.
Treatment: Home Care / Personal Care HHC (home health care)- Level 2 Personal Care Services (PCS), per 15 minutes increase to 84 hours per week.

The insurer denied coverage for requested Home Care / Personal Care HHC- Level 2 Personal Care Services (PCS), per 15 minutes increase to 84 hours per week.
The denial is overturned.

The patient is a female with multiple medical problems including cerebral vascular accident with left hemi-plegia, legally blind and impaired cognition.  She receives Home Care / Personal Care HHC- Level 2 Personal Care Services (PCS), per 15 minutes increase to 70 hours per week. The request is for an increase in Home Care / Personal Care HHC- Level 2 Personal Care Services (PCS), per 15 minutes to 84 hours per week.

According to the Uniform Assessment System (UAS) report, the patient is totally dependent for meal preparation, housework and shopping.  She requires extensive to maximal assistance for bathing, dressing and personal hygiene.  She requires maximal assistance for toilet use and transfers.  She is occasionally and frequently incontinent of bowel and bladder, respectively.  The patient is cognitively impaired, blind and wheelchair dependent.   She reportedly experiences frequent hallucinations, talks to air (family who died) believes strangers are in her house and has panic attacks when left alone. The patient is unable to describe an emergency plan, call or activate an alarm in case of emergencies.  This patient's severe functional, cognitive-behavioral and vision impairments support the request for an increase in Home Care / Personal Care HHC- Level 2 Personal Care Services (PCS), per 15 minutes to 84 hours per week to allow her to continue living safely at home.    

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

From a physical medicine and rehabilitation perspective, the requested increase in Home Care / Personal Care HHC- Level 2 Personal Care Services (PCS), per 15 minutes to 84 hours per week is medically necessary.  

The insurer's denial of coverage for increase in Home Care / Personal Care HHC- Level 2 Personal Care Services (PCS), per 15 minutes to 84 hours per week is overturned. Medical Necessity is substantiated.