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

Diagnosis: Respiratory System. 
Treatment: Surgical Services. 
The insurer denied endobronchial valve device. 
The denial is overturned. 

The patient is a male with very severe chronic obstructive pulmonary disease (COPD) (with a forced expiratory volume one second [FEV1] at 26% of predicted and presence of emphysema noted on imaging) who has experienced progressive and severely disabling dyspnea (occurring with activities of daily living [ADLs] including shaving, showering, dressing) with no evidence of additional or alternative diagnoses clinically or by testing. He has progressed despite appropriate inhaled treatments and pulmonary rehab. The subject under review is whether the proposed endobronchial valve is likely to be more beneficial than any standard treatment for this patient's condition.

The health plan's determination is overturned.

The endobronchial valve device is likely to be more beneficial than any standard treatment. The patient has severe, highly disabling COPD with severe symptoms. There do not appear to be any alternative or additional diagnoses that could explain his symptoms or whose treatment could improve his dyspnea. He has already been treated with standard treatments (inhaled corticosteroids [ICS], long-acting beta agonists [LABA], long-acting muscarinic antagonist [LAMA]) as well as courses of pulmonary rehabilitation. Despite this, severely limiting symptoms persist. While true that he does not wear oxygen universally with exertion, this has not been shown to reduce mortality, hospitalizations, or most relevantly here, consistently improve exercise tolerance and reduce dyspnea.

At this point, the standard treatments for this patient have been exhausted. This leaves lung transplantation, lung volume reduction surgery, and endobronchial valves. All three are established practices and none would be considered experimental given the weight of evidence behind them. Of note, endobronchial valves do have Food and Drug Administration (FDA) approval and are given an evidence grade of A by Global Initiative for Chronic Obstructive Lung Disease. While there are adverse effects that can occur with endobronchial valve therapy, there is also substantial morbidity associated with lung transplantation and lung volume reduction surgery. In the Marchetti study cited below, benefits between the endobronchial valve group and the lung volume reduction surgery group were similar, making the less invasive approach more appealing; this effectiveness with a less invasive approach was at least part of the reason for The Global Initiative for Chronic Obstructive Lung Disease's (GOLDs) support of endobronchial valve therapy.

As such, endobronchial valve therapy is likely to be more beneficial than any standard treatment as he has already failed on standard treatments. Of the remaining treatments, endobronchial valves is at least as effective if not more with lower morbidity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia. 

Treatment: Hospital Stay.

The insurer denied coverage for the Hospital Stay.

The denial is overturned. 

This is a female patient with a history of heroin abuse and recent abortion via methotrexate who presented to the hospital with vaginal bleeding, shortness of breath, fatigue and dizziness.  The patient was found to have a low hemoglobin level of 6.  The patient's blood pressure of (BP) was 89/53.  The patient was given intravenous (IV) bolus and was admitted with a plan for transfusion and IV iron supplementation.  The patient left against medical advice (AMA) on day 2 of admission.

As per Patel et al. (2020), "Anemia is defined by hemoglobin levels under 13 g/dL [grams per deciliter] in men, and under 12 g/dL in women [1]. Anemia affects roughly 25% of the world population [2, 3], of which half is caused by iron deficiency, with 2% of American men and 5% of American women affected [2, 3].  Low iron store causes decreased levels of hemoglobin production by the bone marrow [2].  Iron is required for erythrocytes to produce heme for hemoglobin and for vital proteins in oxygen transportation [2-5]. Metabolically active cells, including myocytes, are highly dependent on this.  Previous literature has shown that in patients with untreated iron-deficiency anemia if severe enough, mortality is possible due to either poor tissue oxygenation, or cardiac arrhythmias from left ventricular hypertrophy.  There is also high morbidity due to decreased exercise tolerance, increased fatigue, and worsened quality of life index [2, 6, 7]." 

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. This patient presented with symptomatic anemia and evidence of hemodynamic instability (i.e. hypotension). Clinical guidelines, such as Milliman Care Guidelines (MCG), support acute level hospitalization for symptomatic anemia with hypotension, as in this case.

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 the Hospital Stay should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tardive dyskinesia, Parkinsonism, depression,anxiety and insomnia.
Treatment: Increase Personal Care Services to 24 Hours per Day (Live-In), Pre-service.
The insurer denied the Increase Personal Care Services to 24 Hours per Day (Live-In), Pre-service.
The denial is overturned. 

The patient is a female with a history of tardive dyskinesia, Parkinsonism, depression, anxiety and insomnia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of an increase in Personal Care Services to 24 Hours per Day (live-In) to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of an increase to 24 Hours per Day (live-In) Personal Assistance Services is deemed medically necessary.

Recent correspondence from the patient's medical provider indicates that due to progressively worsening functional decline, the patient's gait, tremor, posture and balance have made her completely dependent on assistance of others for help with transfers, ambulation, bed mobility, feeding, toileting, meal prep, dressing and her other major ADLs (activities of daily living). Hence, the currently approved plan of 49 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 24 Hours Per Day (live-In) Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: nausea/vomiting
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a female with history of asthma and food allergies who presented to the emergency department (ED) for evaluation of fatigue with nausea and vomiting. Recent events included influenza and meningococcal vaccination the day prior. Review of symptoms is negative for fevers, diarrhea, abdominal pain, shortness of breath, chest pain, dysuria, or rash. There were no ill contacts.

The inpatient hospitalization was not medically necessary. This patient presented to the ED with 1 day of vomiting and fatigue. Laboratory evaluation was normal and vital signs showed mild tachycardia which improved. The patient received intravenous fluids (IVF) and Zofran in the ED without further vomiting. There was no indication of hemodynamic instability or severe systemic illness. The patient had positive response to ED intervention. If not meeting criteria for discharge to home, this patient could easily be managed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Multiple Sclerosis; Vulvovaginal Ulcerations.
Treatment: Gamunex Injection, Pre-service.
The insurer denied the Gamunex Injection, Pre-service.
The denial is overturned. 

The patient is female who has developed pyoderma gangrenosum to the groin secondary to treatment for multiple sclerosis.  She has been treated with prednisone and cyclosporine, and has already had a favorable response to IVIG (intravenous immunoglobulin) x2.  The provider is requesting IVIG (intravenous immunoglobulin).

Yes, the health plan should cover the proposed treatment.

Pyoderma gangrenosum (PG) is an inflammatory disease characterized by painful skin ulcerations with undermined and erythematous borders. The etiology of pyoderma gangrenosum is not well understood, but it is generally considered to be an aberrant immune response characterized by a dermal neutrophilc infiltrate. Given the existence of only a few pyoderma gangrenosum clinical trials, treatment options are largely based upon anecdotal data and small case studies.  Pyoderma gangrenosum patients usually require aggressive immunosuppressive therapy to induce disease remission. The chronic nature of the disease usually requires long-term maintenance therapy to prevent relapses from occurring.

Numerous articles in peer-reviewed literature were found documenting the successful use of IVIG (intravenous immunoglobulin) in pyoderma gangrenosum.
Specifically, three articles were found in the Journal of American Academy of Dermatology. 
Two articles were found in the British Journal of Dermatology. Other articles were published in Journal of Dermatologic Treatment, Clinical and Experimental Dermatology, Australasian Journal of Dermatology, International Immunopharmacology, Clinical Drug Investigation, Internal Medicine, Pediatric Dermatology, Journal of Cutaneous Medicine and Surgery, Journal of Dermatologic Case Reports, Journal of Surgery Case Reports, and American Journal of Gastroenterology.
All articles documented the successful use of IVIG (intravenous immunoglobulin) in pyoderma gangrenosum.

Yes, the requested therapy is likely to be more beneficial for the enrollee than any available standard therapy as there are no real standards for pyoderma gangrenosum.

IVIG (intravenous immunoglobulin) has already proven beneficial for this patient and does not subject the patient to further immunosuppression.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Multiple Sclerosis; Vulvovaginal Ulcerations.
Treatment: Gamunex Injection, Pre-service.
The insurer denied the Gamunex Injection, Pre-service.
The denial is overturned. 

The patient is a female with multiple sclerosis (MS) who has been treated with ocrelizumab. She developed vulvovaginal ulcerations.  She has been treated with prednisone, cyclosporine and IVIG (intravenous immunoglobulin). Her provider is requesting IVIG (intravenous immunoglobulin).

Yes, the health plan should cover the proposed treatment with Gamunex Injection.

This patient has developed a rare, severe complication of treatment with B-cell depletion.  There will never be high quality clinical trials to support the efficacy of any particular treatment for this patient's condition. Therefore, standard of care is determined by expert opinion, case series or retrospective. In this context, IVIG (intravenous immunoglobulin) is considered an effective treatment option for vulvovaginal ulcerations related to B-cell depletion (Sacco et al.; Maloney et al.) and therefore would be appropriate here.

Yes, the Gamunex is likely to be more beneficial for the enrollee than any available standard therapy.

IVIG (intravenous immunoglobulin) is considered an effective treatment option for vulvovaginal ulcerations related to B-cell depletion (Sacco et al., Maloney et al.) and therefore would be considered and effective treatment here.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Optic neuritis. 
Treatment: Procedure code J1599- injection, immune globulin, intravenous, non-lyophilized (example liquid), not otherwise specified, 500mg [milligrams]. 

The insurer denied coverage for Procedure code J1599. 

The denial is overturned. 

This is a male patient who developed bilateral optic neuritis following an upper respiratory infection and sinusitis.  Bilateral optic neuritis following upper respiratory infection (URI) and sinusitis, negative oligoclonal band, neuromyelitis optica (NMO), and negative myelin oligodendrocyte glycoprotein (MOG) was noted.  The plan was: repeat test, reconsider differential diagnosis, repeat image; and treatment with corticosteroid, plasmapheresis, or intravenous immunoglobulin (IVIG).  It was noted the patient was quite impaired at the time. 

Another visit indicated the patient presented for follow-up on optic neuritis, cervical magnetic resonance imaging (MRI) and thoracic MRI with and without contrast revealed mild multi-level discogenic degenerative changes, and no identified abnormal enhancement of the thoracic or cervical spinal cord. 

"Twenty-three patients received treatment with IVIG and 24 matched patients who did not receive treatment with IVIG were followed as controls.  All patients had visual acuity 20/400 or worse in the affected eye.  There was significant improvement in the IVIG group with 18/23 (78%) subjects reaching near normal vision (20/30 or better), compared with the control group with only 3/24 (12.5%) responding similarly" (Tselis, A. et al. 2008). 

Dale in an editorial discussing treatment of optic neuritis if steroids fail notes that "If the patient fails to respond adequately in the 1st week of corticosteroids, further adjunctive therapies can be considered such as intravenous immunoglobulin (IVIG)...

This patient a good candidate for procedure code J1599- injection, immune globulin, intravenous, non-lyophilized (example liquid), not otherwise specified, 500mg [milligrams] and has been refractory to other treatment.  Procedure code J1599 is the best available treatment for this patient at this time. 

He is a good candidate and has been refractory to other treatment.  Being rare, high quality peer review medical articles are not available.  The available literature supports the requested service is likely to be more beneficial than any other standard treatment or procedure.             

The carrier's denial of coverage for procedure code J1599- injection, immune globulin, intravenous, non-lyophilized (example liquid), not otherwise specified, 500mg should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Optic neuritis. 
Treatment: Procedure code J1599- injection, immune globulin, intravenous, non-lyophilized (example liquid), not otherwise specified, 500mg [milligrams]. 

The insurer denied coverage for Procedure code J1599. 

The denial is overturned. 

This is a male patient who presented for a consultation.  He was well until he noted some visual problems.  He had difficulty with peripheral vision in the lower part of the right eye.  It was a subtle problem.  Over the next 2 weeks he saw an Ophthalmologist who referred him to a second Ophthalmologist who diagnosed him with optic neuritis.  It was noted it would get better without treatment and he could consider steroid treatment.  He returned to the first Ophthalmologist.  5 days later he was concerned that the vision was getting worse.  He was referred to a third Ophthalmologist.  A brain magnetic resonance imaging (MRI) scan was obtained and lumbar puncture was recommended.  He was admitted to the hospital and received a course of intravenous (IV) high-dose steroids without taper.  His vision was improving with steroids.  The swelling went down and his vision returned to a limited extent.  He was left with central scotoma with red desaturation.  He was also noted to be red/green color blind.  He was diagnosed with bilateral optic neuritis.   Etiology for bilateral optic neuritis was unclear.  The patient received a blood antibody test that turned out negative.  He was told he did not have multiple sclerosis.  He recalled hearing the possibility of neurosarcoidosis.  The request was made for a trial of intravenous immunoglobulin (IVIG) for complete recovery from optic neuritis, monthly for 6 months, assuming there was no objection from the Neuro-ophthalmologist. 

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. The procedure code J1599- injection, immune globulin, intravenous, non-lyophilized (example liquid), not otherwise specified, 500mg [milligrams] does need final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is a good candidate for procedure code J1599. 

The procedure code J1599 is the best available treatment for this patient at this time. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

IVIG is a safe treatment option in bilateral optic neuritis for acute relapses when there is a failure of improvement with corticosteroids, and plasmapheresis is not available, or for relapse prevention where current therapies are contraindicated or not efficient enough to prevent relapses. 

The carrier's denial of coverage for procedure code J1599- injection, immune globulin, intravenous, non-lyophilized (example liquid), not otherwise specified, 500mg should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Optic neuritis. 
Treatment: Procedure code J1599- injection, immune globulin, intravenous, non-lyophilized (example liquid), not otherwise specified, 500mg [milligrams]. 

The insurer denied coverage for Procedure code J1599. 

The denial is upheld. 

This is a male patient who developed bilateral optic neuritis. He was initially treated with high dose steroids. The current request is for treatment with intravenous immunoglobulin (IVIG). 

The scientific evidence in the peer-reviewed literature does not support improvement in health outcome with the treatment of IVIG for optic neuritis.  The results of IVIG on the visual outcomes from optic neuritis are variable.  Some studies report that IVIG has no effect on long-term visual function after acute optic neuritis (Roed 2005), while other studies found that IVIG improves visual recovery in refractory cases of acute optic neuritis (Ruprecht 2004).  Thus, the literature suggests that IVIG is still not proven for the treatment of optic neuritis. 

Procedure code J1599- injection, immune globulin, intravenous, non-lyophilized (example liquid), not otherwise specified, 500mg [milligrams] does not have Food and Drug Administration (FDA) approval for the diagnosis of optic neuritis. 

This patient is not a good candidate for procedure code J1599.  The patient has refractory optic neuritis with residual visual deficits.  The patient previously received one dose of steroids during a recent hospitalization, but the medical records do not indicate he has received any other treatments since then.  High-dose steroid administration is usually used as first-line treatment for optic neuritis, rather than IVIG. However, in patients who do not respond to steroids and continues to have vision loss, IVIG are alternative immunomodulatory therapies that may offer additional benefit for optic neuritis treatment (Altunrende 2019, Horton 2018). 

J1599 is not the best available treatment for this patient at this time.  High-dose steroid administration is usually used as first-line treatment for optic neuritis, and other than receiving one dose of steroids in the past, the patient has not received any further steroid treatments. 

The requested service is not likely to be more beneficial than the standard treatment/procedure for this patient. 

The carrier's denial of coverage for procedure code J1599- injection, immune globulin, intravenous, non-lyophilized (example liquid), not otherwise specified, 500mg should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 

Treatment: Inpatient services.

The insurer denied coverage for the inpatient services.

The denial is upheld. 

This is a female patient with a medical history of hypertension, hyperlipidemia, and non-ST elevation myocardial infarction, status post stent. This patient presented to the Emergency Department (ED) with thirty minutes of chest pain while driving. On arrival to the hospital, the patient's physical exam was unremarkable. The patient's electrocardiogram (EKG) revealed no evidence of acute ST or T wave changes. The patient's troponin levels were not elevated and the patient was discharged following medical therapy with an outpatient appointment for stress testing.  

Based on the review of the medical record and literature, inpatient services are not considered medically necessary for this patient. The patient's pretest probability of coronary artery disease is high given her history of right coronary artery (RCA) stent placement.1  Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (2018).  Using the history, electrocardiogram, age, risk factors, and initial troponin (HEART) score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. In conclusion, acute inpatient services were not medically necessary for this patient. This patient could have been managed at a lower level of care.

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

The carrier's denial of coverage for inpatient services should be upheld.  The medical necessity is not substantiated.