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

Diagnosis: Rhinosinusitis
Treatment: Dupixent SC Injection, Pre-Service
The insurer denied the Dupixent SC Injection, Pre-Service.
The denial is overturned. 

The patient is a female with a history of chronic rhinosinusitis with polyps.  The request is for approval for Dupixent.

Yes, the proposed Dupixent is medically necessary.

The medical provider indicated that the patient has had a prior nasal surgery.  After the surgery, the patient has persistent nasal congestion and sinusitis despite treatment with oral decongestants, intranasal corticosteroids and oral steroids.  The patient has evidence of nasal polyps on recent computed tomography (CT) scan included in the file.

Dupixent is the first Food and Drug Administration (FDA) approved medicine for adults with chronic rhinosinusitis with nasal polyposis, and the only approved therapy shown to shrink nasal polyp size and also improve the signs and symptoms of the associated chronic rhinosinusitis.  According to the LIBERTY clinical trial program evaluating Dupixent 300 milligrams (mg) every two weeks with standard-of-care mometasone furoate nasal spray compared to placebo.  At 24 weeks, patients treated with Dupixent achieved statistically significant improvements in nasal congestion/obstruction severity, reduction in their nasal polyps score, improvement in sinus opacification, and improvement in loss of smell.  This patient has persistent nasal polyposis after nasal surgeries, and suffers from recurrent rhinosinusitis despite treatment with intranasal corticosteroids and oral steroids.  Therefore, Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty Swallowing
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who had presented to the hospital with complaints of difficulty swallowing. The patient underwent an acute hospitalization.  The patient had experienced decreased tolerance to foods and a weight loss of 30 pounds. The patient had undergone multiple endoscopies and colonoscopies which returned negative. The patient reported that she was on Dexilant, Pepcid, and Protonix with minimal improvement. The patient reported a loss of ability to carry out her activities of daily living (ADL). The patient received intravenous fluid at 80 milliliters per hour, Protonix and Lovenox 40 milligrams subcutaneous daily. The patient was evaluated by a gastroenterologist who made the recommendation for a gastric emptying study, daily Protonix, and aspiration precautions.  The patient's symptoms improved. The patient was discharged with a plan for follow-up.

No, the proposed inpatient admission was not medically necessary.
While the services provided were medically appropriate, the level at which the care was provided was not medically necessary.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had dysphagia, yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gastroesophageal reflux disease.
Treatment:  Esophagogastroduodenoscopy.

The insurer denied the Esophagogastroduodenoscopy.  The determination is upheld.

This is a patient with gastroesophageal reflux disease (GERD). He had persistent gastroesophageal reflux disease symptoms despite omeprazole 20 milligrams (mg) daily. He presented with anemia and heartburn; he had been noted to have a low hemoglobin and normal iron level, followed by a normal hemoglobin level on reassessment. He presented on omeprazole and Pylera for the treatment of a Helicobacter pylori infection, with increased reflux. At issue is the medical necessity of an esophagogastroduodenoscopy.

The medical necessity of an esophagogastroduodenoscopy is not supported by the provided documentation. Per the most recent American Society for Gastrointestinal Endoscopy guidelines for appropriate use of endoscopy, colonoscopy is recommended for evaluation of iron deficiency anemia [1]. Esophagogastroduodenoscopy (EGD) is recommended for evaluation of anemia only if a colonoscopy does not reveal a cause [1]. Additionally, the patient did not have documented persistent anemia, or documented iron deficiency.

Clinical guidelines recommend endoscopy for investigation of upper gastrointestinal symptoms (such as gastroesophageal reflux disease) when those symptoms are refractory to proton pump inhibitor taken properly for 4-8 weeks without response [2]. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful [1]. The most recent American College of Physicians guidelines for use of upper endoscopy in gastroesophageal reflux disease state that upper endoscopy is indicated in men and women with heartburn and alarm symptoms, such as bleeding [2]. The most recent American College of Gastroenterology guidelines for investigation of dyspepsia state that EGD is warranted if symptoms have been refractory to proton pump inhibitor for 4-8 weeks [3]. In this case, documentation that symptoms were refractory to continuous proton pump inhibitor for at least 4 weeks, as recommended by the most recent American College of Gastroenterology guidelines for gastroesophageal reflux disease (GERD), is lacking [4]. Other indications for endoscopy, such as melena, were also not documented. These statements are concordant with more recent guidelines and literature [5-7].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male with a history of seizure who presented after having seizure. At presentation the patient was poorly responsive. He was loaded on parenteral levetiracetam. While in the emergency ward, the patient became alert and oriented. He reported noncompliance with his anticonvulsant regimen. Computed tomography and magnetic resonance image (MRI) of the brain were unchanged from previous evaluations.

No, the acute inpatient admission from was not medically necessary.

The patient had a pre-existing diagnosis of seizure disorder, reported noncompliance with his treatment regimen and returned to his neurological baseline without recurrent events after treatment in the emergency ward. The clinical evaluation, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis.
Treatment: Inpatient hospital admission.

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

This male patient has a benign past medical history who presented to the Emergency Department (ED) with complaints of left arm cellulitis. The patient's vital signs on presentation included: Temperature 97.6 F, Blood Pressure 125/83, Pulse 126, Respiratory Rate 20, Oxygen (O2) saturation 97% on Room Air. The patient's laboratory results included the following: white blood cell (WBC) 7.4, hemoglobin 14.6, hematocrit 47.4, creatinine 0.81, and glucose 100.The patient was started empirically on intravenous (IV) antibiotics (i.e., vancomycin) for a left arm cellulitis. The patient's x-ray of the arm showed soft tissue swelling.  Orthopedics consulted and determined no surgical intervention was required. Infectious Diseases consulted recommended antibiotics. Wound cultures remained negative. The patient remained afebrile, and hemodynamically stable. The patient was discharged to continue outpatient management. 

According to documentation, the patient returned with a left forearm cellulitis.  Otherwise, the patient was afebrile, stable hemodynamically with no evidence for systemic toxicity.  The patient's laboratory values were unremarkable including a normal white blood cell (WBC) count. he patient was able to tolerate oral intake and did not require any surgical intervention.  According to ED note, the patient was noted to "appear very well, playing with Rubik's cube in triage...able to range his elbow without a problem...". Based on above findings, the patient did not fulfill criteria for acute inpatient admission. 

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

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genetic screening.
Treatment: Genetic Testing (81405).
The insurer denied the Genetic Testing (81405).
The denial is upheld. 

The patient is a female. She underwent extensive genetic carrier screening. Both she and her husband were found to be carriers of Canavan disease and of familial dysautonomia.

Based on the documentation, the patient had an expanded carrier screening panel. It is unknown what prompted this test. It is unknown what the patient's personal history, family history and ethnic background are. It is unknown, since the patient was tested for 283 conditions, what the Current Procedural Terminology(CPT) code Genetic Testing (81405) Molecular pathology procedure, Level 6, (e.g., analysis of 6-10 exons by Deoxyribonucleic Acid(DNA) sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons) refers to. Both Canavan disease and familial dysautonomia are part of an Ashkenazi Jewish Panel (11 Tests): CPT 81412.

No, based on the submitted information (and lack of significant information), the proposed treatment is not medically necessary.

According to the American College of Obstetricians and Gynecologists (ACOG), it is important to obtain the family history of the patient and, if possible, her partner, as a screening tool for inherited risk. The family history should include the ethnic background of family members as well as any known consanguinity. Individuals with a positive family history of a genetic condition should be offered carrier screening for the specific condition and may benefit from genetic counseling.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Gender Dysphoria. 
Treatment: Surgical Services. 
The health plan denied mastectomy, nipple reconstruction, removal of excess skin. 
The health plan's determination is partially overturned. 

The patient is a female to male (FtM) transgender who has been on hormone therapy. They have been living and dressing as a male. They have dysphoria regarding breast appearance and cannot look at them in the mirror. Masculinizing chest surgery is recommended. The subject under review is the medical necessity for mastectomy, nipple reconstruction surgery, removal or excess skin.

The health plan's determination is overturned in part. 

Mastectomy and nipple reconstruction is medically necessary, removal of excess skin is not medically necessary. Codes 19303, and 19350 are medically necessary. Code 15839 is not medically necessary. Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines:
Criteria for Breast/Chest Surgery (One Referral)
Criteria for mastectomy and creation of a male chest in 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 has been on hormone therapy for one year. He is the age of majority. He does not have significant mental health concerns at this time other than dysphoria regarding the breasts. A mental health professional has recommended the mastectomies and nipple reconstructions. Removal of excess skin is not medically necessary. Excess skin removal is not a standard or required procedure for gender transformation. Removal of excess skin is to improve appearance of the axillae and is not medically necessary. Code 15839 is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids.
Uterine Surgery (ablation with imaging guidance) (0404T).
The insurer denied the Uterine Surgery (ablation with imaging guidance) (0404T).
The denial is upheld.

The patient is a female with menorrhagia and a fibroid uterus.  She has failed OCPs (oral contraceptive pills) and IUD (intrauterine device).  She has an enlarged fibroid uterus with six fibroids measuring 4.6 cm (centimeters), 2.4 cm (centimeters), 2.4 cm (centimeters), 3.0 cm (centimeters), 1.9 cm (centimeters), and 1.6 cm (centimeters).  The plan is for the Sonata procedure.

No, the health plan should not cover the Uterine Surgery (ablation with imaging guidance) (0404T), because it is not medically appropriate.

Per Toub et al, "This article provides the current evidence related to transcervical radiofrequency ablation of uterine fibroids under integrated intrauterine sonography guidance (the Sonata System).

"Published data on the treatment of fibroids with the Sonata System has demonstrated significant median reductions in total (73.3%) and perfused (73.3%) uterine fibroid volume, menstrual bleeding (72.3%), symptom severity (62.5%), and improvements in health-related quality of life (127%) at 12 months post-ablation. A clinical trial under an FDA [Food and Drug Administration] Investigational Device Exemption is in progress.

"The Sonata System is a promising treatment modality for uterine fibroids. As an incisionless, minimally invasive treatment that does not require general anesthesia or hospitalization, it has the potential for redefining the current paradigm for management of symptomatic fibroids."

In summary, there are not any large randomized controlled trials or large observational tried that provide evidence that this procedure is better than the alternative options.  There are also no data to support use of this procedure as being effective and safe long-term in patients with symptomatic uterine myomas as compared to other alternatives.  This procedure is also not endorsed by the American College of Obstetrics and Gynecology who provides the guidelines for OB/GYNs (Obstetricians/Gynecologists) in the United States.  Therefore this is not considered a standard of medical practice at this time.  Therefore, it should not be covered by the health plan, as it is not medically appropriate.

No, the Uterine Surgery (ablation with imaging guidance) (0404T) is not likely to be more beneficial.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids.
Uterine Surgery (ablation with imaging guidance) (0404T).
The insurer denied the Uterine Surgery (ablation with imaging guidance) (0404T).
The denial is upheld. 

The patient is a female with a diagnosis of symptomatic fibroids. Ultrasound showed 6 fibroids less than 5 cm (centimeters) in size each. The provider and patient are requesting coverage for transcervical Radiofrequency Ablation of Uterine Fibroids, transcervical radiofrequency ablation for the treatment of uterine fibroids using the Gynesonics Sonata System.

No, the health plan should not cover the Uterine Surgery (ablation with imaging guidance) (0404T). There are safer and proven methods to manage her fibroids.

The Sonata System combines intrauterine ultrasound (IUUS) with radiofrequency (RF) ablation in a single handpiece. Sonata is suitable in an inpatient or outpatient setting, and is intended for diagnostic intrauterine imaging and transcervical treatment of symptomatic uterine fibroids, including those associated with heavy menstrual bleeding.

The Sonata system is FDA (Food and Drug Administration)-approved for the management of fibroids. There are multiple studies documenting the safety and efficacy of this procedure in controlling symptoms due to fibroids.

Symptomatic improvement is observed within the first three months postprocedure, and this improvement has been maintained at least through 24 to 36 months of follow-up. Note that this patient is not planning on conceiving and her fibroids are less than 5 cm (centimeters) in size, consistent with the Sonata system recommendations.

However, established alternatives include a hysterectomy, which will be the best option for this patient, since she has more than five fibroids with a high recurrence rate.

The requested health service or procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.

Transcervical radiofrequency ablation is a very effective way to treat fibroids. However, established alternatives include a hysterectomy which will be the best option for this patient since she has more than five fibroids with a high recurrence rate.  A myomectomy is an option, if the patient would like to keep her uterus, and uterine artery embolization.

All those alternatives have a long history of safety and effectiveness, and the requested health service or procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids.
Uterine Surgery (ablation with imaging guidance) (0404T).
The insurer denied the Uterine Surgery (ablation with imaging guidance) (0404T).
The denial is overturned. 

The patient is a woman with a history of uterine fibroids and menorrhagia. She consulted a gynecologist. A pelvic ultrasound revealed two submucous myomas. Multiple medical and surgical treatment options were discussed. Transcervical radiofrequency myoma ablation was recommended.

Yes, the health plan should cover the Uterine Surgery (ablation with imaging guidance) (0404T).

The medical records and medical literature were thoroughly reviewed. Uterine fibroids are the most common benign pelvic tumors in women. More than one-half report symptoms, such as menorrhagia. A variety of treatment options are available to women with symptomatic uterine fibroids, including surgical or procedural treatments. For those who desire uterine conservation these include laparoscopic or abdominal myomectomy, and laparoscopic or transcervical radiofrequency ablation. Radiofrequency (RF) ablation, which can be delivered by laparoscopic, transvaginal, or transcervical approaches has been studied in the medical literature and given FDA (Food and Drug Administration) approval for myoma treatment.

Transcervical fibroid ablation (TFA) has certain advantages that might appeal to patients, including a noninvasive delivery method, uterine preservation, ability to treat a wide range of fibroid types, avoidance of general anesthesia, and rapid recovery and return to ADLs (activities of daily living) following the procedure. The procedure is incisionless and preserves the uterus. Unlike operative hysteroscopy, TFA (transcervical fibroid ablation) is designed for ablation of most nonpedunculated fibroid types.

Considering the demonstrated safety and efficacy of the Sonata treatment in a diverse patient population treated by a large number of treating physicians and different care settings, this treatment has become an acceptable option when provided by an experienced gynecologist. The clinical division of the attending gynecologists have demonstrated extensive experience in this procedure. Transcervical radiofrequency ablation a less invasive option for uterine conservation than surgical intervention. Therefore the treatment is medically appropriate.

Yes, the Uterine Surgery (ablation with imaging guidance) (0404T) is likely to be more beneficial.

Considering the demonstrated safety and efficacy of the Sonata treatment in a diverse patient population treated by a large number of treating physicians and different care settings, this treatment has become an acceptable option when provided by an experienced gynecologist. Other treatment options for uterine conservation in patients with symptomatic myomas include laparoscopic or abdominal myomectomy. Transcervical radiofrequency ablation is a less invasive option for uterine conservation than surgical intervention. Therefore the requested procedure likely to be more beneficial than any standard treatments for the insured's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dysphagia.
Treatment: Inpatient hospital admission.

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

This is a female patient with a history of a cerebrovascular accident (CVA) who presented with dysphagia.  The patient had a diagnosis of gastroesophageal reflux disease (GERD) but was not on a proton pump inhibitor (PPI), medication therapy.  She had a cough but no fever.  Her abdominal exam was benign.  The patient's chest X-ray showed a possible infiltrate.  The patient was started on PPI therapy.  Her esophagram was negative for a mass of stricture.  The patient's endoscopy was also negative for a stricture.  A swallowing evaluation was done, and the patient was able to tolerate a diet.

Clinical indications for admission for Esophageal Disorder, according to Milliman Care Guidelines (MCG), include hemodynamic instability, esophageal perforation, complete esophageal obstruction, severe vomiting, severe dehydration, severe electrolyte abnormalities and an inability to maintain oral hydration.  In this case, the patient did not have these conditions.

The patient required a work-up for dysphagia.  However, inpatient admission was not medically necessary for this patient.  Both the esophagogastroduodenoscopy (EGD) and esophagram were negative for stricture or obstruction.  The patient was stable to have had these tests done in an outpatient setting.  There was a concern about a pulmonary infiltrate.  However, this could have been treated with oral antibiotics as an outpatient.  The swallowing evaluation and PPI therapy could also have been done as an outpatient.  The patient did not meet the MCG criteria for admission for esophageal disorders.  

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 should be upheld.  The medical necessity is not substantiated.