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

Diagnosis: Ankylosing Spondylitis
Treatment: Enbrel
The insurer denied Enbrel.
The determination is overturned.

The patient has with ankylosing spondylitis (AS). Per a letter from the health plan, per the plan's criteria, Enbrel is only covered if it is known whether the patient is using it in combination with a biologic or target synthetic disease modifying anti-rheumatic drug (DMARD). Prior treatment included: methotrexate (MTX), sulfasalazine (SSz). Per the last note from the provider, under current medications, Enbrel, SSz and MTX are listed, however it is unclear what the patient is actually taking. In the plan section, it states the patient is on SSz but nothing else and current medications are listed again . Of note, Cosentyx is listed in addition to MTX and SSz on the 'current medications' list from an earlier note but again, all it says is patient has not responded to SSz and then it states she is on SSz. There is no mention of MTX or Cosentyx or Enbrel in the plan. At issue is the medical necessity of Enbrel.

The requested health service/treatment of Enbrel is medically necessary for this patient to treat her ankylosing spondylitis as she is having breakthrough symptoms on the current regimen. 
 It was not clear from the information provided whether the patient was already on a biologic and what disease modifying anti-rheumatic drug (DMARD) she was taking. 
Clearer documentation to determine what the patient was actually taking for her AS was needed. It was unclear whether she was on MTX or SSz or whether she was actually taking Enbrel or Cosentyx. More documentation was required before Enbrel could be safely prescribed.
Additional information was requested, received, and reviewed. The patient is currently on two DMARD's, MTX and SSz. Given that it is now known that the patient is not already on a biologic, there is no medical reason she cannot undergo a trial of Enbrel for the treatment of her AS. 
Therefore, the Enbrel is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

The patient is a female with a past medical history remarkable for hyperlipidemia, who presented for light headedness and palpitations. Review of system was positive for syncope episodes in the past, diarrhea and nausea. The patient was afebrile (Temp of 36.1 Celsius). She was described as well-developed and with no acute distress. Her blood pressure was 118/80, pulse rate of 97, respiratory rate of 18, and oxygen saturation of 99% (percent) on room air. Physical examination was unremarkable for positive clinical findings. The patient was admitted for cardiogenic versus vasovagal syncope. 

The inpatient hospital admission was not medically necessary for this patient. The patient's care could have been safely rendered at a lower level for intravenous (IV) hydration and syncope workup.

The patient was admitted for syncope in the setting of hypovolemia and diarrhea. The clinical workup was negative, and the patient had no focal neurologic signs. Additionally, the patient's clinical course did not worsen. The patient's electrolytes and kidney function were normal.

Based on the possible syncope diagnosis, the patient did not meet Milliman Care Guidelines (MCG) criteria for inpatient admission for syncope. She did not have any evidence of cardiac abnormalities. She had no evidence of hemodynamic compromise or neurologic deficits. Observation evaluation would have been appropriate given very low risk (0.4% 30-day) for serious adverse event related to syncope based on the Canadian risk score.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This is a case of a gentleman that presented to the hospital complaining of chest pain and shortness of breath. Past medical history was significant for recent onset atrial fibrillation, diabetes mellitus, hypertension, and obstructive sleep apnea. Upon arrival, the patient was tachycardic with a pulse of 147 bpm (beats per minute). Blood pressure was stable (127/87 mmHg [millimeters of mercury]). Physical exam revealed no positive findings other than an irregularly rapid pulse. Serum blood testing revealed hyperglycemia (330mg/dl [millimeters per deciliter]) and no elevation in serum troponin (0.01). A 12-lead electrocardiogram revealed atrial fibrillation with rapid ventricular rates. The patient was admitted to the hospital and underwent successful transesophageal echocardiogram with DC (direct current) cardioversion. After sinus rhythm was restored, he was released with follow up.

The health plan did not act reasonably. Admission for monitoring and treatment was medically necessary. Patients presenting with atrial arrhythmia with ventricular rates up to 140 require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. [1] American Heart Association/American College of Cardiology Guidelines for the management of patients with atrial fibrillation recommend telemetry monitoring for patients treated with atrial fibrillation requiring treatment with rate control and antiarrhythmic therapies. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. [2] In conclusion, inpatient hospital admission was medically necessary in this case. 

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infected sebaceous cyst.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with an infected sebaceous cyst of the back. The patient had a prior incision and drainage, and continued to fail outpatient antibiotics and prior incision and drainage. He presented for IV (intravenous) antibiotic therapy and operative incision and drainage.

Yes, the Inpatient admission was medically necessary.
The patient failed outpatient medical treatment for infected sebaceous cyst. The patient was seen again and required repeat incision and drainage, along with IV (intravenous) antibiotics. The patient was offered bedside incision and drainage, but declined due to not being able to tolerate it.

Therefore, given the above, the Inpatient admission was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient had recurrent infection of the sebaceous cyst that required further incision and drainage of the infected sebaceous cyst, as well as IV (intravenous) antibiotic therapy. On review of the documentation, the patient did meet inpatient criteria for his treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: oncology (prostate) messenger ribonucleic acid gene expression profiling of 22 content genes. 
The insurer denied oncology (prostate) messenger ribonucleic acid gene expression profiling of 22 content genes. 

The determination is upheld.

The patient who had a needle biopsy of the prostate performed for investigation of an elevated prostate-specific antigen (PSA) 4.64. Gleason Grade Group 2 disease was recognized. His clinical stage is T1c. Decipher testing was performed and is under review.

No. This is a prognostic test purportedly beneficial to assist in treatment planning. However, literature does not support the use of this test in this clinical situation.
The American Society of Clinical Oncology (ASCO) notes, " With various degrees of value and validation, multiple biomarkers have been shown to refine risk stratification and can be considered for select men to improve management decisions. There is a paucity of prospective studies assessing short- and long-term outcomes of patients when these markers are integrated into clinical decision making. Tissue-based molecular biomarkers (evaluating the sample with the highest volume of the highest Gleason pattern) may improve risk stratification when added to standard clinical parameters, but the Expert Panel endorses their use only in situations in which the assay results, when considered as a whole with routine clinical factors, are likely to affect a clinical decision. These assays are not recommended for routine use as they have not been prospectively tested or shown to improve long-term outcomes-for example, quality of life, need for treatment, or survival."
The National Comprehensive Cancer Network (NCCN) notes the test is one of several that have been marketed with significant industry influence and no randomized controlled studies.
Literature and specialty societies do not endorse the test for favorable intermediate or low risk prostate cancer.

The health plan's determination is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: oncology (prostate) messenger ribonucleic acid gene expression profiling of 22 content genes.
The insurer denied oncology (prostate) messenger ribonucleic acid gene expression profiling of 22 content genes. 

The determination is upheld.

The patient has prostate cancer and had the Decipher Prostate Biopsy Test performed. The original biopsy was positive and demonstrated a Gleason 3+4=7 adenocarcinoma. The clinical stage was T1c. The prostate-specific antigen (PSA) was less than (<) 10.
At issue is whether the oncology (prostate) messenger ribonucleic acid gene expression profiling of 22 content genes is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No. This is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This is a patient with prostate cancer who had the Decipher Prostate Biopsy Test performed. 
Per the American Urological Association (AUA) Guidelines, "Guideline Statement 32: Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up."
The National Comprehensive Cancer Network (NCCN) Guidelines state that "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclear." "Any of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."

The health plan's determination is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal syndrome, Metabolic Acidosis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


The patient has a past medical history (PMH) of alcohol abuse with prior withdrawal and was admitted  with complaints of (c/o) acute alcohol withdrawal associated with hallucinations, tremors, and possible coffee-ground emesis. Vital signs were notable for a pulse of 125. The physical exam was notable for diffuse abdominal tenderness. Lab work was significant for anion gap metabolic acidosis [AGMA] (bicarbonate 13) and creatinine 3.12 (baseline 3.12). Imaging studies, a right upper quadrant (RUQ) ultrasound (US) showed steatohepatitis, a computed tomography (CT) scan of the head showed no acute intracranial abnormality. An electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with acute alcohol withdrawal and treated with intravenous fluids (IVF), anti-emetics, Clinical Institute Withdrawal Assessment (CIWA), benzodiazepines (BZDs), and a multi-vitamin. The patient's CIWA was noted to be 22 in ED. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

Yes, the hospital stay was medically necessary at an acute inpatient level of care.
The patient had a medical history and physical exam clinically concerning for acute alcohol withdrawal in the setting of recent alcohol cessation. This presentation was further compounded by the patient's clinical concern for coffee-ground emesis and the patient's known metabolic acidosis and severe acute kidney injury, and these types of patients are not appropriate for a lower level of care due to the close clinical monitoring that is required to ensure no respiratory depression and adverse events, including seizures, delirium tremens, Wernicke-Korsakoff syndrome, or severe metabolic or electrolyte derangements. Overall, this patient could not have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Constipation. 
Treatment: Botox (onabotulinumtoxin A (cosmetic)) to treat outlet dysfunction constipation. 

The insurer denied coverage for Botox (onabotulinumtoxin A(cosmetic)) to treat outlet dysfunction constipation. 

The denial is overturned. 

The patient has a history of chronic constipation and outlet dysfunction, He finished 10 sessions of biofeedback with minimal improvement. He spends hours each day on the toilet. Anorectal motility showed sawtooth and paradox. Fecal defecography showed minimal floor motion with squeeze or strain. There was no anatomical pathology. His colorectal surgeon has now advised Botox injection to the levator muscles. It was felt to be a safer alternative to surgery. 

Diseases of the Colon and Rectum 2000 Mar;43{3):376-380 has an article titled "Botulinum toxin in the treatment of outlet constipation caused by puborectalis syndrome." The conclusion was that botulinum toxin injection should be considered as a simple therapeutic approach in patients with puborectalis syndrome. It was advised that because the efficacy of the toxin wears off within 3 months, repeated injections could be necessary to maintain clinical improvement. 

The American Journal of Gastroenterology 2006 Nov(November); 1010(11):2570-5 has an article titled "Experience with type A botulinum toxin for treatment of outlet-type constipation." The conclusion was that botulinum toxin injections should be considered as a simple therapeutic approach in patients with obstructed defecation. The treatment is safe and effective. Repeated injections may be necessary. 

The World J Gastrointest Pharmacol Ther. 2016 Aug (August) 6;7(3):453-62 has an article titled "Efficacy and safety of botulinum toxin in treatment of anismus: A systematic review." The conclusion was "Initial satisfactory improvement of symptoms after BTX-A (Botox type A) injection remarkably deteriorated after 3 months of the procedure. However, repeated injection may provide better sustained results with no additional morbidities." 

The scientific literature supports the use of Botox injections for constipation with outlet dysfunction. The health care plan did not act reasonably or with sound medical judgment. Botox to treat outlet dysfunction is medically necessary for this patient. 

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 Botox (onabotulinumtoxin A) to treat outlet dysfunction constipation is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Prefabricated abutment (6056) and (6062) high noble metal abutment supported crown for implant #9.
The insurer denied prefabricated abutment (6056) and (6062) high noble metal abutment supported crown for implant #9.
The determination is overturned.

The patient presented  for evaluation and treatment of tooth number (#) 9. Provided for review are previous letters of appeal and denial, a full mouth radiographic panoramic image, one page of American Dental Association (ADA) claim forms, a narrative from the patient, letters of approval from the health plan for implant (6010) for site #9. At issue is the medical necessity of the planned treatment of prefabricated abutment (6056) and (6062) high noble metal abutment supported crown for implant #9.

As tooth replacement with a dental implant was approved , there is a need for replacement of the missing tooth portion. After the implants have integrated they will require restorations in the form of abutments and crowns in order to complete the tooth replacement. There is no other way of utilizing the dental implant in this site. The abutment and crown are an extension of the implant placement and are all part of tooth replacement. Hence, the entire treatment of pre fabricated abutment (6056) and (6062) high noble metal abutment supported crown are both medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasis. 
Treatment: POEM (peroral endoscopic myotomy) procedure. 

The insurer denied coverage for POEM procedure. 

The denial is overturned. 

The patient has a diagnosis of achalasia and is having increasing dysphagia. She has now developed significant weight loss. A workup was done, and a diagnosis was made of achalasia. Her physician has advised a POEM procedure as an alternative to a Heller myotomy. 

Up To Date article titled "Peroral Endoscopic Myotomy (POEM)" states that POEM is the endoscopic equivalent of surgical myotomy and a newer technique for the management of achalasia. The POEM procedure can be performed in most patients who have symptomatic, manometry proven primary idiopathic achalasia. It has been shown to be highly efficacious in the short-term management of achalasia. A summary of 14 studies of POEM showed a success rate of 82% (percent). Less than 4 percent required retreatment for achalasia. A subsequent study that involved 117 patients with achalasia undergoing the POEM procedure and were followed for 545 days found a success rate of 91%. It was found to be equally successful as compared to a surgical myotomy in controlling symptoms at the 2-year point. The article states that based on current literature, patients with achalasia should be informed that POEM and a Heller myotomy are equally effective in relieving dysphagia. 

The scientific literature supports the use of the POEM procedure in improving health outcomes. The POEM procedure has been approved by the FDA (Food and Drug Administration). The patient is a good candidate since she has increasing symptoms of dysphagia from achalasia. There are alternative treatments for achalasia but the POEM procedure has been shown to be effective and safe. The POEM procedure is less invasive than a surgical myotomy and is therefore likely to be more beneficial for the patient without increased risk. 

The carrier's denial of the PEOM Procedure should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasis. 
Treatment: POEM (peroral endoscopic myotomy) procedure. 

The insurer denied coverage for POEM procedure. 

The denial is upheld. 

The patient is diagnosed with achalasia. The patient has had an extensive work-up as per the provided records. As definitive treatment, the provider has requested the provision of the peroral endoscopic myotomy (POEM) procedure. The plan declined coverage. This is the subject of this review. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. There is insufficient literature to permit a conclusion on the durable benefit of the POEM procedure. It does have final approval from the appropriate regulatory bodies for this diagnosis. The POEM procedure is in use and is described in the literature. It is a surgical procedure, not a device or medication. 

The patient is not a good candidate for POEM. There is insufficient literature to permit a conclusion on the durable benefit of the POEM procedure. As such it remains investigational.  POEM is not the best available treatment for this patient at this time. A Heller myotomy remains the standard approach to this condition.  

There are no adverse risks increased over standard treatment/services. The risk is that the long-term outcomes have not been shown to be equal or superior to currently available techniques. There is insufficient literature to permit a conclusion on the durable benefit of the POEM procedure. The requested POEM is not likely to be more beneficial than any of the standard treatments. The patient is diagnosed with achalasia. The POEM has not been demonstrated in literature to be more beneficial. A Heller myotomy remains the standard approach to this condition. 

"...a new treatment modality for esophageal achalasia was introduced-peroral endoscopic myotomy (POEM). POEM is a procedure performed endoscopically, which allows transection of the muscular fibers of the distal esophagus and of the lower esophageal sphincter. The procedure is therefore similar to a laparoscopic Heller myotomy without a fundoplication. Short-term studies have shown that POEM is very effective in relieving dysphagia and regurgitation, but concerns have been raised about the incidence of post-POEM gastroesophageal reflux" (Kroch, D. A., & Grimm, I. S., 2018). 

The carrier's denial of the PEOM Procedure should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasis. 
Treatment: POEM (peroral endoscopic myotomy) procedure. 

The insurer denied coverage for POEM procedure. 

The denial is overturned. 

The patient presented for evaluation of achalasis, problems started years ago. It started with food getting stuck then advanced to both food and liquids not going down. The patient is woken up out of sleep almost nightly due to shortness of breath or feels like food is coming back up. The patient indicated that her symptoms was progressively worsen with significant weight loss. The patient underwent upper endoscopy, esophagram and high-resolution manometry (HRM) which has findings consistent of achalasia. The nurse personally reviewed the patient's record and believe the will benefit peroral endoscopic myotomy (POEM) procedure. 

Based on recent and relevant peer literature, the Peroral Endoscopic Myotomy POEM surgical procedure. 

The POEM procedure for the treatment of achalasia is a minimally invasive procedure performed endoscopically. The Peroral Endoscopic Myotomy (POEM) surgical procedure is not supported by recent and relevant peer literature. Peroral endoscopic myotomy (POEM) is an endoscopic method for performing a myotomy of the lower esophageal sphincter (LES) and is being studied for the treatment of achalasia. POEM is a form of natural orifice transluminal endoscopic surgery. POEM uses available laparoscopic instrumentation and, as a surgical procedure, is not subject to regulation by the U.S. (United States) Food and Drug Administration (FDA). The POEM technique has been successfully used to treat spastic esophageal disorders (eg, spastic achalasia, distal esophageal spasm, jackhammer esophagus, or nutcracker esophagus) and severe gastroparesis refractory to medical therapy. Therefore, the Peroral Endoscopic Myotomy (POEM) surgical procedure is likely to be more beneficial that other standard procedure without increased risk. 

Per Ngamruengphong S, Inoue H, Ujiki MB, et al. (2017), "POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM (Heller myotomy). Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups." 

The carrier's denial of the PEOM Procedure should be overturned.