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

Central Nervous System / Neuromuscular Disorder - Seizures
Inpatient Hospital

The patient is a male with Trisomy 13 who presented to the hospital with seizures. Additional medical diagnoses include tracheostomy dependence, laryngeal cleft, bicuspid aortic valve, atrial septal defect, gastrostomy tube dependence, congenital bronchomalacia, and history of aspiration pneumonia. He had history of one prior lifetime seizure, and since successfully managed on daily Keppra. The patient had recent 2 day history of poor sleep, but no fevers, vomiting, respiratory changes, or known ill contacts. The morning of presentation, he had just been started on his morning tube feed when he began having generalized tonic-clonic seizures that lasted 45 minutes. Emergency Medical Services (EMS) was called and administered a total of 4 milligrams (mg) Versed (2mg x 2 doses) which broke the initial seizure.

On arrival to the emergency department (ED), his temperature was 100.2 F and the patient vomited once. Seizure activity was noted again, and Ativan and Keppra were given. Labs showed white blood cell (WBC)=16.8 with 72% segs, bicarb=18, aspartate aminotransferase (AST)=44. The patient was admitted to the Pediatric Intensive Care Unit (PICU) with video electroencephalogram (vEEG) monitoring and medication titration. His vital signs and respiratory status remained stable; he had no further seizures. He was able to be discharged home the following day when feeds were restarted, and home medications given.

At issue is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

Yes, the requested acute inpatient hospitalization was considered medically necessary for this patient with high medical complexity and severe presenting condition (status epilepticus). In addition, this child presented with status epilepticus for 45 minutes, with additional seizure activity resuming in the ED. According to the Epilepsy Society guideline, (2) the risk of adverse complication or even death increases significantly after seizure reaches 30 minutes or longer.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems - Missing Tooth/Teeth
Dental or Orthodontic Procedure

The patient is a male who presents to the office of his dental provider for evaluation and treatment of teeth #6, 7, 8, 9. Included for review are previous letters of appeal and denial, full mouth radiographic images, multiple pages of clinical notes from the dental provider's office, multiple pages of clinical notes from the hospital from the day of admission, and a narrative provided by a patient advocate.
The patient has a history of facial trauma due to direct blunt force for which he was admitted for emergency services in a hospital setting. At the time of the trauma the patient suffered fractures to the anterior teeth #7, 8, 9 as well as lacerations to the lips. Subsequent to the accident teeth #7 and 8 were deemed unrestorable and were extracted. The patient is now edentulous in sites #7 and 8 and subsequent evaluation of the healing has resulted in the finding that the patient does not have adequate bone to allow for reconstruction leaving only restorative dentistry as the option for replacement of the missing teeth.
In question is the medical necessity of the planned treatment of fixed partial denture 6, 7, 8, 9.

The health plan's determination is overturned.

Yes, the requested service of bridge on teeth #6-7-8-9 is medically necessary as the treatment for the missing teeth #7 and 8. Tooth #9 already requires a full coverage restoration due to the extent of tooth structure lost due to the trauma. As such, a fixed partial denture is the treatment of choice as a removable partial dentures delivers non axial forces to the adjacent teeth resulting in mobility and damage to the periodontium.
Appeal type: Medical necessity
Decision: Upheld

Mental Health - Post traumatic stress disorder/PTSD
Mental Health - Inpatient

The patient is a female who was admitted due to increased aggression and violent behaviors towards other family members, as well as making threats to kill her foster parents and herself. The patient was engaging in self-injurious behaviors. The patient was diagnosed with post-traumatic stress disorder (PTSD), reactive attachment disorder by history, and attention deficit hyperactivity disorder (ADHD), combined type. On admission, the patient was restarted on Concerta 54 milligrams (mg), Guanfacine 1mg daily.

The patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. The patient had no medication side effects and was medication compliant. The patient pushed limits at times but was redirectable.

Specific events on the inpatient unit included the patient had a good visit with foster parents. Sertraline 12.5mg was started. Intuniv was increased to 3mg at bedtime.  Sertraline was then increased to 25mg.

The subject under review is the medical necessity of the inpatient level of care.

The health plan's determination is upheld.

No, from a certain date to discharge, the patient had no active suicidal ideation with plan, homicidal ideation with plan or command hallucinations. The patient was not physically aggressive, acutely manic or sexually inappropriate. The patient was not catatonic. The patient had no significant medical instabilities. The patient had no required emergency medications, restraints or seclusions. The patient had no medication side effects and was medication compliant. The patient pushed limits at times but was redirect able. Treatment could have been done at a lower level of care as inpatient level of care was not medically necessary from a certain date going forward.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite
Treatment:  D8080 - Comprehensive orthodontic treatment of the adolescent dentition 

The comprehensive orthodontic treatment of the adolescent dentition is medically necessary.  The patient has a crossbite of an anterior tooth with attachment loss.  This is an automatic qualifier according to the handicapping index scale.  Therefore, the D8080 - Comprehensive orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Idiopathic Short Stature (ISS)
Treatment: Humatrope 12 milligram cartridge
The insurer is denied coverage for Humatrope 12 milligram cartridge.
The denial is overturned. 
This is a male patient with a diagnosis of Idiopathic Short Stature (ISS). This request is for Humatrope. He has been on growth hormone (GH) therapy. His GH stimulation with arginine and L-dopa peaked at 11. His bone age was 2 years behind his chronological age . His pretreatment height velocity is reported to be 2.2 cm/year. He is currently on Hydrocortisone, Florinef, and Humatrope daily injections.
 
The growth charts include heights that are all after age 10. His current height velocity is
reported to be 7.6 cm per year. His pretreatment height was 118.8 cm, (-2.62 standard deviation [SD]). His height on therapy on 4-10-2020 at 16.83 years old was 165.1 cm (-1.33 standard deviation score [SDS]). His mother's height is 162.56 cm and his father's height is 172.72 cm; therefore, the mid parental height is 174.14 cm (-0.38 SDS).

The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10.

The patient had a pre-treatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore met idiopathic short stature criteria for diagnosis and initiation of growth hormone. The patient responded to growth hormone with improvement in his height velocity and his height. The patient's current bone age shows open growth plates.

Continuation of growth hormone in patients with idiopathic short stature is indicated until their height velocity slows to below 2 cm per year or the growth plates show fusion. The patient has open growth plates and an excellent height velocity on treatment. Continuation of growth hormone is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The health plan did not act reasonably, or with sound medical judgment, or in the best interest of the patient as the requested medication is medically necessary.

Based on the above, the medical necessity for Humatrope 12 milligram cartridge is substantiated. The insurer's denial is overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Diseae.
Treatment: LINX Procedure and 1 day inpatient stay.
The insurer denied the LINX procedure and 1 day inpatient stay.
The determination is upheld.

The patient had previously undergone a vertical sleeve gastrectomy complicated by a leak that was subsequently converted to a Roux en Y gastric bypass. She has been suffering for some years with heartburn and does obtain some relief with proton pump inhibitors. She presented to a surgeon for evaluation for surgical treatment of her reflux disease. Her work up included an upper gastrointestinal (GI) series which demonstrated normal esophageal emptying, a small hiatal hernia, reflux, and the prompt passage of contrast into the small bowel. She underwent bravo potential of hydrogen (pH) testing and has a DeMeester score of 37.1. Her endoscopy does not show any evidence of esophagitis. The surgeon is requesting a LINX procedure for management of her gastroesophageal reflux disease.  At issue is whether the proposed health service or treatment laparoscopic esophageal surgery (LINX procedure) and inpatient stay is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There is no convincing evidence that the LINX procedure, with inpatient stay, would be more beneficial than standard medical therapy for treatment of GERD in a patient who has undergone Roux en Y gastric bypass (RYGB) surgery. Magnetic sphincter augmentation using the LINX device is a newer anti-reflux surgical technique which reinforces the lower esophageal sphincter using a ring of spaced magnetic beads that is placed around the sphincter. Research showing the efficacy and safety of this device led to approval by the Food and Drug Administration (FDA) in 2012 by unanimous vote of the expert panel, but all of the clinical evidence for efficacy and safety has been collected in patients with normal gastric anatomy.
It should be recognized that RYGB is generally considered an excellent treatment for GERD in patients who also suffer from severe obesity. However, this patient had previously undergone a vertical sleeve gastrectomy. Fundoplication is no longer an option for surgical treatment of her GERD, due to prior resection of the fundus.
The LINX device is considered a valuable tool for surgical management of GERD in patients with normal gastric anatomy. However this patient has undergone RYGB and there are no scientific studies which support use of the LINX in a post RYGB patient population. There is one case report in SOARD (Surgery for Obesity and Related Diseases) from 2016 which describes a patient who underwent LINX after RYGB with good results, but one case report does not represent generalizable knowledge or scientific evidence.
Thus, without serious studies to provide solid evidence that the LINX device provides benefit for management of GERD in patients following RYGB, compared to standard medical therapy, it is not likely to be more beneficial than standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Diseae.
Treatment: LINX Procedure and 1 day inpatient stay.
The insurer denied the LINX procedure and 1 day inpatient stay.
The determination is upheld.

This patient underwent a sleeve gastrectomy in 2015, complicated by (c/b) a leak, and this was converted to a Roux-en-Y gastric bypass (RYGBP). The patient has proton pump inhibitor (PPI) refractory gastroesophageal reflux disease (GERD). An upper gastrointestinal (UGI)study showed a small hiatal hernia. Manometry was normal. A potential of hydrogen (pH) study showed an elevated DeMeester score consistent with gastroesophageal reflux disease (GERD). At issue is whether the laparoscopic esophageal surgery (LINX procedure) and inpatient stay are likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
LINX is an Food and Drug Administration (FDA) approved treatment for symptomatic GERD in patients who do not document an exclusion. The exclusions to LINX are age less than (<) 18 years, body mass index (BMI)greater than (>) 35, Barrett's esophagus with dysplasia and prior bariatric or gastric surgery. LINX is currently being trialed for use in post bariatric patients, however, this is part of a current clinical trial which has not yet completed. This patient has had bariatric surgery Therefore, the procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Trauma / Injuries / Brain injury.  
Treatment:  Occupational therapy.

The insurer denied Occupational therapy visits.  The denial is overturned in whole.

The patient has a past medical history significant for intraventricular hemorrhage with left non-dominant hemiplegia, dysphagia status/post (s/p) percutaneous endoscopic gastrostomy tube, left radius and ulna fracture s/p open reduction internal fixation (ORIF) and a traumatic brain injury resulting from a motor vehicle accident.

Yes, the requested  occupational therapy visits  are medically necessary, within the standards of general accepted care and medically appropriate for this patient.

The patient was involved in a motor vehicle accident, which resulted in left non-dominant hemiplegia.  The patient also had a left radius and ulnar fracture, which required an ORIF.  Review of all documentation supported that the patient is making slow but steady progress.  For example, a therapy note stated that patient left shoulder flexion strength improved from 2-/5 to 3+/5 and left shoulder abduction strength 2-/5 to 3+/5.  Disabilities of the Arm, Shoulder and Hand (DASH) scored decreased 49 to 42.
Left supination improved from 20 degrees to 50 degrees, and passive wrist extension improved from 20 degrees to 30 degrees.  DASH score had decreased from 42 to 38.  Therefore, the above shows that the patient is making progress with continued therapy and, therefore, the additional occupational therapy visits are medically necessary and appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Weakness in both legs and flat feet
Treatment: Custom Shoe Inserts (L3000 x 2)
The insurer denied the Custom Shoe Inserts (L3000 x 2).
The denial is overturned. 

The patient is a male who was seen by his podiatrist for an intoeing gait.  He had external rotation less than normal and internal rotation both flexed and extended that was greater than normal.  This resulted in an intoeing gait and custom orthotics was prescribed.

Yes, the Custom Shoe Inserts (L3000 x 2) are medically necessary.

Orthotic treatment in an intoeing child is a fairly benign beneficial treatment that is often used before attempting any surgical intervention.  Children typically respond well to orthotic treatment for this condition.  If left untreated, intoeing can lead to downstream problems of the foot knee and hip.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Multiple Sclerosis 
Treatment: MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system 
The insurer denied the MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system. 
The denial is upheld. 

The patient is a female with multiple sclerosis (MS) and functional paraplegia. 

No. The health plan should not cover the proposed MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system. 

No, the MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system is not likely to be more beneficial than any standard treatment. 

There are no high-quality clinical trials to support that FES based cycling systems improve long term outcomes for persons with multiple sclerosis. All studies to date, including those provided by the attending physician (AP), are limited by low subject number, short term follow-up, inappropriate controls or non-randomized study design. A recent review (Pilutti et al., 2019) concluded that "High-quality RCTs of FES cycling exercise are necessary for providing recommendations for integrating exercise training in the management of advanced MS." Therefore, the current medical literature does not breach the threshold of high-quality evidence required to conclude that this intervention is effective compared to standard physical therapy and home exercise programs.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Multiple Sclerosis 
Treatment: MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system 
The insurer denied the MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system. 
The denial is upheld. 

The patient is a female with multiple sclerosis with resultant lower limb paralysis. According to the patient's neurologist, lower limb paralysis is known to cause secondary health conditions such as muscle atrophy, poor circulation, limitations in joint range of motion, and muscle spasticity. The patient's neurologist opined the patient was a good candidate for a MyoCycle home functional electrical stimulation (FES) cycling therapy system, which was needed to actively mobilize her legs and improve both musculoskeletal and cardiovascular health. 

No, the health plan should not cover the proposed MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system. 

No, this service is not likely to be more beneficial than any standard treatment or treatments for the insured's condition, advanced multiple sclerosis. 

Medical literature and practice guidelines do not allow any conclusions whether the FES cycling provides any health benefits comparing with physical therapy or other rehabilitation modalities. 

According to reference 5, "We searched the literature for studies involving FES cycling exercise in persons with MS published in English up until July 2019. Eight studies were retrieved: two studies examined acute effects, two studies examined chronic effects, and four studies reported on both acute and chronic effects of FES cycling exercise. The overall quality of the studies was low, with only one, small, randomized controlled trial (RCT). There is limited but promising evidence for the application of FES cycling exercise among persons with MS who have moderate-to-severe disability. Participants were capable of engaging in regular FES cycling exercise (~ 30 min, 2-3/week), with few, mild adverse events experienced. Preliminary evidence from small, mostly uncontrolled trials supports the potential benefits of FES cycling on physiological fitness, walking mobility, and symptoms of fatigue and pain. High-quality RCTs of FES cycling exercise are necessary for providing recommendations for integrating exercise training in the management of advanced MS." 

Considering that there are no randomized controlled trials (RCT) to document advantages of cycling FES, this service is not expected to be more beneficial than standard rehabilitation modalities.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Multiple Sclerosis  
Treatment: MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system  
The insurer denied the MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system.
 The denial is upheld.  

The patient is a female who has a history of multiple sclerosis and hypertension.  She has symptoms that include fatigue and lower limb weakness.  A MyoCycle functional electrical stimulation cycle ergometer has been recommended for home use to treat the secondary conditions associate with her multiple sclerosis diagnosis, including muscle atrophy, poor circulation, spasticity and limited joint range of motion.  

No, the health plan should not cover the proposed MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system.  

No, the requested MyoCycle Home Functional Electrical Stimulation (FES) cycling therapy system is not likely to be more beneficial than any standard treatment(s) for the insured's condition or disease.  

Some literature of a preliminary nature has been published suggesting that health benefits may potentially be attained through the use of functional electrical stimulation cycle ergometry for persons with limb weakness and dysfunction due to central nervous system pathology.  The available data, however, have not established to date that this type of passive exercise device improves health outcomes in a clinically significant manner.  While this type of device ostensibly provides a means of exercise for persons who are otherwise significantly limited from participating in typical modes of active exercise, there are no proven indications that this passive exercise device improves any clinically significant measures of health with respect to the cardiovascular, pulmonary, musculoskeletal or other relevant organ systems in the setting of this patient's condition.  The device, in addition, has not been proven to promote neurological recovery or mitigate decline in progressive neurological disorders.  The purported benefits of this device have been subjective in nature.  

Overall, the device in question is not proven to improve health or function for this patient's condition.  It is not part of a standard of care for multiple sclerosis or other disorders of the central nervous system causing limb weakness and dysfunction.  It is not likely to be more beneficial than any standard treatment or treatments.  It is not necessary for treatment of this patient's condition.  The health plan should not cover the proposed device.