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

Diagnosis: Cardiac/Circulatory Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is upheld.

The patient is a female with a past medical history significant for hypertension, hypertrophic obstructive cardiomyopathy, atrioventricular (AV)-nodal reentrant tachycardia that required ablation in the past, bradycardia, pacemaker placement, hypothyroidism, and gastroesophageal reflux disease (GERD) who presented to the emergency department with complaints of chest pain. The admitting physician stated that the patient was a poor medical historian, most likely because of underlying dementia. The patient complained of palpitations that were associated with chest pain, lightheadedness, and diaphoresis. The pain was exacerbated by leaning forward and relieved by rest.

The patient was admitted to the hospital with the diagnosis of chest pain.
The patient was seen by a cardiologist who recommended ruling out acute coronary syndrome by checking serial troponin and electrocardiogram (EKG).
They also recommended splitting administration of beta-blockers and calcium channel blockers.
Subsequently, in the hospital, the patient remained hemodynamically stable and had no further episodes of chest pain, palpitations, or lightheadedness.
During the hospital stay, she was screened for human immunodeficiency virus (HIV) infection because of her low white blood cell count. The test came back negative.
An echocardiogram was also performed and demonstrated normal left ventricular ejection fraction with changes significant for hypertrophic cardiomyopathy with left ventricular asymmetric septal hypertrophy, which was expected given the patient's history.
The telemetry monitoring demonstrated frequent premature ventricular contractions (PVCs).
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient hospital stay was not medically necessary for this patient at the acute inpatient level of care.
The review of the medical records clearly demonstrated that the patient had no signs of hemodynamic instability, respiratory distress, chest pain, acute coronary syndrome, or any other serious diagnoses besides coronary artery disease.
The telemetry monitoring did not reveal any evidence of arrhythmias of immediate concern.
During the entire hospital stay, the patient remained in stable clinical condition and did not require any diagnostic tests or procedures that would necessitate admission at the acute inpatient level of care.
Taking into consideration all these facts, neither the severity of the patient's condition nor the complexity of the services provided rose to the acute inpatient level of care.
Considering the patient's complicated cardiac history, the admission for monitoring, and ruling out acute coronary syndrome, and interrogation of the pacemaker was completely reasonable. However, this could have been accomplished at a lower level of care status.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease
Treatment: Scope test- esophagogastroduodenoscopy with radiofrequency ablation (RFA)
The insurer denied Scope test- esophagogastroduodenoscopy with radiofrequency ablation (RFA)
The determination is upheld.

This is a patient with gastroesophageal reflux disease (GERD). She has had heartburn, regurgitation, a sore throat, voice hoarseness, globus, frequent throat clearing, cough, eructation, unintentional weight loss, and associated dysphagia and nausea. An esophagogastroduodenoscopy showed a small hiatal hernia, gastritis, and a normal esophagus and duodenum. A potential of hydrogen (pH) study  was reportedly normal . She has failed proton pump inhibitor therapy, histamine (H2) receptor antagonist receptor antagonists, amitriptyline, and diet and lifestyle modification. At issue is whether the requested Stretta procedure, scope test- Esophagogastroduodenoscopy with radiofrequency ablation (RFA), is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease .

Stretta is not definitively supported as likely to be more beneficial than any standard treatment or treatments for the treatment of gastroesophageal reflux disease (GERD). A systematic review to evaluate controlled trial evidence on the efficacy of Stretta for the management of gastroesophageal reflux did not show any benefit of Stretta over sham therapy (Lipka, et al). Specifically, data on the mean percentage of time that pH was less than 4 (over 24 hours) showed no significant benefit of Stretta over sham therapy. Data on the change in mean lower esophageal sphincter pressure showed no statistically significant advantage of Stretta over sham. The pooled analysis showed no statistical advantage of Stretta over sham for stopping proton pump inhibitor therapy. Finally, the pooled analysis did not show a statistically significant benefit of Stretta over sham on improvement of quality of life scores from baseline. In addition to lack of efficacy, adverse events reported to the U.S. Food and Drug Administration include pneumonia, gastroparesis, esophageal perforation, cardiac arrest, and at least four deaths (Lipka, et al; United States Food and Drug Administration (FDA); American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee). Subsequent studies have not been controlled. A 2019 review of evidence concluded that "high-quality randomized trials are warranted to address the controversy generated" by analysis of randomized trials of Stretta (Nabi, et al). The most recent American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease (GERD) do not recommend Stretta (Katz, et al). Long-term data reports a significant recurrence rate (42%) of symptoms over the long term (Fass, et al).
For these reasons, Stretta is not supported as likely to be more beneficial than any standard treatment or treatments for the treatment of the insured's gastroesophageal reflux disease (GERD).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Irritable Bowel Syndrome
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription medication as not medically necessary. 
The health plan's determination is overturned.

The patient is a female. She has a history of very early onset inflammatory bowel disease (VEO-IBD) involving the colon (colitis). The requested service is Infliximab (Remicade).
At issue is the medical necessity of the requested prescription medication, Remicade.

I overturn the health plan's determination of medical necessity, in whole.

Yes. Denying Remicade based on the patient's age is not appropriate.
This patient has very early onset inflammatory bowel disease (VEO-IBD), ulcerative colitis phenotype. There are no Food and Drug Administration (FDA) approved treatments for this age group. The current standard of care is to manage VEO-IBD with the available therapies for older age groups (including Infliximab). The current peer reviewed literature support using tumor necrosis factor inhibitors such as Infliximab in treating VEO-IBD (referenced).
This patient has already failed conventional treatments (corticosteroids). There are no FDA approved treatment options for this child. The off-label use of Remicade is appropriate despite not meeting the plan's age criterion.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac/ Circulatory Problems
Treatment: Pharmacy/ Prescription Drugs
The insurer denied Edarbyclor 40/12.5 mg tablet. 
The denial was overturned in whole.

This case involves a female who has a history of hyperlipidemia, essential hypertension, and peripheral vascular disease. The patient has previously been prescribed several antihypertensives on the patient's drug formulary including, Candesartan-Hydrochlorothiazide, Ibesartan-Hydrochlorothiazide, and Losartan- Hydrochlorothiazide, but did not tolerate them due to significant side effects. The patient has been treated with Edarbyclor 40-12.5 milligrams (mg) and is tolerating it well with good blood pressure control. A prescription benefit exception request has been submitted for Edarbyclor but it has been denied by patient's health plan because it did not meet established criteria that the patient has tried alternative formulary combination angiotensin receptor antagonists with hydrochlorothiazide (HCTZ) and has failed them due to intolerance/side effects.
The health plan's determination was overturned in whole.
This patient has been treated and failed three of the formulary combination antihypertensives due to significant side effects. The other formulary medications likely would have similar adverse effects for this patient. Therefore, the requested prescription for Edarbyclor 40/12.5 mg is appropriate in this case for the medical treatment of this patient's hypertension. Based on published peer-reviewed medical literature and expert consensus guidelines on hypertension management, the requested medication Edarbyclor is medically appropriate, and coverage should be granted in this case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: hypothyroidism.
Treatment: Tirosint.

The insurer denied Tirosint. The health plan's determination is upheld.

The patient is a female with hypothyroidism from Hashimoto's disease. Abnormal thyroid function tests were noted. Tirosint 100 micrograms (mcg) capsule, which the patient is currently taking, was prescribed. The provider stated that the patient has tried several different thyroid preparations without improvement in symptoms, including combination T4/T3. The patient has also taken levothyroxine but had weight gain while on the medication. She had weight gain and fatigue while on Synthroid.

There is no published literature demonstrating that the formulary alternatives euthyrox, levo-t, levoxyl, or Unithroid are safer than, better tolerated than, or more efficacious than the non-formulary medication Tirosint. The patient has not failed or been intolerant to and has no contraindication to any of these thyroid supplementation formulations. The formulary drugs listed above will not be and has not been ineffective, would be as effective as the non-formulary drug, and would not have adverse effects. A formulary exception is not indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease.
Treatment: LINX Procedure.
The insurer denied the LINX procedure. 

The health plan's determination is upheld. 

The patient is a male with gastroesophageal reflux disease that has been persistent despite medication therapy. An upper gastrointestinal (GI) contrast study shows hiatal hernia and reflux, esophagogastroduodenoscopy (EGD) shows small sliding hiatal hernia, DeMeester score on pH study is elevated at 37.9, and manometry shows diminished peristalsis.
This review concerns the use of the magnetic sphincter augmentation system or LINX device procedure to treat the patient's reflux disease.

The LINX procedure is not likely to be more beneficial than standard medical or surgical therapy. While there is limited low quality evidence of efficacy of the LINX device, there is insufficient evidence over an adequate time frame to determine its efficacy compared to standard therapies, and concerns of erosion of the device into the esophagus remain an unanswered concern over the years following device placement.
As Aolfi writes in a published systematic review and meta-analysis, "Whether magnetic sphincter augmentation (MSA) should be considered a first-line surgical option in appropriately selected patients remains to be determined."
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease.
Treatment: LINX Procedure.
The insurer denied the LINX procedure. 

The health plan's determination is upheld. 

This patient is a male with complaints of long standing symptomatic gastroesophageal reflux disease (GERD) despite proton pump inhibitor (PPI) use. 24 hour potential hydrogen (pH) study revealed an elevated DeMeester score; consistent with GERD. Manometry was considered reasonable for anti-reflux procedure. An esophagogastroduodenoscopy (EGD) revealed a small hiatal hernia without evidence of Barrett's esophagus. Upper gastrointestinal (UGI) revealed GERD and a small hiatal hernia. Height and weight or reported height and weight were not recorded. 

The LINX 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.. The LINX procedure is an Food and Drug Administration (FDA) approved surgical treatment of GERD in patient's who are an adult (age of at least 18 years) without morbid obesity (body mass index (BMI) < (less than) 35), without prior gastric or bariatric surgery, hiatal hernia < 4 centimeter (cm), or Barrett's esophagus. The treatment is supported as a standard surgical anti-reflux treatment which is more effective than medications and as effective as laparoscopic Nissen fundoplication for short and mid term outcomes with less morbidity and mortality. It is supported by high level published literature and is supported by updated guidelines from Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) published in 2017.
This patient has symptomatic GERD, is an adult, with no evidence of Barrett's esophagus, or large > 4 centimeter (cm) hiatal hernia. However, no height, weight or body mass index (BMI) is provided. Therefore, it cannot be determined if the patient has an exclusion to LINX treatment at this time. As such, the LINX procedure is not indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease.
Treatment: LINX Procedure.
The insurer denied the LINX procedure. 

The health plan's determination is upheld. 

This patient is a man (body mass index (BMI) not included with review material) who sought surgical evaluation for the condition of gastroesophageal reflux disease (GERD). The surgical history and physical (H&P) states that he is treated with Lansoprazole for heartburn, but has breakthrough symptoms. He has comorbid health conditions of diabetes, hyperlipidemia, hypertension, chronic liver disease and low back pain. 

The LINX procedure is not likely to be more beneficial than standard treatment for this patient's condition of GERD in the setting of Barrett's metaplasia of the esophagus and ineffective esophageal motility.
While LINX magnetic sphincter augmentation has been shown by scientific evidence to be safe and effective for the condition of GERD with proven elevated esophageal acid exposure, in this case the records indicate a history of Barrett's metaplasia. LINX has not been adequately tested in such a clinical scenario. Therefore, based on the status of peer-reviewed literature and the case specific details of this case, LINX is not indicated in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic arthritis.
Treatment: Xeljanz 5 milligrams (mg).

The insurer denied coverage for Xeljanz 5 mg.  The denial is overturned. 

This is a male patient who has a past medical history of psoriasis, PsA (psoriatic arthritis), dandruff, stye, and detachment (melt) after bilateral eye cataract surgery. The patient has been taking tofacitinib (Xeljanz). The patient presented to an office visit with his Rheumatologist. Since starting tofacitinib (Xeljanz), the patient has noticed marked improvement in his toenail growth, and he also noticed his skin to be softer and without dryness. The visit notes also state the patient has no more dandruff. The patient's medications listed at the time of the office visit were Ipratropium bromide, Xeljanz 5 milligrams (mg) twice daily, and Vitamin C 1 gram twice daily.

The insurer has denied coverage for Xeljanz as not medically necessary. In their Final Adverse Determination letter, the insurer states that Xeljanz plan criteria only allows coverage for Xeljanz for psoriatic arthritis if Xeljanz will be used together with a conventional synthetic disease-modifying antirheumatic drug. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. They did not take the individual circumstances here into account. 

The labeling for Xeljanz does not require co-administration of another disease-modifying antirheumatic drug (DMARD), but it does approve Xeljanz when other DMARDs have failed or are not tolerated. In the www.uptodate.com chapter "Overview of biologic agents and kinase inhibitors in the rheumatic diseases" there is no indication co-administration is needed. 

That being said, Xeljanz is not normally used before methotrexate or a related medication; but, this is not the usual circumstance. The patient had potential corneal melt and all signs of this are gone on Xeljanz, and so are skin and nail changes. The possible alternatives, including potentially high-dose prednisone, methotrexate or Cytoxan (if needed for the eye), are potentially less toxic and are not guaranteed to work even as well as the Xeljanz. In this case, there has been good response to Xeljanz, and it is being tolerated. It should be continued.

The insurer's denial of coverage for Xeljanz 5 milligrams (mg) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hydronephrosis.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a past medical history of hypertension, hyperlipidemia, and a left nephrectomy who presented to the emergency room with complaints of right flank/upper quadrant pain. Associated symptoms included nausea without vomiting, decreased urination and a lack of appetite. On presentation, she was afebrile and hemodynamically stable. Lab results showed a creatinine of 1.31 and a white blood cell count (WBC) count of 11.2. A computed tomography (CT) scan showed severe right hydronephrosis without an obvious stone. After evaluation in the emergency room (ER) she was admitted to the inpatient service. She was managed on the inpatient service and was monitored. Her WBC count and creatinine improved. She passed a voiding trial and was discharged home. The medical necessity for an inpatient stay is under review.

The inpatient admission was not medically necessary.

A majority of patients who present with hydronephrosis can be discharged within 24 hours of presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status do not suggest the need for acute inpatient care. A lower level of care would have been the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Orthodontic treatment
The insurer denied Orthodontic treatment.
The determination is upheld.


The patient has mild maxillary and mandibular crowding. Tooth M is retained. Tooth number (#) 22 is unerupted but is at a favorable angle of eruption. The patient has a Class II occlusion with 4 millimeter (mm) overjet and 3 mm overbite. Tooth #19 is missing. The patient is treatment planned for 24-30 months of orthodontics to align the teeth and correct the bite but the plan was denied due to lack of medical necessity. At issue is the medical necessity of orthodontic treatment (braces) and periodic treatment visits.

Tooth #22 is unerupted but there is nothing on the photograph to suggest it is impacted or that it would not erupt if tooth M was lost. There are no indications of gingival recession or pathology from the tooth position of #22. The tooth is not so crowded that it was prevented from erupting, which if left untreated it could damage the roots of other permanent teeth (1) leading to more invasive procedures than orthodontic treatment.

While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence (2), however, this patient presents with none of those conditions. This patient has a 4 mm overjet but research shows overjet does not affect oral health related quality of life unless it was greater than 6 mm. (3) If her teeth were aligned, it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Total knee arthroplasty
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient is a female with right knee pain. She was admitted to hospital for elective total knee arthroplasty. Her past medical history was significant for fibromyalgia, arthritis and brain aneurysm. She underwent the procedure without problem. Her post surgical course was noncomplicated. 

No, the proposed inpatient admission was not medically necessary.
The records showed the patient underwent a non-complicated total knee replacement. She did not have underlying medical problems which required management. The operation was approximately two hours. There was limited blood loss. Her vital signs were stable with no evidence of fever. There were no reported problems with her wound. There was no evidence of infection or bleeding. She was able to tolerate oral pain medications. Physical therapy services and home care were provided.  The patient did not require additional imaging nor management for other conditions.  There were no extenuating circumstances to warrant the admission and length of stay at the provided level of care.  There were no medical conditions to support "Extended length of stay" as per the Milliman Care Guideline (MCG).