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

Diganosis: GERD
Issue under review: LINX

Determination:
The health plan should cover the LINX.

The patient has had some response to medication, but continues with symptoms of GERD, abdominal pain, dysphagia despite medication use. This patient does not document any exclusion criteria at this time, as she is older than 18 years, does not document a BMI that is greater than 35 kg/m2 and has not had prior bariatric or gastric surgery or documentation of Barrett's esophagus. The patient has failed medical management and would be an appropriate candidate for LINX for treatment of GERD, which is documented on 24 hour pH study with a significantly elevated Demeester score more than 10 times normal.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical chest pain 

Treatment: Inpatient admission 

Summary:
Patient was admitted for monitoring for rule out acute coronary syndrome; and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia. The outpatient testing had not shown evidence of CAD.  All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was medically unnecessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Bilateral eustachian tube dysfunction
Treatment:  69799- Eustachian tube balloon dilation
The health plan should cover 69799- eustachian tube balloon dilation.
69799- eustachian tube balloon dilation is likely to be more beneficial than any standard treatment(s) for the patient's condition of chronic eustachian tube dysfunction.
This patient meets all the indications for the balloon dilatation of the eustachian tube.  The patient has a classic history of long-standing bilateral eustachian tube dysfunction with complications.  The literature reviewed demonstrates this procedure yields the best results for managing the patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Bilateral eustachian tube dysfunction
Treatment:  69799- Eustachian tube balloon dilation
The plan should cover 69799- eustachian tube balloon dilation.
Eustachian tube balloon dilation is Food and Drug Administration (FDA) approved for safety.  Efficacy has been established through clinical trials since 2016.  Most recently, a comprehensive review and consensus statement was developed by leaders in the specialty of Otolaryngology.  Relevant to this review, the consensus statement included the conclusion that eustachian tube balloon dilation is an alternative to tympanostomy tube placement for obstructive eustachian tube dysfunction.  Consistent with the reviewed literature, they also reached consensus that patient-reported symptom scores are useful in assessing baseline eustachian tube dysfunction symptoms and treatment outcomes and that change in patient-perorated symptom scores is appropriate for assessing outcome following eustachian tube balloon dilation.
69799- Eustachian tube balloon dilation is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.
The requested service is presently a standard treatment option for eustachian tube dysfunction in adults.  Review of the literature finds it to be safe and efficacious with controlled clinical trials continuing to follow the long term outcomes.  It is a therapeutic option in place of repeated bypass of the eustachian tube problem with ventilation tubes that extrude periodically or permanent tubes that lead to tympanic membrane perforations with high frequency.  It is a well-tolerated, minimally invasive technique with positive outcomes for control of patient disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Bilateral Eustachian tube dysfunction
Treatment: Eustachian tube balloon dilation (69799)
The plan should cover 69799- Eustachian tube balloon dilation.
Eustachian tube balloon dilation is Food and Drug Administration (FDA) approved for safety. Efficacy has been established through clinical trials since 2016.  Most recently, a comprehensive review and consensus statement was developed by leaders in the specialty of Otolaryngology. Relevant to this review, the consensus statement included the conclusion that eustachian tube balloon dilation is an alternative to tympanostomy tube placement for obstructive eustachian tube dysfunction.  Consistent with the reviewed literature, they also reached consensus that patient reported symptom scores are useful in assessing baseline eustachian tube dysfunction symptoms and treatment outcomes, and that change in patient- perorated symptom scores is appropriate for assessing outcome following eustachian tube balloon dilation.
Eustachian tube balloon dilation is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.
The requested service is presently a standard treatment option for eustachian tube dysfunction in adults.  Review of the literature finds it to be safe and efficacious with controlled clinical trials continuing to follow the long term outcomes.  It is a therapeutic option in place of repeated bypass of the eustachian tube problem with ventilation tubes that extrude periodically or permanent tubes that lead to tympanic membrane perforations with high frequency.  It is a well-tolerated, minimally invasive technique with positive outcomes for control of patient disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: Inpatient admission, diagnostic testing, medication administration

The insurer denied inpatient admission. That denial was upheld.

This patient was seen in the Emergency Department (ER).  The patient complained of symptomatic anemia and was sent to the ER by her primary care physician.  The patient stated that at her primary care doctor, her iron levels were 6. The patient stated that she sometimes had dizziness, lightheadedness, and her menstruation was very heavy. The patient was then given 3 units of packed red blood cells.  The patient was status post transfusion for severe anemia.  The patient was discharged in stable condition.

The medical literature indicates that inpatient admission is indicated for patients with hemodynamic instability, active hemolysis, active bleeding that cannot be controlled, altered mental status that is severe/persistent, recurrent syncope or near syncope, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high risk low platelet count, acute renal failure, clinically significant signs or symptoms are severe/persistent despite Emergency Department and observational care treatment such as transfusion or volume replacement, or pulmonary artery catheter or other invasive monitoring needed.  

The documentation indicated that the patient was seen in the Emergency Department due to complaints of dizziness with a hemoglobin at the physician's office of 6.  The patient was diagnosed with iron deficiency anemia.  The patient's hemoglobin level in the Emergency Department was noted to be 6.  The patient was given 3 units of packed red blood cells.  However, there was no evidence of hemodynamic instability, active hemolysis, active bleeding that could not be controlled.  The patient's condition was appropriate for an observational level of care rather than an inpatient level of care
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) for chest pain and shortness of breath that started one and half hours prior to presentation. The patient reported pain in the center of the chest, and  developed palpitations and could not catch breath. The patient was evaluated in ED. Blood pressure (BP) was elevated to 163/96. The rest of the vitals were normal. Physical examination was abnormal with leg swelling. Initial electrocardiogram (ECG) showed no ischemic changes. Subsequent ECG revealed ST depression in V5 and V6. Chest x-ray (CXR) was normal. Blood sugar was 657 and troponin was 0.095. The patient was given intravenous (IV) fluids, insulin, aspirin, ticagrelor and started on IV heparin. The patient was admitted to telemetry. The health plan's determination is upheld.

The patient presented with chest pain. The patient has multiple coronary risk factors. Vital signs were stable, and the patient was not in any distress. CXR was normal. Blood sugar was elevated, but the patient did not have evidence of ketoacidosis or other possible acute complications of hyperglycemia. Venous blood gas did not reveal acidosis. Na was low, but balanced if adjusted for high blood sugar.
The patient had elevated creatinine; therefore, the elevated troponin is not necessarily acute. it could be chronic. Repeated troponin had down trended from the initial troponin (0.095-0.078).
Based on above, this patient was treated appropriately and warrants coronary angiography (versus noninvasive assessment for ischemia). However, there was no confirmation that the patient had acute coronary syndrome (ACS). Based on available information (results of coronary angiography not available), the patient does not meet criteria for inpatient admission.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient  who was initially seen by his rheumatologist  for the acute onset of inflammation in the right 1st metacarpophalangeal joint ( MCP), right knee, and left ankle, with a history of right eye iridocyclitis. At issue is whether the proposed treatment of Xeljanz is likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.The health plans determination is overturned in whole.The proposed treatment with Xeljanz is likely to be more beneficial than any standard treatment for the patient's disease. There are no Food and Drug Administration (FDA) approved agents for reactive arthropathy. . Limited case reports and expert opinion with extrapolation given the similarities within the SPA family should allow the use of biologic agents and OSM such as xeljanz.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient has a history of Reiter's Syndrome and chronic iridocyclitis of the Right (R) eye. The patient has tried and failed both Methotrexate (MTX) and Humira. At present, the patient is doing well on samples of Xeljanz 11mg extended release (ER) tablets.
The issue for review in this case is whether Xeljanz is likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.The  health plans determination is upheld  in whole. Xeljanz is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease. Reiter's syndrome (also called reactive arthritis) is a type of arthritis that occurs following an infection, although the pathogens cannot be cultured from the affected joints. Treatment usually starts with nonsteroidal anti-inflammatory drugs (NSAID's) and steroids, followed by MTX or Sulfasalazine (SSz), and then an anti-tumor necrosing factor (TNF) agent for patients who are refractory for disease -modifying antirheumatic drugs (DMARD's).
Appeal type: Experimental/Investigational
Decision: Upheld

The patient with HLA-B27 positive spondyloarthritis (SpA) with associated uveitis (iridocyclitis) for whom Xeljanz (Tofacitinib) extended release (XR) 11 milligrams (mg) daily was requested. Previously, the patient had failed Methotrexate and Humira. The prescribing rheumatologist also referred to this patient's condition as "Reiter's Syndrome", more commonly referred to as "Reactive Arthritis." Xeljanz was proposed . The health plans determination was  upheld in whole Xeljanz extended release (XR) is not more likely to be beneficial than any standard treatment or treatments for the insured's condition.The criteria for the diagnosis of axial spondyloarthritis would not be met . The  current medical literature does not support use of Xeljanz XR for the patient's peripheral SpA or his reported uveitis.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with multiple substance use disorders who was admitted to the inpatient detoxification level of care.

He reported daily use of alcohol, cocaine, marijuana and benzodiazepines. He had a past history of heroin use and was in a methadone maintenance program. His blood alcohol level was negative. His urine was positive for cocaine, benzodiazepines, cannabis, and methadone. At that time of admission he was recorded to have a Clinical Institute Withdrawal Assessment (CIWA) score of 17 and to have subjectively endorsed multiple symptoms of withdrawal. He was admitted to the detoxification unit and placed on a five day Librium taper.

The health plan's determination of medical necessity is upheld.
The submitted records from 3/8-3/19/19 do not include any updated CIWA assessments, updated LOCADTR reports, physician progress notes, and no documentation of evidence-based therapies being delivered. The limited information that is available documents normal vital signs and no issues with the Librium taper. The LOCADTR tool resulted in a finding that ongoing detoxification level of care was not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
Inpatient level of care was neither indicated nor provided.
This was an elective, uncomplicated catheterization that was scheduled after a positive ETT. The patient was always hemodynamically stable with normal vital signs, normal EKG, normal left ventricular (LV) function, and no ectopy. The only care given after the uncomplicated radial catheterization with left anterior descending (LAD) stenting was monitoring, intravenous fluids and routine medications. This does not meet the definition of acute inpatient level of care. Many institutions protocols (including for LAD and left main lesions) include a same day discharge.  Centers for Medicare and Medicaid (CMS), Recovery Audit Contractors (RAC) surveys, proposed two midnight rule and all guidelines do not specify this as an inpatient procedure for an uncomplicated PCI.  Standard of care would be a lower level of care.
Radial catheterization was developed with one of its advantages being the safety in early ambulation and discharge. The overnight stay for observation and telemetry does not change that determination. While possible, bleeding post radial artery intervention is not seen, nor does it require extended monitoring. No evidence base study suggests that uncomplicated, elective LAD stenting requires a higher level of care.
The letter of appeal was carefully considered but it offered no evidence to support a higher level of care.  The only care provided was telemetry, frequently performed at a lower level of care. The patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no "complex" care that was required in this patient's care post catheterization.  While there is always a potential for an adverse event, one did not happen and no actual treatment was needed. The admitting note said admission was for "extended observation and monitoring". In the appeal letter, it referenced Milliman Care Guidelines and the need for admission for unstable angina. Milliman criteria requirements for acute coronary syndrome (ACS) do not apply as the patient does not meet criteria to support that diagnosis. It is incorrect to label the presentation of this case as unstable angina, as patient had pain for months, did not fail maximal medical therapy, and EKG showed no changes. All testing and therapy performed would be appropriate, safe and guidelines consistent to be at a lower level of care. Thus, inpatient level of care was not medically necessary.
The denial was consistent with guidelines and usual community care. Post cardiac care as described is routine performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has medical history significant for osteoarthritis and Type 2 diabetes. The current treatment plan is for a full-coverage crown on tooth #19 because of multiple failures of amalgam and/or composite restorations of the tooth, as well as fracture and recurrent decay.

The health plan's determination is overturned. A crown on tooth 19 is medically necessary. Tooth #19 still has a substantial lifespan, and it is not currently serviceable in its' state of fracture and recurrent decay. A full-coverage crown will repair the tooth and allow it to have normal function within the mouth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypervascular liver nodule, history of diabetes, Hepatitis B, gastroesophageal reflux disease (GERD), hyperlipidemia

Treatment: Surgery

The insurer denied inpatient admission. That denial was upheld.

This patient presented to the Emergency Department (ED) for an elective interventional radiology transcatheter embolization of a 2 cm hypervascular nodule in the dome of the liver.  The patient underwent a transarterial hepatic chemoembolizationand  was admitted to surgery.

The patient underwent a celiac artery angiogram, superior mesenteric artery angiogram, right hepatic artery angiogram, and transarterial hepatic chemoembolization via the right common femoral approach under moderate sedation.  There were no complications.  The report was dictated around 11:50 that morning.  More details including start and time were not included.

As per the progress note at 16:34, the patient was admitted to surgery post chemoembolization for pain control and follow up labs.  As per the nursing vital sign flow sheet, the patient had stable vital signs and the right groin band aid was dry and intact with no bleeding noted.  The patient had no shortness of breath (SOB) or distress noted.

As per discharge summary, the patient did well without complications.  He received intravenous (IV) fluid until his diet was advanced. He received IV then oral analgesics.  He was hemodynamically stable and discharged with minimal pain that was well controlled with oral analgesics.

Based upon the records provided, the inpatient hospital admission was not justified at the acute care level. This was due to the fact that he was admitted clearly for observation, and this did not require an acute care admission.  As shown in the chart, the patient was stable and had no complaints except for pain and was tolerating a diet.  He could have been managed on an observation status for pain management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, history of diabetes mellitus and hypertension

Treatment: Inpatient admission, diagnostic testing and medical management.

The insurer denied inpatient admission. That denial was upheld.

This patient presented to the Emergency Room (ER) with the onset of intermittent right-sided chest pain and right-sided facial numbness with difficulty speaking, moving his tongue to the right and mild nausea.  In the Emergency Room, his blood pressure was 172/103 with a heart rate of 64. An EKG revealed sinus rhythm at 59 beats a minute and a right bundle branch block.  A head CT was negative. An MRI of the brain was negative for an acute infarct. The patient was evaluated by Neurology and the clinical impression was possible Bell's palsy. The stroke team was called due to the patient's high risk for stroke, and the decision was made to admit the patient for further evaluation of stroke and possible acute coronary syndrome. The symptoms resolved in the ER approximately two hours after arrival.  

MCG list clinical indications for admission to inpatient care for transient ischemic attack (TIA). These include hemodynamic instability, focal neurologic signs or symptoms that persist or recur, diagnosis of stroke, finding on brain imaging that requires inpatient care, altered mental status, suspected arteritis, cardiac arrhythmias of immediate concern or severe hypertension with a systolic blood pressure greater than 180 or diastolic blood pressure greater than 110.  

In the clinical records submitted for review, there was documentation that the patient presented to the ER with intermittent right-sided chest pain and right-sided facial numbness with difficulty speaking, moving his tongue to the right and mild nausea.  An EKG was performed and revealed sinus rhythm, a heart rate of 59 beats per minute (bpm) and a right bundle branch block. The CT of the head was negative, and an MRI of the brain was negative for acute infarct. The symptoms resolved in the ER approximately two hours after arrival.  Therefore, the inpatient hospital stay was not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia

Treatment: Xeljanz

The insurer denied the medication Xeljanz.

The patient has a 2.5 year history of hair loss.  The patient has previously used Intralesional Kenalog (ILK) and topicals without regrowth.  Her scalp has 50% hair loss.  The request is for the medication Xeljanz.

Published results from one 2-center, open-label, single-arm trial, by Kennedy, C. M., et al. (2016), showed that of 66 subjects with alopecia areata treated with tofacitinib, 32% experienced 50% or greater improvement in Severity of Alopecia Tool (SALT) score.  Additionally, a retrospective review of 90 patients showed that of the 65/90 patients that responded to therapy, 58% achieved a 50% or greater improvement in SALT score.  After reviewing Liu, L. Y., et al. (2017), results for Tofacitinib are promising, but at this time no controlled trials are available.      

Xeljanz is not yet considered standard of care for the treatment of alopecia areata.  Its use is supported by minimal medical evidence at this time. 

Xeljanz is not Food and Drug Administration (FDA) approved for the treatment of alopecia areata.  The treating provider has included references, one of which is a single case report of a patient who responded to treatment with Xeljanz for his alopecia areata and psoriasis.  The other is a report of three patients on another Janus Kinase (JAK) inhibitor, ruxolitinib, and also describes a mouse model.  This is insufficient medical evidence to approve the use of Xeljanz for alopecia areata.