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

Diagnosis: Intradural melanotic neoplasm.
Treatment: Image-Guided Radiation Therapy (IGRT); Proton Beam Field, Special physics consult; Special treatment procedure.

The insurer denied the Image-Guided Radiation Therapy (IGRT); Proton Beam Field, Special physics consult; Special treatment procedure.  The denial is overturned.

The patient is a male with a diagnosis of intradural melanotic neoplasm with leptomeningeal disease involvement status post T8-T9 (eighth thoracic spine vertebra - ninth thoracic spine vertebra) laminectomy and biopsy. Craniospinal radiation (CSI) to 50.4Gy (grey) was recommended and proton therapy was requested.

Yes, the Image-Guided Radiation Therapy (IGRT); Proton Beam Field, Special physics consult; Special treatment procedure is medically necessary.

Proton beam radiation therapy has been shown to be safe and effective for any CNS (central nervous system) lesions that are adjacent to critical structures such as optic nerve, base of skull, brain stem or spinal cord, and is considered medically necessary per most guidelines.

Because of extensive volume of radiation required including craniospinal irradiation, and because the target is in close proximity to critical structures, conventional radiation techniques can result in adverse effects on vision, hormone, and neurocognitive functioning in this young patient. In addition, proton therapy can also help reduce the risk of injury to heart, lung, thyroid, GI (gastrointestinal) tract and reproductive organs. Furthermore, studies have shown that there is a potential reduction of the incidence of radiation induced secondary cancer by using proton beam radiation. Other types of radiation therapy such as photon IMRT (intensity-modulated radiation therapy) or tomotherapy has also been used to treat this disease, however, they are not the optimal modalities for this patient.

A study by Brown, et al evaluated 40 adult patients with meduloblastoma treated with proton therapy. The authors concluded that "patients treated with p-CSI (proton craniospinal irradiation) experienced less treatment-related morbidity including fewer acute gastrointestinal and hematologic toxicities." Because of the special "Bragg peak" characteristic, proton beam radiation therapy is the most appropriate treatment for this patient and is medically necessary.

A proton/photon comparison plan was done. The proton plan was able to significantly reduce dose to surrounding critical structures. The mean heart dose was 6.92Gy with photon, and 0.03Gy with proton. The bowel bag Dmax (maximum dose) was 22.51Gy with photon and 13.27Gy with proton therapy. The reduction in the heart dose would significantly reduce the risk of heart disease. NCCN (National Comprehensive Cancer Network) also states that "considering protons over photons (if available) for craniospinal irradiation in adults is reasonable."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Degenerative arthritis to the left knee. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female. She has a past history of diabetes, hypertension and hyperlipidemia. She had degenerative arthritis to her left knee. She was admitted to hospital and underwent a total knee arthroplasty. Her post-surgical course was non-complicated. She was discharged. 

No, the Inpatient admission was not medically necessary. 

The records show a non-complicated operation and post-surgical course. The patient's vital signs were stable. There was no evidence of fever. Her wound was without reported problem of drainage. There was no evidence of infection. She did not have drain placed. The operation was of satisfactory duration (1 hour 40 minutes) and limited blood loss (100 cc [cubic centimeters]). Satisfactory gains were made in PT (physical therapy). She was able to tolerate oral medications. She did not require treatment for an underlying medical condition.

Therefore, given the above, there were no extenuating circumstances to warrant the admission. As such, the Inpatient admission was not medically necessary. 

These findings do not substantiate necessity for a full admission. The services provided would have been appropriate at a lower level of care, as per MCG (Milliman Care Guidelines) 24th edition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertriglyceridemia

Treatment: Vascepa

The insurer denied coverage for Vascepa.

The denial is overturned. 

This male patient has a history of hypertension, hyperlipidemia, diabetes, coronary artery disease (two-vessel) and hypertriglyceridemia. The patient is currently being treated on maximally tolerated dosage of pravastatin and has failed multiple other statin medications due to severe myalgia. Prior to initiating Vascepa, the patient's serum triglycerides were 900s. After initiating Vascepa (icosapent ethyl), the patient's triglycerides were 619. 

As per Miller, et al (2011), the American Heart Association (AHA) defines very high triglyceride (TG) levels as those greater or equal to 500mg/dl. The guidelines recommend intensive statin therapy for the treatment of moderate to severe hypertriglyceridemia as well as omega-3 fatty acid treatment (Grundy, et al, 2018). There have been conflicting trial results demonstrating the efficacy of omega-3 fatty acids in reducing atherosclerotic cardiovascular disease (ASCVD) risk in those with hypertriglyceridemia. However, these findings were largely due to differing patient enrollment and differing doses of omega-3 fatty acids. The REDUCE-IT trial was a prospective double blind placebo-controlled trial that enrolled patients with high cardiovascular risk. Over half of the patients had diabetes and all had statin resistant hypertriglyceridemia. Among patients with elevated triglyceride levels despite the use of statin, the risk of ischemic events and cardiovascular death was significantly lower in the patients treated with Vascepa (Bhatt, et al, 2019). The AHA science advisory noted that the use of Vascepa is an effective and safe option for reducing triglycerides (Skulas-Ray, et al, 2019).

Based on the review of the medical record and literature, Vascepa (icosapent ethyl) is considered medically necessary for this patient who presented with known two-vessel coronary artery disease, diabetes and a triglyceride level of 900 mg/dl (milligrams per deciliter). Following statin therapy, the patient's triglyceride levels remained above 500mg/dl. This patient's physician has documented myositis on multiple statin medications and states that the patient is on maximally tolerated pravastatin. Untreated, this patient is at an elevated risk of cardiovascular events as well as pancreatitis.

The health plan did not act reasonably, with sound medical judgment or in the best interest of patient. 

Based on the above, the medical necessity for the medication Vascepa for the treatment of elevated triglycerides is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure.
Treatment: Private duty nursing.
The insurer denied 24 Hours of Private Duty Nursing Care Daily. 
The health plan's determination is upheld. 

The patient is a  boy who has multiple medical problems.
The patient was born at term by Cesarian section, following labor complicated by failure to progress. There were no neonatal problems. He was healthy until he was admitted to hospital in cardiogenic shock. He was found to have renal artery stenosis and underwent angioplasty. The patient sustained hypoxic ischemic encephalopathy during his acute illness. He now has medically intractable epilepsy (Lennox Gastaut syndrome), spasticity (legs affected more than arms) and intellectual disability. He has chronic lung disease, delayed gastric emptying, gastroesophageal reflux, and is fed by gastrostomy tube. The patient has a history of anemia, malignant hypertension, and bradycardia. He is incontinent of bowel and bladder and uses a wheelchair.

Per the documentation provided, the requested 24 Hours of Private Duty Nursing Care Daily is not medically necessary for this patient. Documentation does not support the need for home nursing 24 hours per day. The patient is described in the nursing notes as having brief seizures lasting around 5 seconds, without the need for rescue medication. His pain is described as 0/10 most days. He appears to be tolerating gastrostomy tubes feeds without problems. Infrequent suctioning was required.

The 16 hours per day of home nursing approved by the health plan is appropriate at this time. Although the patient does not have care needs in the Level 1 category, he does require frequent skilled attention during the day and night. His needs are greater than can be reasonably performed by his parents alone. Boss et al note that pediatric home health care is a chronic need. The authors reached five conclusions in their paper: benefits of home health care include child survival and family stability;  family life is inextricable from home health care schedules, staffing, and services; home health care gaps threaten family physical, mental, and financial well-being; Out-of-pocket costs are common; and families must fight for services as their children's medical conditions evolve.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: skeletal Class II malocclusion 
Treatment: Braces and Monthly Visits 
The insurer denied Braces and Monthly Visits. The health plan's determination is overturned. 

The patient in question is a female presenting with a skeletal Class II malocclusion with maxillary and mandibular spacing. She has an anterior open bite. She is treatment planned for orthodontics to address the open bite, but the treatment was denied due to lack of medical necessity.

Braces and Monthly Visits are medically necessary for this patient.
Anterior open bite patients are among the most difficult patients to treat. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite.
Braces and Monthly Visits are medically necessary for this patient due to the side effect described above, and the fact that this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion 
Treatment: Braces and Monthly Visit (x12) 
The insurer denied Braces and Monthly Visit (x12). The health plan's determination is overturned. 

The patient in question is a female. She has a Class II malocclusion with significant crowding and protrusive maxillary and mandibular incisors. Tooth 14 is in crossbite. She has a 6-millimeter (mm) overjet. She is treatment planned for 30-36 months of orthodontics with extraction of teeth 5, 12, 20 and 29 to correct the overjet, crowding and protrusion. Under review is the medical necessity of Braces and Monthly Visit (x12).

Braces and Monthly Visit (x12) are medically necessary for this patient.
Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. Orthodontic treatment with premolar extractions will make the teeth significantly less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+ (plus) mm overjets, which this patient has. (The Overjet was calculated digitally using the reference ruler included in the cephalometric image). For these reasons, the requested Braces and Monthly Visit (x12) are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: anterior crossbite on tooth 7
Treatment: Braces/Monthly visits
The insurer denied Braces/Monthly visits. The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 7.  She presents with a skeletal Class I malocclusion with severe crowding in the maxilla and mandible. She is treatment planned for 30-36 months of Braces and Monthly Visits to address the crowding and crossbite.

The braces and monthly visits are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 7. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peptic ulcer disease and Helicobacter pylori (H. pylori) infection. 

Treatment: Emergent hospital admission.

The insurer denied coverage for the emergent hospital admission. 

The denial is upheld. 

This is a female patient with a history of coronary artery disease (CAD), hypertension, and hyperlipidemia. The patient presented to the hospital with abdominal pain and dark stools. She had a previous history of ulcer disease and anemia. She was found to have a Helicobacter pylori (H. pylori) infection but did not take the treatment. She was afebrile and the vital signs were stable. The abdominal exam was benign. The hemoglobin was 5.9. She received transfusion and the hemoglobin went up to 7.9. An endoscopy revealed a duodenal ulcer that was treated with endoclips. There was no further bleeding.  

Clinical indications for admission for upper Gastrointestinal bleeding, based on Milliman Care Guidelines (MCG) include hemodynamic instability, ongoing active bleeding, high risk endoscopic feature, server coagulopathy, and anemia with vital signs of cardiac ischemia. The patient did not have these conditions.

This patient had peptic ulcer disease and H. pylori infection. She required transfusions and the hemoglobin improved. She was stable to have been transfused and to have had the endoscopy with observation status. The endoscopy reported good hemostasis with the endoclips. The patient's hemoglobin remained stable. 

The patient did not meet MCG criteria for admission for upper gastrointestinal bleeding. The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. 

The insurer's denial of coverage for the emergent hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease/GERD.
Treatment: Surgical Services.
The health plan denied the requested procedure as not medically necessary. 
The health plan's determination is overturned.

This is a female with a history of gastroesophageal reflux disease (GERD) treated with Proton-pump inhibitors (PPI). She endorses well-controlled acid reflux symptoms with adherence to PPI and an anti-reflux lifestyle. She expresses the wish to be off PPI therapy but report recurrent GERD symptoms with cessation of PPI therapy. Therefore, she is seeking endoscopic therapy over PPI therapy for long-term treatment of GERD.

The health plan's determination is overturned, in whole.

Esophagogastroduodenoscopy (EGD) with radiofrequency ablation (Stretta procedure) is not more beneficial than any standard treatment (PPI therapy or Reflux surgery). The most current literature review evidence offers an equivocal conclusion about the efficacy of the Stretta procedure compared to standard treatment. Stretta procedure is less effective compared to fundoplication, but it has fewer complications compared to fundoplication surgery.
However, the goal of the patient is to be off PPI therapy to avoid complications of chronic PPI use and avoid surgical complications of fundoplication surgery. There is reasonable clinical evidence based on the most current and up-to-date literature review to support the use of Stretta procedure to achieve non-medical management of GERD by transitioning off PPI and avoiding the surgical complication of fundoplication surgery. Therefore, the proposed test (EGD with radiofrequency ablation (RFA)) is more likely to beneficial than standard therapy in this patient who wishes to transition off PPI therapy.
The patient was unsuccessful in transitioning off PPI therapy with recurrence of GERD symptoms. The patient wants to avoid complications of chronic PPI use. It is prudent to pursue non-surgical treatment for long-term management of GERD to prevent surgically related complications. The most up-to-date literature review indicated an equivocal conclusion about the efficacy of stretta procedure over standard treatment (PPI therapy and surgical fundoplication).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease/GERD.
Treatment: Surgical Services.
The health plan denied the requested procedure as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with gastroesophageal reflux disease (GERD). Esophagogastroduodenoscopy showed Grade A esophagitis, a small hiatal hernia, and gastritis; biopsies showed no reflux changes at the gastroesophageal junction, reactive gastropathy, and normal small bowel. Pantoprazole has been effective, but she has symptoms on discontinuation. The coverage is requested for endoscopy with radiofrequency ablation (Stretta) for the treatment of gastroesophageal reflux disease (GERD).

The health plan's determination is upheld, in whole.

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 potential hydrogen (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; US FDA; 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 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 this patient's gastroesophageal reflux disease (GERD).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Gastroesophageal Reflux Disease/GERD- complication of existing gastric band. 

Treatment: Surgical Services- lap band removal and repeat stomach surgery for weight loss. 

The health plan denied the surgical procedure as not medically necessary. 

The reviewer has overturned in whole the health plan determination. 

This patient has a body mass index (BMI) of 31.7 kilograms per meters squared (kg/m2). She has comorbid health conditions of asthma, dysphagia, esophageal dysmotility, gastroesophageal reflux disease (GERD), and diabetes. The patient underwent placement of a gastric band as treatment of morbid obesity. Her greatest weight prior to this procedure was 300 pounds (lbs.) (BMI 48 kg/m2). She was able to transiently lose weight to a nadir of 176 lbs. 

The patient sought bariatric surgical consultation for the condition of dysphagia and GERD. An upper gastrointestinal (UGI) study showed delayed transit through the banded area of the stomach. The esophagus was dilated and showed dysmotility with intra-esophageal reflux and there was gastric pouch dilatation. She was initially treated with deflation of the gastric band. She followed with the bariatric program post decompression of the band and did have resultant weight gain. The patient consulted with a dietician and received nutritional counseling and education and medical clearance was granted. 

Given this patient's diagnosis, her current health condition and generally accepted guidelines for patient selection, the proposed removal of the dysfunctional gastric band with conversion to sleeve gastrectomy is medically necessary for this patient. She has experienced a complication of an existing gastric band. The patient has required decompression of the lap band due to dysphagia and obstructive symptoms. 
Removal of the existing gastric band with conversion to an alternative bariatric operation (laparoscopic sleeve gastrectomy (LSG)) is medically necessary for this patient per generally accepted guidelines as her initial BMI was 48 kg/m2 in association with weight related illness, there is serial documentation of active participation in a multidisciplinary bariatric program, she was initially successful with weight loss to a nadir of 176 lbs. prior to the development of the gastric band complication, and there is documentation of a significant complication of the gastric band that precludes ability to adjust the band to establish restriction and satiety. The patient has undergone a preoperative medical consultation and is felt to be an acceptable candidate. Removal of the existing gastric band with conversion to laparoscopic sleeve gastrectomy would be health beneficial for her and that she meets generally accepted National Institutes of Health (NIH) and American Society for Metabolic and Bariatric Surgery (ASMBS) criteria for the proposed revisional bariatric operation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion 
Treatment: Braces
The insurer denied braces. The health plan's determination is overturned. 

The patient in question is a female presenting with a skeletal Class I malocclusion and significant crowding. She has an anterior open bite. She is treatment planned for 24-30 months of Braces to address the crowding and open bite.

Braces are medically necessary for this patient. Anterior open bite patients are among the most difficult patients to treat. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. This patient is treatment planned for extractions/braces, which is less invasive than orthognathic surgery.
Braces are medically necessary for this patient due to the fact that this is not something that will self-correct without orthodontic intervention.