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

Diagnosis: Prematurity and Respiratory Distress Syndrome
Treatment: Synagis 100mg/1ml, Pre-service
The insurer denied the Synagis 100mg/1ml, Pre-service.
The denial is upheld.

The patient is female child born prematurely, complicated by retinopathy of prematurity, respiratory distress syndrome, and bronchopulmonary dysplasia with chronic lung disease. She was intubated at birth. There is no documentation regarding her NICU (neonatal intensive care unit) course and chronology of respiratory support. There is no documentation provided that notes the patient is currently on any medications to treat sequelae of chronic lung disease.

No, a second season of Synagis is not medically necessary for this child based on the information provided.

The American Academy of Pediatrics (AAP) issued new guidelines for the administration of Synagis for RSV (respiratory syncytial virus) prophylaxis based on review of current peer-reviewed literature related to burden of RSV in infants and children with emphasis on those at highest risk of severe disease. The following groups of patients are considered at highest risk, with recommendations for administration of Synagis: infants born before 29 weeks' gestation younger than 12 months of age at the start of RSV season; infants with chronic lung disease of prematurity born before 32 weeks' gestation during the first year of life, with some consideration during the second year of life if continued medical support is necessary; infants 12 months of age or younger with hemodynamically significant congenital heart disease (excluding those with lesions adequately corrected by surgery unless medication is necessary for ongoing congestive heart failure); consideration for infants 12 months of age or younger with anatomic pulmonary abnormalities or neuromuscular disorders that have difficulty clearing secretions; consideration for infants less than 24 months of age that are profoundly immunocompromised; and consideration for infants with Down syndrome or cystic fibrosis that have evidence of other risk factors such as chronic lung disease or congenital heart disease. This child was denied based on not meeting AAP guidelines for administration. 

According to the letter of medical necessity, this child has history of respiratory distress syndrome, bronchopulmonary dysplasia, and chronic lung disease. There is no discussion of current medication usage or ongoing symptoms of chronic lung disease that would warrant a second season of Synagis administration. According to the AAP, Synagis is only medically necessary for children for a second season if they continue to experience sequelae from chronic lung disease or hemodynamically significant congenital heart disease. Even in the letter of medical necessity, there is no discussion of ongoing signs and symptoms of chronic lung disease, current medication usage, or ongoing need for supplemental oxygen. So based on the documentation provided, Synagis is not medically necessary for a second season.

Yes, the  health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Colitis
Treatment: Pentasa 250mg Capsule Sustained Action (SA)

The insurer denied the Pentasa 250mg Capsule Sustained Action (SA).
The denial is overturned.

The patient is a male with Crohn's disease of the terminal ileum and colon with mild activity based on labs and endoscopic finding. The patient has had rectal bleeding and diarrhea with endoscopic findings of colitis and histology of Crohn's disease. The patient has been treated for mild Crohn's disease/colitis with pentasa and mesalamine enema therapy, which the patient has clinically responded to as well as a diminution of the calprotectin.

Yes, the requested Pentasa is more beneficial than any standard treatment for this patient's condition.
The requested therapy is more beneficial than other standard therapies i.e.(for example) administration of other mesalamine forms colazol, apriso, lialda,  asacol, which cannot be given to a child who cannot swallow a capsule.

At this time with the patient improved on pentasa and there is no need, based on the treating physician's recommendations, to advance therapy, the current therapy with pentasa is medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Colitis
Treatment: Pentasa 250mg Capsule Sustained Action (SA)

The insurer denied the Pentasa 250mg Capsule Sustained Action (SA).
The denial is upheld.

The patient is a male. He was recently diagnosed with Crohn's disease. He has been on budesonide. His doctor also prescribed Pentasa 250 mg (milligrams) CR (controlled release) capsule. The reason for prior denial was that the requested Pentasa is not approved for children per the plan and the patient did not try formulary mesalamine products.

No, the health plan should not cover the Pentasa.
The enclosed plan covers formulary mesalamine including 400 mg (milligrams) mesalamine capsule which may be opened and swallowed. The requested product is Pentasa 250 mg (milligrams) capsule. There has been no literature to support the brand name Pentasa is superior to generic mesalamine. The patient has not tried and failed formulary mesalamine capsule. Thus, the health plan should not cover the requested health service.

No, the requested Pentasa is not more beneficial.
5-ASA (mesalamine) has been widely used in pediatric patients with mild to moderate inflammatory bowel disease, including Crohn's disease. ImproveCareNetwork and guidelines recommend mesalamine dose of 60-100 mg/kg/day (milligrams per kilogram per day) up to 4.8 g/day (grams per day) for active colitis (references 1-3).

Even though mesalamine has been used widely in children with Crohn's disease, there has been no clinical studies to show that the specific mesalamine brand Pentasa is better than any other mesalamines such as generic mesalamine. Thus, the requested Pentasa capsule is not more beneficial than any standard treatment for the insured's condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis.
Treatment: Inpatient Hospital Stay.

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

The patient presented to the hospital emergency department (ED) with upper abdominal pain. She had been previously evaluated with an abdominal ultrasound that showed gallstones. At the time of presentation, the patient was without a fever, and her vital signs showed a heart rate of 82 beats/minute and a blood pressure of 152/91 millimeters of mercury (mmHg). She had tenderness in the upper abdomen. The white blood cell count (WBC) count was normal at 8.3 thousand (K). The complete metabolic panel identified normal aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin. An ultrasound in the ED showed cholelithiasis and a normal caliber common bile duct.

She was initially treated with intravenous (IV) fluid and antiemetics. A surgical consultation was obtained and a laparoscopic cholecystectomy was performed. Surgery was completed without complication.

The patient tolerated oral intake. She was discharged from the inpatient setting with instructions for outpatient surgical follow up.

An inpatient level of care was not medically necessary in this case.

This patient presented to the ED with abdominal pain. Evaluation identified gallstones. She was hemodynamically stable at the time of presentation. The WBC count and serum chemistries were normal. The patient had no significant comorbid health conditions that required an inpatient stay. A laparoscopic cholecystectomy was performed without complications. The patient remained hemodynamically stable during the period of monitoring. A lower level of care would have allowed for overnight monitoring, surgery, confirmation of clinical stability, and diet advancement.

There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care in this case. A lower level of care would have been consistent with generally accepted standards of care. It would have allowed for surgical assessment, treatment with IV fluid and antibiotics, surgery, and arrangements for outpatient follow up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspepsia

Treatment: Hepatobiliary iminodiacetic acid scan (HIDA)

The insurer denied coverage for a hepatobiliary iminodiacetic acid scan (HIDA)

The denial is upheld.

According to the documentation submitted, this patient has a medical history of hypothyroidism, gastroesophageal reflux disease (GERD), genital herpes simplex, fibromyalgia, rheumatoid arthritis, neurocardiogenic syncope, Raynaud's disease and anemia. The patient had dyspepsia with episodes of nausea and vomiting. She was felt to have gastroparesis. The abdominal exam was benign. An endoscopy revealed only mild gastritis. An abdominal ultrasound was reported to be normal. Her physician also ordered a HIDA scan with ejection fraction as part of the workup for nausea and vomiting.

UpToDate has an article titled "Functional Gallbladder Disorders in Adults." This condition is characterized by biliary pain in the absence of gallstones or sludge. The clinical manifestation of this disease is biliary-type pain. It is characterized by an intense discomfort in the right upper quadrant (RUQ) or epigastric areas of the abdomen. If a patient has biliary colic, then CCK [cholecystokinin] stimulated cholecystography is indicted.

UpToDate has an article titled ''Approach to the Adult with Nausea and Vomiting." Endoscopy and a gastric emptying scan are recommenced parts of the workup. However, a HIDA scan is not a standard part of this workup unless there is evidence of gallbladder disease. 

This patient has nausea or vomiting. The ultrasound is reported to be normal. The submitted chart does not give any indication that the patient was having biliary colic. There is no documentation that the patient was having epigastric or RUQ pain. Since she was not having biliary colic, she did not fulfill criteria for a HIDA scan. Therefore, the health care plan acted reasonably and with sound medical judgement. The HIDA scan was not medically necessary.

Based on the above, the medical necessity for the hepatobiliary iminodiacetic acid scan (HIDA) is not substantiated. The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease (GERD).
Treatment: Implantation of LINX Reflux Management System.

The insurer denied implantation of LINX Reflux Management System.  The denial was overturned in part.

The patient is a male, with a past history of gastroesophageal reflux disease (GERD), status/post (s/p) LINX procedure.  He presented with early recurrence of symptomatic GERD.  Proton-pump inhibitors (PPI) were resumed with improvement of symptoms, which were quantitatively better than before surgery.  Conversion of the present LINX to a smaller LINX has been recommended and agreed to by the patient.

At issue is whether the LINX procedure is likely to be more beneficial than any standard treatment for the patient's condition.

The health plan's determination regarding the proposed health service or treatment is overturned in part. 

The proposed health service or treatment LINX Procedure is likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease, in part.

The final decision of placing a smaller LINX or doing a Nissen fundoplication would be made in the operating room after the surgeon has fully assessed the previous procedure.  The proposed health service or treatment LINX Procedure is more likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease, if determined after the surgeon has fully assessed the previous procedure. 

The surgeon has indicated that he believes that the patient needs a smaller size LINX device.  An individual therapeutic approach based on an exact analysis of the reasons for failure of the initial procedure is essential for the successful management of these patients; patients who are still symptomatic postoperatively must be thoroughly evaluated to identify the cause of failure, and treatment must be individualized.  The final decision of placing a smaller LINX or doing a Nissen fundoplication would be made in the operating room after the surgeon has fully assessed the previous procedure.  Therefore, the proposed health service or treatment LINX Procedure is likely to be more beneficial than any standard treatment or treatments for the patient's condition or disease, in part.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease (GERD).
Treatment: Implantation of LINX Reflux Management System.

The insurer denied implantation of LINX Reflux Management System.  The denial was upheld.

This patient is a male with a body mass index (BMI) at 25.6 kilograms (kg)/meter squared (m2).  The patient sought surgical evaluation for the condition of heartburn, chest pain and regurgitation.  These symptoms are partially responsive to proton pump inhibitors (PPI) medication (Omeprazole), but he does have breakthrough symptoms. He has no dysphagia.

A potential hydrogen (pH) study identified an elevated esophageal acid exposure with a composite DeMeester score of 32.7 over 96-hours of study.  He continues to have some GERD symptoms that are controlled with PPI therapy.  Treatment options at this time included continuation of medical therapy, conversion of the LINX to surgical fundoplication or conversion of the current LINX to a smaller size implant.

At issue is whether the proposed health service or treatment LINX Procedure, is likely to be more beneficial than any standard treatment or treatments for the patient's condition or disease.

The health plan's determination regarding the proposed health service or treatment is upheld in whole.

The proposed health service or treatment LINX Procedure, is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.

The use of LINX for the treatment of GERD in the setting of this condition is not established.  While the LINX procedure has been approved by the United States Food and Drug Administration (FDA) for treatment of GERD, has demonstrated long term efficacy to support that it is safe and effective as alternative therapy, such as a traditional fundoplication for the specific treatment of proven GERD in the absence of a contraindication to use of LINX, in this case there is a possible esophageal motility disorder.  This procedure is experimental or investigational and is not supported by the peer-reviewed literature.

Therefore, the proposed health service or treatment LINX Procedure, is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal Reflux Disease (GERD).
Treatment: Implantation of LINX Reflux Management System.

The insurer denied implantation of LINX Reflux Management System.  The denial was upheld.

This patient is a male with a body mass index (BMI) of 24 kilograms (kg)/meter squared (m2).  A 24-hour potential hydrogen (pH) study revealed an elevated DeMeester score consistent with gastroesophageal reflux disease (GERD).

An upper endoscopy revealed Grade B reflux esophagitis.  The biopsy was negative for intestinal metaplasia.  Esophageal manometry revealed esophageal dysmotility with impedance and only 30% clearance.  The patient underwent a LINX procedure at a remote point and now is found to have persistent reflux requiring medication intake.

At issue is whether the proposed LINX Procedure is likely to be more beneficial than any standard treatment for this patient.

The health plan's determination regarding the proposed health service or treatment is upheld in whole.

The proposed health service or treatment 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.

This patient already had the LINX procedure, with relative contraindication, with impaired esophageal motility at some remote time and continues with GERD.  The request is for repeat implantation of a smaller LINX device.  There is a paucity of medical data to support re-implantation of a smaller LINX device at this time as either a safe or effective practice for persistent GERD, particularly in the setting of relative esophageal dysmotility.  Medical necessity of the requested explanation and re-implantation of LINX is not appropriate or the standard of care at this time.  

Therefore, the LINX procedure is not likely to be more beneficial than any standard treatment for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholelithiasis. 
Treatment: Inpatient Hospital Stay. 

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

The patient presented to the hospital emergency department (ED) with complaints of upper abdominal pain and vomiting that was progressive and severe. He had a past medical history of a brain tumor status post resection. At the time of presentation, the patient was without a fever and the vital signs showed a heart rate of 72 beats/minute and blood pressure of 122/69 millimeters of mercury (mmHg). He was tender in the upper abdomen. The white blood cell count (WBC) count was normal at 7.18 thousand (K). The complete metabolic panel identified normal aspartate aminotransferase (AST) and slightly elevated alanine aminotransferase (ALT). The bilirubin was normal. A computed tomography (CT) scan showed cholelithiasis and wall thickening. An ultrasound was also performed that confirmed an edematous gallbladder with sludge. 
He was initially treated with intravenous (IV) fluid and antiemetics. A surgical consultation was obtained. A repeat WBC count was 5.4 K. The patient tolerated oral intake. He was discharged from the inpatient setting  with instructions for outpatient surgical follow up and continued oral antibiotics. 

At issue is the medical necessity of an inpatient stay. 

An inpatient level of care was not medically necessary in this case. This patient presented to the ED with abdominal pain. Evaluation identified gallstones. He was hemodynamically stable at the time of presentation. The WBC count was normal and serum chemistries showed a slight elevation of ALT. The patient had no significant comorbid health conditions that required an inpatient designation. He was treated with non-surgical therapy (antibiotics). The patient remained hemodynamically stable during the period of monitoring. A lower level of care would have allowed for overnight monitoring, provision of antibiotics, confirmation of clinical stability, and diet advancement. 

There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins

Treatment: Procedure code 36475, endoluminal ablation of varicose veins

The insurer denied coverage for procedure code 36475, endoluminal ablation of varicose veins.

The denial is overturned.

This patient was seen for a consultation with complaints of varicose veins.  The documentation indicated exacerbating factors to consist of the affected extremity being in a dependent position.  Relieving factors consist of elevation and support hose.  The patient did indicate she has been participating in conservative therapy for greater than 6 months.  Physical examination revealed evidence of CEAP [C = clinical condition, E = etiology, A = anatomic location, P = pathophysiology] 2-varicose veins.  The physician indicated a reflux study revealed reflux greater than 500 to the greater saphenous vein.  It was recommended she undergo additional definitive treatment.  The request has been received for CPT (current procedural terminology) code 36475. Additional documentation from the physician indicated she has had associated symptoms of ulcers, tenderness and edema and has had treatment with a partial great saphenous vein ablation a few years prior.  However, she has developed reflux to the remnant great saphenous vein that require surgical intervention.  The physician again indicated due to the above it was recommended she undergo right remnant great saphenous ablation and stab phlebectomies.
The procedure of right lower extremity GSV (great saphenous vein) RF (radio frequency) ablation, 36475, is not a cosmetic procedure, but a medically necessary procedure for symptomatic right lower extremity superficial venous insufficiency refractory to conservative measures.  

This patient had a past history of superficial venous insufficiency and status post right GSV RF ablation in the past, who presents to the vascular clinic with recurrent symptoms of right leg edema, pain, fullness and tightness. She had tried elevation, compression stockings >6 months and avoiding prolonged standing.

She had a venous reflux study performed, which revealed the upper GSV was ablated, but that the mid-thigh and distal GSV had reflux >0.5 sec (meets criteria).  

Thus, given that the patient had recurrent symptoms, had failed conservative management, and had proven superficial venous reflux in the remnant right mid to distal GSV, treatment with RF ablation is indicated.  Repeat procedures are efficacious and are recognized as such in the literature and the vascular community as standard of care.

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 procedure code 36475, endoluminal ablation of varicose veins is overturned. Medical necessity is substantiated.