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

Diagnosis: Pituitary adenoma
Treatment: Proton Beam Therapy
The proton beam therapy is medically necessary.

The patient is a female with a diagnosis of recurrent pituitary adenoma status post (s/p) resections.  The patient recently developed another recurrence s/p another resection.  Post-operative radiation therapy was recommended and proton beam radiation therapy was requested. 

Proton beam radiation therapy is a type of very precise external radiation treatment in which protons are used to treat cancer and other conditions.  Compared to photon, a proton beam that is delivered with sufficient energy has a low "entrance dose".  A proton beam also has a high-dose "Bragg peak" region, which is designed to cover the entire tumor and there is no "exit dose" beyond the tumor involved in proton radiation therapy.  Because of this unique property, proton beam therapy is highly successful in minimizing damage to normal tissue and surrounding organs, resulting in fewer side effects.  Proton beam radiation therapy is an FDA approved procedure and is not subject to institutional review board (IRB) review.

Proton beam radiation therapy has been shown to be safe and effective for any central nervous system (CNS) lesions that are adjacent to critical structures such as optic nerve, base of skull, brain stem or spinal cord.  This patient is a female with a diagnosis of recurrent pituitary adenoma s/p resections.  The patient recently developed another recurrence s/p another resection.  Post-operative radiation therapy was recommended and proton beam radiation therapy was requested.  Because of the location and size of the tumor involving the cavernous sinus encasing the right internal carotid artery and in close proximity to the optic nerves and chasm, the patient is not a good candidate for stereotactic radiosurgery.  There are several studies showing that proton therapy is a safe and effective treatment for pituitary adenoma.  A 2014 multi-institutional study evaluated 165 patients with pituitary adenoma treated with proton therapy.  The study showed that at a median imaging follow-up time of 43 months, tumor control was 98% among 140 patients and the authors concluded that "Proton irradiation is an effective treatment for FPAs (functional pituitary adenomas), and hypopituitarism remains the primary adverse effect".  

In this case, a proton therapy/photon intensity modulated radiation therapy (IMRT) comparison plan was done.  The radiation exposure to the lens, brainstem and optic chasm exceeded dose tolerance with the IMRT plan, and the proton therapy plan was able to reduce dose to those structures.  In addition, the proton plan also reduced radiation dose to the temporal lobes and lacrimal gland.  Because of the special "Bragg peak" characteristic and clinical studies showing its safety and effectiveness, proton beam radiation therapy therefore, is a medically necessary treatment option for this patient at this time.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System - Cough
Inpatient Hospital

The patient is a female who presented to the emergency department (ED) with a 7 day history of cough, congestion, and fever.  Fevers have been reported daily for the past week, ranging from 101-102 Fahrenheit (F), and responsive to Tylenol.  Additional symptoms included cough, eye redness, and sore throat.  There was no vomiting, diarrhea, rash, ill contacts, or recent travel.

Vital signs in the ED were temperature (T) 39.5 Celsius (C), heart rate (HR) 154, respiratory rate (RR) 24, and oxygen (O2) saturation 97% on room air.  Physical exam noted no rashes, bilateral cervical lymphadenopathy, posterior pharyngeal erythema, and mild conjunctivitis.

Labs were remarkable for white blood cell (WBC) count 22.4 with 58% segs and 30% lymphs, hematocrit (Hct) 34, platelets (Plt) 354, and C-reactive protein (CRP) 66.1.  Chest x-ray showed bilateral peribronchial thickening with patchy opacities in the lower lung zones with peribronchial thickening.  There was suspicion for developing bronchopneumonia, per radiologist reading.  Electrocardiogram (EKG) was performed and was normal, and Strep testing was negative.  Urinalysis showed large protein and ketones.

Due to the duration of fever and presenting physical exam findings, the patient was admitted for concern of Kawasaki disease versus viral etiology.  On the inpatient unit the patient was started on intravenous fluids (IVF), ceftriaxone, and Decadron.  Additional lab work came back positive for Epstein-Barr virus (EBV) (immunoglobulin M [IgM] greater than [>]160) as the probable source for fevers and additional findings; the patient's condition improved, and she was able to be discharged home the following day.

At issue is the medical necessity of the inpatient stay.

The health plan's determination is overturned.

Yes, the requested inpatient hospitalization was considered medically necessary for this patient due to the duration of illness, findings at presentation, and diagnostic considerations.  This is a young child who presented with 7 days of fevers (including being febrile in the ED) and additional findings that were concerning for infection.  Kawasaki disease was a diagnostic consideration based on the physical examination (conjunctival injection, oral changes, cervical lymphadenopathy) and laboratory (elevated CRP) findings.  Given the potential for adverse health consequences, an accurate diagnosis and prompt treatment with intravenous immunoglobulin (IVIG) are imperative to a diagnosis of Kawasaki disease.  Thus, this patient required close monitoring and additional testing at the inpatient level of care in order to ensure the best medical outcome.
Appeal type: Medical necessity
Decision: Overturned

Teeth Spacing Problem
Dental/Orthodontic Procedure

The patient in question is a male with anterior and posterior crossbites and severe crowding. Teeth 6 and 11 are blocked out to the labial. He is treatment planned for D8080 Braces and D8670 monthly visits (x4) to correct his bite. This is the subject of this review.

The health plan's determination is overturned. The Braces and Related Monthly Visit(s) are medically necessary for this patient. The patient has anterior and posterior crossbite with severe crowding. 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. 
This patient presents with anterior and posterior crossbites, crowding, and constricted arches. He would be an excellent candidate for orthopedic rapid maxillary expansion to assist with orthodontic correction. Such a procedure can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve orthopedic expansion is greatly reduced. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastrointestinal
Secondary: GERD
Treatment: Surgical services
This case involves a patient with a long history of reflux that is not effectively managed with maximal medical therapy. The current potential hydrogen (pH) testing is markedly abnormal demonstrating gastroesophageal reflux disease (GERD) with a DeMeester score of 59. The upper G.I. contrast study shows normal anatomy with the exception of a small hiatal hernia and esophagogastroduodenoscopy (EGD) shows no esophagitis. The HP determination is overturned in whole. Until 2012, the surgical options for management of GERD had been limited to Nissen fundoplication or, in some patient populations (morbidly obese), roux-en-Y gastric bypass. This patient does not have a body mass index that would indicate gastric bypass. 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  in 2012 by unanimous vote of the expert panel.Currently, numerous published clinical studies have confirmed that the Linx device reinforces the lower esophageal sphincter, effectively reduces the percent time of esophageal acid exposure, and improves GERD health-related quality of life similar to that of fundoplication. The plurality of the evidence demonstrates that the device is more beneficial than the alternative surgical option of fundoplication. Data shows that the procedure is similarly effective against reflux but with lower risks of surgical trauma, bleeding risk, risk of postoperative complications such as gas-bloat and inability to vomit.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastrointestinal
Secondary:Gerd
Treatment: Surgical Services
This patient  (body mass index (BMI) 29 kg/m2) sought surgical evaluation for the condition of gastroesophageal reflux disease. Symptoms include heartburn. Patient has been treated with Ranitidine, but has refractory symptoms. 
An esophagogastroduodenoscopy (EGD) on 6/14/19 showed a 3-cm hiatal hernia and a normal esophagus. There was no esophagitis noted.
A 48-hour potential hydrogen (pH) study on 5/14/19 showed a composite DeMeester score of 59.4 (nl < 14.7). The study was performed while off acid suppressing medications.
Esophageal motility showed no hiatal hernia noted on manometry. 91% of peristaltic waves were peristaltic. Contrast upper gastrointestinal (UGI) on 8/28/19 showed a small hiatal hernia, severe gastroesophageal (GE) reflux and normal motility.The treating surgeon has proposed the LINX procedure as treatment of chronic GERD. The HP determination is overturned in whole. The requested LINX procedure offers this patient equivalent reduction in esophageal acid exposure and ability to stop use of ongoing proton pump inhibitor (PPI)/histamine (H)2 blocker medication, but with preserved ability to belch and vomit compared to the alternative, standard therapy (surgical fundoplication). Therefore, the proposed LINX is likely to be more beneficial for this patient than alternative standard treatment. LINX (Magnetic Sphincter Augmentation [MSA]) has been approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use since 2012. LINX is not subject to review and approval by any institutional review board for the proposed use. LINX is not the subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the Food and Drug Administration (FDA) regulations. Finally, there is sufficient long-term data to support that this therapy is as efficacious as the established alternative (laparoscopic fundoplication). The body of published literature regarding the LINX procedure has expanded with data supporting the efficacy and safety of magnetic sphincter augmentation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive system/GI
Secondary: GERD
Treatment:surgical services
This patient with a body mass index (BMI) of 28.8 kg/m2 with long standing gastroesophageal reflux disease (GERD) despite medication intake with a proton pump inhibitor (PPI) and a histamine (H)2 blocker. A 24 hour potential hydrogen (pH) study revealed a very elevated DeMeester score consistent with GERD. An upper gastrointestinal (UGI) revealed severe GERD with a small hiatal hernia. Endoscopy revealed a 3 centimeter (cm) hiatal hernia.The health plan determination is overturned in whole. This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The only current exclusion is adolescents, BMI >35 kg/m2 and history of prior gastric/bariatric surgery which this patient has not had.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Type 1 diabetes mellitus

Treatment:  Glucose monitoring system sensors

The insurer denied coverage for the continuous glucose monitoring system sensors. The denial was reversed.

This patient is a male with a history of Type 1 diabetes mellitus, hyperlipidemia, and Vitamin D deficiency.  The patient is in followed-up by an endocrinologist and is on Medtronic 670 G pump with Fiasp insulin.  In early-2018 his A1c was 6.4, and in early-2019 it was 7.  He is requesting coverage for continuous glucose monitoring system (CGMS) Guardian 3 sensor used in conjunction with Medtronic.  The insurer has denied that.  The Endocrinologist is recommending it in order to maximize the amount of time the patient's blood sugars will remain in range of 70-180 mg/dl, thereby reducing glycemic variability and exposure to hypo- or hyper-glycemia.

The Guardian 3 sensor is part of the MiniMed 670 G HeL system, and the safety and glucose profiles of the sensor have been reported (1,2).  Use of CGMs compare to self-monitored blood sugars (SMBS) values, has afforded significant improvement in the management of diabetes mellitus, demonstrated by improving HbAc (3), reduced glucose variability (4), and reduced hypoglycemia (5).  Since the Guardian 3 is part of the Medtronic 670G system, if the insurer approved the insulin pump, they have to approve the Guardian 3 sensor that is part of this system.

Due to all of the above benefits of it in improving the patient's glycemic control, based on data provided to this reviewer, there was worsening of this patient's glycemic control from 6.4 in 2018 to 7 in 2019.

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

The carrier's denial of coverage for the continuous glucose monitoring system sensors provided is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Bone fracture/break
Physical Therapy
This is a patient who was participating in physical therapy. According to the records, a request for a fourth skilled physical therapy (PT) modality code 97140 for the same condition was denied by the health plan. It was noted that the patient had been approved for coverage for up to a maximum of three timed modality codes and it was noted that the request for an additional fourth time the unit for the date in question was not supported from a skilled and time perspective.
There is a letter of appeal from the physical therapist stating that the progress note clearly indicates the parameters of manual therapy treatment, specifically the flowsheet and typed notes indicate the description of passive range of motion, notes clearly cites the area of application at the left knee, and the time of application is clearly indicated in the notes and flowsheet at 15 minutes of application.
A daily physical therapy record noted the patient was being treated for a nondisplaced longitudinal fracture of the left patella . It was noted the patient had no new complaints since the last visit. There was no physical exam performed. The patient performed therapeutic exercises including strap heel slides, bone hang, bridges, Theraband sidesteps, leg press, hamstring curls, calf stretch, STAR and SL Deadlifts. Neuromuscular reeducation was performed with wobble board squats and single leg balance on trampoline. The provider then performed manual therapy for 15 minutes for passive range of motion to the left knee. The provider documented 60 direct minutes and 60 treatment minutes of one-on-one patient contact. It was stated that short-term goals were met including the patient being independent in a home exercise program and long-term goals were 50% met. At issue is the medical necessity of the manual therapy.
The health plan's determination is upheld.
 Manual therapy was not medically necessary for this patient. The records provided indicate that this was visit #16 for the same condition and there was no documentation indicating objective measurements on the state of service showing current deficits with passive range of motion that would require manual therapy. It is noted that the patient was approved for a maximum of up to 3 timed modality codes and billing a fourth code for the state of service was not medically necessary. It was noted at that time that the patient was already independent in a home exercise program and the progress note lacks details regarding the patient's current range of motion or other objective measures or any specific functional assessment on validated measures, with no specific detailed support for the need of passive modalities such as manual therapy as a 4th timed modality for this date of service.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented for neck and back pain, and was treated with chiropractic treatment. She was treated for this chief complaint, under unchanging diagnoses of thoracic pain, segmental dysfunction and sprain. The notes do not indicate any clinical improvement. The Visual Analog Scale (VAS) was noted as 9/10; 5-6/10; 7-8/10, after sleeping on a different bed than usual; 5/10 and 5/10. Notes which indicate mainly neck pain, always VAS 5-6/10, the same as one year later, which reinforces that there is no objective evidence of clinical improvement. The health plan's determination is upheld.
The notes did not indicate ongoing clinical improvement, and without such improvement , such care is not considered medically necessary. Maximum therapeutic benefit would be considered to have been reached. The notes lacked any change in treatment, even when clinical improvements were not being made. The notes lacked ongoing disability scoring, such as Oswestry scores, and indicated condition "unchanged". There were no details on any non-supervised home rehabilitation programs or exercises. Continuing care which does not produce objective clinical improvements is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who had last been seen four months previously.  She had tapered off steroids since that time, and her blood sugar was better controlled.  She had not worsened or improved since stopping steroids.  She remained on mycophenolate without side effects.  The family asked about a trial of intravenous immunoglobulin (IVIG).  Examination revealed impaired balance with positive Romberg sign, past pointing, dysdiadochokinesia, dysmetria, mildly slow left finger taps, axial ataxia, wide based gait with use of a cane and normal general appearance, counts/constitutional, eye, cranial nerve, motor, reflex, sensory, and sensory examinations.  Diagnoses were Hashimoto encephalopathy, ataxia, and abnormal gait.  It was noted that there had been a five year lag between the onset of symptoms and treatment, and provider does not believe that she could improve further.  A course of IVIG was requested.
A prior authorization request dated indicated a request for intravenous immunoglobulin for a diagnosis of Hashimoto encephalopathy.
A  specialty immunoglobulins (IG) enrollment form indicated a request for IVIG for Hashimoto encephalopathy for home infusions.
An IVIG prescription indicated a request for IVIG for 20 grams (g) per day for five days every four weeks for three months.
A letter of medical necessity indicates that the patient has a diagnosis of Hashimoto encephalitis, with anti-glutamine acid decarboxylase (anti-GAD) antibodies.  This has been treated with prednisone and mycophenolate, with impaired glycemic control due to the prednisone.  She had not worsened on the medication but had not improved with regard to ataxia and balance.  An initial three month course of IVIG was requested.  The health plan's determination is upheld.  This is a patient with diagnosis of Hashimoto encephalitis, with anti-glutamine acid the carboxylase (gag) antibodies.
There is no evidence, based on clinical data from prospective clinical trials, that IVIG is effective in the treatment of Hashimoto's encephalitis.  A review of current peer-reviewed medical literature fails to reveal any prospective trials supporting its efficacy.  There have been no randomized placebo-controlled prospective trials providing definitive evidence of efficacy.  There have been no prospective open label trials supporting efficacy.  All medical evidence is based on case reports or retrospective analyses.  Case reports and retrospective analyses cannot support efficacy of any treatment, as non-effective treatments tend not to be reported.
Therefore, in the absence of any evidence of efficacy in the peer-reviewed medical literature, the use of IVIG in the form of Gamunex-C is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-displaced longitudinal fracture of the left patella closed fracture 

Treatment: Physical therapy services under CPT code 97140 for manual therapy

The insurer denied coverage for physical therapy services under CPT code 97140 for manual therapy. The denial upheld.

This patient is a male who is status post fall and was seeking treatment for a diagnosis of non-displaced longitudinal fracture of the left patella closed fracture.  There was documentation of a physical therapy initial examination in early-2019. There is documentation that the slip and fall occurred in late-2018. The patient had been in a knee brace and was non-weight bearing with crutches for the next 4 weeks and progressed to weight bearing as tolerated for the following 3 weeks.  The brace was discontinued in early-2019. However, the orthopedist wanted the patient to continue using crutches until his gait normalized.  The patient was receiving physical therapy services including therapeutic exercise, therapeutic activity, gait training, neuromuscular rehabilitation, manual therapy, massage and patient education.  Long-term and short-term goals were established including gaining independence with a home exercise program, reduction of pain and improvement of strength and mobility.

CPT code 97410 is defined as "Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes." The patient is status post non-displaced longitudinal patella fracture with bracing until early-2019. The physical therapy treatment notes do not support the medical necessity for physical therapy services under CPT code 97140 (manual therapy), rendered on a specific date in early-2019.   The initial physical therapy note earlier in 2019 indicated left knee active range of motion measured 5-110 degrees. CPT code 97140 is specifically described in the physical therapy notes as left knee passive range of motion (ROM).  However, subsequent knee range of motion measurements were not made available for review. Moreover, the note as on a specified date in early-2019 indicates ongoing improvement in knee condition. No specifics are provided. A note on another specified date in early-2019 reports no new knee symptoms since last treatment.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  Including but not limited to, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies' boards and associated were taken into consideration.  

From a physical medicine and rehabilitation/pain management perspective, physical therapy services under CPT code 97140 for manual therapy were not medically necessary.

The insurer's denial of coverage for the physical therapy services under CPT code 97140 for manual therapy, which was rendered, should be upheld.