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

Diagnosis: Gender Dysphoria
Treatment: Surgical Services (breast augmentation)
The health plan denied the requested surgical procedure as not medically necessary. 
The health plan's determination is overturned.

This is a male to female transgender. She has been on hormone therapy and now has B/C cup sized breasts. She wishes to be a DD cup. According to her surgeon's note, she has had minimal breast development despite hormone use for over one year. Her chest is a source of emotional and psychological distress. Breast augmentation is planned.

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

Yes, the procedure is medically necessary to facilitate the patient's transition and have her appearance more closely align with the average female in the United States (US). The patient has B/C sized breasts. The average bra size in the United States is 34DD. To have an appearance that is consistent with average female appearance in the US, breast augmentation is medically necessary. Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines:

Criteria for Breast/Chest Surgery (One Referral)

Criteria for breast augmentation (implants/lipofilling) in Male to Female patients:

1) Persistent, well-documented gender dysphoria; 2) Capacity to make a fully informed decision and to consent for treatment; 3) Age of majority in a given country (if younger, follow the standard of care for children and adolescents); 4) If significant medical or mental health concerns are present, they must be reasonably well controlled.

Although not an explicit criterion, it is recommended that Male to Female patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

The patient meets these guidelines. She has well documented gender dysphoria and has been on hormone therapy for a year. Breast growth with hormone therapy has been maximized. She is the age of majority. Significant mental health concerns are not documented. The requested breast augmentation is consistent with the WPATH criteria and should be certified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Rhinosinusitis With Nasal Polyposis. 
Treatment: Dupixent Syn 300. 

The insurer denied the Dupixent Syn 300. 
The denial is overturned. 

The patient is a male with a history of chronic sinusitis with nasal polyposis. He has been treated with Dupixent for approximately over 1 year. The provider is requesting continuation of treatment with Dupixent. The request was previously denied coverage by the health plan as not being medically necessary, and the provider is appealing the denial. 

Yes, the requested Dupixent is medically necessary. 

All records were reviewed. The patient has a history of nasal polyposis with polyps on exam. He was treated in the past with nasal and oral steroids and was started on Dupixent approximately 1 year ago. He has improved taste and smell with the Dupixent and less nasal congestion. He is now on a nasal steroid spray as well as the Dupixent. The patient is no longer being treated with oral steroids. Therefore, based on the information provided and scientific literature, the medical necessity of the continued Dupixent for the patient's condition would be confirmed. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

As the medical necessity of the Dupixent is now confirmed, it cannot be stated that the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient presented to the hospital complaining of chest pain, shortness of breath and lightheadedness. Past medical history was significant for shizoaffective disorder, ethanol abuse, myocardial infarction and asthma. Upon arrival to the emergency department (ED) vital signs were blood pressure (BP) 119/83 and pulse 88.  Physical exam was significant for psoriasis over the mid back. A 12-lead electrocardiogram revealed normal sinus rhythm an no ST (interval on ECG [electrocardiogram] or T (interval on ECG) wave abnormalities.  Serum troponin was not elevated (0.01ng/ml [nanogram per milliliter]). The patient was admitted to the hospital and computed tomography (CT) angiogram was ordered.  The patient left against medical advice before testing.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with chest pain and a past medical history myocardial infarction. His pretest probability of coronary artery disease was low (Reference 1). Utilizing the HEART [history, ECG [electrocardiogram], age, risk factors, and troponin] score, he was considered low risk (Reference 2). Utilizing the TIMI [Thrombolysis in Myocardial Infarction] risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient 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 (All)-LINX
The health plan denied the surgical procedure as experimental/investigational. 
The reviewer upholds the health plan's determination in whole. 

The patient has type 2 diabetes and obesity who describes several years of worsening heartburn, regurgitation, bloating, cough, and a sensation of food stuck in her chest. She did take Prilosec for a period without relief but later was described as not taking a proton pump inhibitor (PPI) because of concern of osteoporosis. An upper gastrointestinal (GI) series demonstrated a small amount of reflux and generally normal anatomy. An esophagogastroduodenoscopy (EGD) showed grade C esophagitis, and pathology showed changes consistent with reflux without Barrett's metaplasia. Esophageal manometry was normal. Gastric nuclear emptying study is not described. The LINX procedure was recommended.

No, the LINX procedure is not likely to be more beneficial than standard treatment for this patient's gastroesophageal reflux disease.
While the LINX procedure has demonstrated some efficacy in reducing gastroesophageal reflux disease (GERD) and improving quality of life in short and medium term, there is paucity of evidence with direct comparison groups of fundoplication of significant duration. There remains a concern about potentially serious erosion risk and dysphagia over the longer term. It is not currently possible to conclude that LINX is more beneficial than standard therapy.
As Guidozzi writes, "magnetic sphincter augmentation achieves good GERD symptomatic control like that of fundoplication, with the benefit of less gas bloating. The safety of magnetic sphincter augmentation (MSA) also appears acceptable with only 3.3% of patients requiring device removal. There is an urgent need for randomized data directly comparing fundoplication with MSA for the treatment of GERD to truly evaluate the efficacy of this treatment approach."(1)
The LINX procedure is investigational and not demonstrably better than standard therapy of PPI and fundoplication. Most of the data is cohort observational and shorter in duration than would be needed to answer the key questions of relative safety and effectiveness compared to fundoplication.
In summary, the LINX procedure remains investigational as existing data leave unanswered the primary questions of longer term safety from erosion, and relative effectiveness compared to fundoplication beyond the short term.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal-Gastroesophageal Reflux Disease/GERD
Treatment: Surgical Services (All)-LINX
The health plan denied the surgical procedure as experimental/investigational. 
The reviewer has overturned the health plan's determination in whole. 

This patient has a body mass index (BMI) of 30 kilograms per meters squared (kg/m2) with complaints of symptomatic gastroesophageal reflux disease (GERD) refractory to medication use. The patient is also concerned about long term medication side effects. An upper gastrointestinal (UGI) test revealed small amount of GERD and no evidence of hiatal hernia (HH). An esophagogastroduodenoscopy (EGD) revealed Los Angeles (LA) grade C esophagitis with no bleeding consistent with (c/w) GERD. Pathology did not reveal evidence of intestinal metaplasia (Barrett's esophagus). Esophageal manometry showed normal motility.
This patient has GERD refractory to medical management. 
Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both 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 nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. Exclusions to LINX treatment include age less than (<) 18, pregnancy, metal allergy, BMI>35 kg/m2, HH greater than (>) 3 centimeter (cm), Barrett's esophagus with dysplasia and esophageal motility disorder. This patient does not document any exclusion to LINX treatment, which is determined to be medically necessary and appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Anxiety and Depression

Treatment: mental health services

The insurer denied coverage for mental health services

The denial is upheld

According to discharge summary, the patient was admitted and discharged on. His diagnoses were: Generalized anxiety disorder, Persistent depressive disorder, moderate with anxious distress, unspecified neurodevelopmental disorder, Parent-child relational problem. While the facility, the patient received group therapy twice a week and individual therapy once a week. It was noted that there is a possibility of relapse in areas of social difficulties, depression and anxiety, after returning home, even with intensive outpatient treatment and school accommodations. It was recommended for the patient, after discharge, to go directly to an international empowering and supportive boarding school. 

According to peer-reviewed literature, longer-term treatment for adolescents with SUD (substance use disorder) in residential programs, therapeutic communities, and adventure programs such may be available for some adolescents with SUD who have failed less intensive treatment. There are no randomized clinical trials of the efficacy of these interventions in adolescents. Observational study of substance use before and after these programs (more extensive for therapeutic communities) provides limited support for them. The patient does not have SUD and there is no literature supporting efficacy of wilderness program for generalized anxiety disorder (GAD) and depression. 

There is no evidence supporting wilderness program level of care for youth with GAD and depression. 

The mental health services provided at an outpatient treatment level of care are not the best available treatment for this patient at this time. Some experts have questioned whether some wilderness/adventure programs might be not only ineffective but potentially harmful to youth, who may be essentially incarcerated and cut off from contact with anyone.	

The requested service is not likely to be more beneficial that any of the standard treatments/procedures for this patient.

The carrier's denial of mental health services should be upheld.  It is not more beneficial than any other standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Anxiety and Depression

Treatment: mental health services

The insurer denied coverage for mental health services

The denial is overturned

This case involves a male who was initially admitted to a therapeutic wilderness program.  He has diagnoses that include generalized anxiety disorder, persistent depressive disorder with anxious distress, unspecified neurodevelopmental disorder, and parent-child relational problem.  The documentation indicated he initially had primary concerns regarding a significant history of attention deficit hyperactivity disorder (ADHD), school failure, depression and anxiety.  There was considerable conflict with his parents, lying alienation from peers, withdrawal and emotional reactivity which produced significant impairment in daily functioning.  Initially, he did present as withdrawn and dysphoric showing limited insight or understanding.  He struggled to build connections and presented as arrogant and mildly condescending.  However, over the course of treatment he displayed significant progress in his ability to self-regulate periods of anxiety and emotional reactivity.  He did demonstrate greater humility.  He developed an awareness of factors contributing to conflict with his parents and address the issues in individual and group therapy.  The documentation indicated the program initiated a healthy balance of sleep and exercises in addition to healthy nutrition.  He did continue to display significant symptoms of anxiety throughout the course of treatment.  He was discharged and aftercare instructions were discussed.  It was noted that he would benefit from a small, structured setting with clear rules and boundaries in addition to immediate consequences.  A more supervised environment would encourage continuation of experiential and psychoeducation strength that he did gain.  The documentation indicated he received treatment.

The scientific evidence supports health outcomes. The patient was diagnosed with anxiety and depression.  Individual and group therapy treatment was provided.

This patient was a good candidate based on the diagnosis of depression and attention deficit.  

Mental health services were not the standard of care but a possible alternative treatment that may provide similar support and outcomes. There is no evidence of increased risks in this case. This does appear to be a well-organized form of alternative treatment.

The carrier's denial of mental health services provided at an outpatient treatment level of care should be overturned.  It was likely more beneficial than any other standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tubo-Ovarian Abscess (TOA)

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient was admitted for lower abdominal pain associated with nausea and was found to have a tubo ovarian abscess by CT (computed tomography) scan and ultrasound. She was seen by infectious disease and was started on intravenous (IV) antibiotics. The patient's symptoms improved and was discharged on Flagyl  and doxy for 14 days.

Most women with pelvic inflammatory disease (PID) can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include:
1) Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain)
2) Complicated PID with pelvic abscess (including tubo-ovarian abscess)
3) Possible need for invasive diagnostic evaluation for alternate etiology (eg, appendicitis or ovarian torsion) or surgical intervention for suspected ruptured tubo-ovarian abscess
4) Inability to take oral medications due to nausea and vomiting
5) Pregnancy
6) Lack of response or tolerance to oral medications
7) Concern for nonadherence to therapy

This patient had a tubo-ovarian abscess. Tuboovarian abscess (TOA) is typically considered a complication of pelvic inflammatory disease (PID), and the classic presentation is the same as for PID alone, including acute lower abdominal pain, fever, chills, and vaginal discharge.  However, the presentation of some women with TOA differs from the classic scenario. Fever is not present in all patients and some patients report only low-grade nocturnal fevers or chills. Also, not all women present in an acute fashion. In addition, some women with TOAs may present with seemingly unrelated symptoms, such as diffuse persistent upper abdominal pain or a change in bowel habits. Most women will not be overtly septic appearing if their TOA is intact.

Experts agree that women with a TOA should be treated as an inpatient with intravenous antibiotics, at least initially. This is consistent with the recommendation by the United States Centers for Disease Control.

This patient presented with abdominal pain, elevated WBCs and a TOA on ultrasound and CT scan. She was admitted according to the standard of care and the CDC (Center for Disease Control) recommendation. Once, the patient was deemed stable with an improvement of her symptoms, she was discharged home. 

Based on the above, the inpatient care was medically necessary.

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Psoriasis

Treatment: calcipotriene betamethasone dipropionate ointment/suspension

The insurer denied coverage for calcipotriene betamethasone dipropionate ointment/suspension

The denial is overturned.

The patient has a diagnosis of psoriasis who has failed therapy with multiple topical medications.  The patient has been treated successfully with topical calcipotriene-betamethasone ointment for years without complications.  The requested medication is continuation of calcipotriene-betamethasone ointment. 

A review of the provided documentation indicates that the patient has a diagnosis of psoriasis and has failed numerous topical therapies.  The patient has not required systemic therapies and has been successfully maintained with topical calcipotriente-betamethasone ointment.  Based on the provided medical documentation and the history of the patient, the continued use of calcipotriene-betamethasone ointment is likely to be more effective than any of the formulary options.

The decision is overturned based on the standard of care and the use of topical calcipotriene-betamethasone ointment is approved under the medical supervision of the treating physician.

The insurer's denial of coverage for Formulary Exception for calcipotriene betamethasone dipropionate ointment/suspension is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurativa

Treatment: Kineret (Anakinra)

The insurer denied coverage for Kineret

The denial is overturned.

The patient is a female with a diagnosis of hidradenitis suppurativa, Hurley stage II. The patient has severe disease with numerous painful lesions. The patient has failed systemic therapy with Humira and Stelara. The requested medication is Anakinra.  

Anakinra is medically necessary for the treatment of the patient's condition, hidradenitis suppurativa. The patient has severe hidradenitis suppurativa affecting multiple areas and has failed therapy with FDA (Food and Drug Administration) approved Humira as well as Stelara.  

Anakinra is a reasonable next step in this clinical scenario based on the appeal letter and notes presented. The decision is reversed and Anakinra is approved for the treatment of the patient's hidradenitis suppurativa at the discretion of the treating physician.  

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 Kineret for treatment of hidradenitis suppurativa is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, 1st degree block, pacemaker, left hip degenerate joint disease, reactional anxiety with depressive symptoms, dementia, hypothyroidism, gastritis. 

Treatment: Personal care services (PCS), 24 hours a day split shift (two 12-hour shifts), 7 days a week, for a total of 168 hours. 

The insurer denied coverage for personal care services (PCS), 24 hours a day split shift (two 12-hour shifts), 7 days a week, for a total of 168 hours. 

The denial is overturned. 

This is a patient with multiple medical problems including dementia, cardiac arrhythmia on anticoagulation medication and recent Covid infection.  Partial denial of personal care services (PCS), 24 hours a day split shift (two 12-hour shifts), 7 days a week, for a total of 168 hours is currently under review. 

The insurer approved PCS 24 hours/day 7 days/week live in, for a total of 91 hours is insufficient to meet the safety needs of this female with severe debility and dementia. The patient has had multiple falls out of bed as well as transferring from a bedside commode.  She is at particular risk for severe injury due to her anticoagulation medication.  Her mental status continues to decline; she remains unsafe at home and requires 24-hour supervision.  She requires constant attendance.  The requested 24 hours a day split shift (two 12-hour shifts), 7 days a week, for a total of 168 hours will allow the patient to continue living safely at home. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, the requested personal care services (PCS), 24 hours a day split shift (two 12-hour shifts), 7 days a week, for a total of 168 hours are medically necessary. 

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 personal care services (PCS), 24 hours a day split shift (two 12-hour shifts), 7 days a week, for a total of 168 hours is overturned. Medical Necessity is substantiated.