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

This is a patient with Erythema Multiforme, with recurrent severe oral ulcers that are always preceded by abdominal pain. The patient cannot eat and has difficulty drinking liquids with the condition flares up. The patient has tried and failed topical lidocaine, tacrolimus, and triamcinolone, as well as magic mouthwash, and also oral cyclosporine, valacyclovir, prednisolone, and acetaminophen. The patient has had this condition for several years and has had to be hospitalized for this condition. At issue is whether the proposed health service or treatment Enbrel likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The health plan's determination is upheld.
Chronic and recurrent erythema multiforme in children that is resistant to antiviral therapy and is not triggered solely by viral infections and/or immunizations, is extraordinarily rare and without any proper consensus on how to ideally treat these unfortunate patients. Diagnostic considerations and safety/efficacy considerations are difficult to discern in adult patients but are especially vexing in pediatric patients. Both Enbrel and Mycophenolate Mofetil have been used successfully in pediatric psoriasis and arthritis patients, and in atopic dermatitis patients, respectively.
Neither Enbrel nor Mycophenolate Mofetil are Food and Drug Administration (FDA) -approved for this patient's extraordinarily rare condition, and modern dermatology literature reviews [1-6] do not have any specific recommendations of one agent for chronic erythema multiforme resistant to antiviral therapy (which is usually sufficient to treat pediatric erythema multiforme along with supportive care). However, Mycophenolate Mofetil has consistently more literature and treatment history, and has a more time-tested approach towards the control of erythema multiforme resistant to antiviral therapy.
Mycophenolate Mofetil is safer and more well-suited for long-term use than Cyclosporine or Prednisone (both of which this patient has used), and Enbrel has an extraordinarily limited literature to support its use in conditions of mucosal or gastrointestinal diseases (such as hidradenitis suppurativa or Crohn's Disease). Arguably, either Humira or Remicade would be more suited compared to Enbrel if anti-Tumor Necrosis Factor treatment were to be utilized by this patient, both of which would be off-label.
Yet Mycophenolate Mofetil is also off-label, although its safety and time-tested use in children for atopic dermatitis and other pediatric illnesses supports its use over the requested Enbrel. Alternative immunosuppressants/immunomodulators include Azathioprine or Dapsone.
Accordingly, the requested Enbrel is not as likely to be more beneficial for this patient's disabling condition than other treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with severe oral ulcers believed to be erythema multiforme (EM), treated with valacyclovir, famciclovir, prednisone, cyclosporine, Protopic, and orabase. The provider is requesting Enbrel. At issue is whether Enbrel is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The health plan's determination is upheld. The proposed health service or treatment, Enbrel, is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
According to the current peer reviewed medical literature, primary therapies after failure to suppressive doses of anti-virals include myophenolate mofetil, dapsone, or azathioprine for at least six months before concluding that the drug is ineffective. Other treatments that have been utilized for the treatment of recurrent EM include intramuscular immune globulin G, hydroxychloroquine, cyclosporine, thalidomide, lenalidomide, interferon alfa (in patients with associated hepatitis C virus infection and in one patient without hepatitis C infection), apremilast, adalimumab, tofacitinib, levamisole, and cimetidine.
Rituximab was effective for severe and chronic EM in a case series of five patients unresponsive to other typical therapies; four patients achieved complete remission and one achieved partial remission, although disease relapsed within 3 to 11 months in all patients.
There does appear to be more evidence for the use of Otezla (apremilast) for this condition, which is not approved for this age. Therefore, Enbrel is not likely to be more beneficial than any standard treatment for this condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, cough and wheezing 
Treatment: Inpatient admission 

The insurer denied the inpatient admission. The denial is upheld. 

No, the Inpatient Admission is not "medically necessary". 

The patient is a female at the time of admission to the hospital, with a past medical history significant for hypothyroidism, who developed upper respiratory symptoms, including cough, rhinorrhea, fever, as well as wheezing and was treated with Zithromax by her primary care doctor. Her symptoms persisted after five days of antibiotics and the patient presented to the ER. She had persistent cough and chest pain associated with coughing. She was admitted to rule out ACS (acute coronary syndrome). The patient was hemodynamically stable. Her oxygen saturation was 99%. Her ECG revealed normal sinus rhythm with T-wave inversions inferiorly. Chest X-ray revealed no abnormalities. Her CRP (C-reactive protein) was elevated, consistent with the ongoing inflammatory/infectious process. She tested positive for Entero/Rhino virus. She was treated with bronchodilators, a dose of Solu-Medrol, cough syrup, symptomatic therapy for URI (upper respiratory infection).  An echocardiogram was obtained, revealing a small pericardial effusion. She was diagnosed with viral pericarditis and was treated with colchicine and indomethacin. She improved symptomatically, and was discharged home with a plan for outpatient follow-up. 

This patient presented for evaluation of atypical chest pain in the setting of URI. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. She was found to have an acute viral infection. The patient was found to have a pericardial effusion, which was not hemodynamically significant. She was diagnosed with viral pericarditis and was treated with NSAID (non-steroidal anti-inflammatory drug) and colchicine. No surgical or percutaneous drainage was required. No ischemic work-up was planned due to atypical nature of chest pain. The patient felt better with symptomatic therapy and was discharged home. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), respiratory distress, malignant arrhythmia, pericardial tamponade or hemodynamic instability. There was no hypoxemia. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibroid Uterus 
Treatment: Orilissa (Elagolix) 
The insurer is denied coverage for Orilissa (Elagolix). 
The denial is upheld. 

This is a female patient with a diagnosis of fibroid uterus complaining of pelvic pain. Ultrasound showed a fibroid uterus and a hemorrhagic cyst. The patient was offered the combination of Orilissa and Voltaren for pain control.

Based on the review of the medical record, the etiology of this patient's pain is not clear. The information suggests that the pain was due to the patient's uterine fibroids. The patient also had a hemorrhagic cyst. The patient was never diagnosed with endometriosis (laparoscopically) or was treated for endometriosis. The diagnosis was based on a one time finding of a hemorrhagic cyst. Ideally, the patient's ultrasound needs to be repeated to see whether or not the cyst has resolved.

If the patient's pain is caused by endometriosis then the following applies: the treatment of endometriosis-related pain is based on the severity of symptoms, and other causes of pelvic pain should be excluded prior to treatment. For women with mild to moderate pain, nonsteroidal anti-inflammatory drugs (NSAIDs) and continuous hormonal contraceptives are recommended rather than either agent alone (Grade 2C). These therapies are low-risk, have few side effects, are low-cost, and are generally well-tolerated compared with other medical therapies. For women with adequate symptom improvement, continuation of the hormonal therapy/NSAID regimen until pregnancy is desired or until the average age of menopause is reached. For women whose symptoms do not improve, continuation of NSAID treatment and an alternate hormonal combination (e.g., change to a different estrogen-progestin contraceptive or norethindrone acetate) are suggested. For women with severe symptoms, symptoms that do not respond to the above therapies, or recurrent symptoms, a trial of gonadotropin-releasing hormone (GnRH) agonist with add-back hormonal therapy is recommended (Grade 2C). GnRH agonist treatment has demonstrated efficacy without the risks or negative impact on ovarian reserve of surgery. 

A new drug Orilissa just approved by the FDA is a Gonadotropin-hormone releasing (GnRH) antagonist which also suppresses the pituitary gonadotropin hormone production and creates a hypoestrogenic state.

This patient does not have a definitive diagnosis of endometriosis. This patient did not fail treatment with oral contraceptives, progestins or Lupron, nor does she have a contraindication to trial these products. Thus, as of now, Orilissa is not considered medically necessary for this patient. 

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

The carrier's denial of coverage for Orilissa (Elagolix) should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infectious disease/other 
Treatment: Home health care 
The insurer denied the requested 12 hours per day, 5 days per week and 5 hours per day, 2 days ; total 70 hours per week. 
The denial is overturned in whole. 

The patient is a female with a past medical history of asthma, coronary artery disease, hypertension, congestive heart failure, gastroesophageal reflux disease (GERD), constipation, osteoarthritis, low back pain, transient ischemic attack (TIA), vertigo, incontinence, history of breast cancer and frequent falls.
Yes, the requested Personal care assistance 12 hours per day 5 day per week and 5 hours per day for x2 day total 70 hours per week is medically necessary.
The patient had a significant change in health following 2 hospital admissions with the requirement of nebulized medication, oxygen therapy 24 hours per day and BIPAP therapy. This change in status was not documented in her most recent assessment tool. There was limited documentation regarding the new oxygen order, nebulized medication or BIPAP. The patient requires assistance with equipment management, walking and locomotion due to the new therapies and her needs. The patient walks with a cane and is at risk for fall/tripping due to oxygen tubing. The patient's recent hospitalization increased her need for follow up visits with medical providers and transportation needs. Her PCP noted the medical necessity of increased PCA service hours in the two letters submitted for review.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive system gastrointestinal/other.
Treatment: Surgical services.
The insurer denied the  POEM- Per Oral Endoscopic Myotomyas experimental.investigational.
The denial is overturned in whole.

The patient with achalasia.  The patient  has had daily dysphagia with solids and liquids for over 2 years, regurgitation, chest pain, and unintentional weight loss of over 20 pounds in the past year; her Eckard score is 3.
Yes, peroral endoscopic myotomy (POEM) is likely to be more beneficial than any standard treatment or treatments for the patient's achalasia than any available alternatives.
The American Gastroenterological Association best-practice guideline for peroral endoscopic myotomy states that "if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (Kahrilas, et al). Accordingly, the provider is a POEM expert (Stavropoulos, et al). The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, stating that POEM is a "a potential attractive option for the treatment of achalasia that offers a minimally invasive endoscopic approach to myotomy with the potential for a durable response to therapy" (ASGE PIVI Committee, et al). Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available (Barbieri, et al; Schlottmann, et al). However, despite comparable efficacy, POEM is significantly less invasive than surgical intervention, resulting in less postoperative pain and a more rapid recovery (Docimo S, et al).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive system gastrointestinal/other.
Treatment: Surgical services.
The insurer denied the  POEM- Per Oral Endoscopic Myotomyas experimental/investigational.
The denial is overturned in whole.
 
The patient  achalasia. The patient has had 2 years of significant dysphagia. The patient  has trouble swallowing both solids and liquids. As a consequence,  has lost significant weight. The patient underwent an esophagogastroduodenoscopy (EGD) followed by barium esophagram and then High-Resolution Manometry (HRM) of the esophagus and was found to have type 3 achalasia. The patient has early (stage 1) disease.
Yes, POEM is likely to be more beneficial than any standard treatment for the insured's disabling condition. Specifically, for Types II and III achalasia, POEM is now positioned as a first-line treatment.
Performing POEM is backed by high quality peer-reviewed literature. Specifically, POEM has been shown to have superior efficacy compared to pneumatic dilation with a longer treatment effect. Patient usually develop recurrent dysphagia with dilation and need repeat procedures.[1] POEM is equally efficacious compared to laparoscopic Heller myotomy which is the former gold-standard of treatment. POEM provides equivalent symptom relief and fewer serious adverse events.[2]
References
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive system gastrointestinal/other.
Treatment: Surgical services.
The insurer denied the  POEM- Per Oral Endoscopic Myotomyas experimental/investigational.
The denial is overturned in whole.

The patient requesting peroral endoscopic Myotomy (POEM). The patient has history of achalasia. The patient's Esophagus x-ray showed narrowing of the distal esophagus with proximal dilation consistent with achalasia. Manometry was performed. The appeal letter describes 20-pound weight loss, dysphagia, and chest pain.
Yes, the POEM is likely to be more beneficial then standard treatment for the patients' condition or disease.
Since this patient has well documented achalasia, manometry/endoscopy/x-ray findings all consistent with achalasia, and the literature supports the use of this procedure as a first-line therapy for treatment of achalasia, the requested procedure is medically necessary, and more beneficial than standard treatments for this disease.
Cho describing POEM as the main therapy for achalasia: "Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted."
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal
Pharmacy/prescription drug

Diagnosis: Ulcerative Colitis
Treatment: Xeljanz
The insurer denied Xeljanz. 
The health plan's determination is overturned. 

The patient is a female with Ulcerative Colitis. She failed oral and rectal mesalamine. A colonoscopy showed moderate inflammation in the rectum. She started Xeljanz 10 milligrams (mg) twice daily. She has since been stable on Xeljanz, with good control of symptoms.

Xeljanz is medically necessary for this patient. The patient had active Ulcerative Colitis with failure of conventional alternatives including mesalamine. Xeljanz is approved by the Food and Drug Administration for the treatment of Ulcerative Colitis, and has proven effective in a double-blind, placebo-controlled trial of patients with moderate-severe Ulcerative Colitis. The American College of Gastroenterology guidelines recommend the use of Xeljanz for the treatment of Ulcerative Colitis. The patient has attained remission on Xeljanz. Discontinuation of Xeljanz or a change to an alternative may result in ongoing disease symptoms, worsening flare, disease complications such as toxic megacolon or dysplasia leading to colorectal cancer, need for surgery, or hospitalization. For these reasons, continuation of Xeljanz is supported as medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal.
Chiropractic Services.

Diagnosis: Back pain.
Treatment: Chiropractic Manipulative Treatment.
The insurer denied the Chiropractic Manipulative Treatment. The health plan's determination is upheld.

The patient is a female who presented for chiropractic treatment for complaints of low back pain, Visual Analog Scale (VAS) 8/10. Spinal manipulative treatment was started, and the patient's back pain was self-rated as 4/10.

The patient had a trial of chiropractic manipulation and made clinical progress during this time, but not after this date, when the VAS scores varied from 3-7/10, with no ongoing clinical improvement. Additionally, there were no ongoing Oswestry scores, no re-examinations, no exacerbations, no documented short and long term goals, and no non-supervised home rehabilitation program, all of which would better support both claims of clinical improvement and actual patient improvement. There was a lack of objective documentation of ongoing clinical improvement, making such care not medically necessary. Therefore, the CMT in question was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory failure, sepsis, congestive heart failure.
Treatment: Inpatient Skilled Nursing Facility Admission.
The insurer denied the Inpatient Skilled Nursing Facility Admission.
The denial is overturned. 

Yes, the Inpatient Skilled Nursing Facility Admission is medically necessary.

The patient is a male with history of congestive heart failure, who was admitted to acute inpatient level of care for the management acute respiratory failure due to pneumonia, severe sepsis, as well as acutely decompensated heart failure. During the inpatient hospitalization, patient was treated with IV antibiotics, high flow oxygen, IV diuresis, as well as IV steroids and frequent nebulization. At the time of discharge, due to prolonged hospitalization, patient was discharged to skilled nursing facility.

The patient's complex medical issues, as well as acute sepsis complicating mental status, as well as CHF (congestive heart failure), the inpatient skilled nursing facility admission, was medically indicated.  The patient was still recovering from sepsis, as well as acute respiratory failure. The patient's cardiac medications were being adjusted. The patient's mental status was slowly improving. Although there was a family support, the care required would not be safe at home and beyond the capabilities of the home care services. Additionally, the patient's Physical Therapy evaluation suggested that patient would likely benefit the most from inpatient skilled nursing facility care since the patient had episodes of hypoxia with ambulation. The Inpatient Skilled Nursing Facility Admission was medically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder 
Treatment: Surgical Services 

The insurer denied the nerve decompression. The denial is upheld.

The patient is a female who underwent a right occipital nerve decompressio for cervico-occipital neuralgia. In 2017 she underwent an occipital block and ablation of the right inferior occipital lobe. She had an anterior discectomy and fusion C3-4 through C7 with posterior fusion across C6-7. She also had a prior right sided craniotomy due to right anterior temporal lobe arteriovenous malformations (AVM) resection. Neurosurgery notes were reviewed. She was seen for a telemedicine visit. She was suffering immensely due to her occipital region pain and had failed best medical management. Her pain was severe, intractable and interfered with her quality of life and activities of daily living. Notes indicated that she was pain free in the region where the particular occipital nerve branches were decompressed. She would benefit from further exploration and decompression. Earlier notes from 2018 were reviewed and occipital stimulation was recommended. Her pain was persistent in the right scalp region and her other pain significantly improved with decompression of her occipital and zygomaticotemporal nerve. She had a history of multiple spine operations with severe intractable occipital region pain. Her medications included Morphine, Zanaflex, Zofran, gabapentin, Zoloft, Toprol, Mobic and Tegretol. Her last noted exam showed a positive Tinel's sign over the right occipital region and right temporal region. 

The patient has had a prior occipital nerve decompression with positive results. She continues to have pain in the region and her surgeon stated that she would benefit from further exploration and decompression. She recently had a trigger point injection to the occipital area that was beneficial. It appears her last exam that showed a positive Tinel's in the occipital area was in 2017 and there has been no neurological exam since by the surgeon. Her exams by Neurology are normal. The appeal and office notes are not specific as to where there is compression of the nerve, and if there has been any other imaging done to show a compression. Therefore, there is not sufficient evidence that the decompression would likely be more beneficial than any standard treatment or treatments. 

The American Association of Neurological Surgeons (AANS) does not list occipital nerve decompression as a treatment for occipital neuralgia but lists occipital nerve stimulation, spinal cord stimulation and C 2,3 Ganglionectomy for treatment of the condition.