Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: LINX Procedure and Full Hospital Admission
The insurer denied the LINX Procedure and Full Hospital Admission. The health plan's determination is overturned in part. The LINX procedure is indicated for this patient; however, a full inpatient admission is not.

This patient is a woman (body mass index (BMI) 22.5) who sought surgical evaluation for the condition of heartburn. This symptom of gastroesophageal reflux disease (GERD) persists despite use of prescription proton pump inhibitor (PPI) medication (Dexilant). She continues to have breakthrough symptoms. She has no dysphagia. The treating surgeon has proposed the LINX procedure with full hospital admission as treatment of GERD. This is the subject under review.

Based on the current evidence-based literature and the patient-specific objective clinical evaluation in this case, the LINX procedure is likely to be more beneficial than any standard treatment for this insured's condition of proven GERD. However, a full hospital admission is not indicated as this procedure could be appropriately performed at a lower level of care. The patient has symptoms of chronic GERD (heartburn). She has been appropriately evaluated with EGD (esophagogastroduodenoscopy) that showed normal esophagogastric anatomy. There is no contraindicating esophageal motor condition based on the esophageal motility study. There is confirmed pathologic esophageal acid exposure with elevated esophageal acid exposure over the course of a 96-hour pH (potential hydrogen) study. Finally, the patient does not have specific contraindication to implantation of the LINX device such as Scleroderma, suspected or confirmed esophagogastric cancer, prior esophageal or gastric surgery or endoscopic intervention, esophageal motor pathology, symptoms of dysphagia more than once per week, esophageal stricture or other gross anatomic abnormalities, esophageal or gastric varices, lactating, pregnant or plan to become pregnant, morbid obesity, or age < 21.
Therefore, based on the status of peer reviewed literature and adequate long-term follow up, specialty surgical society position statement affirmation regarding LINX and FDA approval, the LINX procedure is indicated in this case. However, this procedure could be performed at a lower level of care and does not require inpatient admission. A lower level of care would allow for provision of the operative intervention, post-surgical monitoring and care, and diet progression, including overnight observation if needed.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Digestive System/gastrointestinal
Surgical Services

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: LINX Procedure and Full Hospital Admission
The insurer denied the LINX Procedure and Full Hospital Admission. The health plan's determination is overturned in part. The LINX procedure is indicated for this patient; however, a full inpatient admission is not.

This patient is a female with body mass index (BMI) 22.5 with a history of symptomatic gastroesophageal reflux disease (GERD) refractory to medication use (maximal proton pump inhibitor (PPI)). A 24 hour potential hydrogen (pH) study revealed an elevated DeMeester score of 21.8 consistent with GERD. Upper gastrointestinal (UGI) revealed a tiny hiatal hernia. Manometry was normal. An esophagogastroduodenoscopy (EGD) did not reveal esophagitis or Barrett's esophagitis. Under review is the LINX Procedure and Full Hospital Admission.

The LINX procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. However, a full admission is not required, or indicated.
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 exclusions to LINX and Nissen fundoplication include BMI > (greater than) 35 in which case treatment of obesity is thought to be important for treatment of GERD. Other exclusions for LINX include Barrett's esophagus with dysplasia, age < (less than) 18 and prior gastric or bariatric surgery. This patient is not documented to have any exclusions to LINX treatment.
Although the LINX treatment is considered appropriate for this patient, this procedure is routinely performed in an ambulatory or observational setting and does not require an inpatient stay. There is nothing unique about this patient in regards to medical complexity of other co-morbid conditions that would require or support the need for inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical Chest Pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is a patient that presented to the hospital complaining of chest pain on exertion associated with shortness of breath.  Past medical history was significant for cardiomyopathy, implantable cardioverter defibrillator (ICD) in situ, paroxysmal atrial fibrillation, interstitial lung disease, antiphospholipid syndrome, recent deep vein thrombosis (DVT) and pulmonary embolism (PE), and monoclonal gammopathy of unknown significance.  Upon arrival to the emergency department (ED), vital signs were: Blood pressure (BP) 166/67, and pulse 109.  Twelve-lead electrocardiogram (ECG) revealed normal sinus rhythm with an incomplete right bundle branch block. Serum Troponin level was elevated <0.04 and Hemoglobin was reduced (9.3mg/dl [milligrams per deciliter]).  Computed tomography (CT) angiogram demonstrated interstitial lung disease and no evidence of pulmonary embolism. The patient was admitted to the hospital for treatment. The patient had presented to the hospital one month earlier and diagnosed with costochondritis. Previous echocardiogram revealed preserved left ventricular (LV) ejection fraction.  Chest pain was deemed to be noncardiac and the patient was ultimately discharged home with follow up.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  This patient presented with atypical chest pain and a recent admission for costochondritis. His pretest probability of coronary artery disease is low (Reference 1).  Utilizing the HEART [history, ECG, age, risk factors, and troponin] score, he was considered low risk (Reference 2).  Utilizing the thrombolysis in myocardial infarction (TIMI) 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 (interval on ECG) 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 (defined as 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 (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) 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.
Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic /Musculoskeletal 
Treatment: Stelara 
The insurer denied Stelara. 
The health plan's determination is overturned in whole. 

The patient is a female with severe Crohn's arthritis. The patient is currently receiving Stelara 90 milligrams (mg) every 4 weeks and doing well. There is a note from her provider stating that she has been on Stelara and receiving every 4 weeks. It has kept both her Crohn's, as well as the joint component, under control. Prior treatment includes Remicade, sulfasalazine (SSZ), Imuran, Entyvio, methotrexate (MTX), Arava, 6-MP, prednisone, Lomotil and budesonide. The subject under review is the medical necessity for Stelara 90 mg every 4 weeks.

The health plan's determination is overturned in whole.

The requested health service/treatment of Stelara 90 mg every 4 weeks is medically necessary for this patient. The patient has severe Crohn's arthritis and is doing well on Stelara 90 mg every 4 weeks and there is ample data to support its efficacy and safety in this scenario.

The patient has severe Crohn's arthritis. She has tried and failed multiple disease modifying anti-rheumatic drugs (DMARDs) and biologics. She is doing well both in terms of gastrointestinal (GI) and musculoskeletal (MSK) components of Crohn's arthritis on Stelara 90 mg every 4 weeks and there is data that supports its use.

A study published in Clinical Gastroenterology Hepatology in 2021 concluded that "shortening the ustekinumab 90 mg dose interval to 4 weeks for patients with Crohn's Disease (CD) who did not respond to doses every 8 weeks improved clinical and biological indices of disease activity. Patients who lose response to the standard dose of ustekinumab might benefit from dose interval shortening, which was effective and safe." Moreover, an article in Journal of Crohn's and Colitis published in February 2021 found that "two-thirds of patients (with CD) recaptured response following treatment intensification with ustekinumab 90 mg every 4 weeks."

Lastly, a study in Alimentary Pharmacology & Therapeutics published in 2020 concluded "intensification of ustekinumab maintenance dosage was effective in over 50% of the patients. This strategy should be considered in patients who are non-responsive to every 8 weeks ustekinumab maintenance dosing."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma to ankle from a fall.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who suffered a fall.  The patient was discharged home after closed reduction.  The patient returned several days later and underwent open reduction internal fixation.  No complications were noted in the operative note. 

The patient was admitted, underwent open reduction with an external fixator placed. The external fixator was then removed several days later.  The patient then underwent internal fixation.

No, the proposed inpatient admission was not medically necessary.
The patient did suffer a moderate to severe injury as it did require open reduction and fixation.  However surgeries of this nature, unless there are complications (infection, uncontrolled pain, or if there is a risk for safety to the patient such as when the patient is an elderly and cannot reasonably care for themselves or would be a danger to themselves if discharged) do not require inpatient admission.

Medical records provided did not indicate that there were any complications or any barriers to being discharged.  The medical records provided do not support that the ankle open reduction internal fixation would require a full hospital admission and therefore it was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The hospital admission was not medically necessary and did not meet criteria based on the medical records provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with a history of psychopathology who presented after a possible seizure characterized by shaking, dizziness and loss of consciousness. At presentation, the computed tomography (CT) of the brain was normal.  Toxicology was positive for cocaine and marijuana. The patient was started on levetiracetam. He was diagnosed with focal seizure activity based on electroencephalography (EEG), was continued on levetiracetam and was discharged.

No, the proposed treatment is not medically necessary.
The patient has a single reported episode and was at neurological baseline at presentation. There were not recurrent events documented after presentation. Appropriate anticonvulsant therapy was initiated in the emergency ward. The diagnostic studies, clinical evaluation and monitoring could have been completed safely and effectively at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal
Treatment: Surgical Services
The health plan denied the procedure of Endoscopy as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient is under evaluation for dyspeptic symptoms including upper abdominal discomfort and bloating. The patient had a gastrointestinal (GI) series that was unremarkable. One office note and the upper endoscopy procedure is included for review. The provider performed an upper endoscopy for the indication of dyspepsia. 

The Endoscopy was not medically necessary for this patient. Per the American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) Clinical Guidelines [1] endoscopic evaluation of patients less than 60 years should be reserved for patients with any one of the following:
-	Clinically significant weight loss (greater than 5 percent usual body weight over 
 6 to 12 months).
-	Overt gastrointestinal bleeding.
-	greater than 1 other alarm feature*
-	Rapidly progressive alarm features.
*Alarm features include:
-	Unintentional weight loss
-	Dysphagia
-	Odynophagia
-	Unexplained iron deficiency anemia
-	Persistent vomiting
-	Palpable mass or lymphadenopathy
-	Family history of upper gastrointestinal cancer
Based on the information provided the patient has no alarm features. The recommended treatment would be to empirically test and treat for H pylori. Patients who are H. pylori negative or who continue to have symptoms after successful eradication of H. pylori should be treated with antisecretory therapy with a proton pump inhibitor. The standard of care is to empirically test and treat for H pylori. Upper endoscopy is generally not indicated because of the very low yield of finding significant pathology.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Myeloma
Treatment: Velcade 3.5 milligrams Intravenously Twice Weekly, 2 weeks on and 1 Week Off Every Three Weeks (1.77 mg per square meter)
The insurer denied the Velcade 3.5 milligrams Intravenously Twice Weekly, 2 weeks on and 1 Week Off Every Three Weeks (1.77 mg per square meter).
The denial is upheld.

The patient in this case is a woman diagnosed with multiple myeloma. Treatment with Velcade 3.5mg (milligrams) (1.77mg/m2 [milligrams per meters squared]) given twice weekly, two weeks on and one week off on a 21 day cycle has been prescribed.  Records indicate that this patient has been on treatment with Velcade, though do not specify dose.

No, the requested Velcade is not medically necessary.
Velcade at a dose of 1.77mg/m2 (milligrams per meters squared) given twice weekly is not a standard treatment for multiple myeloma.  There is no evidence showing that this treatment is safe and effective for treatment of multiple myeloma and it is not an accepted standard means of giving this agent.  While Velcade is a standard drug for treatment of multiple myeloma, the dose and schedule being prescribed is not standard of care and is not medically necessary.

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

Diagnosis: Plagiocephaly

Treatment: Cranial orthotic, current procedural terminology (CPT) S1040

The insurer denied coverage for cranial orthotic, current procedural terminology (CPT) S1040.

The denial is overturned.

This case involves a patient who was seen regarding plagiocephaly.  The documentation indicated the infant was born at 39 weeks via cesarean section due to breech presentation.  The document indicated the parents first noticed flattening of the head very soon after birth.  The parents stated they have not noticed improvement in shape.  The physical examination revealed the anterior fontanelle was soft and sunken.  The physician indicated the patient had left plagiocephaly with anterior displacement of ear and ipsilateral frontal bossing.  The recommendation was made for the patient to be seen for helmet placement and follow-up in few weeks.  The documentation indicated the patient was seen for an appointment regarding the requested orthotic.  The patient's mother indicated there were no issues at birth.  However, there is deformational plagiocephaly with 2 quadrant involvements.  The recommendation was made to receive the orthotic and instruction was given on use.

Based on the medical literature, the patient has a history of plagiocephaly for which the recommendation was made for the patient to be seen for cranial orthotic. According to the medical literature, orthosis therapy in patients with deformational plagiocephaly (DP) leads to significantly better long-term outcomes. Additionally, it is noted that early orthosis was significantly more effective than later orthosis. Therefore, the request is 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 cranial orthotic, current procedural terminology (CPT) S1040 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis and Severe Left Knee Pain

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay.

The denial is upheld.

This patient has a history of osteoarthritis and severe left knee pain.  She underwent a left total knee replacement and was admitted for further management. The patient received physical therapy (PT) following surgery, and referrals were made to rehab facilities. The patient was discharged to a skilled nursing facility for further therapy.

The medical records report the patient underwent a left total knee replacement. Her post surgical course was non complicated. Her vital signs remained stable. There was no evidence of bleeding nor infection. Her wound was without problem. She was able to tolerate oral pain medications. She did not require treatment for an underlying medical condition. She was evaluated by social work and discharge planning instituted for skilled nursing facility (SNF). She was able to be mobilized by PT and could walk 25 feet with walker by post operative day (POD) #1.
 
These findings do not substantiate the necessity for the acute inpatient admission. Criteria would be applicable for Observation status. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient stay is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment inpatient hospitalization

The insurer denied coverage for inpatient hospitalization

The denial is upheld

The patient presented with diarrhea, nausea, and vomiting. She had a low-grade fever and mild hypertension. There was no abdominal rebound or guarding. There was no leukocytosis. A stool occult blood was negative. An abdominal computes axial tomography (CAT) scan was negative for acute disease. She was diagnosed with gastroenteritis. Intravenous (IV) hydration, proton pump inhibitor (PPI) therapy, and antiemetics were given. Her symptoms improved and she was able to tolerate a diet.

Milliman Care Guidelines (MCG) clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, hemodynamic instability, severe vomiting that is not responsive to treatment, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

This patient had a gastroenteritis. Intravenous (IV) hydration with potassium replacement, PPI therapy, and antiemetics could have been given with observation status. She did not meet MCG criteria for admission for a gastroenteritis. The healthcare plan acted reasonably and with sound medical judgement an inpatient hospitalization was not medically necessary.

Based on the above, the medical necessity for the inpatient hospitalization is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is overturned

The patient is an infant male with a family history of asthma who had been sick for two days with a cough and nasal congestion. He had been feeding poorly during this illness. On the day of admission, he developed shallow labored breathing and retractions. His mother was concerned and brought him to the emergency room (ER) for medical treatment.

In the ER, he was noted to have persistent respiratory distress with tachypnea and increased work of breathing. On physical examination, his respiratory rate was 60 and his pulse oximeter was 89% (percent). There were retractions, bilateral decreased air entry, some wheezing and an increased respiratory rate. His respiratory viral panel was negative but his blood testing was significant for an elevated white blood count of 20,000 and a low HCO3 [bicarbonate] level of 18. He was treated with several inhalation treatments with albuterol, IV (intravenous) fluids and steroids. When his respiratory distress persisted despite treatment in the ER, the decision was made to admit him to the hospital with a diagnosis of bronchiolitis and a plan to continue IV fluids and albuterol as needed.

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

The patient was treated appropriately in the ER for respiratory distress with tachypnea and hypoxemia. The family history of asthma placed this child at an increased risk for respiratory failure since the child had an elevated white blood count and evidence of acidosis with a low HCO3 level of 18. The decision to admit for continued intravenous (IV) fluids and albuterol as needed was consistent with the standard of care for a young infant with bronchiolitis and possible sepsis. 

Based on the above, the medical necessity for the hospital admission is substantiated. The insurer's denial is overturned.