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

Diagnosis: Appendicitis
Treatment: Inpatient stay

The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

This is the case of a female with a history of acute appendicitis and right salpingectomy for ruptured ectopic pregnancy, who presented to the emergency department with abdominal pain. She was diagnosed with acute appendicitis. Notably, she had significant cecal thickening and inflammation on computed tomography (CT) scan, as well as an appendicolith. Because of the significant inflammatory changes around the appendix and cecum, the decision was made to admit the patient for intravenous (IV) antibiotics and trial of non-operative management. The patient improved and was discharged to home in improved condition.

The inpatient hospital admission is medically necessary. A lower level of care would be unlikely to fully address this patient's medical needs. While there are numerous trials of nonoperative management of acute appendicitis with antibiotics, the original major trial treated the patients with admission and intravenous (IV) antibiotics for 3 days. This patient had significant inflammation beyond the appendix and an appendicolith. This patient had a high likelihood of antibiotic treatment failure and would likely need an operative intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cholecystitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a female who presented to the emergency department on with a complaint of abdominal pain. She had a history of cholelithiasis and was diagnosed with early acute cholecystitis. She was admitted and given intravenous (IV) antibiotics, kept nothing by mouth (NPO), and underwent laparoscopic cholecystectomy. The operative procedure was uneventful. The patient did have an episode of chest/back pain, emesis and dizziness in the recovery area. However, this was determined to be a reaction to anesthetic and plans were made to discharge to home from the post-anesthesia care unit (PACU). However, she stayed one more night and was discharged to home with plans for outpatient follow up.

The inpatient hospital admission was not medically necessary.
This patient had mild, uncomplicated, cholecystitis. She underwent an expeditious laparoscopic cholecystectomy which was uneventful. She did have one episode of vomiting, pain, and dizziness in the recovery area, but was deemed stable for discharge to home from recovery if pain was controlled. She did stay 1 more night and was discharged the next day. There is no evidence that she had any ongoing instability or needs that required an inpatient admission. It is well established that laparoscopic cholecystectomy can be performed safely in an outpatient setting. There are even patients with acute cholecystitis in some of these studies. Uncomplicated acute cholecystitis does not meet criteria for inpatient admission. The patient could receive all of the necessary evaluation and treatment at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological-Vaginal Bleeding
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient has dizziness, weakness, nausea, pelvic pain, and vaginal bleeding. She was having longer and heavier menses for the last few months. She has a history of obesity and was taking iron. Her vital signs were normal in the emergency room, and she was tender to deep palpation. Her hemoglobin was low at 7.1. Pelvic ultrasound showed an enlarged fibroid uterus. She was admitted as an inpatient and proceeded with a hysteroscopy dilation and curettage. She was given tranexamic acid for two doses. She proceeded with a total laparoscopic hysterectomy, bilateral salpingectomy, and cystoscopy with minimal blood loss of 100 cubic centimeters (cc). She was discharged on the next day with a hemoglobin of 7.9 and was progressing postoperatively. 

The requested health service/treatment of Inpatient Stay is not medically necessary for this patient.
The patient had symptomatic anemia however vital signs were stable and her anemia was chronic in nature. There was no acute hemodynamic instability that needed inpatient admission. She received no blood transfusions after her procedure, during the admission. With acute bleeding,  hysteroscopic visualization is a problem which is why it is not standard of care for acute bleeding. Her hysterectomy could have been performed at a lower level of care with no need for acute intervention.  She had no comorbid conditions such as pulmonary failure, renal failure nor hepatic failure. Her treatment could have been accomplished at a lower level of care for both the tranexamic acid and hysteroscopy. There were no complications such as sepsis, hemorrhage, nor poor wound healing. She progressed well and her blood loss was minimal and did not require transfusion after her procedure. She had no anesthesia complications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission.  The denial is upheld. 

The patient presented with abdominal pain and diarrhea. She was afebrile, and the vital signs were stable. There was no abdominal rebound or guarding. The white blood cell (WBC) count was 18.97. The renal function was normal. A computed tomography (CT) scan revealed colitis. Intravenous (IV) fluids and antibiotics were given. She improved and was able to tolerate a diet. 

Clinical indications for admission for Gastroenteritis [Milliman Care Guidelines] (MCG) M-170 include having a severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe electrolyte abnormalities, and an inability to maintain oral rehydration after observation care. The patient did not have these conditions. 

This patient had gastroenteritis. However, she could have been treated with IV hydration in the Emergency Room (ER) with observation status. The colitis could have been treated with a course of oral antibiotics as an outpatient. She did not meet MCG criteria for admission for Gastroenteritis. 

The health care plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary. 

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Areata.
Treatment: Xeljanz 10 mg (milligrams).

The insurer denied coverage for Xeljanz 10 mg.  The denial is overturned.

The patient is a female who has a diagnosis of alopecia areata. The patient has been successfully treated with oral Xeljanz without complication and with improvement. The requested medication is continuation of Xeljanz.  

The patient is currently stable with her current regimen. It would be medically inappropriate to deny coverage for a therapy shown in studies to improve the patient's condition following successful therapy, having failed numerous topical and oral alternatives. As a result, the denial is reversed; the use of Xeljanz is medically necessary for use in the treatment of the patient's condition at the discretion of the prescribing physician's medical judgment. 

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

The insurer's denial of coverage for Xeljanz 10 milligrams (mg) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sarcoidosis. 
Treatment: Humira. 

The insurer denied the Humira. 
The denial is overturned. 

The patient is a female with sarcoidosis and is prescribed Humira.  The patient has tried and failed prednisone, hydroxychloroquine. Humira is prescribed for the treatment of sarcoidosis. This request is denied due to lack of medical necessity. This denial is being appealed. 

The proposed treatment is "medically necessary". 

The anti-tumor necrosis factor agents (anti-TNFs) such as Humira have been recommended as third-line therapy for sarcoidosis. Available evidence suggests good efficacy and safety of anti-TNF (tumor necrosis factor) use in pulmonary, cutaneous, ocular, neurologic, and multisystem sarcoidosis.  The patient has tried and failed prednisone as well as hydroxychloroquine. Humira has been shown to have positive outcomes in cutaneous sarcoidosis and is well tolerated. The use of Humira for the treatment of cutaneous sarcoidosis is medically necessary. 

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

The anti-tumor necrosis factor agents (anti-TNFs) such as Humira have been recommended as third-line therapy for sarcoidosis. Available evidence suggests good efficacy and safety of anti-TNF (anti-tumor necrosis factor agents) use in pulmonary, cutaneous, ocular, neurologic, and multisystem sarcoidosis.  Patient has tried and failed prednisone as well as hydroxychloroquine. Humira has been shown to have positive outcomes in cutaneous sarcoidosis and is well tolerated. The use of Humira for the treatment of cutaneous sarcoidosis is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is overturned.

The patient has a Class II Division 1 malocclusion with spacing and protrusive maxillary incisors. She has a 9 millimeter (mm) overjet. She is treatment planned for 36 months of orthodontics to correct the spacing and protrusion.
At issue is the medical necessity of braces.

There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. (1) Orthodontics will make these teeth significantly less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. There is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjet, which this patient has. (2) For these reasons orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructive Sleep Apnea. 
Treatment: One battery back-up. 

The insurer denied one battery back-up.  The determination is upheld. 

The patient has obstructive sleep apnea.  He is noted to be using a bi-level positive airway pressure (BiPAP) during sleep to manage his obstructive sleep apnea.  His medical history includes hypertension, coronary artery disease (CAD) (status/post (s/p) stenting), Bell's Palsy (right side), and temporomandibular joint (TMJ) disorder.  Notes from a follow-up visit indicated that the member was using BiPAP at 14/10. The member noted a positive response to therapy.  He had a Phillips Respironics device at the time and was awaiting more information from the manufacturer about the device recall. 

A letter from the provider states that the member has since received a ResMed BiPAP unit to replace his Respironics device.  A request was also made for a backup battery unit for the BiPAP device.  At issue is the medical necessity of the one battery back-up.  
The requested one battery back-up is not medically necessary for the patient.  The use of battery backup devices for continuous positive airway pressure (CPAP)/BiPAP units are generally considered to be patient convenience items.  In contrast to CPAP units, masks and other parts of the positive airway pressure (PAP) interface, a battery unit is not a prescription item.  The requested battery back-up pack is considered to be an optional patient accessory which can be purchased on a retail basis.  It is not common or customary to order battery back-up units for CPAP devices either.  Therefore, at this time this service would not be medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Gastroesophageal Reflux Disease (GERD). 
Treatment: Procedure code 43210 to treat heartburn (transoral incisionless fundoplication procedure using the EsophyX). 

The insurer denied coverage for procedure code 43210 to treat heartburn (transoral incisionless fundoplication procedure using the EsophyX). 

The denial is upheld. 

The patient has chronic gastroesophageal reflux disease (GERD). She has had epigastric pain, and weight loss. A computed tomography (CT) Abdomen/ Pelvis was unremarkable. She has had an upper gastrointestinal (GI) x-ray, and an esophagogastroduodenoscopy (EGD) with Bravo study which revealed gastritis, gastric polyps, and a DeMeester score of 36.1. Her esophageal biopsies were unremarkable. She has had ENT (ears, nose and throat) evaluation and was thought to have laryngopharyngeal reflux (LPR). She has been treated with several proton pump inhibitors (PPI) including Omeprazole, Nexium, and Dexilant. A Transoral Incisionless Fundoplication (TIF) procedure using EsophyX has been recommended for her. 

The TIF procedure has concerns regarding its long-term efficacy and safety according to current evidence-based peer-reviewed medical literature, and therefore, it is not considered to be medically necessary. The TIF procedure cannot be considered to improve the health outcome at this time. 

"Studies have shown that approximately 3% (percent) to 10% of patients who undergo TIF will experience some type of adverse event. Some of the more concerning side effects of TIF include mucosal tear, perforation, bleeding, pneumothorax, and mediastinal abscess. From providers' point of view, I think that gastroenterologists are hesitant to refer patients for TIF because of the concern about the durability of this procedure. Furthermore, some providers may be concerned about endoscopic therapy for GERD due to the failure of the first generation of endoscopic therapies for GERD." (Fass, R., 2017) 

"Transoral incisionless fundoplication and radiofrequency energy delivery are not endorsed in any of the evaluated PPI unresponsive profiles." (Yadlapati, R. et al., 2018). 

The TIF procedure does not have final approval from the appropriate regulatory bodies for this diagnosis. 

This patient is not a good candidate for this procedure to treat chronic heartburn. 

The TIF procedure has concerns regarding its long-term efficacy and safety according to current evidence-based peer-reviewed medical literature, and therefore, it is not considered to be medically necessary, and cannot be approved. The TIF procedure cannot be considered to improve the health outcome at this time. The TIF procedure is not the best available treatment option for this patient at this time. 

The adverse risks are increased over standard treatment services. 

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

The carrier's denial of procedure code 43210 to treat heartburn (transoral incisionless fundoplication procedure using the EsophyX) should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Gastroesophageal Reflux Disease (GERD). 
Treatment: Procedure code 43210 to treat heartburn (transoral incisionless fundoplication procedure using the EsophyX). 

The insurer denied coverage for procedure code 43210 to treat heartburn (transoral incisionless fundoplication procedure using the EsophyX).

The denial is overturned. 

The patient has had chronic gastroesophageal reflux disease (GERD) symptoms while on PPI [proton pump inhibitor] therapy. She had a workup including endoscopy and ambulatory pH (potential of hydrogen) monitoring. The DeMeester score was 36.1. A transoral incisionless fundoplication (TIF) procedure was advised to the patient. 

The American Society for Gastrointestinal Endoscopy (ASGE) has published a guideline on the role of endoscopy in the management of GERD. The paper states that the TIF procedure was approved by the FDA (Food and Drug Administration). It reports that 15 studies and 550 procedures found improved GERD health related quality of life scores after the procedure. Three randomized trials with at least 6 months follow up found that TIF was more effective than high dose PPI therapy in eliminating troublesome regurgitation or extraesophageal symptoms of GERD. 

The physician has submitted an article from Surgical Endoscopy titled "Transoral fundoplication offers durable symptom control for chronic GERD: 3-year report from the Tempo randomized trial with a crossover arm." The conclusion was that the TIF procedure provides sustained symptomatic relief, healing of reflux esophagitis, and prolonged improvement in all esophageal pH parameters at 3-year follow-up. The results further confirm the safety, efficacy, and durability of TIF in symptomatic GERD patients on chronic PPI therapy. 

The scientific evidence supports the use of the TIF procedure in patients with chronic GERD. The procedure has Food and Drug Administration (FDA) approval. The patient is a good candidate for the procedure since she has remained symptomatic on PPI therapy. There are many procedures for GERD treatment. However, this procedure has been shown to be both effective and safe. The patient has chronic GERD with a high DeMeester score and has remained symptomatic on PPI therapy. 

The requested procedure is likely to be more beneficial than any other standard therapies without increased risk. 

The carrier's denial of procedure code 43210 to treat heartburn (transoral incisionless fundoplication procedure using the EsophyX) should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders
Pharmacy/Prescription drugs

Diagnosis: hidradenitis suppurativa 
Treatment: Cimzia Starter Kit
The insurer denied a Cimzia Starter Kit. The health plan's determination is upheld. 

The patient is a female with Hurley Stage III hidradenitis suppurativa and acne vulgaris. On examination, she was noted to have scarring in the axillae and groin, with draining nodules in the groin. She has tried and failed oral contraceptive pills, clindamycin solution, and intralesional kenalog injections. She has also failed doxycycline. She is actively trying to conceive per the appeal letter. The medication under review is Cimzia Starter Kit.

The requested Cimzia Starter Kit is not medically necessary for this patient. According to the evidence-based dermatology literature and textbooks, the conventional medicines clindamycin and rifampin, which are also safe in pregnancy, are effective treatments for the management of hidradenitis suppurativa. The standard of care antibiotic agents are appropriate agents for the treatment of the patient's hidradenitis suppurativa. The conventional medications should be tried and failed prior to initiating Cimzia.

After review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Cimzia prior to the conventional alternatives such as the combination of clindamycin and rifampin, which are safe in pregnancy. There is no proof or documentation provided the patient has tried these conventional drugs and had an adverse effect or proof that these tried drugs did not work for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Feeding difficulty.
Treatment: Feeding therapy program.
The insurer denied the feeding therapy program. 
The health plan's determination is overturned. 

This patient is a  male with a history of feeding problems and autism. He is only able to consume pureed foods and was noted to have aversion to solids. He tried feeding therapy offered at school but did not make a significant progress.

The feeding therapy program is medically necessary for this patient.
This patient has a complex condition and has feeding problems, food aversion and inappropriate diet for age. The current standard of care is to provide intensive feeding therapy to overcome the feeding dysfunction. The patient has already tried and failed therapy sessions at school. Therefore, utilizing an extensive feeding program is recommended in this case.
The requested feeding program provides a superior level of collaboration and evidence based approach. The therapy is provided by a multidisciplinary team that includes speech therapy, occupational therapy, psychology and nutrition service. The team is supervised by a pediatric gastroenterologist.

The requested feeding program is proven to be safe and effective in improving the patient's condition. The feeding program is proven to reduce the need for feeding tube placements in children with feeding disorders. The patient has autism and already tried and failed less intensive therapy programs offered at school. Therefore, enrollment in the intensive feeding program is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, pancreatic cancer, recent fall.

Treatment: Increased Consumer Directed Personal Assistance Services (CDPAS) from 36 hours per week to 84 hours per week.

The insurer denied coverage for an increase of Consumer Directed Personal Assistance Services (CDPAS) from 36 hours per week to 84 hours per week as not medically necessary.

The denial is overturned.

According to the documentation submitted, this is an elderly female with a history of dementia, pancreatic cancer on chemotherapy, and hospitalization for pneumonia, fall, and deep vein thrombosis. She requires assistance with activities of daily living and receives Consumer Directed Personal Assistance Services (CDPAS) from 36 hours per week and the request is for an increase to 84 hours per week. 

Uniform Assessment System (UAS) notes moderate cognitive impairment. Except for supervision for bed mobility, she needs limited-extensive assistance with other activities of daily living (ADL). UAS notes that family and RN (registered nurse) note cognitive and functional decline. She is frequently incontinent. The recent UAS shows a higher number of ADLs needing extensive assistance compared to a previous UAS.

The patient's physician notes that due to dementia and pancreatic cancer the patient needs care 12 hours/day. A letter written by a family member notes that the patient wanders, is confused and inattentive to her needs, she is incontinent and cannot clean up after herself. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

UAS shows extensive assistance is needed in all ADLs except bed mobility. She has worsening cognitive function. She has deteriorated and needs more extensive assistance in multiple ADLs, especially toileting.  She is incontinent. In view of the degree of cognitive and physical impairment, the worsening and the incontinence the increase to 84 hours is approved. 

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 the Consumer Directed Personal Assistance Services (CDPAS) is overturned. Medical necessity is substantiated.