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

Diagnosis: Stage IV lung cancer, bradycardia.
Treatment: Increase Consumer Directed Personal Assistant Program to 50 Hours per Week.

The insurer denied the Increase Consumer Directed Personal Assistant Program to 50 Hours per Week.  
The denial is overturned.

The patient is a female with a history of Stage IV lung cancer currently undergoing active treatment with chemotherapy. In addition, she has hypertension, bradycardia, anxiety and insomnia. Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs). Appeal review requested for potential approval of 50 hours per week Personal Assistance Services to offer increased activities of daily living support.

Yes the proposed treatment of 50 hours per week Personal Assistance Services is deemed medically necessary.

This is a female with a history of Stage IV lung cancer currently undergoing active treatment with chemotherapy. In addition, she has hypertension, bradycardia, anxiety and insomnia. Due to impairments related to these conditions, she requires assistance for completion of many of his activities of daily living.

Recent documentation noted in the medical records from clinic encounter with a provider indicated that the patient is having difficulty with performing exertional house chores, traveling and grocery shopping due to increased weakness and fatigue. She requires someone to assist/accompany her to the hospital.  This documentation revealed that the currently approved plan of 20 hours per week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 50 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital
The insurer denied the inpatient stay. 
The denial is upheld.

The patient is a male with intersphincteric perianal fistula, who underwent examination under anesthesia and debridement of large posterior wound with placement of a vacuum-assisted closure (VAC). The patient had been seen one month prior to the examination and the disease had significantly worsened. During the surgery, no tract was found that entered into the anal canal; the tract appeared to extend posteriorly to the level of the coccyx and had a significant amount of hair within the wound. A VAC was then placed. The patient was hospitalized with plan to do a VAC change a few days later with colorectal assistance. The patient was doing well. Pain was controlled. The patient was encouraged to ambulate. The patient underwent wound VAC and examination by colorectal. The pilonidal cyst was excised and no fistula to the anus was identified. The patient was monitored overnight and discharged home.

The health plan's determination is upheld.

Inpatient stay was not medically necessary for this patient. The patient had a large perineal wound from a pilonidal cyst which was debrided, but did not have evidence of other complications. The patient was in the hospital because he had a wound VAC. The patient did not require much other than a wound VAC while in the hospital. The patient did not have a high level of monitoring, testing, or other interventions other than surgery while hospitalized. The patient did not have any evidence of active comorbidities requiring inpatient management. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Paresthesia, sleep paralysis, and other insomnia.
Treatment: Sleep Study, Current Procedural Terminology (CPT) Codes 95810 / 95805.
The insurer denied coverage for Sleep Study, CPT Codes 95810 / 95805. 
The denial is overturned. 

This is a female patient with a diagnosis of paresthesia, sleep paralysis, and other insomnia. The documentation indicated the patient initially contacted the physician's office reporting a feeling of being paralyzed while lying in bed. She indicates these only occur in the evening and night. She states her symptoms occur when lying on her back, stomach, and both sides. The documentation indicated the patient also complained of experiencing apnea episodes. She has been observed snoring and has unrefreshing sleep as well as frequent non-refreshing daytime naps. She has difficulty with morning awakening and has also been experiencing episodes of sleep paralysis now lasting up to 5 seconds. It has been recommended that she undergo a sleep study.

The submitted documentation notes indicate this patient does have a history of sleep paralysis as well as apnea episodes, snoring, poor sleep and daytime fatigue. The current standard of care per referenced literature does detail this patient is appropriate to undergo a sleep study due to the above. Therefore, the prior denial is overturned.

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

The insurer's denial of coverage for Sleep Study, Current Procedural Terminology (CPT) Codes 95810 / 95805 is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea; Vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.

The denial is upheld.

The patient is a man with a history of internal hemorrhoids and chronic alcohol use. The patient had been brought in by ambulance to the Emergency Department (ED) for an emergency evaluation due to severe, persistent nausea, vomiting, abdominal pain, and watery diarrhea as well as rhinorrhea. The patient also noted a progressive generalized weakness as well as fatigue, and loss of appetite.

On initial presentation, the patient was tachycardic (pulse of 104 beats per minute) and hypertensive (blood pressure up to 170/82 mmHg [millimeters of mercury]). The laboratory studies showed a white count of 26 left-shift (neutrophils 81%) as well as normocytic anemia as follows: hemoglobin 11.5 g/dl (grams per deciliter) with MCV (mean corpuscular volume) 96.8 fL (femtoliters). Labs also showed hyponatremia (sodium 135 mmol/L [millimole per liter]), hypokalemia (potassium 3.5 mmol/L [millimole per liter]), hypomagnesemia (magnesium 1.5 g/dl [grams per deciliter]), metabolic acidosis (bicarbonate 19 mEq/L [milliequivalents per liter]), hyperbilirubinemia (total bilirubin 2.1 mg/dl [milligrams per deciliter]), and lactic acidosis (lactate 3.5 mmol/L [millimole per liter]). The electrocardiogram (ECG) showed a sinus tachycardia with heart rate of 104 beats per minute and left ventricular hypertrophy.

In the emergency department, the patient was administered intravenous fluid hydration, intravenous meropenem, intravenous magnesium sulfate, and acetaminophen. 

No, the Inpatient admission was not medically necessary. The services as provided were medically appropriate; however, the services were not medically necessary at the level at which they were rendered.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for prolonged NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Hiatus hernia and gastroesophageal reflux disease.
Treatment: Transoral incisionless fundoplication (43210).
The insurer denied coverage for transoral incisionless fundoplication (43210).

The denial is upheld. 

This is the case of a female patient whose medical history includes gastroesophageal reflux disease (GERD), diverticulitis, colon polyps, fibromyalgia, and osteoporosis. Her surgical history includes colonoscopy, laparoscopic hiatus hernia repair, esophagogastroduodenoscopy (EGD), laparoscopic cholecystectomy, and previous transoral incisionless fundoplication (TIF). The patient presented to an office visit with her General Surgeon to discuss having a TIF procedure redone. Per the office visit note, the patient's GERD symptoms were returning and the risks and benefits of redoing the TIF procedure were discussed.

The patient has a history of GERD. She had a previous fundoplication and a TIF procedure. The fundoplication was noted to be loose. She reports an increase in her reflux symptoms. She had a hiatus hernia.

The American Society for Gastrointestinal Endoscopy (ASGE) has published a guideline titled "The role of endoscopy in the management of GERD." A review of multiple trials were done and it was determined that it improved health outcomes, symptom relief and decreased proton pump inhibitor (PPI) utilization. However, there is no recommendation made that a repeat TIF procedure should be done if the initial procedure failed. In addition, the TIF procedure is not indicated if there is a hiatus hernia that is greater than 2 centimeters (cm). In this case there are multiple reports that the patient has a hiatus hernia although the size of the hernia is unclear.

The TIF procedure is not an experimental procedure. However, doing a second TIF procedure after the first one failed has not been shown to improve healthcare outcomes. The TIF procedure is Food and Drug Administration (FDA) approved. The patient is not a good candidate because she failed the first TIF procedure and has a hiatus hernia. It is not the best available treatment for this patient. In a recent single center study of 28 patients who had undergone TIF and had recurrent symptoms, they performed laparoscopic fundoplication with "excellent clinical outcomes." Thus, other anti-reflux procedures should be considered. The requested procedure is not likely to be more beneficial than any other existing standard health service.

The carrier's denial of transoral incisionless fundoplication (43210) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Hiatus hernia and gastroesophageal reflux disease.
Treatment: Transoral incisionless fundoplication (43210).
The insurer denied coverage for transoral incisionless fundoplication (43210).

The denial is overturned. 

This is the case of a female patient whose medical history includes gastroesophageal reflux disease (GERD), diverticulitis, colon polyps, fibromyalgia, and osteoporosis. Her surgical history includes colonoscopy, laparoscopic hiatus hernia repair, esophagogastroduodenoscopy (EGD), laparoscopic cholecystectomy, and previous transoral incisionless fundoplication (TIF). The patient presented to an office visit with her General Surgeon to discuss having a TIF procedure redone. Per the office visit note, the patient's GERD symptoms were returning and the risks and benefits of redoing the TIF procedure were discussed. She reported no heartburn. The physical examination was normal. The patient wanted to proceed with a redo of the TIF procedure.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. The TIF procedure has final approval from the appropriate regulatory bodies for this diagnosis. The procedure is Food and Drug Administration (FDA) approved and included in American Gastroenterological Association (AGA) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) (medical and surgical guidelines). There are guidelines supporting the use of TIF for patients with gastroesophageal symptoms like this patient. This procedure is especially beneficial for this patient with regurgitation (vomiting). Regurgitation is not alleviated by medical therapy and an endoscopic procedure like TIF will offer more benefit than medical treatment. These less invasive endoscopic procedures are standard of care in lieu of surgical fundoplication. The patient is a good candidate for the procedure and TIF is the best available treatment for this patient at this time. The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of transoral incisionless fundoplication (43210) should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Hiatus hernia and gastroesophageal reflux disease.
Treatment: Transoral incisionless fundoplication (43210).
The insurer denied coverage for transoral incisionless fundoplication (43210).

The denial is upheld. 

This is the case of a female patient whose medical history includes gastroesophageal reflux disease (GERD), diverticulitis, colon polyps, fibromyalgia, and osteoporosis. Her surgical history includes colonoscopy, laparoscopic hiatus hernia repair, esophagogastroduodenoscopy (EGD), laparoscopic cholecystectomy, and previous transoral incisionless fundoplication (TIF). The patient presented to an office visit with her General Surgeon to discuss having a TIF procedure redone. Per the office visit note, the patient's GERD symptoms were returning and the risks and benefits of redoing the TIF procedure were discussed.

Transoral incisionless fundoplication offers an endoscopic approach to the treatment of GERD. [1] TIF received original Food and Drug Administration (FDA) approval in 2007. [8] Studies have demonstrated that TIF has led to improved quality of life and improvements in GERD symptoms with short-term follow-up. Long-term studies regarding the impact of TIF are lacking. [1] TIF for chronic GERD is a safe, minimally invasive alternative to surgery in selected patients. [2] Nissen fundoplication is the gold standard procedure for treatment of GERD. Nissen fundoplication, TIF, and magnetic sphincter augmentation (MSA) have been shown to have comparable effectiveness. [3] The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) states that TIF leads to better control of GERD symptoms, compared with proton pump inhibitor (PPI) treatment, and least invasive endoscopic procedures should be attempted before more complex, surgical procedures. [4] Patients who have undergone TIF have elimination of troublesome GERD symptoms, including regurgitation. The procedure is a cost-effective alternative to laparoscopic Nissen fundoplication. [5] TIF is associated with persistent GERD in some patients. Laparoscopic Nissen fundoplication has been the standard treatment for GERD management in patients who have had other previous anti-reflux procedures. [6, 7]

Per clinical documentation, this is a patient with a history of GERD. Current medications for GERD include Famotidine. The patient has a history of a laparoscopic hiatal hernia repair with TIF. The patient presented with recurrent GERD. However, clinical documentation notes that the patient does not have any heartburn. There is no description of the patient's current symptoms. There is no indication through manometry, endoscopy, or potential of hydrogen (pH) testing that the patient has recurrent GERD. Due to lack of symptoms consistent with GERD, and no clinical evidence of recurrent GERD, the patient is not a good candidate for TIF. TIF would not be the best available treatment for this patient at this time. The requested service is not more beneficial than standard treatments/procedures for this patient. 

The carrier's denial of transoral incisionless fundoplication (43210) should be upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional/Diabetes.
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested medication as not medically necessary. 
The health plan's determination is upheld.

This is a male diagnosed with Type 1 Diabetes Mellitus with hypoglycemia. This request is for Humalog. As reported, he tried and failed Novolog, Insulin Aspart, and Lantus. He is using Novolog via Omnipod insulin pump and Dexcom G5. He does experience episodes of hypoglycemia at 2-4 pm.
His Hemoglobin A1C in 4-2021 was 6.8 %; in 12-2020 it was 7.4 %; on 9-2020 it was 7.1 %; on 9-2019 it was 6.8 %; on 10-2018 it was 8.5 %.
At issue is the medical necessity of the requested prescription medication.

The health plan's determination is upheld, in whole.

The patient can use the formulary alternative drug NovoLog and has been using this drug with success. The patient can also use the formulary alternative drug Fiasp.
There are no studies demonstrating superiority of one rapid acting insulin analog over another  [1-4]. The patient has been using the formulary alternative NovoLog without difficulty. The hemoglobin A1c is excellent. The patient can also use the other formulary alternative Fiasp.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid Arthritis
Treatment: Xeljanz 10MG (milligrams) every morning and 5MG every evening, Pre-service
The insurer denied the Xeljanz 10MG every morning and 5MG every evening, Pre-service
The denial is upheld.

The patient is a male with rheumatoid arthritis (RA) and Sweet's syndrome.  He failed treatment with cyclosporine, CellCept, dapsone and Remicade, and previously responded to Xeljanz ten milligrams in the morning and five milligrams in the evening.  He experienced a skin disease flare off Xeljanz, requiring local steroid injections by his dermatologist.  There is no documentation as to whether this patient tried or failed standard Xeljanz dosing (i.e., five milligrams twice daily, or Xeljanz XR 11 milligrams daily).  The physician wishes to resume Xeljanz ten milligrams in the morning and five milligrams in the evening (quantity limit override) in combination with dapsone for the treatment of Sweet's syndrome in the setting of rheumatoid arthritis.

No, the proposed treatment with Xeljanz is not medically necessary.
Xeljanz is Food and Drug Administration-approved for the treatment of rheumatoid arthritis at a dose of five milligrams twice daily.  It is not Food and Drug Administration (FDA)-approved at higher dosing for this indication, and it is not Food and Drug Administration-approved at any dose for the treatment of Sweet's syndrome.  In addition, there is no  documentation as to whether this patient tried or failed standard Xeljanz dosing (i.e., five milligrams twice daily, or Xeljanz XR 11 milligrams daily).  Treatment of rheumatoid arthritis and Sweet's syndrome with Xeljanz ten milligrams in the morning and five milligrams in the evening is not in accordance with standard of care in the rheumatology or dermatology communities, and is not clinically appropriate.  Therefore, the proposed Xeljanz ten milligrams in the morning and five milligrams in the evening is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nerve Root and Plexus Disorder
Treatment: Gamunex, Pre-service
The insurer denied the Gamunex, Pre-service.
The denial is upheld.

The patient is a female with a history of chronic pain, neuropathic pain, thiamine deficiency and insomnia and a diagnosis of sensory neuronopathy with symptoms of paresthesia, imbalance and ataxia. The provider is requesting Gamunex IVIG (intravenous immunoglobulin). She has previously been treated with amitriptyline, duloxetine, gabapentin and IVIG.

The patient's neurological examination showed she has normal strength and absent deep tendon reflexes. The provider is requesting continuation of IVIG, which has been denied coverage as not medically necessary.

No, the treatment with Gamunex is not medically necessary.

There are no high-quality clinical trials supporting the efficacy of IVIG for this patient's condition. Specifically, this patient has known thiamine deficiency which can cause peripheral neuropathy (Gwathmey and Grogan). Her lumbar puncture results and neuro-imaging do not support a diagnosis of CIDP (Chronic Inflammatory Demyelinating Polyneuropathy) variant. There is no identification here of a paraneoplastic process to support the use of IVIG for sensory neuronopathy (Gwathmey and Pearson; Antoine, et al). This is not a standard-of-care treatment for her condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankylosing Spondylitis
Treatment: Humira (dosed once weekly), Pre-service
The insurer denied the Humira (dosed once weekly), Pre-service
The denial is upheld. 

The patient is a female with ankylosing spondylitis (AS).  She failed treatment with various non-steroidal anti-inflammatory drugs (NSAIDs), methotrexate, sulfasalazine, Enbrel, and steroids.  She has been treated with Humira, 40 milligrams, every other week for several years, in combination with Plaquenil, 200 milligrams, twice daily, for Sjogren's syndrome overlap.  The patient reports that Humira efficacy now wanes after day #8, and she has persistent tenosynovitis.  The attending physician (AP) suggested increasing Humira to weekly dosing versus switching Humira to secukinumab (Cosentyx), and the patient preferred weekly Humira dosing.  Weekly Humira dosing was denied as off-label dosing for ankylosing spondylitis.  The appeal is for Humira, 40 milligrams, weekly, for the treatment of ankylosing spondylitis.

No, the proposed treatment with Humira is not medically necessary.
Humira is Food and Drug Administration (FDA) approved for the treatment of ankylosing spondylitis at a dose of 40 milligrams every other week.  It is not Food and Drug Administration (FDA)-approved for this indication at a dose of 40 milligrams weekly, as requested for this patient.  

The physician refers to a published long-term extension of the ATLAS trial (referenced below), which followed 53 patients who received benefit from open label extension weekly Humira dosing for at least one year, and did not have an increased risk of side effects. However, this study was not designed to compare weekly versus every other week dosing of Humira for ankylosing spondylitis.  Furthermore, there are other standard of care biologic therapies that may be used for this patient within Food and Drug Administration (FDA)-prescribing guidelines.  The physician offered to treat this patient with one such option, secukinumab (Cosentyx).  Treatment with Humira, 40 milligrams, weekly, for ankylosing spondylitis is not in accordance with standard of care in the rheumatology community or clinically appropriate, and is therefore not medically necessary for this patient.