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

Diagnosis:  CNS/Neuromuscular
Treatment:  Inpatient hospital stay

The patient has a past medical history significant for diabetes mellitus type 2, hyperlipidemia, and hypertension,  presented to the emergency department with complaints of dizziness.
The patient reported intermittent episodes of dizziness for several months.  The patient stated that there was blurred vision in the left eye in the past, that has since resolved. The patient also complained of some intermittent ringing in the ears.  The patient denied any spinning sensation, fever, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, lethargy, blurred vision.  Reportedly, at the time of the evaluation in the emergency department, the patient had no weakness or numbness.  A computed tomography (CT) scan of the head was performed and demonstrated no evidence of bleed.  On the physical exam, the patient was afebrile, heart rate was 64 beats per minute (bpm), respiratory rate 17, blood pressure 208/98, oxygen saturation 95% on room air.  The rest of the physical exam was unremarkable, including a neuro exam.  The patient was admitted to the hospital with a diagnosis of unsteady gait, as well as hypertensive urgency.  A magnetic resonance imaging of the brain was ordered and demonstrated no acute intracranial pathology.  In the hospital, the patient was seen by a neurologist, who suspected that the patient had nonspecific dizziness and ataxia that was possibly otogenic and recommended treatment with Antivert.  The patient's blood pressure medications regimen was resumed; Hydrochlorothiazide was added to the regimen.  The health plan's determination of medical necessity is upheld in whole.  This patient presented to the hospital with complaints of intermittent dizziness, a recent history of blurred vision and ringing in the ears.  This patient had an unremarkable neurological exam and unrevealing diagnostic tests.
Even though the patient had severely elevated blood pressure, there was no evidence of end-organ damage.  This was confirmed by physical exam, results of the laboratory studies, and diagnostic tests.  The patient's blood pressure became much better controlled during the hospitalization.
In general, hypertensive urgency is not considered to be a reason for inpatient hospitalization.  Taking into consideration persistent complaints of dizziness, the patient was admitted to the hospital and ruled out for acute TIA/CVA.  The symptoms were suspected to be otogenic, possibly related to labyrinthitis, for which the patient did not require any interventions or treatment necessitating admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Trauma/injuries
Inpatient hospital

The patient is a female with a past medical history of alcohol use disorder and seizure disorder, controlled with phenytoin 300 milligrams (mg) daily, who presented to the Emergency Department after a mechanical fall. The patient reported having fallen when the railing on her steps gave way, resulting in her falling forward on to her face. She was seen upon arrival in the trauma room. The patient presented with an elevated blood pressure of 158/84, and normal pules of 78 beats per minute, respiratory rate of 18 breaths per minute, temperature of 98.5 degrees Fahrenheit, and pulse oximetry reading of 99% or room air. She reported severe right eye pain and loss of consciousness. She denied any abdominal pain, chest pain, shortness of breath, headache, nausea or vomiting. She was found to have a large right sided eyelid hematoma and was unable to open her eye to examine the globe. There was no pain reported with movement of the eye. The rest of her examination was negative for trauma or neurological deficit.

She was noted to be intoxicated, but alert and oriented to person, place, and time. She was admitted to the hospital.

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient presented after a fall with loss of consciousness while intoxicated. She was determined to have multiple facial fractures involving her orbit, nose, and sinuses, with a vision threatening injury requiring surgical intervention to relieve the pressure on her globe caused by severe swelling. She was noted to be lethargic during her trauma evaluation as it progressed throughout the day. This was a concerning finding in light of her recent head trauma and warranted admission for monitoring. She required frequent wound care (compresses and topical antibiotics) to her lateral canthotomy site, as well as pain medications and intravenous antibiotics and fluids. Her case was complicated by a long history of alcohol use disorder and seizure disorder. Her phenytoin level was found to be at toxic levels, possibly contributing to her lethargy and fall. Additionally, she answered four of four questions of the CAGE questionnaire in the affirmative, which is virtually diagnostic of alcohol use disorder, for which she was placed on the CIWA protocol to monitor for signs of alcohol withdrawal and received a psychiatry consultation. Her care was appropriate for an inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2:

This is a male patient with a history of gastroesophageal reflux disease (GERD), hiatal hernia, esophagitis, esophageal diverticulum, Zenker's diverticulectomy. LINX procedure was recommended. 

The LINX Reflux Management System (a sphincter augmentation device) (Torax Medical, Shoreview, MN) is used, according to the Food and Drug Administration (FDA), "to treat gastroesophageal reflux disease (GERD) in patients who continue to have GERD symptoms despite the use of maximum medical therapy for the treatment of their reflux." 

Furthermore, the "LINX device is used in patients who continue to have symptoms of GERD, such as heartburn and reflux, despite maximum medical therapy (daily use of medicines such as proton pump inhibitors). It is intended to be used by patients who would be considered candidates for anti-reflux surgery." 
From UpToDate; "In 2013, the US Federal Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm.  The device is a ring made up of a series of rare earth magnets that have sufficient attraction to increase the lower esophageal sphincter [LES] closure pressure, but allow for food passage with swallowing. Results from early studies at four years are encouraging.  Based upon a prospective study that included 44 patients, the mean total percent time pH <4 was reduced from 11.9 percent at baseline to 3.8 percent at three years (p<0.001).  Most patients at >=4 years of observation experienced improved quality of life and complete cessation of the use of proton pump inhibitors [PPIs]." 

Position statement from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) noted that the implementation of the LINX device requires minimal dissection and relatively few technical steps when compared to Nissen fundoplication and that the LINX device may provide an option currently lacking in clinical practice for patients with medically refractory GERD who have not yet progressed to end-stage reflux disease with associated complications. The conclusion was that "on the basis of the available evidence, the LINX device should be an option available to patients and providers for the management of medically refractory GERD." 

Ganz and colleagues (2013) evaluated the safety and effectiveness of a new magnetic device to augment the LES.  The authors concluded that in this single-group evaluation of 100 patients before and after sphincter augmentation with a magnetic device, exposure to esophageal acid decreased, reflux symptoms improved, and use of proton pump inhibitors (PPIs) decreased. 

The carrier's denial of coverage for LINX procedure for GERD should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD)
 
Treatment: LINX Procedure

The insurer denied the LINX Procedure. The denial was reversed.  

Reviewer #1:

This is a male patient with a long history of gastroesophageal reflux disease (GERD), hiatal hernia, esophagitis, esophageal diverticulum, Zenker's diverticulectomy. It was reported that he had a DeMeester score of 27 and normal esophageal motility. 

In March 2017, the Society for American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the LINX Reflux Management System.  With regard to safety, the conclusion was that long-term follow-up supports the Food and Drug Administration (FDA) conclusion that the device is safe.  With regard to efficacy, there were several conclusions.  The LINX implant results in pH normalization, improved quality of life, and cessation of regular proton pump inhibitor (PPI) use on a consistent basis.  When compared to laparoscopic fundoplication, rates of success in alleviating GERD symptoms and dysphagia are similar following LINX.  The long-term follow-up data demonstrate that the LINX Reflux Management System is effective in the management of GERD.  

Based on the recommendation of SAGES, it has been shown that LINX results in improvement of health outcomes.  LINX does have FDA approval.  Since the patient has persistent reflux symptoms, he is a good candidate for this procedure.  There are several options for both surgical and endoscopic treatments, but LINX has been shown to be an effective treatment for GERD.  As such, this procedure is likely to be more beneficial than any standard treatment/procedure for this patient.  A minimally invasive treatment such as LINX is appropriate for patients who have ongoing reflux symptoms and do not want to have more extensive surgery such as a Nissen fundoplication.  The denial is reversed.

The carrier's denial of coverage for LINX procedure for GERD should be reversed.
Appeal type: Experimental/Investigational
Decision: Upheld

Skin Disorders - Other
Cancer Screening

The patient is a male with a diagnosis of 2.5 millimeter (mm) Breslow depth Clark's level IV melanoma of the left calf. Clinical staging was T3a, stage IIa. The DecisionDx melanoma gene expression profile was performed. The subject under review is whether the assay is likely to be more beneficial for the patient for his disease than standard treatment.

The health plan's determination is overturned.

The Decision Dx Melanoma testing is likely to be more beneficial than any other testing for cutaneous melanoma and allows the clinician to formulate a treatment plan based on as much evidence regarding the biology of the tumor as possible. The assay allows for a better understanding of the biology of the tumor cells. Differentiating aggressive tumor biology versus nonaggressive tumor biology at the initial onset of disease allows for a more tailored approach to adjuvant treatment. In this particular case, the gene assay demonstrated a high risk and the clinician will be able to use this information to formulate adjuvant treatment plans that will allow for the early detection of recurrent disease and hopefully prevent distant disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cancer/Prostate cancer. 
Treatment:  Cancer Screening (Oncotype Dx Prostate testing).

The insurer denied the Oncotype Dx Prostate testing.  The denial is upheld in whole. 

The patient is a male who underwent a prostate biopsy for an elevated prostate specific antigen (PSA).  The biopsy showed Gleason 6 adenocarcinoma in 3 out of 12 cores.  The clinical stage was T1c.  An Oncotype Dx test was ordered on the biopsy specimens.

No, the Oncotype Dx testing is not medically necessary for this patient.

The Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies.  The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS).  A lower GPS score means more favorable biology and less aggressive disease.  This test may be utilized to counsel men regarding the best course of therapy (active surveillance vs. treatment) in newly diagnosed low or low-intermediate prostate cancer.

Recent studies have suggested that Oncotype Dx can predict adverse pathology and unfavorable outcomes after radical prostatectomy.  These studies have financial conflicts of interest, are recently published and need continued validation from a widespread clinical use.  In addition, it is difficult to ascribe clinical utility of Oncotype Dx Prostate in patients planning to undergo active surveillance, as all patients in the above studies, regardless of clinical criteria, elected radical prostatectomy within 6 months of diagnostic biopsy.  Moreover, the validity of using different degrees of tumor pathology as "markers" to extrapolate the risk of progression of a tumor in vivo is unclear.
While Oncotype Dx may eventually have a role in making treatment decisions about patients with prostate cancer, there is limited data on clinical outcomes to currently support routine use.

Hence, it is not considered a generally acceptable standard of care for management of patients with a diagnosis of prostate cancer.  Therefore, the testing is not medically necessary in this particular  case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Abuse.
Treatment:  Inpatient substance abuse admission.

The insurer is denied coverage for inpatient substance abuse admission.  The denial is overturned.

This is a male patient who was admitted to inpatient substance detoxification treatment from alcohol and heroin.  He had withdrawal symptoms.  He was reportedly inhaling 15 bags of heroin per day, drinking 1/2 pint of liquor per day, and smoking 2 joints of cannabis per day.  He had a positive toxicology for opiates, methadone, and benzodiazepines.  He had a recent past inpatient substance detoxification treatment for 5 days.  He was placed on 2 detoxification medications, Librium and Methadone.  He was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  In this case this patient had use of multiple substances, including heroin and alcohol as well as cannabis and was at risk for death from overdose.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24 hour treatment, as he could not safely and effectively be treated for detoxification in a less restrictive setting, as he continued to use substances despite a recent past inpatient detoxification treatment, and he needed 2 detoxification medications to modify withdrawal including Methadone and Librium.  He also had long term multiple substances abuse including alcohol, heroin, and cannabis, and he needed 24-hour treatment then, as he was at risk for worsened withdrawal symptoms if not in this 24-our setting then, and he likely would have relapsed again, as evidenced by relapsing after past treatment.  It also was unlikely that he would remain abstinent while still having withdrawal symptoms, so he required the time in this treatment setting to stop withdrawals and decrease the chance that he would relapse again when not in this 24-hour setting.  The risk of life-complicating withdrawal, such as delirium tremens can occur 3-4 days after alcohol use, so he required inpatient detoxification protocol treatment and was at risk medically for both severe, complicated, and life threatening withdrawal, as well as overdose.  His environment was not conducive to recovery as evidenced by his continued use.

It did not appear that the health care plan acted reasonably or in the best interests of the patient then.

The carrier's denial of coverage for the inpatient substance abuse admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive System/Gastrointestinal.
Treatment:  Inpatient Hospital.

The insurer denied: Inpatient stay.  The denial is upheld in whole.

The patient is a male who presented to emergency room for abdominal pain, nausea, vomiting, and diarrhea.  Lab work indicated a white blood cell count of 12.5.  Computed tomography (CT) scan demonstrated "at least 3 short segment enteroenteric intussusception in the left abdomen, which are most likely transient in nature.  There is no definite evidence for bowel obstruction."  The patient improved with treatment in the emergency room.  The patient was hospitalized, made nothing by mouth (NPO) status, and planned for repeat computed tomography (CT) scan in the morning.  The next morning the patient reported his abdominal pain and nausea and vomiting had resolved.  CT scan was repeated and reported "No acute Pathology."

The subject under review is the medical necessity for the inpatient stay.

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

The patient presented with significant nausea and vomiting, but the patient improved significantly after being treated in the emergency department.  The patient continued to do well the next morning.  Repeat CT scan demonstrated no problems.  There is no evidence in the documentation that the patient had problems after hospitalization.  There is no evidence that a complicating event occurred during the hospitalization.  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 or peritonitis, or bacteremia.  The patient was discharged without significant monitoring or intervention necessary.  The provided documentation does not support the medical necessity of inpatient level of care.  The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Coronary heart disease, heart failure, hyperlipidemia; type 2 diabetes; ESRD, renal dialysis, kidney transplant.
Treatment:  Personal Care Services to 24 hours per day, 7 days per week (live-in).

The insurer denied coverage for Personal Care Services to 24 hours per day, 7 days per week (live-in).  The denial is overturned.

This is a female, who has complex medical history and extensive functional impairment.  She lives at home with a relative, who provides some assistance with ADLs, but availability is limited due to work.  The patient receives personal care services (PCS) 50 hours per week.  The patient goes to dialysis center 3 days per week.  The patient requested increase of PCS to 24 hour live-in, which was denied by the insurer.  The patient requested an external appeal via patient advocate.

The patient needs assistance with all daily activities.  She needs extensive or maximal assistance for all IADLs, except for phone use (setup help).  She does not use stairs (elevator building) but is totally dependent if she had to use stairs.  For most ADLs, she needs extensive or maximal assistance or total dependence, except bed mobility and eating (limited assistance).  The patient has peripheral vascular disease (most likely due to type 2 diabetes mellitus).  As per physician's letter, patient had gangrene, resulting bilateral lower leg amputations.  UAS indicates the patient has prosthesis for each leg but did not use in previous month.  It is not known whether patient ever had functional mobility with the prostheses.  She is now dependent on wheelchair mobility, and needs to be wheeled by others.

It is apparent that the patient needs caregiver assistance for all ADLs and is at risk for health and safety related adverse events when she does not have a caregiver present to provide timely assistance through the day and night.  The patient is at risk for skin injury due to incontinence and immobility.  Caregiver assistance is needed throughout the day and night for toileting/incontinence care, and repositioning when in or out of bed to decrease risk of skin injury.  She is at risk for falls from her wheelchair, and possibly from bed if, for example, she attempts to get something out of her reach.  The patient also needs caregiver assistance for medication administration, so when a caregiver is not present, she is unable to self-administer medication if she is in pain.  Repositioning is also necessary for the patient's comfort, so she may need repositioning for pain relief as well as pressure relief.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.  Personal Care Services, 24 hours per day, 7 days per week (live-in), total of 91 hours per week are medically necessary.

The carrier's denial of coverage for the requested increase in Personal Care Services to 24 hours per day, 7 days per week (live-in) is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic arthritis
Treatment: Xeljanz XR 11mg OR TB24
The insurer denied Xeljanz XR 11mg OR TB24.
The denial is Overturned.

The patient is a male with psoriatic arthritis. He failed treatment with sulfasalazine, methotrexate, Enbrel, Humira and Cimzia. At his office visit, the combination of Cimzia 200 mg every 14 days and methotrexate 15 mg weekly was losing efficacy. Due to concern for antibody-mediated resistance to monoclonal antibody therapy, the patient began treatment with Xeljanz XR 11 mg daily via samples. Per attached AP (attending physician) appeal letter, the patient had a dramatic clinical response to Xeljanz XR samples within one week. This patient has not tried or failed the Plan-preferred alternatives Otezla or Cosentyx. Appeal is for Xeljanz XR 11mg OR for the treatment of psoriatic arthritis.

Xeljanz XR is FDA-approved for the treatment of psoriatic arthritis, as seen in this patient. This patient has failed treatment with multiple DMARD (disease-modifying antirheumatic drug) and biologic therapies, as discussed above. The AP was concerned about antibody-mediated resistance to monoclonal antibody therapy,
and thus chose treatment with the small molecule targeted synthetic DMARD Xeljanz XR. Per attached, this patient had a dramatic clinical response to Xeljanz XR samples. The Plan-preferred agents Cosentyx (a monoclonal anti-IL17 antibody) and Otezla are additional appropriate treatment options for psoriatic arthritis. Although Otezla is an alternate small molecule targeted synthetic DMARD, switching this patient to an alternate Plan-preferred agent at this point, when he is already responsive to Xeljanz XR samples, would put him at an unnecessary risk of disease flare. Therefore, continuation of Xeljanz XR 11 mg for the treatment of psoriatic arthritis in this patient is clinically appropriate and in accordance with standard of care in the rheumatology community. This patient is at risk of disease flare if Xeljanz XR is switched to a Plan-preferred alternative.