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

The patient is a male who has had recurrent atrial fibrillation. He had undergone 2 cryoablations, the last being over a year ago, as well as multiple cardioversions. He has continued to have bouts of atrial fibrillation. He was referred for surgical treatment of atrial fibrillation. He had a stroke 5 years earlier when atrial fibrillation (AF) was discovered. He also has hypertension and hyperlipidemia. Echo showed normal ejection and mildly enlarged left atrium. Based on 2 failed percutaneous ablations, the provider recommended "minimally invasive" surgically treated atrial fibrillation with a Maze procedure. The health plan's determination is overturned.

Yes, the proposed procedure is likely to be of greater benefit than any standard treatment for this patient's atrial fibrillation.
This patient has symptomatic atrial fibrillation as well as a previous stroke. Multiple cardioversions have failed to keep the patient in sinus rhythm. Two cryosurgeries have failed to maintain sinus rhythm. In this setting, minimally invasive Maze surgery is reasonable in this setting. The American Heart Association (AHA) American College of Cardiology (ACC) 2014 atrial fibrillation guidelines recommend surgery in selected patients. This patient is such a patient. The exact wording of the guideline reads as follows:
Class IIb
1. A stand-alone AF surgical ablation procedure may be reasonable for selected patients with highly symptomatic AF not well managed with other approaches (440). (Level of Evidence: B)
In selected patients, surgical treatment of atrial fibrillation is a reasonable option. It is likely to be more beneficial for this patient than any standard treatment, as supported by standard of care guidelines.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a male with a five year history of atrial fibrillation. He was diagnosed  after an embolic cerebrovascular accident (CVA) to the middle cerebral artery (MCA) with infarction. He was placed on medical management with six cardioversions and two catheter ablations and remains in atrial fibrillation. The last catheter ablation was over a year ago. The issue under review is the convergent procedure for atrial fibrillation. The health plan's determination is overturned. 

The proposed treatment of hybrid/tissue ablation is more likely to be beneficial than any standard treatment(s) for the patient's condition.
This treatment is guideline-based, and given the failure of prior treatments, the best treatment available. This patient has failed cardioversion, catheter based ablation and medical therapy. In the course/progression of this patient's atrial fibrillation, the patient has suffered an embolic CVA as a result of the atrial fibrillation. This event places this patient at the highest risk of further events. Therefore, this minimally invasive direct ablation should be performed (Convergent procedure).

The proposed treatment is in the patient's best medical interest and should be provided. On the basis of the literature, the convergent procedure should be offered to patients who are high risk for (further) atrial fibrillation related events, who are severely symptomatic, and do not tolerate medical therapy. This patient meets several of those criteria.
This procedure is likely to be more beneficial than any standard treatment for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced Alzheimer's disease
Treatment: Personal Care Worker Services

Summary:
This is a female with advanced Alzheimer's disease and associated cognitive impairment.  Due to this condition, she requires assistance to perform the majority of her activities of daily living (ADLs) including meal preparation, grocery shopping and for safety including prevention of wandering and leaving her house in a confused/disoriented state.  Lastly, recent Neurology evaluation indicated that the patient had demonstrated significant functional and cognitive decline over the past six months, now suffering from chronic disorientation, hallucinations and is no longer able to recognize immediate family members.  For these reasons, appeal review requested for potential approval of increase in PCW services from 7 days/week, 8 hours/day to 7 days/week, 12 hours/day is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient has multiple medical problems and psychological problems. The patient has a past medical history significant for bipolar depression, schizophrenia, anxiety, mild intellectual disability, gait disorder, low back pain, diabetes, torn meniscus, hypertension, asthma, osteoarthritis, hyperlipidemia, history of falls and urinary incontinence. The patient had a hospitalization secondary to diabetes. Requests increase in Personal-care level 2 service hours. HP determination is upheld. The patient had a UAS evaluation in last year  and a repeat evaluation this year. There has not been a significant change in the underlying medical condition or psychological condition. There is no noted medical need for additional patient care service hours. The patient's activities of daily living (ADLs) and Instrumental Activities of Daily Living (IADLs), as far as the ability to perform these activities, were similar with both evaluations. Therefore, the increase in personal-care level 2 service hours are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dermatitis. 
Treatment: Dupixent. 

The insurer denied Dupixent. The health plan's determination is upheld. 

The patient is a male with moderate to severe atopic dermatitis (over 30% body surface area involvement) of the face, neck, chest, arms, stomach, legs, buttocks, genitals, and back. The patient also has eczema herpeticum. The patient has tried and failed topical steroids (such as mometasone and clobetasol and triamcinolone) and Protopic, and when oral prednisone is discontinued, the skin condition worsens. A trial of Abricitinib for 3 weeks is reported. Health plan coverage of Dupixent is under review for medical necessity. 

Dupixent is not medically necessary. The patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line oral medications such as Azathioprine or Mycophenolate Mofetil. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature, the requested Dupixent is not medically necessary. 

Dupixent is of no greater or proven benefit that standard and plan formulary-preferred alternatives for severe atopic dermatitis such as azathioprine or mycophenolate mofetil. At times, both Dupixent and these oral immunomodulators must be used in combination for severe cases of atopic dermatitis. Accordingly, without having used these mainstays of systemic atopic dermatitis therapy, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hurley Stage II hidradenitis suppurativa 
Treatment: Pharmacy/Prescription Drugs/ Cosentyx
The health plan denied the requested prescription drug. 
The health plan's determination is upheld.

The patient is a male with severe Hurley Stage II hidradenitis suppurativa involving his groin, buttocks, and axillae. The patient has tried and failed topical benzoyl peroxide wash, topical Clindamycin gel, and oral Doxycycline. The patient has cerebral palsy and has a chronic ventilator/tracheostomy/percutaneous endoscopic gastrostomy (PEG) setup, and a history of severe bloodstream infections. The medical necessity of Cosentyx (which is preferred over Humira) is under review. 

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

No. Cosentyx is in an experimental phase with respect to possible future treatment in the condition of hidradenitis suppurativa. The patient has not yet been treated with Humira, which is the only FDA-approved treatment for moderate to severe hidradenitis suppurativa. The patient has no significant safety risks and is a medically appropriate candidate for Humira and not Cosentyx. Cosentyx is therefore not medically necessary for this patient's particular clinical scenario.

The current dosing of Cosentyx for hidradenitis suppurativa, the concerns over Cosentyx causing (or worsening) hidradenitis suppurativa, and the long-term treatment results argue against any conclusions that Cosentyx is medically necessary or appropriate for the treatment of hidradenitis suppurativa currently [1-5]. Only scant case reports and case series are available for any review of clinical experience of Cosentyx in the treatment of hidradenitis suppurativa currently.
The treatment of hidradenitis suppurativa is therefore restricted to Humira and off-label Remicade with respect to either Food and Drug Administration (FDA) -approval or consensus in the treatment of moderate to severe hidradenitis suppurativa [1-5]. Although infections pose a more serious issue for Remicade patients, the use of Humira is associated with significantly greater infections for those first patients who used Humira for its initial indication of rheumatoid arthritis. Patients with either psoriasis or hidradenitis suppurativa have a considerably lower risk of significant infections, and it should be noted that hidradenitis suppurativa patients are FDA-approved even for teenagers, despite Humira being dosed twice as high as it is for psoriasis patients.
Accordingly, the health plan acted reasonably, and with sound medical judgment, and in the best interest of the patient, in denying coverage of Cosentyx when the reliably safe use of FDA-approved Humira was and is the medically appropriate treatment for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain; Lumbar stenosis
Treatment: Spine Surgery 
The insurer denied the spine surgery.
The denial is upheld. 

The patient is a female with lumbar stenosis and complaints of low back pain. The patient reports some numbness and tingling. She also has pain radiating down her legs. She has relief with flexion. She had ESI (epidural steroid injection) with minimal relief. The patient has done physical therapy. 

The patient's MRI (magnetic resonance image) lumbar spine shows moderate to severe lumbar stenosis.

The patient's provider recommends minimally invasive lumbar decompression (MILD) procedure.

No, the Spine Surgery is not medically necessary.

There are not any well-conducted studies that show safety and efficacy as compared to traditional lumbar laminectomy, which remains the gold standard. There is a high failure and recurrence rate with the MILD procedure. Many patients that undergo the MILD procedure will ultimately require revision open laminectomy. The Midas Encore study compares MILD procedure to lumbar epidural steroid injections and not to laminectomy which is the standard of care. Epidural injections are known not to provide long term relief for spinal stenosis symptoms and are not an appropriate control. Furthermore, the MILD procedure is associated with a T (transitional) code and does not have a formal CPT (Current Procedural Terminology) code indicating it is still under investigation.
Appeal type: Medical necessity
Decision: Overturned

Cancer
Pharmacy/Prescription Drugs

Diagnosis: osteosarcoma
Treatment: Cabometyx
The insurer denied Cabometyx. The health plan's determination is overturned. 

The patient is a male with progressive, multi centric osteosarcoma that was initially diagnosed with presumed primary site of the left proximal tibia with right femoral and lung metastases. He was originally treated with methotrexate, doxorubicin and cisplatin, then surgical resections, and later high-use ifosfamide and etoposide and then regorafenib with disease progression. The patient's tumor has a point mutation but is not eligible for the pediatric MATCH study. A compassionate access request for apelisib was submitted to Novartis. The use of Cabometyx is under review.

Cabometyx 20 mg Tablet is medically necessary for this patient.
This patient has progressive, recurrent, metastatic osteosarcoma and has failed all standard treatment options. The provider has recommended treatment with Cabometyx (cabozantinib).
Cabozantinib is a small molecule inhibitor of several different tyrosine kinases. It has been studied in patients with relapsed solid tumors and has shown some response and/or stable disease.
As per Italiano et al, cabozantinib was noted to have anti tumor activity in patients with osteosarcoma and was well tolerated. This CABONE trial showed that 12 % of patients with osteosarcoma had a partial response and another 33% had 6 months of no progression. It is being considered for future larger studies in this type of tumor. Schoffski et al have taken it a step further and noted that cabozantinib has shown activity in soft tissue sarcomas (such as DSRCT [Desmoplastic small round cell tumor), gastrointestinal stromal tumors (GIST), osteosarcoma, and Ewing sarcoma. It inhibits the growth and viability of these types of tumors and promotes regression in some groups. Kokkali-Zervos et al studies several patients with recurrent osteosarcoma and their response to Cabometyx and concluded that this product was a promising treatment option for those with advanced osteosarcoma with manageable safety profile.
There are no Food and Drug Administration (FDA) -approved treatment option for this disease situation. Cabometyx appears to be a viable option in inducing remission of this patient's disease. He has tried and failed many different treatments and combinations of medications as noted in the clinical summary and there are no other standard treatments that can be used in place of the Cabometyx. The patient has a mutation identified in his tumor tissue that is expected to respond at least in part to this therapy and the medication is considered a promising treatment option in this disease that has not FDA approved options for this stage of recurrence.
Therefore, based on the clinical information provided for review and the current standards of care / peer-reviewed literature, the use of Cabometyx 20 mg tablet is considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Scleroderma
Treatment: Pharmacy/Prescription Drugs (Rituximab)
The health plan denied the requested prescription drug. 
The health plan's determination is overturned.

The patient is a female with systemic sclerosis (scleroderma) (SSc) with lung involvement. She is on Cellcept 1000 mg twice daily (bid) as well as Rituxan (RTX) every 6 months for arthritis, which she finds helpful, per chart review. Prior treatment includes Plaquenil.
The issue in this case is the medical necessity of Rituximab.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of Rituximab injection is medically necessary for this patient. This is a female with scleroderma who is doing well on Cellcept 1000mg bid and Rituxan every 6 months. Per chart review, she is 'very tired and in a lot of pain' and has done well with Rituxan. There is data showing benefit in patients with scleroderma. A study published in Autoimmune Rev in 2015 'suggest a possible therapeutical role of RTX in SSc, along with its good safety profile. The specific activity of RTX on B-cell-driven autoimmunity might explain its beneficial effects on some particular SSc clinical symptoms, namely the improvement of skin and articular involvement, and possibly the attenuation of lung fibrosis'.
The treatment of scleroderma presents many challenges due to the complex nature of the disease. She is already on Cellcept and has tried Plaquenil. Methotrexate (MTX) is not an option due to lung disease. She is on Rituxan for arthritis and has benefited and there is data supporting that Rituxan has a role in scleroderma, as stated above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Orthotics. 
The insurer denied: Custom Shoe Inserts (L3000x2). 
The denial is overturned in whole. 

The patient is a female who presented for evaluation of right heel pain caused by plantar fasciitis. Her health care provider had been treating the patient for 4 months; he recommended custom molded orthotics. The health plan has denied the custom foot orthotics based on lack of medical necessity. The subject of this review is the medical necessity for custom shoe inserts (L3000 x2) for this patient. 

The health plan's determination is overturned in whole. 

The conservative treatments recommended are: rest, ice, elevation, shoe modification, non-steroidal anti-inflammatory medication, cortisone injection therapy, physical therapy, and biomechanical support (strapping, over the counter orthotics, and custom molded orthotics) of the plantar arch (fascia). When conservative treatments have failed, surgical intervention may be recommended. 

The American College of Foot and Ankle Surgeons (ACFAS) published clinical practice guidelines for treating plantar fasciitis includes mechanical interventions such as plantar arch strapping, over-the-counter arch supports and heel cups. When treatment has failed over the first six weeks, the guidelines recommend custom functional foot orthoses. 

The medical records reviewed demonstrate plantar fasciitis treatment for a 4 month period. The patient was treated with stretching exercise program, modification shoe gear, strapping of the foot, and prefabricated orthotics use. Therapeutically, she was treated with non-steroidal anti-inflammatory drugs (NSAIDS), cortisone injections, and oral steroids. The records reveal a reasonable amount of conservative treatments before the prescription for custom molded foot orthotics. The determination for medical necessity for the custom orthotics is documented in the medical records, as reported by the provider.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy; History of preterm premature rupture of membranes.
Treatment: Inpatient admission.

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

The patient is a female G3P0111 (three pregnancies, zero term infants, one preterm infant, one abortion, one living child) patient presented at 13 weeks three days gestation for admission to the hospital for elective placement of prophylactic cerclage.  In a previous pregnancy she had preterm premature rupture of membranes at 22 weeks with subsequent pre-viable delivery and then a pregnancy in which a cerclage was performed and had a successful outcome with delivery at 36 6/7 weeks.  

The patient, in the current pregnancy, had successful placement of the cerclage with no documented surgical or anesthesia complications and was discharged on the day of surgery.  The health plan contends that the "full admission" was not medically necessary, as the care could have been given as an ambulatory stay. They referenced MCG (Milliman Care Guideline) Obstetric and Gynecologic Surgery or Procedure (W0143). The facility contends that the admission was medically necessary based on criteria for preterm labor with cerclage being a possible care need (Preterm labor, threatened), for inpatient admission vulvar, vaginal, or cervical procedure needed, and physician judgment.  It also raises a question of how the denial of inpatient level could occur, prior to the procedure, given that at that time it could not be known that there would or would not be complications that would require admission and it was not scheduled to occur until later in the month.  

No, the Inpatient Admission was not medically necessary.

Prophylactic cervical cerclage is typically performed as an outpatient procedure unless there are significant medical, surgical, anesthesia, or postoperative complications.  There is no evidence of benefit for admission level of care for cerclage procedures without complications.  There is no documentation that any of these complications were present.  At the time of request for authorization admission level of care was requested and was denied, because, typically, these procedures are done as an outpatient surgery.  If complications had occurred at the time of surgery, the facility could have asked for admission level of care based on the unforeseen complications, but they did not in fact occur.  Therefore, admission level of care was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  GERD (gastroesophageal reflux disease).
Treatment:  LINX Procedure.

The insurer denied the LINX procedure.  The denial is overturned.

The patient is a man with GERD (gastroesophageal reflux disease) symptoms.  He was found to have a hiatal hernia on upper endoscopy, elevated esophageal acid exposure on esophageal pH (potential of hydrogen) monitor, and normal motility on manometry.  He had a normal Nuclear Gastric Emptying study.  He was recommended to undergo laparoscopic hiatal hernia repair with LINX.  He has tried omeprazole with breakthrough symptoms.

Yes, the health plan should cover the LINX Procedure.

Yes, the LINX Procedure is likely to be more beneficial.

This patient suffers from GERD (gastroesophageal reflux disease).  Even with a PPI (proton pump inhibitor), there is refluxing gastric contents.  Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF (Laparoscopic Nissen Fundoplication) make it a less than ideal operation.  LINX is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA (Food and Drug Administration).  There is published data on patients, who have had the device for 12 years, showing a very low complication rate and a high resolution of GERD (gastroesophageal reflux disease).