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

Diagnosis: Glaucoma
Treatment: Xen Gel Stent
The insurer denied the Xen Gel Stent.
The denial is upheld. 

The patient is a male with the diagnosis of glaucoma, for whom request is made for coverage of the Xen Glaucoma Treatment System.

There are no clinical notes provided indicating what medical or surgical treatments the patient has tried/failed. The current intraocular pressure is not documented, and the current eye drops are not known.

No, the requested health service is not more beneficial.

"Generally accepted standards of medical practice" means the following: Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes. If no credible scientific evidence is available, these standards should be based on physician specialty society recommendations or professional standards of care. They would be consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines.

Per the American Academy of Ophthalmology:
"No randomized clinical trials assessing the safety and efficacy of the Xen gel stent exist. A Cochrane Systematic Review did not identify any randomized controlled clinical trials assessing the safety and efficacy of the Xen gel stent. Thus, the selection of the Xen gel stent should be left to the discretion of the treating provider."

In this case, the coverage of the XEN Gel implant is requested to treat a patient with glaucoma. However, no clinical information is provided to establish what medical and or surgical therapy the patient has tried and failed. Therefore, medical appropriateness is not established.

In summary, further investigation with RCTs (randomized controlled trials) are needed on the XEN Glaucoma Treatment System, especially with its long-term effectiveness and safety.

In this case, the coverage of the XEN Gel implant is requested to treat a patient with glaucoma. However, no clinical information is provided to establish what medical and or surgical therapy the patient has tried and failed, and that the patient was unresponsive to medical therapy.  Therefore, medical appropriateness is not supported, and it should not be covered by the health plan.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Glaucoma
Treatment: Xen Gel Stent
The insurer denied the Xen Gel Stent.
The denial is upheld. 

The patient is a male with primary open angle glaucoma for whom coverage of XEN Gel Stent (66183) (left eye [OS]) (right eye [OD]) is the subject of review. Coverage was previously denied per health plan policy as experimental/investigational. No clinical records are provided for review.

No, the health plan should not cover the requested health service.

The Food and Drug Administration (FDA) approved the XEN45 Gel Stent and the XEN Injector "for patients with refractory glaucoma who failed previous surgical treatment or in patients with primary open angle glaucoma, pseudoexfoliative or pigmentary glaucoma with open angles that are unresponsive to maximum tolerated medical therapy."

According to the American Academy of Ophthalmology, the implant itself is made out of a soft, collagen-derived, gelatin that is known to be non-inflammatory. The goal of implantation is to create an aqueous humor outflow path from the anterior chamber to the subconjunctival space. The implant is injected through a small corneal incision with the use of an inserter similar to those used for intraocular lenses (IOLs). Similar to other implants, it can be performed in conjunction with cataract surgery. XEN also allows for keeping postoperative options open, allowing physicians to utilize other intraocular pressure (IOP)-reduction techniques should they be required after surgery.

An international multicenter retrospective study has recently been published that compares the efficacy, safety, and risk factors for failure of standalone XEN45 gel stent implantation versus trabeculectomy, both with adjunctive mitomycin C (MMC). In this study by De Gregorio, et al, 354 eyes with uncontrolled glaucoma and no prior incisional filtering surgery underwent microstent implantation or trabeculectomy. The results demonstrated that there was no difference in efficacy, risk of failure, and safety profile between the two surgical procedures.

Similarly, Reitsamer, et al evaluated the effectiveness of an ab interno subconjunctival gelatin implant as primary surgical intervention in reducing intraocular pressure (IOP) and intraocular pressure (IOP)-lowering medication count in medically uncontrolled moderate primary open-angle glaucoma (POAG). They found that the gelatin implant effectively reduced intraocular pressure (IOP) and medication needs over two years in primary open-angle glaucoma (POAG) uncontrolled medically, with an acceptable safety profile.

In this case, the patient is not identified as having refractory glaucoma. As there are no patient specific records provided to establish the patient's diagnosis and previous treatments, the medical appropriateness of the XEN Gel stent cannot be established.

No, based on the information provided for review, the requested health service or treatment is not more beneficial for the patient's condition or disease, as there are no records indicating that this patient has the condition of refractory glaucoma.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender Dysphoria

Treatment: Outpatient procedure codes 15877 and 15879, lipectomy of the bilateral thighs and hips

The insurer denied coverage for outpatient procedure codes 15877 and 15879, lipectomy of the bilateral thighs and hips.

The denial is upheld.

This is the case of a transgender male with a history of gender dysphoria. The patient underwent a top surgery and a bilateral flank liposuction. The appearance of the patient's hips and thighs contribute to gender dysphoria and prevent the patient from wearing certain clothing due to the body's gendered appearance. The physician noted that the patient is an excellent candidate for gender affirming bilateral flank and thigh liposuction. 

According to the World Professional Association for Transgender Health (WPATH) guidelines, pages 63-64: "Other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adam's apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). Other surgeries for assisting in body masculinization include liposuction, lipo-lling, and pectoral implants. Voice surgery to obtain a deeper voice is rare but may be recommended in some cases, such as when hormone therapy has been ineffective. Although these surgeries do not require referral by mental health professionals, such professionals can play an important role in assisting clients in making a fully informed decision about the timing and implications of such procedures in the context of the social transition. Although most of these procedures are generally labeled 'purely aesthetic,' these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient's condition and life situation. This ambiguity reflects reality in clinical situations, and allows for individual decisions as to the need and desirability of these procedures." 

The records document that the patient suffers from dysphoria due to the patient's lower body silhouette. Although several authors have published studies on the benefits of facial and chest contouring, there is a paucity of studies showing masculinizing lower body contouring improves anxiety, dysphoria, or quality of life. For this specific patient, photos showing lower body features inconsistent with male gender are not provided for review. A search of PubMed using the terms "transgender male and thigh" yielded no publications regarding this procedure. These are procedures to make the patient more attractive in the new gender and are not supported by the current literature. 

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for the outpatient procedure codes 15877 and 15879, lipectomy of the bilateral thighs and hips is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: Inpatient hospital admission
The insurer denied the Inpatient hospital admission
The denial is upheld.

This is a adult female patient with type II diabetes on insulin therapy who presented
with weakness, polyuria, and polydipsia. Her temperature was 98.1, heart rate was
80, respiratory rate was 18, blood pressure was 129/84, and oxygen saturation (O2)
was 98% (percent). The patient was in mild distress with normal neurological exam. Her
glucose was 577 milligrams per deciliter (mg/dL), carbon dioxide (CO2) was 25,
anion gap was 20, creatinine was 1.49, power of hydrogen (pH) was 7.34,
osmolality was 317, and glycated hemoglobin (A1C) was greater than 15.5%. The
patient was treated with fluids and insulin. Glucose was 253 milligrams per deciliter
(mg/dL). The patient's inpatient hospital admission is under
review.

No, the inpatient hospital admission was not medically necessary.

This patient presented with hyperglycemia and dehydration in the setting of known
type II diabetes. She was hemodynamically stable. She had an elevated creatinine
that quickly improved with hydration. She did not have evidence of sepsis or
infection. Her blood gas showed a normal power of hydrogen (pH) level. She did
not have acidosis to support a diagnosis of diabetic ketoacidosis. She did not have
altered mental status to support a diagnosis of hyperglycemic hyperosmolar state.
Her glucose quickly improved with hydration and insulin therapy. She did not have
an acute illness that required an inpatient admission. Therefore, the inpatient
admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Crises. 
Treatment: Inpatient Admission. 

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

The patient has a history of schizophrenia and sickle cell anemia. He presented to the emergency room with complaints of sickle cell crisis and priapism. Priapism got worse after receiving an Adakveo injection. In the ER (emergency room) the patient received intravenous (IV) fluids, morphine, and Dilaudid. Urology did a corpus cavernosum aspiration. The patient was admitted with a sickle cell crisis. On the floor he was given morphine and Ketorolac. His hemoglobin dropped from 8.3 to 7.5 and hematocrit dropped from 23.7 percent to 21.8 percent. He was transfused with one of unit blood. During the transfusion the patient had an episode of emesis and nausea. Vital signs were within normal limits and Benadryl was given. After the transfusion, IV fluids were continued. The patient's condition improved after treatment. He was discharged the following day. 

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine, 2021).

"In summary, hospital case managers are a crucial resource for making admission decisions. Hospitalists should be familiar with Medicare criteria for inpatient versus observation status. Patients who are likely to require 24 hours or less for a disposition decision should be assigned observation status. When in doubt, admit to observation since conversion to inpatient status is a simple process." (Pinson, R., 2012).
                                                         
The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The inpatient hospital admission is not considered medically necessary for this patient. 

This patient could have been managed in a lower level of care such as observational status. He would have been able to receive transfusion and monitoring in observational status. Uncomplicated sickle cell pain crisis requiring a simple transfusion would not be expected to result in a stay of more than 48 hours. As this patient was hemodynamically stable and could have been managed in a lower level of care, acute hospitalization 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: Turner Syndrome. 
Treatment: Norditropin 10/1.5 milliliter (ml) injection. 

The insurer is denied coverage for Norditropin 10/1.5 milliliter (ml) injection. 
The denial is overturned. 

This female patient has a history of Turner Syndrome. 

The Pediatric Endocrine society is the relevant society. Their literature and recommendations are reviewed here. According to the Food and Drug administration (FDA) indication (1, 2) and the Lawson Wilkins Pediatric endocrine society (3, 4), recombinant human growth hormone therapy should be initiated as soon as the height of a girl with Turner syndrome falls below the fifth percentile for age (5), which usually occurs between two and five years of age. (4) Early initiation of growth hormone is necessary (6) to achieve normal adult height (159-162cm). (7) 

The patient is a continuing therapy patient with Turner syndrome whose height is less than the 5th percentile. There have been issues with receiving the medication because of burning at the site of injection. The patient is reported to be now receiving the medication consistently. Continuation of growth hormone for girls with Turner syndrome is indicated until they achieve final height which is determined by closure of the growth plates. The patient has open growth plates based on the bone age. Continuation is consistent with generally accepted standards of medical practice and is therefore medically necessary. 

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

The carrier's denial of coverage for Norditropin 10/1.5 milliliter (ml) injection is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied implant placement. 
The denial is upheld. 

The patient is a female who presented to the office of her dental provider for evaluation and treatment of tooth #2. Included for review are previous letters of appeal and denial, a narrative from the provider, a full mouth panoramic radiograph from an unknown date, one page of American Dental Association (ADA) claim forms, a health history, and clinical notes. According to the claim form, the requested treatment is for #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 18, 19, 20, 28, 29, 30, 31. The subject under review is the medical necessity of the requested implant placement.

The health plan's determination is upheld in whole.

The medical necessity of dental implants in these sites has not been established. The current implant sites are not established to even have opposing occlusion while in function nor is any reason given for why current teeth or restorations currently in the mouth are being replaced. There are not codes for any extractions or any diagnosis or rationale for any of the treatment mentioned. The claim form submitted requests treatment on # 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 18, 19, 20, 28, 29, 30, 31.
There is nothing in the documentation that indicates that the patient has had a partial denture provided and then that the partial denture did not function correctly. There is nothing in the provided documentation that shows that the patient even uses a partial denture currently. Further based on the provided documentation, the teeth do not appear to have been prepped for a partial denture in the past. There has been no evaluation of any current prosthesis by the doctor. The need for implants has not been established. Hence the treatment of implant placement is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Missing teeth
Treatment: Implants For Teeth 2, 13, 14, 15, 30 and 31
The insurer denied the Implants For Teeth 2, 13, 14, 15, 30 and 31.
The denial is partially overturned.

This patient is a female requesting six implants be placed rather than wearing partial dentures. The denial was because there was no documentation indicating a reason why implants are the only viable treatment for this patient. The provider then sent a letter stating that the patient could not tolerate a partial denture because of difficulty in eating and speaking. She also had a strong gag reflex with a denture in place. These were the reasons why implants would be needed, instead of a denture.

Yes, in part; the proposed implants 30 and 31 are medically necessary. However, the proposed implants 2, 13, 14 and 15 are not medically necessary.
This patient it stated to have difficulty in eating and speaking with dentures in place.  In addition, she is stated to have a strong gag reflex with a denture in place.  

There is enough bone for placement of implants in the areas of teeth 30 and 31. This would give the patient two more teeth to chew with on the right side.
Placement of implants for teeth numbers 2, 13, 14 and 15 are not possible due to the maxillary sinus being in the way. There is not enough bone in these areas for the implants to be placed.

Yes, in part; the Health plan acted reasonably for teeth 2, 13, 14 and 15 as the implants are not medically necessary for these teeth. However, the Health plan did not act reasonably for teeth 30 and 31 as the implants are medically necessary for these teeth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: osteopenia

Treatment: Prolia

The insurer is denied coverage for Prolia

The denial is upheld. 

This female patient has a history of hypercholesterolemia, hypertension, hyperlipidemia, gastroesophageal reflux disease, and osteopenia.

Denosumab (Prolia) is a medication which is useful in the treatment of post-menopausal women with osteoporosis at high risk for fracture. 

As a biologic drug, it is man-made and closely resembles proteins, called antibodies, which naturally occur in the body. In this case, it stops a molecule, called RANKL, which normally causes bone turnover. By blocking RANKL, it helps to strengthen bones. Denosumab is generally not viewed as a first line therapy and is usually given to patients when they are unable to take bisphosphonates or have unsuccessful results.

The records show a diagnosis of osteoporosis is not present. The patient has osteopenia. It was localized solely to the left hip and not right hip. The medical records failed to demonstrate treatment nor problems with taking a first line agent. The recent visit to GI (gastrointestinal) specialist does not report  medication problems. 

The FRAX score (asses fracture risk) was 11% (percent) which is below the recommended value for use (20%). There was no evidence of an elevated FRAX score for hip. These findings do not support necessity for the administration of Prolia.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for Prolia is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ears/Nose/Throat. 
Treatment: Surgical Services. 
The insurer denied nose surgery. 
The denial is upheld.

The patient is a male with eustachian tube dysfunction. Audiogram shows a borderline normal to mild conductive hearing loss with type B tympanograms bilaterally. Previous procedures have included: bilateral ear tubes, left tympanoplasty, left balloon eustachian tuboplasty. (Right eustachian tube dilatation could not be carried out due to deviated septum.) Physical examination revealed a left patent ear tube and normal right ear drum (ear tube had fallen out). Balloon eustachian tube dilatation has been proposed. The subject under review is whether the requested treatment is likely to more beneficial for the patient than any standard treatment.

The proposed balloon eustachian tube dilatation is not likely to be more beneficial than standard ear tubes. Well designed, randomized studies have not shown balloon dilatation to be more effective than ear tubes for the treatment of eustachian tube dysfunction.
Although balloon dilatation of the eustachian tube (BDET) provides exciting research for chronic eustachian tube dysfunction, the literature does not support long term effectiveness. The current literature is based on non-controlled case series with poor standardization. Recent 12-month studies showed a 50-60% (percent) improvement rate in symptoms and tympanogram data. (Poe and Anand), yet these studies are prone to bias as there were few patients left in the control arm. Although the procedure is safe, there is no strong, high-quality evidence that this procedure is effective. A recent systemic review concluded, "Due to the limited and poor-quality evidence it is inappropriate to make conclusions on the effectiveness of any intervention; the evidence base is insufficient to guide recommendations for a trial of any particular intervention. Consensus on diagnostic criteria for Eustachian tube dysfunction is required to inform inclusion criteria of future trials. "(Norman).

"Multiple studies have investigated the short- and long-term efficacy of BDET. In a recent systematic review, Huisman et al. evaluated the impact of BDET on reducing symptoms of obstructive eustachian tube dysfunction (OETD) in adult patients. Fifteen studies were identified, all of which were case series, encompassing 1155 patients and 1881 procedures. Of the 8 studies that used patient-reported symptoms as an outcome measure, all showed significant short-term improvement after a mean follow-up of 6.9 months (range, 0-50 months). Meta-analysis of pooled data from 3 studies (670 procedures) also demonstrated significant improvement in multidimensional eustachian tube scores. However, no conclusions could be drawn regarding the long-term effectiveness of BDET. In addition, as none of the studies had a control group or were blinded, risk of selection bias was high.

The procedure is not likely to be more beneficial for this patient than standard treatment.