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

Diagnosis: Gastroesophageal reflux disease (GERD) and Barrett's esophagus
Treatment: LINX Reflux Management System, Pre-service
The insurer denied the LINX Reflux Management System, Pre-service.
The denial is overturned. 

The patient is a male with longstanding gastroesophageal reflux disease (GERD) and Barrett's esophagus. He has failed medical therapy. He takes daily pantoprazole. He attempted but was unable to complete esophageal manometry. He had a normal barium impregnated bagel esophagram. He has a DeMeester Score of 53.5, indicating very abnormally high esophageal acid exposure due to GERD. He was treated for Helicobacter (H) pylori infection. Upper endoscopy revealed Barrett's esophagus, a hiatal hernia.

Yes, the health plan should cover the LINX procedure.

This patient suffers from GERD. Even with PPI (proton pump inhibitor), there is refluxing gastric contents. Surgical therapies exist that resolve this very well.

The records indicate the patient has severe GERD and Barrett's esophagus objectively, and has normal esophageal motility. He has met the criteria to benefit from the procedure.

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

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 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 (United States 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD) and Barrett's esophagus
Treatment: LINX Reflux Management System, Pre-service
The insurer denied the LINX Reflux Management System, Pre-service.
The denial is upheld. 

The patient is a male with longstanding gastroesophageal reflux disease (GERD) and Barrett's esophagus. He has failed medical therapy. He takes daily pantoprazole. He attempted but was unable to complete esophageal manometry. He had a normal barium impregnated bagel esophagram. He has a DeMeester Score of 53.5, indicating very abnormally high esophageal acid exposure due to GERD. He was treated for Helicobacter (H) pylori infection. Upper endoscopy revealed Barrett's esophagus, a hiatal hernia.

No, the health plan should not cover the LINX Reflux Management System.

In general, the requested procedure (LINX) is considered a standard operative treatment for symptomatic GERD for the well-selected patient. It is not investigational, and it is supported by numerous medical societies, including SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) and the AFS (American Foregut Society) as an FDA (United States Food and Drug Administration)-approved treatment for symptomatic GERD, with similar efficacy but less morbidity than standard operative Nissen fundoplication in large comparative and prospective studies.

FDA exclusions to treatment (LINX) include age less than (<) 18, BMI (body mass index) greater than (>) 35 kg/m2 (kilograms per meters squared), prior gastric or bariatric surgery or presence of Barrett's esophagus and a hiatal hernia > 4 cm (centimeters). 

No, the LINX procedure is not likely to be more beneficial for this patient.

This patient has a BMI just under 35 kg/m2 and he has 1 cm of Barrett's esophagus, both of which are concerns for placement of LINX. These were not studied in these populations, and therefore would be considered FDA treatment exclusions.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Alopecia universalis.

Treatment: Xeljanz 10 milligrams (mg) tablet. 

The insurer denied coverage for Xeljanz 10 mg tablet.

The denial is upheld.  

This is a female patient with a history of alopecia universalis. The patient had a Dermatology Telehealth visit. Per the visit notes, the patient has had alopecia universalis for many years and has tried oral, topical, and intralesional steroids without improvement. Physical examination revealed scalp, eyebrows, and eyelashes without hair, bilateral arms without hair, and nails with normal growth. Xeljanz 10 milligrams (mg), 1 tablet twice daily was ordered for the patient.

The accompanying documentation states that the patient has "failed oral, topical, and intralesional steroids" without further detail as to which specific steroids, the dose or duration of treatment. The patient has not failed nor shown to have a contraindication to numerous non-systemic therapies known to possibly improve her condition, including light therapy, squaric acid, diphenylcyclopropenone (DPCP), calcipotriene, and anthralin.(1-11) Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata, further studies are needed to demonstrate the long term efficacy and safety of Xeljanz. It is noted that the Food and Drug Administration (FDA) released a statement in early 2019 finding increased risk of deep vein thrombosis and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10mg twice daily.(1)  

The standard of care would necessitate an attempt to use the above mentioned treatment options. The patient has not failed nor shown to have a contraindication to numerous non-systemic therapies known to possible improve her condition, including light therapy, squaric acid, DPCP, and anthralin. (1-11)   

Xeljanz is not likely to be more beneficial than any other existing standard health service.
The carrier's denial of coverage for Xeljanz 10 mg tablet should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Trigeminal Neuralgia. 
Treatment: Injections to block or destroy a certain nerve for pain (peripheral nerve block). 

The insurer denied injections to block or destroy a certain nerve for pain (peripheral nerve block). 
The determination is overturned. 

This is a patient who has bilateral V2 (Maxillary) V3 (Mandibular) trigeminal neuralgia with more severe pain on the right side. She has severe knifelike pain over the lip and cheek. The pain level ranges from 0/10 to 8/10. She underwent multiple trigeminal blocks. According to the available medical records, the patient had about 2 months of pain relief from the each of the blocks. It was documented in the medical records that the injection was very effective, patient reported in the follow up visit after the injection, " I have no pain, it has been great". The nerve block was denied by the health plan. 

The issue for review is whether the proposed health service or treatment injections to block or destroy a certain nerve for pain (peripheral nerve block) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The proposed health service or treatment injections to block or destroy a certain nerve for pain (peripheral nerve block) is likely to be more beneficial than any standard treatment or treatments disabling condition. 

This patient has persistent severe pain from trigeminal neuralgia. The standard treatment for trigeminal neuralgia is medication therapy. However, when medication therapy fails, trigeminal nerve block can be an effective treatment. From reviewing the medical records, this patient responded well to trigeminal nerve blocks. In addition, there is adequate clinical evidence showing the effectiveness of trigeminal nerve blocks. The referenced studies provided adequate clinical evidence to support trigeminal block as an effective treatment for trigeminal neuralgia.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Trigeminal Neuralgia. 
Treatment: Injections to block or destroy a certain nerve for pain (peripheral nerve block). 

The insurer denied injections to block or destroy a certain nerve for pain (peripheral nerve block). 
The determination is overturned. 

The patient has a diagnosis of trigeminal neuralgia (TN). As per the most recent visit, the patient was evaluated via telemedicine. The patient is noted to have right V2 (maxillary), V3 (mandibular) trigeminal neuralgia with vascular loop left V1 TN. The patient underwent a right trigeminal nerve block. It was noted this block was effective. The physical exam demonstrated sensory intact. The facial pain was rated 4 out of 10. The patient's medications include baclofen. At issue is whether the proposed health service or treatment, injections to block or destroy a certain nerve for pain (peripheral nerve block), likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

Trigeminal neuralgia (TN) is a type of neuropathy characterized by periods of intense paroxystic pain, usually of short duration and triggered by innocuous stimuli, although resulting in excruciating pain. In this case, the patient has trigeminal neuralgia. She is being treated with medications, as well as intermittent injections. The patient suffers from severe facial pain, and intermittent trigeminal peripheral nerve blocks have proven to be very beneficial. Not all trigeminal neuralgia is surgically correctable, as is evident in this clinical scenario. Given the evidence of improvement in symptomatology with prior trigeminal perform nerve blocks, ongoing treatment is supported. There is support in the medical literature for the use of such blocks in improving pain, function, as well as overall quality of life. 

Given the above, the proposed health service or treatment injections to block or destroy a certain nerve for pain (peripheral nerve block) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 

The insurer denied Inpatient hospital admission for medical necessity. 
The denial was upheld. 

The patient is a female with allergic rhinitis, asthma, chronic pain, and anxiety, who presented with 2 days of cough, dyspnea, fatigue, and malaise. In the emergency department (ED), her temperature was 102.7, blood pressure (BP) was 129/83, heart rate (HR) was 132, respiratory rate (RR) was 21, and peripheral capillary oxygen saturation (SpO2) was 94% on room air (RA). She was ill appearing, tachypneic without accessory use, crackles in her bases, breathing comfortably, and alert and oriented.
Her white blood cell count (WBC) was 1.2, sodium (Na) was 140, bicarbonate was 28, blood urea nitrogen (BUN)/creatinine (Cr) was 10/0.75, and lactate was 2.0. The chest x-ray (CXR) found a right lower lobe (RLL) infiltrate. She was diagnosed with community acquired pneumonia (CAP), elevated troponin (Tn) and liver function test (LFT)s and was started on antibiotics, cultured, and serial troponin levels were ordered. 

The patient felt better, she was afebrile, saturating well on RA, appeared comfortable, and had few rhonchi. The cefepime was changed to ceftriaxone; azithromycin was continued, and the computed tomography (CT) scan of the thorax found bilateral consolidation and patchy ground glass. She was started on prednisone for her mild wheeze. 
She continued to do well and was discharged on prednisone, and cefpodoxime. 

At issue is the medical necessity of the Inpatient stay. 

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

The requested health service/treatment of Inpatient stay was not medically necessary for this patient. 

The patient was not severely ill at presentation and was unlikely to become so. The patient presented with fatigue, dyspnea, and cough and was ultimately diagnosed with pneumonia. At presentation, she was not severely ill, with no organ dysfunction (encephalopathy, hemodynamic instability, respiratory distress or significant gas exchange abnormality, acute kidney injury or marked electrolyte abnormality) and by routine scoring systems, such as Pneumonia Severity Index (PSI/PORT), CURB-65 (confusion, BUN, RR, BP, age), SMART-COP Score for Pneumonia Severity (systolic BP, multilobar infiltrates, albumin, RR, tachycardia, confusion, oxygen and power of hydrogen [pH]), and American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) minor criteria, she was unlikely to worsen or need the Intensive Care Unit (ICU). There were no additional or alternative diagnoses. She had improved by the next day. Without severe illness at presentation or a high likelihood of becoming severely ill, she did not require inpatient only monitoring, testing, or treatment. 

Therefore, the Inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-asthma.
Treatment: Pharmacy/Prescription Drugs-Dupixent.
The insurer denied Dupixent SOPN 300MG/2ML.
The denial was upheld. 

This patient is a female with a medical history of uncontrolled moderate persistent asthma despite therapy with high dose Trelegy, Singular, Albuterol and as needed steroids. The patient does not eosinophilia greater than (>) 150 cells/microgram (uL), on her complete blood count (CBC) and does not have documentation of steroid dependent asthma.  The provider has ordered biologic therapy with Dupixent to treat the patient's moderate persistent asthma.
At issue is the medical necessity of Dupixent solution pen-injector (SOPN) 300 milligrams (MG)/2 milliliters (ML).

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

No, the requested health service/treatment of Dupixent SOPN 300MG/2ML is not medically necessary for this patient.
Dupixent is indicated as an add-on maintenance treatment in patients with moderate-to-severe asthma aged 12 years and older with an eosinophilic phenotype or with oral corticosteroid dependent asthma. Castro et al demonstrated that patients who received Dupixent had significantly lower rates of severe asthma exacerbation than those who received placebo, as well as better lung function and asthma control. Wenzel et al demonstrated Dupixent increased lung function and reduced severe exacerbations in patients with uncontrolled persistent asthma. Rabe et al demonstrated that in patients with glucocorticoid-dependent severe asthma, Dupixent treatment reduced oral glucocorticoid use while decreasing the rate of severe exacerbations and increasing the forced expiratory volume (FEV1). Per the clinical documentation, this patient has uncontrolled moderate persistent asthma despite therapy with Trelegy, Singular, Albuterol and as needed steroids. Also, per the laboratory results provided, the patient does not have eosinophilia (> 150 cells/uL) on her complete blood count (CBC) or have documentation of steroid dependent asthma.
Therefore, without documentation of eosinophilia or steroid dependent asthma, the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Advanced Imaging Services (including PET, MRI, CT). 
The Positron Emission and Computed Tomography was denied for medical necessity. 
The denial was overturned. 

This patient is a female with metastatic stage 4, estrogen receptor (ER) positive (+)/human epidermal growth factor receptor 2 (HER2) negative (-), right breast cancer. The patient has been on multiple lines of therapy. She is currently in no apparent distress and with an unremarkable physical exam beyond her known breast cancer. A positron emission tomography (PET) and computed tomography (CT) scan has been ordered for re-staging.
At issue is the medical necessity of the Positron Emission Tomography and Computed Tomography (PET CT) scan.

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

The requested health service/treatment of Positron Emission Tomography and Computed Tomography (PET CT) is medically necessary for this patient.
The National Comprehensive Cancer Network (NCCN) recommends a PET CT "in situations where standard imaging studies are equivocal or suspicious."  A technetium bone scan was obtained which demonstrated left scapular uptake without a corresponding finding on CT. The scans are otherwise unremarkable for evidence of progression. A PET CT was requested to try to evaluate this area with concern for metastatic disease. In this clinical scenario, the PET CT is being obtained in a fashion consistent with guideline recommendations.
Therefore, the health service/treatment of Positron Emission Tomography and Computed Tomography (PET CT) is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Cellulitis
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a history of relapsed acute lymphocytic leukemia (ALL), status post bone marrow transplant and graft versus host disease (GVHD) admitted to the hospital as an inpatient with a perineal abscess. 
He reported increasing redness and pain over his right groin. Vital signs were normal. There were blood cultures with Vancomycin Resistant Enterococcus (VRE) and he was given intravenous (IV) antibiotics. There was a wound vac in place. He received pain medications and received infectious disease (ID) consults. Debridement occurred by surgery.
At issue is the medical necessity of the inpatient stay.

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

The requested health service/treatment of inpatient stay is not medically necessary for this patient.
According to Milliman Care Guidelines (MCG) Health, Cellulitis Guidelines, inpatient hospitalization is indicated for hemodynamic instability, altered mental status, failure of outpatient therapy as indicated by all of the following: Progression or no improvement after adequate trial (minimum 48 hours), adequate antibiotic regimen, outpatient IV antibiotic therapy is not appropriate. These also include if limb threatening infection present or if clinical presentation is judged to require intense patient monitoring of vital signs, infection progression that cannot be provided at other than inpatient level of care. Other indications include high risk comorbid condition such as diabetes, cirrhosis, neutropenia, asplenia, long term steroids, or congestive heart failure (CHF), bacteremia, necrotizing soft tissue infection, surgical procedure not amenable to outpatient or observation level of care, gangrene, orbital infection or progressive perineal infection, severe pain requiring inpatient management, inability to maintain oral hydration, compartment syndrome or laminar flow isolation.
The primary treatment of perineal abscess is surgical drainage with incision, wound packing, and in some cases fistulotomy.  This should be followed by empiric antibiotics until final cultures have been completed.   The surgical drainage can be performed in an outpatient setting under local anesthesia.  If prolonged antibiotics are necessary, this can be accomplished in the outpatient setting with a Peripherally inserted central catheter (PICC) line or some other longer term IV access catheter.  This could have also been performed under observation status and if the clinical situation deteriorated the patient could have been admitted to inpatient care.  (2)

Therefore, the inpatient days of hospitalization were not medically necessary. This patient could have been treated in observation status or outpatient and admitted inpatient if there were signs or symptoms of deterioration while on that level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis

Treatment Gammagard liquid to treat MS [multiple sclerosis]

The insurer denied coverage for Gammagard liquid to treat MS

The denial is upheld

The patient has a past medical history of multiple sclerosis.  The patient was being seen for the evaluation of his multiple sclerosis.  The patient reported that his balance has been worse.  The patient was using a cane and had not been having walking difficulties.  Fear of falling was an issue for him.  The patient had been utilizing Gammagard.  The provider recommended continuing of Gammagard, Copaxone, and considering hand controls.  The patient was also to be treated with physical therapy.

Gammagard (immune globulin infusion) is not appropriate for this patient. In a recent review of the role of immune globulin for multiple sclerosis (MS), Up to Date states "Although data are equivocal, there is no compelling evidence that intravenous immune globulin (IVIG) is effective for patients with RRMS [relapsing and remitting multiple sclerosis]. Some [206-209], but not all [210] early clinical trials reported beneficial effects for IVIG in RRMS. However, these trials generally involved small numbers of patients, lacked complete data on clinical and MRI [magnetic resonance imaging] outcomes, or used questionable methodology [211]. A later multicenter placebo-controlled trial of 127 patients with RRMS found that IVIG treatment conferred no benefit for reducing relapses or new lesions on MRI."

The patient is taking Copaxone with symptoms of disease progression.  There are close to 20 effective DMT [disease modifying treatments] on the market.  If the patient has failed Copaxone, they should be switched to a different DMT.  The choice of the new DMT would be based on specific patient situation, as these meds are not interchangeable.

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

Based on the above, the medical necessity for the Gammagard liquid to treat MS is not substantiated. The insurer's denial is upheld.