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

Diagnosis: Eosinophilic granulomatosis with polyangiitis, Peripheral neuropathy
Treatment: Lyrica (pregabalin)
The insurer denied coverage for Lyrica (pregabalin).
The denial is overturned.

This is a female patient with a history of eosinophilic granulomatosis with polyangiitis and mycobacterium avium-intracellulare (MAI) infections. The patient was seen by rheumatology for management of her vasculitis. The patient had right leg foot drop, neuropathy, and pulmonary involvement. The patient has been treated with Rituxan in the past which was complicated by recurrent MAI infections. The patient has tried gabapentin for pain relief without any effect. The patient has used Lyrica (pregabalin) for pain in her leg at night. The patient reported that Lyrica has been helping. A note stated that the patient still had neuropathy of her feet, and that Lyrica (pregabalin) would be continued; Percocet was added.  

The rheumatologist requested a continuation of Lyrica (pregabalin), stating that the patient has been on it for a while with good control of symptoms and that stopping the medication now would be detrimental to the patient's health. There is no specific therapy for treating the pain of vasculitis neuropathy. There is no specific medication indicated for neuropathic pain from vasculitis neuritis, and the choice of medication would reflect those medications used for neuropathic pain caused by other conditions, such as diabetes and shingles. 

As noted in an UpToDate article on "Pharmacologic management of chronic non-cancer pain in adults", both gabapentin and pregabalin have shown effectiveness in other types of neuropathy. There are no head-to-head comparisons of gabapentin vs. pregabalin noted. The patient has been on Lyrica (pregabalin) for 5 years with benefit and no apparent toxicity reported. The patient has tried gabapentin and it did not work. There is no guarantee that any medication change would be as effective as this patient's positive response to Lyrica (pregabalin), and it could be less. Changes now would be subjecting the patient to the risk of new side-effects and enhanced pain when her current symptoms have been well-controlled on Lyrica (pregabalin). In this case, literature review supports that Lyrica (pregabalin) is medically necessary for this patient. 

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

Based on the above, the medical necessity for Lyrica (pregabalin) is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Septicemia; Decubitus ulcers

Treatment: Skilled Nursing and Rehabilitation 

The insurer denied coverage for Skilled Nursing and Rehabilitation.

The denial is upheld.

This male patient has chronic medical problems including chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and dementia.  The patient was transferred to a skilled nursing and rehabilitation center.  Under review is the medical necessity for the continued stay at the skilled nursing and rehabilitation center.  

Therapy (including physical, occupational and speech therapy) notes documenting treatment or functional progress were not enclosed for review.  However, according to the Discharge Planning Instructions note, the patient continued to require the assistance of another person for getting in/out of bed and activities of daily living including using the toilet, personal hygiene and taking his medications.  In the Care Plan Activity Report, the patient required "extensive assist" for activities of daily living.  The rehabilitation therapy provided is best described as custodial, given the patient's limited functional improvement.  In addition, the medical and nursing (including wound) care could have been provided at a lower level of care (e.g., long term care with visiting nursing, home with visiting nursing or outpatient services).  

Based on literature review, the continued stay at the skilled nursing and rehabilitation center was not medically necessary. This determination is made upon consideration of the clinical standards of the plan, the absence of any detailed data regarding physical, occupational or speech therapy during the period in question,  information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  

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

Based on the above, the medical necessity for the continued stay in a skilled nursing and rehabilitation center is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Schizophrenia. 
Treatment: Behavioral Health Inpatient Services. 
The health plan denied Behavioral Health Inpatient Services. The health plan's determination is overturned in part. Six additional days of Behavioral Health Inpatient Services are medically necessary. 

The patient is a male with diagnoses of chronic schizophrenia (SCZ), Cannabis Use D/O (CUD), and Ecstasy Use Disorder (EUD). He has required multiple psychiatric admissions. He has been non-adherent to his medication. The admission under review was initiated via emergency services due to the patient's violence and aggression toward his family (father and sister). 

Six additional days are medically necessary for several reasons. This patient's SCZ is severe, chronic, and functionally impairing. His form of SCZ is of a very severe type, marked by prominent negative symptoms, and less responsive to medications. Additionally, his use of two substances made his treatment more complex. The patient was not able to tolerate the daily interview of the mental status but walked out of the room. He would not engage in attempts at group therapy. He was still disheveled. He had minimal spontaneous speech. He showed thought blocking and poverty of thoughts. He was illogical and appeared to be internally preoccupied. He reported no suicidal or homicidal ideation. He was not behaviorally aggressive. He denied hallucinations or delusions. He had no side effects from his medications. While he was very functionally impaired, he appeared to have reached his baseline state of functioning. His mood was good. 
While he was still substantially impaired by his negative symptoms on day 5, he appears to have returned to his baseline state. There was no evidence predictive of violence. He had no suicidal ideation. He has no positive psychotic features. Therefore, he could be discharged on day 6 with good medical judgment, in accord with current standards of best care, and in accord with the medical literature. While his actual discharge appeared to be delayed beyond day 6 due to his family declining to take him back home, this was not a medical reason for continued BHIS.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tongue swelling
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with hypertension who presented with angioedema likely due to angiotensin-converting enzyme (ACE) inhibitors. The patient was found to have swelling of the tongue. In the emergency room, the patient received intravenous (IV) steroids, Benadryl and racemic epinephrine nebulization. The patient was admitted to acute in hospital level of care. The patient's condition partially improved with emergency room and due to continued tongue swelling, the patient was admitted to intensive level of care. By the time patient was admitted to the hospital, the patient's condition improved significantly. The patient was able to speak in full sentences. The patient was hemodynamically stable. The patient was able to protect the airway. The patient was off oxygen. The patient was tolerating.  

No, the proposed treatment was not medically necessary.

Since the patient improved significantly with emergency room care, the inpatient admission was not medically necessary.  Also, since the patient was able to protect the airway, was able to go off oxygen and had no respiratory distress after 24 hours, the entire admission was not medically necessary. The patient could have been safely and effectively be treated as an observation level of care with outpatient follow up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous system/Neuromuscular disorders
Treatment: Inpatient hospital 
The insurer denied the inpatient hospital stay.
The denial is upheld in whole.

Summary: The patient is a male with a past medical history significant for hypertension, cerebrovascular accident (CVA) with a residual left-sided hemiparesis, dyslipidemia, and schizophrenia who presented to the emergency department by Emergency Medical Services (EMS) due to episodes of shaking in his body and sweating. The EMS reported that the patient was standing in his doorway and was nonverbal for a few seconds.

No, the hospital stay was not medically necessary for this patient at the acute inpatient level of care. Reportedly, the patient presented to the hospital with complaints of shaking in his body and swelling. In the emergency department, the patient had intermittent episodes of a long blank stare.

The admission for a lower level was still more appropriate in this clinical case, since there was no evidence of concomitant cardiac arrhythmias of immediate concern, severe or persistent altered mental status, presence of focal neurologic deficits beyond the baseline, significant metabolic abnormalities that could trigger seizures, or recurrent seizures. The imaging studies did not reveal acute abnormalities.

This type of care required admission for a lower level of care rather than admission at the acute inpatient level of care. Other medical problems at the time of admission included hypertensive urgency. Hypertensive urgency usually does not require admission at the acute inpatient level of care. Furthermore, the patient's elevated blood pressure improved very quickly.

At the time of admission, the patient was diagnosed with urinary tract infection, which did not require long-term administration of intravenous antibiotics, since the patient remained afebrile and hemodynamically stable and tolerated oral intake.

There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at the lower level of care, rather than admission to an inpatient level of care.

Overall, the patient remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The hospital stay was within the scope of a lower level care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental issue

Treatment: Dental core buildup on tooth #30

The insurer denied coverage for D2950, (core buildup, including pins) on tooth #30

The denial is overturned.

This is a female patient who was seen for evaluation of dental issues.  The treating dentist is requesting authorization for D2950 (core build up, including pins) for tooth #30.  

Upon review of the submitted documentation, the patient exhibited endodontic therapy on #30 completed in Russia.  Based on these clinical findings, the dentist recommended core buildup on this tooth, presumably prior to crown placement. The insurer has denied this service stating that the quality of the endodontic therapy, i.e. poor quality obturation and fill, does not support these treatments.  The treating dentist states that the "cement" used as a filling material does not negatively affect long term tooth retention/health.

The existing restoration placed on this endodontically treated tooth appears to be failing. Given this clinical circumstance, core buildup and placement of full coverage crown is indicated and is a conservative restorative option which would represent a standard of care for this clinical circumstance in general dental practice. As such the service noted above, which is a covered service for this individual, is deemed medically necessary.

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

The carrier's denial of coverage for D2950 (build-up) on tooth #30 is overturned.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services.  
The insurer denied LINX procedure. 
The denial is overturned in whole. 

The patient is a male singer with burning symptoms of the throat despite Dexilant proton pump inhibitor (PPI) therapy. At present he reports that he cannot sing due to these symptoms. He has undergone evaluation with endoscopy which shows no hiatal hernia but does indicate esophagitis. Abnormal acid exposure is confirmed by pH testing with a DeMeester score of 23 with symptom correlation based on only one reported symptom event. Manometry indicates normal esophageal peristalsis.
This review concerns the proposed LINX sphincter augmentation device implantation.

The health plan's determination is upheld.

The LINX procedure is not likely to be more beneficial than standard medical and surgical treatments for this patient. The evidence in support of LINX is insufficient to demonstrate that LINX is likely to be superior to medical therapy with PPI medication, or to surgical fundoplication. Furthermore, there is inadequate data to support the LINX device for specific subgroups of patients such as this individual with atypical symptoms.
Early and mid-term cohort studies of LINX have reported reduced esophageal acid exposure and lower patient-reported GERD (1-5). However, the quality and duration of trials directly comparing LINX to accepted surgical fundoplication or maximal medical therapy are poor, as Kirkham reports in a comprehensive 2020 review (6). While the device is meant to remain distensible over time, severe fibrotic reactions and erosion have been reported, with challenging explantation surgery required (7).
Evidence for the efficacy of the LINX device compared to medical and surgical management of GERD is of poor quality. In perhaps the most comprehensive published review of the evidence for LINX magnetic sphincter augmentation, Kirkham's 2020 review concludes, "Most studies on magnetic sphincter augmentation (MSA) lacked information about patient selection, governance, expertise, techniques and outcomes, or varied between studies. Currently, MSA is being used despite a lack of robust evidence for its effectiveness." (6). In the 2020 systematic review by Schizas, the author concludes, "The findings of our review suggest that MSA has the potential to bridge the treatment gap between maxed-out medical treatment and laparoscopic fundoplication (LF). However, further studies with longer follow-up are needed for a better elucidation of these results" (12). Until such further studies of higher quality and longer follow-up are complete, the LINX procedure is not the standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services.  
The insurer denied LINX procedure. 
The denial is overturned in whole. 

This patient is a male (body mass index [BMI] 28 kilograms per square meter [kg/m2]) who sought surgical evaluation for the condition of gastroesophageal reflux disease (GERD). His symptoms consist of substernal burning. He has been treated with anti-acid medications (Dexilant, Ranitidine, Omeprazole), but has refractory symptoms. He has followed lifestyle and diet recommendations for GERD treatment.
Esophagogastroduodenoscopy (EGD) showed no hiatal hernia and no mention of esophagitis.
A pH study report showed a composite DeMeester score of 23.1 (normal [nl] less than [<] 14.7). There was reported to be good symptom correlation.
Motility testing showed no hiatal hernia and normal distal contractile integral. There was intact peristalsis with 75 % of swallows. There was no Chicago Classification abnormality.
The treating surgeon has proposed the LINX procedure as treatment of chronic GERD.
The LINX procedure is under review to determine if it will be more beneficial for this patient than any standard therapy.

The proposed LINX is likely to be more beneficial than standard therapy for the patient's proven condition of GERD.
Considering the submitted documentation, the published literature, and the clinical details of this case, the requested LINX procedure is supported in peer reviewed literature as an appropriate procedure for the condition being treated in this case. The clinical documentation does substantiate the diagnosis of surgically amenable GERD in this case. The pH study shows a composite score of 23.1 (nl < 14.7) with good symptom correlation. There is adequately preserved esophageal function per motility testing. Finally, there is no contraindication to an anti-reflux intervention such as LINX in this case. This treatment is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the proven condition of GERD.

The submitted records support treatment with the proposed LINX procedure for this patient. The patient has symptoms of chronic GERD. He has been appropriately evaluated with EGD, motility testing, and pH testing. He has proven pathologic esophageal acid exposure based on the findings of these studies and there is no contraindicating esophageal motor condition based on manometry. Finally, the patient does not have specific contraindication to implantation of the LINX device.
The LINX procedure has demonstrated long term efficacy to support that it is as safe and effective as alternative therapy such as traditional fundoplication and has an improved risk profile with preserved ability to belch and vomit (if necessary) post-procedure. Therefore, this procedure is likely to be more beneficial than standard therapy for the patient's proven condition of GERD.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Surgical Services.  
The insurer denied LINX procedure. 
The denial is overturned in whole. 

The patient is a male with a body mass index (BMI) of 28.43 kilograms per square meter (kg/m2) with symptomatic gastroesophageal reflux disease (GERD) refractory to medication use. 24 hour pH study revealed an elevated DeMeester score consistent with GERD. Esophagogastroduodenoscopy (EGD) was normal. Manometry was normal.
The subject under review is whether the LINX procedure is likely to be more beneficial for this patient than any standard treatment for his condition.

The health plan's determination is overturned.

This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The exclusions to LINX and Nissen fundoplication include BMI greater than (>)35 kg/m2 in which case treatment of obesity is thought to be important for treatment of GERD. Other exclusions for LINX include Barrett's esophagus with dysplasia, age less than (<) 18 and prior gastric or bariatric surgery. This patient has no exclusion to LINX treatment.
Based on published studies, the LINX procedure is likely to be more beneficial for this patient than any standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Hospital admission
The insurer denied coverage for the full hospital admission.
The denial is upheld.

This is a female patient with a history of hypertension and family history of coronary artery disease. The patient presented to the Emergency Department (ED) complaining of intermittent chest pain that she was experiencing for months. The patient reported that the pain lasts for about 2 to 3 minutes before subsiding, and the pain occurred with exercise and with rest. The patient's myocardial perfusion testing performed one month prior to this ED presentation revealed a fixed inferior wall defect, without ischemia; left ventricular ejection fraction (LVEF) was 49%. Upon arrival to the ED, the patient's physical exam revealed no significant abnormalities. The patient's electrocardiogram (EKG) upon presentation revealed no evidence of ischemic changes. The patient's serial troponin testing was negative. The patient underwent cardiac catheterization that revealed normal coronary arteries without obstruction and she was discharged on antihypertensive medications.

Based on the review of the medical record and literature, the full hospital admission was not medically necessary for this patient. This patient was complaining of atypical chest pain and had a fixed defect on myocardial perfusion testing without active ischemia. The patient's EKG did not reveal ischemic changes, and the patient's serial troponin levels were not elevated. The patient's pretest probability of significant coronary disease was low. Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction, need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events, defined as all - cause mortality, myocardial infarction, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. Thus, inpatient admission was not medically necessary. The patient could have been safely treated at a lower level of care.

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

Based on the above, the medical necessity for the full hospital admission is not substantiated. The insurer's denial should be upheld.