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

Diagnosis: Crossbites with loss of gum attachments,
protruding and flared upper incisors
Treatment: D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition and D8670 Periodic Orthodontic Treatment Visit x12
The insurer denied the D8080 Comprehensive Orthodontic Treatment of the Adolescent Dentition and D8670 Periodic Orthodontic Treatment Visit x12.
The denial is overturned. 

The patient is a male requesting orthodontic benefits.

Yes, the proposed orthodontic benefits are medically necessary.

The patient's lower canines (teeth #22 and #27) are in crossbite with his upper lateral incisors. There is clinical attachment loss around tooth #10 (upper left lateral incisor) and both lower canines. The gingival margin of #10 is higher than it should be, indicating loss of gum attachment. The lower canines show a reduced band of attached gingiva, which is due to their being in a more buccal position, towards the lips. The lower canines also have frenum attachments (muscle attachments) which are aggravating the loss of attached gingiva. The anterior tooth crossbites with loss of gum attachments are "automatic qualifiers" according to the Handicapping Index Scale.

In addition, the upper incisors are protruding and flared. This means that during a protrusive chewing motion there will be no" incisal guidance". This means that during the chewing function the patient's teeth will grind together in a traumatic fashion that could over time cause trauma such as tooth loosening and / or fracturing. The upper front teeth need to be properly positioned to allow them to guide the lower teeth during chewing. The orthodontic treatment with monthly visits is medically necessary to correct this severe malocclusion.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with obesity, history of gastric bypass, mixed connective tissue disease (MCTD) / systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS) and chronic pain on narcotic therapy.  The patient was admitted as an inpatient with abdominal pain, nausea, vomiting, decreased oral intake, weakness, myalgias and subcutaneous nodules.  She had recently been treated for right hip cellulitis with Keflex. Over the ensuing two weeks, she developed progressive diffuse tender nodules over her torso, thighs and upper arms.  

On admission, the patient was afebrile with stable vital signs. Laboratory evaluations revealed erythrocyte sedimentation rate (ESR) of 50, normal C-reactive protein (CRP) and mildly elevated liver function tests.  Electrocardiogram (EKG) and chest x-ray (CXR) were unremarkable, and COVID testing was negative. She underwent computed tomography (CT) scan of the abdomen and pelvis, which demonstrated mild circumferential skin thickening and subcutaneous edema, but no intra-abdominal pathology.  The concern was for Dercum's disease, angiomatous lipomas or panniculitis.  She was seen by rheumatology, and all serologies for systemic lupus erythematosus (SLE), mixed connective tissue disease (MCTD) and antiphospholipid syndrome (APS) were negative, calling these diagnoses into question.  She was seen by dermatology, and underwent an ultrasound, followed by recommendation for an outpatient wedge biopsy.  Her pain was controlled with Percocet and lidocaine, and she was discharged to outpatient rheumatology and dermatology follow up.  

No, the proposed inpatient admission was not medically necessary.

She was afebrile and vital signs were stable on admission.  Electrocardiogram (EKG) and chest x-ray (CXR) were unremarkable, and COVID testing was negative. Computed tomography (CT) scan of the abdomen and pelvis demonstrated mild circumferential skin thickening and subcutaneous edema, but no acute intra-abdominal pathology.  Her pain was well-controlled with lidocaine and Percocet.  Given her stable vital signs and labs, absence of signs of a systemic inflammatory response syndrome, no evidence of acute intra-abdominal pathology, and ability to control her pain with oral agents, additional workup and treatment of her tender subcutaneous nodules could have been appropriately and safely conducted in the outpatient hospital setting.  Therefore, her inpatient hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Palpitations.
Treatment: Inpatient admission.
The insurer denied inpatient admission.
The denial is overturned. 

The patient is a female. She has a past medical history significant for hypertension, diabetes mellitus, atrial fibrillation, valvular heart disease, status post aortic and mitral valve replacement, Maze procedure, left atrial appendage ligation.

The patient presented to the ER (emergency room) with new onset palpitations and was diagnosed with SVT (supraventricular tachycardia) with a heart rate of 160/minute and was hypotensive with that rate. She was given IV (intravenous) metoprolol and her tachycardia improved - she had persistent atrial arrhythmia, but with normal heart rate in the ER (emergency room), and her blood pressure stabilized. The patient's doses of metoprolol and amiodarone were increased.

The patient was admitted to telemetry for monitoring and management of the arrhythmia. On telemetry, the patient had persistent atrial tachycardia, despite medical therapy, she was seen by electrophysiology specialist and underwent a cardioversion. She was re-loaded with amiodarone and was discharged home with a plan for outpatient follow-up.

Yes, the Inpatient admission was medically necessary.

This patient with multiple prior medical comorbidities, as well as status post complex cardiac surgery, presented with new onset SVT (supraventricular tachycardia) with hemodynamic compromise. The patient was stabilized in the ER (emergency room) with medications and her hemodynamics had improved, however the arrhythmia was not controlled, and the patient had persistent abnormal rhythm, despite the medical therapy, ultimately requiring electric cardioversion. Given the hemodynamically unstable rhythm at presentation, failure of the medical therapy to convert her to normal sinus rhythm, need for high dose antiarrhythmic loading, multiple cardiac comorbidities, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abnormal uterine bleeding.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This female patient has a history of abnormal uterine bleeding.  The patient presented to the hospital for a scheduled abdominal myomectomy and hysteroscopic myomectomy. The procedure was performed and the patient was admitted for postoperative monitoring. The postoperative course was complicated by tachycardia, subjective fevers, and shortness of breath. The patient's symptoms improved, and the patient was discharged after a period of hemodynamic stability.    

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient. This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not.  The standard of care is for patients who undergo an open procedure to stay in hospital for 48 hours. On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, and clear liquid diet is started.  On postoperative day 2, if the patient is passing flatus and tolerating regular diet, the patient is discharged home. In this case, this patient was managed according to the guidelines and the standard of care. Actually, the patient was discharged 24 hours earlier than expected and the admission was medically necessary.

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 the inpatient admission is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD
Treatment: Chest vest
The insurer denied a chest vest. The health plan's determination is overturned. 

The patient is a male with a medical history of chronic cough with failed attempts at using a cough assist device as well as manual chest physical therapy. He has had multiple exacerbations in the past and reports an increase in cough with excessive phlegm and wheezing. The question posed is whether a Chest Physiotherapy vest is considered medically necessary for this patient.

The chest vest is medically necessary. This patient has a history of chronic obstructive pulmonary disease (COPD). He also is noted to have findings of bronchiectasis as documented in the note provided by his internist. This disease is often marked by flares, increased mucous production and progressive loss of pulmonary function secondary to the recurrent infections. Because of this, mucociliary clearance must be optimized. This patient has tried several options for enhancing mucous clearance and is still documented as having frequent flares in association with increased cough and sputum production.
This individual has bronchiectasis and has documentation of frequent flares of the disease that require intervention and treatment. He is also described as having chronic and productive cough. He has tried manual chest percussion and this has not been shown to effectively mobilize his secretions. The chest vest is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Posterior crossbite.
Treatment: Braces.
The insurer denied braces. 
The health plan's determination is overturned.

The patient in question is a male with a Class I malocclusion and a posterior crossbite on the left. He has a mandibular deviation to the left. He had moderate crowding. He is treatment planned for 36 months of braces with rapid palatal expansion to correct his crossbite.

Braces are medically necessary for this patient. There is strong medical evidence that early correction of unilateral posterior crossbites with a shift reduces the need for future treatment. This patient presents with a posterior crossbite, crowding, and constricted arches. He would be an excellent candidate for rapid maxillary expansion to assist with orthodontic correction. Such a procedure can only be performed before the patient reaches skeletal maturity, otherwise the ability to achieve expansion is greatly reduced. He is nearing the end of the time that orthodontics alone can correct his crossbite. Therefore, braces are medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Quadriplegic cerebral palsy.

Treatment: Physical Therapy (PT) - Exercises Increase to 3 Visit(s) per week.

The insurer denied coverage for Physical Therapy (PT) - Exercises Increase to 3 Visit(s) per week.

The denial is upheld. 

This is a female patient with quadriplegic cerebral palsy.  She has been receiving physical therapy services 3 times/week over many years.  She also receives left upper extremity Botox injections for better control of her motorized wheelchair.  Currently under review is the medical necessity of physical therapy (PT)-exercises increase to 3 visits/week.

The patient's diagnosis is quadriplegic cerebral palsy.  She has received physical therapy since infancy.  The patient also has a home health aide.  She remains non-ambulatory and requires maximal assistance of another person to perform transfer activities and bed mobility.  The treating physician indicated the patient "requires the therapy by skilled therapists that cannot be provided or performed by an aide."  However, the treating physician does not specifically describe what particular treatment(s) provided by the therapists cannot be adequately performed by the home health aide.  In addition, the treatment is essentially maintenance therapy.  Continued (3 times/week) physical therapy is unlikely to result in functional improvement and is not medically necessary.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  Including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies boards and associated were taken into consideration.  All decisions are evidenced based.

The Carrier's Partial denial of coverage for Physical Therapy (PT) - Exercises Increase to 3 Visit(s) per week is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Orthopedic/Musculoskeletal-debility.
Treatment: Home Health Care. 
The insurer denied an increase in personal care hours to 84 hours per week. 
The denial was overturned, in part. 

The patient is a male with a past medical history significant for prostate cancer, gait abnormality, eosinophilia, left bundle branch block and pancytopenia. He currently lives alone in an apartment. He is non-ambulatory and moves around in the apartment in his wheelchair. The patient is currently approved for 6 hours a day 7 days a week for a total of 42 hours per week. The patient's provider requested an increase in personal care level services to 7 days a week 12 hours a day for a total of 84 hours a week.
The patient's health plan denied additional services stating the patient is receiving care hours for basically all his activities of daily living. The tasking tool notes that the patient needs a total of 33.42 hours of care week and the patient is currently receiving 42 hours a week.
At issue is the medical necessity of home care/personal home health care (HHC)-Level 2 personal care services, per 15 minutes increase to 84 hours per week.
The health plan's determination of medical necessity is overturned, in part.
The requested health service is medically necessary for this patient, in part.
This reviewer recommends overturning the decision in part. An increase in personal care service hours to 56 hours a week is medically necessary for this patient. Additional service hours are necessary for the patient's unscheduled needs.
The patient is a male with multiple medical problems. He suffers from age-related debility, dementia, and prostate cancer. He did have heart block which was corrected with pacemaker placement. The patient currently lives alone in an apartment. He is non-ambulatory and moves in the apartment in his wheelchair. He currently is receiving 42 hours per week and is requesting 84 hours. The patient has incontinence and has been managed with pull ups. The comprehensive nursing assessments were reviewed, with the last assessment, noting no change in his status since the last encounter.
The patient does have unscheduled needs which are not being met completely with the hours provided. 56 hours per week is medically necessary for this patient.  Splitting these hours may be more appropriate to meet this patient's needs. 84 hours per week is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Malignant neoplasm.
Treatment: Gilotrif.
The insurer denied coverage for Gilotrif.
The denial is upheld. 

This is a female patient with a history of primary malignant neoplasm of right upper lobe of lung metastatic to bone, last treated with osimertinib.  The rationale for Gilotrif (afatinib) use in this patient's case is the emergence of an epidermal growth factor receptor (EGFR) L718A mutation in addition to the original EGFR L858R mutation.

As per Yamaguchi et al. (2019), afatinib was identified as one of the therapeutic options after first tyrosine kinase inhibitor (TKI) failure in the patients with advanced non-small cell lung cancer (NSCLC) harboring EGFR mutation when the time of treatment by prior first TKI is more than 10 months.  There is speculation based on case reports and series that it may be effective, but no prospective study evidence.

As per the Food and Drug Administration (FDA),"Gilotrif is a kinase inhibitor indicated for: First-line treatment of patients with metastatic NSCLC whose tumors have non-resistant EGFR mutations as detected by an FDA-approved test (1.1); Limitation of Use: Safety and efficacy of Gilotrif were not established in patients whose tumors have resistant EGFR mutations (1.1); Treatment of patients with metastatic, squamous NSCLC progressing after platinum-based chemotherapy (1.2)" (FDA, 2018).      

As per the FDA, Gilotrif is approved only for first line treatment of NSCLC.  Gilotrif is indicated for the first-line treatment of patients with metastatic NSCLC whose tumors have non-resistant EGFR mutations as detected by an FDA-approved test. This is not the case for this patient. This patient developed EGFR mutations on osimertinib treatment. 

Based on the review of the medical record and literature, Gilotrif is not the best available treatment for this patient at this time. Alternative appropriate treatments include chemotherapy, Keytruda alone or with chemotherapy. 

Gilotrif is not likely to be more beneficial than any of the standard treatments/procedures for this patient

The carrier's denial of coverage for Gilotrif should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Malignant neoplasm.
Treatment: Gilotrif.
The insurer denied coverage for Gilotrif.
The denial is upheld. 

This is a female patient with metastatic epidermal growth factor receptor (EGFR) mutated non-small cell lung cancer (NSCLC) with progression on Tagrisso (osimertinib).  The attending physician (AP) has proposed therapy with Gilotrif (afatinib). The patient has developed an EGFR L718A mutation with a L858R mutation.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

There is currently no evidence in the medical literature to support a benefit to the use of afatinib following progression on osimertinib in the treatment of NSCLC. Phase II studies have suggested a possible benefit to the use of Gilotrif+ cetuximab following failure of single agent tyrosine kinase inhibitors (TKIs) in metastatic EGFR mutated NSCLC, leading to the National Comprehensive Cancer Network (NCCN) statement, "however, it should be noted that in a front line setting, this is associated with no benefit and increased toxicity."  As per Goldberg et al. (2020), "The addition of cetuximab to afatinib did not improve outcomes in previously untreated EGFR-mutant NSCLC, despite recognized activity in the acquired resistance setting."

Gilotrif (afatinib) does need/have final approval from the appropriate regulatory bodies for this diagnosis.  Gilotrif is not approved by the Food and Drug Administration (FDA) for use following failure of osimertinib in the treatment of NSCLC with EGFR mutation.     

Based on the review of the medical record and literature, this patient is not a good candidate for Gilotrif.  There is no evidence to support the use of Gilotrif for this individual. The NCCN does not support the use of Gilotrif following failure of Tagrisso unless it is given with cetuximab. Gilotrif is not the best available treatment for this patient at this time.  There is no evidence that Gilotrif would be of benefit to this patient.  

Gilotrif is not likely to be more beneficial than any of the standard treatments/procedures for this patient

The carrier's denial of coverage for Gilotrif should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, dilated gastrojejunal anastomosis,
hiatal hernia
Treatment: Revision (endoscopic surgical procedure on the stomach), Pre-service
The insurer denied the Revision (endoscopic surgical procedure on the stomach), Pre-service.
The denial is upheld. 

This patient is a woman who is status post roux en Y gastric bypass surgery performed for refractory morbid obesity.  The patients body mass index (BMI) is 34 kilograms per meter squared (kg/m2).  Comorbid health conditions include depression.  

Upper endoscopy was performed with findings of gastric bypass anatomy with a normal sized gastric pouch.  The gastrojejunal anastomosis was 3.5-4.0 centimeters diameter.  There was not a hiatal hernia noted on endoscopy.  A letter dated states that the patient now has a dilated gastrojejunal anastomosis and a hiatal hernia.   The patient's provider has offered endoscopic suturing of the stoma to promote weight loss.

No, the proposed revision (endoscopic surgical procedure on the stomach) is not medically necessary.

Based on the submitted clinical documentation and the current status of peer reviewed literature regarding the proposed endoscopic suturing of the gastrojejunal anastomosis to treat post gastric bypass weight gain, this is not a generally accepted treatment for the condition of weight gain in the post gastric bypass setting.  The proposed endoscopic reduction of a roux en Y gastric bypass gastrojejunostomy is unproven and not medically necessary.

In this case, the proposed endoscopic revisional procedure is not in general use in the medical community for the proposed condition (weight gain post gastric bypass).  There is limited published literature beyond case studies and small series reports that provide long term data on weight reduction post endoscopic suturing of the gastrojejunal anastomosis in the setting of prior gastric bypass.

This treatment is not appropriate for weight gain post gastric bypass.  This treatment is not within the standards of good medical practice with the organized medical community and is not the most appropriate procedure or service based on scientific evidence that demonstrates that the expected health benefits are clinically significant and produce a greater likelihood of benefit for this patient's particular medical condition compared to alternative treatment. 

Alternative treatment for this patient may include strict dietary compliance with a prescribed nutritional program.  Nutritional consultation and ongoing follow up may also help promote weight reduction.