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

Diagnosis: Breast wound.
Treatment; inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

This woman with breast cancer underwent bilateral mastectomies and SIEA (superficial inferior epigastric artery) microvascular free flap breast reconstruction. She was readmitted as an emergency for debridement and revision of the left breast free flap. Since then, she has undergone 3 additional flap debridements for partial flap necrosis. This has resulted in a 7 centimeter (cm) round defect into the flap with a viable wound base. A vacuum-assisted closure (VAC) dressing was applied and is managed by home care visiting nursing which has dramatically reduced the size of the wound at a time when she is simultaneously undergoing chemotherapy.

The inpatient admission was not medically necessary. The patient had undergone free flap reconstruction of her breast. She returned to the hospital and underwent debridement. Admission to the hospital prior to debridement was not medically necessary. The records are limited but do not document that the patient was sick or septic. The records do not document that she required extensive preoperative preparation for surgery. She could have presented and treated with debridement the same day. The records do not document any rationale or medical justification for admission prior to wound debridement and attempted flap salvage. Hospital records are not provided but the limited information provided in the surgeon's records does not offer a medical justification for admission prior to surgery. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Dupixent. 

The insurer denied Dupixent. 
The denial is upheld. 

The patient is a male with atopic dermatitis (AD). He has tried and failed clobetasol and triamcinolone. The prescriber is a dermatologist. The subject under review is the medical necessity for Dupixent. 

The health plan's determination is upheld. 

The requested health treatment of Dupixent is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan are effective treatments for the management of atopic dermatitis. (1, 2) 
Within the peer-reviewed literature, in 2018, Gerbens et al. writes "methotrexate (MTX) and azathioprine (AZA) seem to be effective and safe as maintenance treatments in moderate-to-severe AD up to 5 years." (3) Shah et al. 2018 writes "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk." (4) There are several published studies that show that methotrexate is effective and safe for moderate-severe atopic dermatitis. (5-8) The evidence-based literature is consistent and in line with the plan's alternative drugs. There are no unique clinical circumstances to this particular individual that would make Dupixent medically necessary. The patient has no true contraindications to the use of the preferred medications. The preferred agents, such as methotrexate, are appropriate agents for the treatment of the patient's atopic dermatitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer.
Treatment: proton beam therapy.
The insurer denied proton beam therapy.
 The health plan's determination is upheld.

This is the case of a female patient who presented with cancer recurrence in the iliac nodes. The patient had recurrence in the vagina several years ago and was treated with surgery followed by adjuvant ART (adaptive radiation therapy).
The patient had metastatic disease in the lung and was treated with SBRT (stereotactic body radiation therapy). Now the patient has new pelvic sidewall recurrence. A recent computed tomography (CT) scan showed bilateral pulmonary metastasis.

The requested Outpatient Proton Radiation Treatment is not medically necessary for this patient.

Medically necessary treatment is defined as those which are in accordance with generally accepted treatment in the USA. Conventional palliative radiation treatment is in accordance with generally accepted treatment in USA. This patient has widespread metastatic disease in both lungs. Keeping in mind widespread metastatic disease, this patient can be treated with conventional palliative RT (radiation therapy) rather than Proton beam therapy. There are no published data to support Proton beam therapy is this patient's clinical scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cystic Fibrosis. 
Treatment: Trikafta. 

The insurer denied Trikafta. The health plan's determination is overturned. 

The patient has CF (cystic fibrosis), gastrointestinal (GI) issues related to CF and severe lung disease with CF exacerbations on beta agonists and ICS (inhaled corticosteroids). 

Trikafta 50-25-37.5 & 75 MG (milligrams) Oral Tablet Therapy Pack (elexacaftor-tezacaftor-ivacaftor and ivacaftor) is medically necessary for this patient. 
The Food and Drug Administration (FDA) approved Trikafta for patients above 6 years. Also, in clinical trials it showed that patients who received Trikafta had decreased frequency of CF exacerbations. In addition, the pulmonary functions were improved significantly after Trikafta. The Data also shows increased quality of life with Trikafta.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Open fracture to the distal phalanx right little finger.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This is the case of a male with no significant past medical history. He presented to the emergency room (ER) with complaints of right pinky pain from an injury 9 days prior to arrival. He was given intravenous (IV) antibiotics and IV pain medications. Imaging revealed an open fracture. The patient underwent an open reduction internal fixation (ORIF) of the right 5th finger. After surgery he was given IV antibiotics, IV pain medications, and IV fluids. He was discharged after a period of hemodynamic stability. 

The medical records document a diagnosis of an open fracture to the distal phalanx right little finger. The condition is not complex nor extensive. Simply stated the man sustained a crush injury to the tip of his right little finger 9 days ago. 

He underwent surgical management consisting of exploration, irrigation, and open reduction to the distal phalanx. The operation was 12 minutes. The blood loss was 2 cubic centimeters (cc). His post-surgical course was non complicated. 

There was no evidence of bleeding nor wound problems. His vital signs were stable. He was able to tolerate oral pain medication. He did not require additional imaging nor treatment for other medical conditions. These services could have been provided at a lower level of care. There were no extenuating circumstances to substantiate admission and length of stay.

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

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: Diabetes mellitus, hypertension and kidney disease. 
Treatment: Consumer Directed Personal Assistance Program (CDPAP); 12 hours per day, 7 days per week for a total of 84 hours per week. 

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP); 12 hours per day, 7 days per week for a total of 84 hours per week. 

The denial is overturned. 

This is an elderly female with chronic medical problems including diabetes mellitus, hypertension and kidney disease.  She lives in an assisted living center and the family is paying a private caregiver aide 4 hours/day. The patient currently has Consumer Directed Personal Assistant Program (CDPAP) of 8 hours per day, 7 days per week for a total of 56 hours per week.  Under review is the request for increase CDPAP; 12 hours per day, 7 days per week for a total of 84 hours per week. 

According to the Uniform Assessment System (UAS) report, the patient requires maximal assistance or totally dependent for bathing, lower body dressing and toilet use.  She is incontinent of bowel and bladder.  She requires extensive assistance for personal hygiene, upper body dressing and transferring on/off the toilet.  Her cognitive skills are described as "severely impaired" and have reportedly "declined."  The reports document the patient's functional and cognitive decline.  The combination of the patient's progressive dementia and continued functional decline support the requested CDPAP increase of 12 hours/day, 7 days/week for a total of 84 hours/week, as medically necessary.  The increased CDPAP will allow the patient to continue living safely at the assisted living facility. 

The healthcare did not plan acted reasonably, with sound medical judgment or in the best interest of the patient. 

From a physical medicine and rehabilitation perspective, the requested increased Consumer Directed Personal Assistance Program (CDPAP); 12 hours per day, 7 days per week for a total of 84 hours per week is considered medically necessary for this patient.   

The insurer's denial of coverage for Consumer Directed Personal Assistance Program (CDPAP); 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD).

Treatment: Current procedural terminology (CPT) code 43284 (surgery to place a device around the lower part of the esophagus - Linx Reflux Management System).

The insurer denied coverage for current procedural terminology (CPT) code 43284 (surgery to place a device around the lower part of the esophagus - Linx Reflux Management System).

The denial is overturned.

This case involves a male who was diagnosed with refractory gastroesophageal reflux disease. The patient was seen for persistent heartburn which had begun years prior. He had regurgitation intermittently. He reported sensations of food being stuck in his upper throat and slept on a wedge pillow. He had been diagnosed with lactose intolerance and had undergone pH (potential of hydrogen) testing. He had an acid exposure time of 14.7% with 67 reflux events mostly upright. He had normal esophageal motility. The provider was recommending Linx placement. The requested device was denied as experimental or investigational as medical studies have not shown that the device helped with gastroesophageal reflux disease. The treating provider wrote a correspondence stating that the FDA (food and drug administration) approved the device in 2012 as a premarket approved device. The provider wanted to offer the patient a minimally invasive treatment to restore the esophageal sphincter without major side effects. He had failed proton pump inhibitor medications in the past.

ACG (American College of Gastroenterology) Guidelines list Linx as acceptable option for failed medical therapy.

The FDA approved the device and it is cited in the ACG Guidelines.

He had an acid exposure time of 14.7% with 67 reflux events mostly upright. He had normal esophageal motility. These meet criteria for Linx,

He had an acid exposure time of 14.7% with 67 reflux events mostly upright. He had normal esophageal motility. These meet criteria for Linx,

All procedures carry risk.  The risks associated with Linx are no greater than alternative surgical options.

This patient has failed medical therapy and meets criteria for surgical options such as Linx.  The denial should be overturned.

The carrier's denial of current procedural terminology (CPT) code 43284 (surgery to place a device around the lower part of the esophagus - Linx Reflux Management System)  should be overturned.  It is more beneficial than any other standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD).

Treatment: Current procedural terminology (CPT) code 43284 (surgery to place a device around the lower part of the esophagus - Linx Reflux Management System).

The insurer denied coverage for current procedural terminology (CPT) code 43284 (surgery to place a device around the lower part of the esophagus - Linx Reflux Management System).

The denial is overturned.

The patient has chronic GERD and has also developed symptoms of dysphagia. He has been on PPI (proton pump inhibitor) therapy in the past. Esophageal pH (potential of hydrogen) testing showed increased acid exposure time in the esophagus and manometry testing was normal. The DeMeester score was 47.3. His physician has advised the Linx procedure.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the Linx Reflux Management System. With regards to safety, the conclusion was that long-term follow-up supports the FDA (food and drug administration) conclusion that the device is safe. With regards to efficacy there were several conclusions. The Linx implant results in pH normalization, improved quality of life, and cessation of regular PPI use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating GERD symptoms and dysphagia are similar following Linx. The long-term follow-up data demonstrates that the Linx Reflux Management System is effective in the management of GERD. 

The Linx procedure has been shown to be beneficial for patients with chronic GERD. It is supported in the peer-reviewed scientific literature. It has FDA approval. The patient is a good candidate since he has a long history of symptomatic GERD. There are several options for both surgical and endoscopic treatment of GERD, but Linx has been shown to be an effective treatment with a good safety profile. A minimally invasive procedure such as the Linx system is appropriate for patients with ongoing GERD symptoms who have not responded well to medical therapy, 

The denial is overturned.

The carrier's denial of current procedural terminology (CPT) code 43284 (surgery to place a device around the lower part of the esophagus - Linx Reflux Management System) should be overturned. It is more beneficial than any other standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia.
Treatment: Home health care./  Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift). 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift). 
The health plan's determination is upheld. 

The patient is a male with past medical history of Parkinson's, dementia, urinary incontinence, hyperlipidemia, benign prostatic hyperplasia (BPH), depression, diabetes mellitus type II, congestive heart failure (CHF), deep vein thrombosis (DVT), gastroesophageal reflux disease (GERD), osteoarthritis, history of sacral ulcer, macular degeneration, bladder cancer, and orthostatic hypotension who had been assigned PCA (personal care assistant) services 42 hours/week based on assessment performed assessing the patient at total assistance with task of managing finances while maximum assistance with tasks of meal preparation, ordinary housework, managing medication, shopping, and transportation. With tasks of phone use and stairs, the patient was assessed at extensive assistance while limited assistance with tasks of bathing, personal hygiene, walking, locomotion, transfer toilet, and toilet use. The patient was assessed as supervision with task of eating and independent with task of bed mobility.

Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift) is not medically necessary for this patient.
There is documentation of increased care needs when comparing the recent assessments as well as documentation of multiple hospitalizations in previous year with subsequent rehabilitation stay. The plan appropriately increased PCA services from 42 hours a week to 24 hours/day, live-in, 7 days/week following latest assessment. The documentation provided does not support the need for PCA services 24 hours/day, split-shift, 7 days/week as there is no documentation of overnight care needs. There is also no documentation of the need for turning and repositioning at least every 2 hours. In addition, there is no documentation of care needs that would not allow a PCA 5 hours of uninterrupted sleep. PCA services are not provided for safety and supervision or when tasks are not being performed. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services: 24 Hours per Day (Split Shift) is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inflammatory Arthritis
Treatment: Rinvoq 15mg, Pre-service
The insurer denied the Rinvoq 15mg, Pre-service
The denial is upheld.

This patient is a male with history of pain and stiffness in the back and neck and inflammatory bowel disease. The patient has previously tried and failed prednisone along with conventional disease modifying anti-rheumatic drug (DMARD) methotrexate. The patient has also tried and failed biologic DMARDs (disease-modifying anti-rheumatic drugs) Humira, Remicade and Entyvio.

The request for Rinvoq was initially denied coverage by the health plan due to the patient not having a diagnosis of rheumatoid arthritis, psoriatic arthritis or atopic dermatitis. The physician is appealing the determination.

No, the requested Rinvoq is not medically necessary.
Per the submitted records, there is no diagnosis specified, there is no past medical history specified, there is no musculoskeletal physical exam specified, there is no assessment and plan identified. The appeal letter only states that the patient has neck and back pain but does not specify any underlying specific diagnosis and does not specify the type of inflammatory bowel disease the patient has.

Rinvoq is Food and Drug Administration (FDA) approved for the treatment of rheumatoid arthritis, psoriatic arthritis or atopic dermatitis. Again there is no clinical note submitted to further define what the patient's underlying clinical diagnosis is. The appeal letter just states that the patient has back and neck pain, which is not identifiable as psoriatic arthritis, rheumatoid arthritis or atopic dermatitis. Therefore, there is not any clinical documentation to support that the patient would benefit from the use of Rinvoq. Therefore, the requested Rinvoq is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
At this time, without any further clinical information, it cannot be determined that the patient would have clinical benefit from the requested medication Rinvoq. Therefore, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Elevated Blood Pressure. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This case involves a female diagnosed with hypertension and hyperlipidemia.
The patient was seen in the emergency department regarding right-sided numbness.  There were reports of numbness on the right side of the face.  Discomfort was in the right posterior ear since the day prior and paresthesia to the right face was noticed.  There were reports that the right side was weaker than the left and she was unable to close the eye.  There was no extremity weakness, gait instability, speech difficulty, visual changes, trauma, fevers, chills, nausea, vomiting, chest pain, shortness of breath, abdominal pain, leg swelling, or calf pain.  Blood pressure was 209/111 and heart rate was 109 bpm (beats per minute).  Flattening of the right nasal labial fold was present.  The patient was able to raise the right eyebrow but was weaker than the left.  Weakness in the right oral and ocular muscles was noted.  There was tongue deviation on the left.  Computerized tomography (CT) was negative for cerebral vascular accident (CVA).  Computerized Tomography Angiography (CTA) of the head and neck was negative.  The patient was admitted for a cerebral vascular accident (CVA) assessment.  The patient was discharged after assessment.  

The patient had focal neurological signs and symptoms, with an extremely high blood pressure.  She was admitted for CVA management which would be following the standard of care, given the elevated blood pressure.  Therefore, the request is medically necessary, and the prior determination is overturned.  

The insurer's denial of coverage for the inpatient emergency admission is overturned.  Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Leg Pain. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 
	
The patient has chronic medical problems including hypertension, stroke with aphasia and hemiplegia.  He presented to the emergency room complaining of right leg pain and the inability to walk.  According to the ED (emergency department) note, "baseline residual from previous CVA (cerebral vascular accident), no recent injury, wife states he slipped out of chair yesterday."  He was admitted to the hospital, received intravenous/oral medications, clinical consultations and further diagnostic testing.  He was transferred to a skilled nursing facility the following day. 

The enclosed clinical information does not support a level of medical acuity or complexity that warranted acute inpatient hospital admission.  He was medically stable.  Clinical workup performed in the ED including physical examination, radiologic studies and laboratory blood studies did not demonstrate evidence of acute pathology. The patient's subsequent clinical work-up and consultations could have been performed while under observation in the ED and did not require hospital admission or subsequent 1 day length of stay. 

The insurer's denial of coverage for an inpatient admission upheld. Medical Necessity is not substantiated.