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

Diagnosis: Cervical Dystonia.
Treatment: Xeomin.

The insurer denied Xeomin.  The determination is upheld.

The patient has a history of cervical dystonia that is treated with Xeomin. A review of multiple notes indicates treatment on a more frequent basis than every 12 weeks on a lower dose due to wearing off towards the end of the treatment cycle. Most recently the patient presented for repeat Xeomin injections for cervical dystonia, and could no longer undergo treatment every eight weeks. He lost 40 pounds in the previous few months. He had a moderate dystonic head tremor worse with attempted head movements. He received Botox 600 units at that time.

A letter of medical necessity from the provider indicates that Xeomin was cheaper and was more cost-effective than any other type of botulinum toxin (ARB) and would contribute to cost savings. The provider did not document any differences in efficacy between Xeomin another preparations of the botulinum toxin preparations. The reason for denial on prior review was that no treatment plan was provided. A pharmacy review & recommendation indicated that Xeomin dosing was up to a maximum cumulative dose of 400 units per session. At issue is whether Xeomin 600 units is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Xeomin 600 units is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The standard treatment for cervical dystonia with Xeomin allows for the provision of up to 400 units every 12 weeks, based on a response at lower doses. There is no evidence an the peer-reviewed medical literature that Xeomin at a dose of 600 units every 12 weeks is more beneficial in the treatment of cervical dystonia than Xeomin at a dose of 400 units or below. There is also a greater chance of botulinum toxicity associated with these doses. Therefore, use of Xeomin 600 units is not more beneficial than dosing of up to 400 units.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dysphagia, Continuous positive airway pressure (CPAP) use at day, Mechanical ventilator use at night, Stage 4 sacral pressure ulcer.
Treatment: Continued Skilled Nursing Facility Services.
The insurer denied coverage for continued Skilled Nursing Facility Services.
The denial is overturned. 

This is a female patient with multiple medical problems including hypertension, diabetes mellitus, and dysphagia.  She was admitted to a Skilled Nursing Facility (SNF) and her treatment included nursing care, pulmonary specialist consultation, physical, occupational and respiratory therapies.  Under review is the medical necessity for continued Skilled Nursing Facility (SNF) services for the time period under review. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the patient has the medical acuity level and requires ongoing skilled nursing care that supports continued Skilled Nursing Facility (SNF) services for the time period under review.(1, 2, 3)  The patient has multiple current clinical issues that require physician and nursing care, which are at least at the Skilled Nursing Facility (SNF) level of care.  She has a Percutaneous Endoscopic Gastrostomy (PEG) tube, uses continuous positive airway pressure (CPAP) during the day and is mechanical ventilator dependent at night.  She also has a stage 4 sacral pressure ulcer.  During the time period under review, the treating physicians were in the process of weaning the patient from the mechanical ventilator at night, which further supports the medical necessity of continued Skilled Nursing Facility (SNF) services for the time period under review.

The healthcare plan has not acted reasonably, with sound medical judgment or in the best interest of the patient, Skilled Nursing Facility (SNF) services for the time period under review was medically necessary. 

The carrier's denial of coverage for continued Skilled Nursing Facility Services is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a woman with a history of hypertension, autoimmune hepatitis and breast cancer status post lumpectomy, who was admitted to the hospital with severe dizziness and nausea that started a few hours prior to arrival in the emergency department. She was sitting in front of a computer and suddenly started feeling dizzy, as if the room was spinning around her. She attempted to stand up but was unable to do so. She also reported nasal congestion recently but denied fevers, chills, ear pain, and tinnitus. Vital signs showed blood pressure 150/68, heart rate 68, temperature 98.4 Fahrenheit, and respiratory rate 19. On physical exam, heart was regular, breath sounds were normal, abdomen was soft, and no cranial nerve deficit was reported. Nose to finger test was normal but she was unable to walk. Labs showed white blood cell (WBC) 5.9, hemoglobin 15, platelets 141, creatinine 0.6, potassium 3.8, alanine aminotransferase (ALT) 400, and aspartate aminotransferase (AST) 409. Chest x-ray was performed and showed no acute abnormalities. The patient was admitted for dizziness likely secondary to the vestibular neuropathy status post viral infection. 

The inpatient hospital admission was medically necessary. The patient required treatment for vertigo and evaluation of non-sustained ventricular tachycardia. She also had a brain MRI as recommended by neurology and treatment with intravenous (IV) Reglan and meclizine. Non-sustained ventricular tachycardia can lead to cardiac arrest and death, and cardiology requested transfer for a cardiac electrophysiology procedure at an outside hospital. The overall acuity was appropriate for the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems-Braces.
Treatment:  Braces and Monthly Visits x 12 (Pre-Service). 
The insurer denied braces and monthly visits x 12 (Pre-Service). 
 The denial is overturned.

The patient is a female presenting with a skeletal Class I malocclusion. She has maxillary crowding and mandibular spacing. She is missing teeth numbers 19 and 30. She has an anterior open bite. She is treatment planned for orthodontics to address the crowding and open bite, but the treatment was denied due to lack of medical necessity.

The health plan's determination is overturned.

The requested treatment is medically necessary. Anterior open bite patients are among the most difficult patients to treat.(1) One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. Therefore, orthodontic treatment is medically necessary for this patient, due to the side effect described above and the fact that this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac Circulatory-varicose veins.
Treatment: Surgical Services. 
The insurer denied ablation of right and left great saphenous veins. The denial is overturned. 

The patient is a female who presented with bilateral lower extremity symptomatic varicose veins. Her main symptoms include cramping and swelling. Her symptoms are reported to interfere with her activities of daily living. The patient has attempted and failed conservative therapy with graded compression stockings. Her duplex scan demonstrates reflux in her bilateral great saphenous veins. Her provider is recommending endovenous ablation of her bilateral great saphenous veins for treatment of her condition. 

The health plan's determination is overturned. 

Bilateral great saphenous vein ablation is medically necessary for this patient based on the peer reviewed literature and the current standard of care in the vascular surgery community. 

Endovenous ablation of the bilateral great saphenous veins is the current standard of care treatment for patients with symptomatic varicose veins and saphenous vein reflux. The most recent consensus guidelines for the Society for Vascular Surgery and the American Venous Forum support endovenous thermal ablation for this patient based on her clinical presentation. Endovenous ablation is supported by the peer reviewed literature including level 1 randomized evidence. Several current peer reviewed papers support the use of endovenous thermal ablation for patients with symptomatic varicose veins with excellent results. 

Hamann and colleagues demonstrated excellent results with thermal ablation (radiofrequency and laser) in patients with symptomatic varicose veins. They wrote that the current treatment strategy for many patients with varicose veins is endovenous thermal ablation. The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). However, at present there is no clear consensus on which of these treatments is superior. The objective of this study was to compare EVLA with two forms of RFA: direct RFA (dRFA; radiofrequency-induced thermotherapy) and indirect RFA (iRFA); VNUS ClosureFast(TM). Patients with symptomatic great saphenous vein (GSV) incompetence were randomized to receive EVLA, dRFA or iRFA. Patients were followed up at 2 weeks, 6 and 12 months. The primary outcome was GSV occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score and adverse events. Some 450 patients received the allocated treatment (EVLA, 148; dRFA, 152; iRFA, 150). The intention-to-treat analysis showed occlusion rates of 750 (95 per cent confidence interval [c.i.] 680 to 820), 599 (521 to 677) and 813 (751 to 876) per cent respectively after 1 year.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obsessive compulsive disorder.
Treatment: Transcranial magnetic stimulation.

The insurer denied transcranial magnetic stimulation.  The denial is overturned in whole.

The patient is a male with obsessive compulsive disorder (OCD) associated with severe symptoms and impaired functioning. Symptoms include intrusive thoughts, rituals focusing on clear communication and excessive time with efforts to address obsessive thoughts. The symptoms of obsessive-compulsive disorder (OCD) are severe and longstanding with a Yale-brown Obsessive-Compulsive Scale (YBOCS) score of 35. The patient's clinician has recommended treatment with repetitive transcranial magnetic stimulation (rTMS) therapy with a clinically appropriate number of sessions in order to address the patient's OCD.

The health plan's determination is overturned.

The requested benefit of Repetitive Transcranial Magnetic Stimulation (rTMS) to address OCD and anxiety is reasonable, clinically appropriate, medically necessary, and in the patient's best interest. The requested TMS service is backed by credible scientific study and is consistent with prevailing standards of medical practice for the condition under treatment in this case, treatment refractory OCD.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Areata

Treatment: Xeljanz Tofacitinib Tablets (TAB) 10 milligrams (mg)

The insurer denied coverage for Xeljanz TAB 10mg

The denial is upheld 

The patient is a male with a diagnosis of alopecia areata. According to the appeal letter, the patient has had a positive response to Xeljanz with a request for continuation of Xeljanz oral therapy. According to the appeal letter, the patient has failed therapy with topical, intralesional, and oral steroids. No documentation is provided to demonstrate which steroid or non-steroid medications the patient has previously tried, what dose, and the results of these treatments. Similarly, no medical documentation is provided regarding the length of time the patient has been treated with Xeljanz.  

The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, 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 per day (BID).(1)  

The standard of care for treatment of alopecia areata would necessitate an attempt to use the above mentioned non-systemic options for the treatment of alopecia areata. The patient has not failed or shown to have a contraindication to numerous non-systemic therapies known to possible improve alopecia areata, including light therapy, squaric acid, DPCP, and anthralin.(9-11) As a result, Xeljanz is not medically necessary for the patient's condition, alopecia areata.  

The healthcare plan acted reasonably and with sound medical judgment and in the best interests of the patient. 

The insurer's denial of coverage for Xeljanz TAB 10mg is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure (CHF). 

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. 

The denial is overturned. 

This is a male patient with a history of atrial fibrillation (AF), hypertension, obstructive sleep apnea (OSA) and morbid obesity who presented to the hospital for an elective right and left heart catheterization following complaints of dyspnea at rest and lightheadedness. Attempts to titrate medication as an outpatient did not result in resolution of symptoms. Echocardiography performed several days earlier revealed biatrial dilatation with severe pulmonary hypertension and severe tricuspid valve regurgitation and moderate mitral regurgitation with preserved left ventricular (LV) systolic function. Electrocardiogram (EKG) revealed atrial fibrillation (AF) and with a controlled ventricular rate. On physical exam the patient was morbidly obese without other reported abnormalities. 

Right and left heart catheterization were performed and revealed a low cardiac output with severe pulmonary hypertension and elevated pulmonary capillary wedge pressure (PCWP). 50-60% Left anterior descending artery (LAD) coronary artery disease was also noted. Serum blood testing revealed an elevated B-type natriuretic peptide (BNP) of 150. The patient was treated with intravenous (IV) diuretics. The patient was admitted for treatment with IV diuretics and was discharged after losing almost 8 kilograms (kg).

This patient presented to the cardiac catheterization lab with acute chronic systolic Congestive Heart Failure (CHF). Findings on echocardiography were consistent with right and left sided systolic CHF. He required aggressive diuresis and monitoring given his low cardiac output and severe pulmonary hypertension. He required treatment with IV diuretic agents. Hospital observation during the transition from IV to oral diuretics is critical for managing patients with CHF. (Reference 1) Careful monitoring of blood pressure, renal function and serum potassium levels are required during such treatment. (Reference 1) The American College of Cardiology (ACC)/ American Heart Association (AHA) guidelines recommend transition to oral diuretic therapy and other guideline directed medical therapy while still in the inpatient setting. (Reference 2) 

In conclusion, inpatient hospital admission was medically necessary. This patient could not have been managed at a lower level of care and required inpatient care. The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient.

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

Diagnosis: Musculoskeletal/Orthopedic 
Treatment: Inpatient Hospital 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a history of severe right hip osteoarthritis and hip pain who failed attempts at conservative treatment. He underwent elective right total hip replacement surgery. The patient progressed well with supervised physical therapy and was deemed stable for discharge. The inpatient hospital admission was denied by the patient's health plan. At issue in this case is the medical necessity of the inpatient hospital stay.

The health plan's determination is upheld in whole.

The requested health inpatient stay was not medically necessary for this patient.

This determination is based upon the provided medical records from the case and the recommendations of the current, peer-reviewed orthopedic literature. This patient underwent elective total hip replacement, which was successful with no documented complications. The patient had a history of Paget's disease and had a slight drop in hemoglobin down to 12.2 the day after surgery and then 11.7 the following day. The patient, however, had normal vital signs and did not require a blood transfusion. His heart rate was well controlled after the administration of Lopressor. Therefore, based upon the documentation in the records, the medical necessity of the inpatient stay is not established.

The current, peer-reviewed literature has established the safety and efficacy of short stay as well as outpatient total hip and total knee replacement surgery. A recent article published by Leroux and colleagues in the Journal of Bone and Joint Surgery in 2020 concluded that "Patients undergoing short-stay total hip arthroplasty (THA) or total knee arthroplasty (TKA) with a discharge home were more likely to be younger, healthy, male patients from a higher socioeconomic status. Higher-volume surgeons are also more likely to perform short-stay THA or TKA. These characteristics confirm the previously held belief that a selection bias exists when comparing cohorts based on time to discharge. When comparing matched cohorts of patients who underwent short-stay and longer-stay THA or TKA, we observed no difference in outcomes, suggesting that a short stay with a discharge home in the appropriately selected patient is safe following THA or TKA."

The medical necessity of the inpatient stay in this case is not supported. The patient could have been appropriately managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Occlusion
Treatment: Braces And Monthly Visits, Pre-service
The insurer denied the braces and monthly visits, pre-service
The denial is upheld. 

The patient is a female requesting orthodontic benefits. She is appealing the denial herself. The patient thinks her "overbite" warrants orthodontic benefits. She has a Class I occlusion at both molars and canines.

No, the braces and monthly visits are not medically necessary.

The patient has a Class I occlusion. She does not come close to the 26-point threshold needed on the Salzmann index for benefits. She does not have a severely handicapping malocclusion. There is no medical necessity in this case. The patient's objections are for cosmetic issues.

Based upon documentation provided, this patient does not have a malocclusion that is in severe need of being orthodontically corrected. The patient's case does not rise to the level of medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ductal carcinoma in situ (DCIS) of the right breast

Treatment: Outpatient service - genetic testing

The insurer denied coverage for outpatient service - genetic testing

The denial is upheld 

This patient has a history of ductal carcinoma in situ (DCIS) and a family history of colon cancer. The treating provider performed genetic testing, which is the topic of this review.

The outpatient service, genetic testing is not considered medically necessary for this patient.  This patient does not meet accepted criteria for hereditary breast/ovarian cancer screening with a personal history of DCIS.  Appropriate criteria for BRCA 1/2 [BRCA1 (BReast CAncer gene 1) and BRCA2 (BReast CAncer gene 2)]testing (hereditary breast cancer and ovarian cancer screening) include a personal diagnosis of breast cancer under the age of 45, a personal history of breast cancer at any age with family history of breast cancer, or ovarian cancer/prostate cancer/pancreatic cancer.  A personal history of DCIS with a family history of colon cancer does not meet accepted criteria for genetic testing.  No genetic testing was needed to effectively manage this individual.

"The USPSTF [United States Preventative Services Task Force] recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with BRCA1/2 gene mutations with an appropriate brief familial risk assessment tool.  Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. (B recommendation) The USPSTF recommends against routine risk assessment, genetic counseling, or genetic testing for women whose personal or family history or ancestry is not associated with potentially harmful BRCA1/2 gene mutations. (D recommendation)."(USPSTF 2019).

"Individuals are considered to be candidates for cancer risk assessment if they have a personal and/or family history (on the maternal or paternal side) or clinical characteristics with features suggestive of hereditary cancer.  These features vary by type of cancer and specific hereditary syndrome. Criteria have been published to help identify individuals who may benefit from genetic counseling." (PDQ [Physician Data Query] Cancer Genetics Editorial Board, 2021).       

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

The insurer's denial of coverage for outpatient service- genetic testing is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Digestive System
Inpatient hospital

Diagnosis: abdominal pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a woman who was admitted to the hospital. She had a history of hypothyroidism and gallstones and she presented with right upper quadrant pain for the past two days. She stated that her pain had been worsening. She denied nausea, vomiting or diarrhea. She was diagnosed with gallstones but had not yet scheduled her surgery due to insurance delays. She denied fevers, chills, dizziness and chest pain. Vitals showed temperature 38.7 Celsius, Blood pressure 170/81, heart rate 99, Glucose 143, sodium 140, potassium 4.1, and creatinine 0.7. On physical exam, heart was regular, breath sounds were normal, and the abdomen was soft and tender in the right upper quadrant. Skin was warm and dry. Labs showed white blood cell (WBC) 11.9, aspartate aminotransferase (AST) 60, and alanine aminotransferase (ALT) 41. The patient was admitted for biliary colic versus acute cholecystitis. The plan of care included pain management, surgery consult, right upper quadrant ultrasound, trend liver enzymes, complete blood count, and intravenous (IV) fluids. 

The inpatient hospital admission was medically necessary. The patient was being managed for suspected acute cholecystitis and subsequently for acute pulmonary embolus with evidence of hypoxia. She required prompt consultation with surgery and cardiology. In addition, she was at increased risk for developing hemodynamic instability in the setting of acute pulmonary embolus. The inpatient hospital admission was medically necessary for a patient with this degree of complexity.