Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Menopause.
Treatment:  Femring (estradiol vaginal ring).

The insurer denied coverage for Femring (estradiol vaginal ring).  The denial is overturned.

The patient has a diagnosis of menopausal symptoms. According to the patient, they have tried Vivelle Patches and estradiol vaginal cream without relief of their symptoms. The patient has been using Femring with good relief of their symptoms.

The insurer has denied coverage for Femrring. In their Final Adverse Determination letter, they stated that the plan approved criteria may approve Femring when the patient is unable to take the required number of formulary alternatives for this given diagnosis due to an intolerance or contraindication. The patient may have tried and failed the required number of formulary alternatives. Formulary alternatives are estradiol vaginal cream, Imvexxy, and Vagifem. The requirement is trial of 3 in a class with 3 or more alternatives. The patient did not meet criteria for approval.  

The patient's Obstetrician-Gynecologist is appealing. The summary of the appeal stated that the patient has tried and failed Vivelle patches and estradiol vaginal cream. The patient did not experience relief of symptoms from these alternatives.

This patient is complaining of vasomotor symptoms. Femring is indicated to manage both vasomotor symptoms and vaginal atrophy. Note that the alternative products, estradiol vaginal cream, Imvexxy, and Vagifem are not indicated for management of vasomotor symptoms but only of vulvovaginal atrophy. In other words, the formulary drugs will not be effective in managing this patient's symptoms.
 
As such, the requested Femring is medically necessary.

The formulary drug(s) are unlikely to cause the patient an adverse reaction. 

The formulary drug(s) have not been ineffective based on the patient's clinical history. However, they are not indicated for the management of this patient's symptoms.

The requested drug will be more effective than the formulary drug.

The carrier's denial of a request for a Formulary Exception for Femring (estradiol vaginal ring) is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Abdominal pain/ fever.
Treatment:  Inpatient hospital.

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

The patient is a former premature infant who presented with abdominal pain and fever. She was in her usual state of health until 1 month prior to admission when she developed abdominal pain. The pain continued on and off, and on the day prior to presentation she developed a fever up to 102 F (Fahrenheit). Her abdominal pain had gotten progressively worse, and she presented to the emergency department. A computed tomography (CT) of the abdomen and ultrasound were done at that time. Her urinalysis showed greater than 50 white blood cells as well as 6-10 red blood cells. 

Inpatient Hospital Stay was medically necessary for this patient.

This is a young girl with a complex medical history who presented with probable pyelonephritis. She had been seen the day before and had been treated appropriately with antibiotics, however her symptoms continued to get worse. In fact, she was described as being in distress at the time of presentation with both abdominal pain and costovertebral angle tenderness. She was felt to have probable pyelonephritis, and therefore required hospital admission for prompt initiation of parenteral therapies along with intravenous fluids to maintain her hydration status.

Indications for hospitalization and/or parenteral therapy for children with pyelonephritis include a failure to respond to therapy. This patient received appropriate treatment in the emergency department and returned the following day with worsening symptoms including pain and costovertebral angle tenderness. Therefore, inpatient admission for parenteral therapy was warranted.

The decision making at the time of admission for this patient was consistent with her young age, the presence of presumed pyelonephritis with worsening symptoms despite appropriate treatment, and the need for ongoing intensive therapy along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Gastroenteritis.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This is an infant with sickle cell trait, who presented to the emergency department (ED) at with fever and 2-3 days of decreased oral intake, diarrhea, decreased urine output, and concern for appearing fatigued in the setting of adenovirus and rhinovirus.  The patient was seen at an urgent center and emergency department (ED) twice for similar complaints within 7 days, where he was given Intravenous Fluids (IVF) and famotidine followed by discharge. 
 
A Practice Parameter issued by the American Academy of Pediatrics pertaining to children aged 1 month to 5 years has recommended that children with acute gastroenteritis with mild to moderate dehydration be treated with oral rehydration.(1) While oral rehydration is preferred, in children who fail oral rehydration, administration of rehydration fluids intravenously is effective and should be recommended.(2)  According to 2014 guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include shock, severe dehydration, neurological abnormalities (lethargy, seizures, etc.), intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition.(3) 

A publication from the Morbidity and Mortality Weekly Report (MMWR) states that regarding the management of acute gastroenteritis in children:
 
"Inpatient care is indicated for children if caregivers cannot provide adequate care at home; substantial difficulties exist in administrating oral rehydration therapy (ORT), including intractable vomiting, oral rehydration solutions (ORS) refusal, or inadequate ORS intake concern exists for other possible illnesses complicating the clinical course;
ORS treatment fails, including worsening diarrhea or dehydration despite adequate volumes; severe dehydration (>9% of body weight) exists; social or logistical concerns exist that might prevent return evaluation, if necessary, or such factors as young age, unusual irritability or drowsiness, progressive course of symptoms, or uncertainty of diagnosis exist that might indicate a need for close observation."(4)
 
In the case of this child, as per the indication above (refusal to take fluids in the setting of mild dehydration and ongoing losses (diarrhea), inpatient care for ongoing administration of Intravenous Fluids (IVF) and monitoring was warranted. In addition, this is a unique circumstance where the patient was seen by multiple other Emergency Departments, received Intravenous Fluids (IVF) and continued to bounce back with similar symptoms signifying failure of outpatient management. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Inpatient Admission is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease
Treatment: LINX procedure
The insurer denied the LINX procedure.
The health plan's determination is upheld. 

The patient is a male who has a body mass index (BMI) of 35.18 kilograms per meters squared (kg/m2) with history of gastroesophageal reflux disease (GERD) despite daily proton pump inhibitors (PPI's). The esophagogastroduodenoscopy (EGD) from 2019 revealed a 3 centimeter (cm) hiatal hernia, Hill grade 3 valve. The 24 hour potential hydrogen (pH) study revealed an elevated DeMeester score consistent with GERD. The Manometry from 2019 was normal. The patient was initially interested in anti-reflux surgery in 2019 which was delayed secondary to Coronavirus (COVID).

The proposed health service or treatment LINX procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Although LINX is a standard treatment for GERD in patients who are refractory or do not want to continue with medical treatment. There are a few exclusions to treatment which include elevated BMI of 35 kg/m2 or greater, given the overall higher surgical failure rates which are higher with class 2 obesity. LINX has not been studied in any prospective or high level trial in patients with morbid obesity or class 2 obesity. Consideration of medical or surgical weight loss should be considered for patients with significant GERD and concomitant obesity.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease
Treatment: LINX procedure
The insurer denied the LINX procedure.
The health plan's determination is overturned. 

The patient is a male who has refractory gastroesophageal reflux disease (GERD). The esophagogastroduodenoscopy (EGD) showed erosive esophagitis and a 3 centimeter (cm) hiatal hernia. The patient had a Demeester score of 23.7 and the Manometry was normal.

The proposed health service or treatment LINX procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This patient has GERD according to the bravo study and also has a moderate size hiatal hernia. The patient is a candidate for LINX.

As per Society of American Gastrointestinal and Endoscopic Surgeons (SAGES):
Conclusions:
Longer-term (3-5 years) experience with the LINX Reflux Management System confirms the initial safety profile that led to FDA approval of the device. The LINX device has been demonstrated to result in long-term GERD control based on symptomatic outcomes, PPI utilization, and potential hydrogen (pH) studies.
The LINX is a reasonable treatment option for appropriately selected patients with GERD who meet indications for antireflux surgery. The LINX procedure is part of the armamentarium in the treatment of GERD. As such, it should be performed by surgeons familiar with the workup and different management alternatives of GERD and not offered in isolation. Implantation of the LINX device should be covered and reimbursed by insurance for appropriate patients who meet the selection criteria as described above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Nephrotic syndrome.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This patient is a child, who presented with generalized edema and was diagnosed with nephrotic syndrome (NS). She presented to the Emergency Room (ER) with neck, and bilateral lower extremity swelling, odynophagia, abdominal distention, arthralgias, joint swelling, and anasarca. Labs were significant for nephrotic syndrome. Imaging revealed echogenicity of the bilateral kidneys. The patient was given an albumin infusion, a Lasix infusion, solumedrol, and famotidine. She was admitted and received albumin and Lasix with excellent diuresis and improvement in the swelling. She was hemodynamically stable during the course of her admission.

This patient presented with generalized edema and was diagnosed with nephrotic syndrome. She had neck, and bilateral lower extremity swelling, odynophagia, abdominal distention, arthralgias, joint swelling, and anasarca. The patient was given an albumin infusion, a Lasix infusion, solumedrol, and famotidine. She required intravenous albumin infusion to optimize diuresis in the management of her fluid overload which would be difficult to accomplish with other than an inpatient admission. The hospital admission for managing fluid overload and managing this patient with painful swallowing and generalized edema was warranted.

"Our findings support previous published reports that childhood NS is a disease of high morbidity and results in significant healthcare burden. The median hospitalization rate of our cohort was high at 0.50 hospitalization per patient year, and the majority of patients were hospitalized at least once (71%). On average, hospitalizations lasted approximately 4 days. Serious complications occurred in 14% of the patients in the first 3 years of follow-up. These results suggest that each NS patient has the potential to contribute significant burden to the healthcare system." (Wang et al., 2017). 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke, Diabetes, Coronary Artery Disease

Treatment: Home care / personal care home health care (HHC) - level 2 personal care services, per 15 minutes increase to 56 hours per week

The insurer denied coverage for home care / personal care home health care (HHC) - level 2 personal care services, per 15 minutes increase to 56 hours per week

The denial is upheld 

This is a patient with chronic medical problems including heart disease, stroke, diabetes and osteoarthritis.  The patient lives with their spouse in a private residence.  Under review are the denied home care / personal care home health care (HHC) - level 2 personal care services, per 15 minutes increase from 35 hours per week to 56 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's cognitive skills are described as minimally impaired.  The patient is reportedly totally dependent for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires extensive assistance for bathing, personal hygiene, dressing, locomotion, toilet transfer/use and ambulation (ambulates with a cane).  Limited assistance is reportedly needed for bed mobility and eating.  The patient is reportedly frequently incontinent of bladder and continent of bowel.  The patient's activities of daily living (ADL) status and self-sufficiency has reportedly declined over the prior 90 days.  However, the patient's cognitive status and functional ability have not significantly changed when compared to the most recent UAS report.  There have been no reported falls over the prior 90 days.  

The patient's condition and functional deficits are not at a level or unpredictable as to require the requested increase PCS 56 hours/week.  This physician would agree the patient may benefit from monitoring for safety; particularly due to the patient's decreased mobility and falls risk. Consumer Directed Personal Assistance Services (CDPAS) for companion care or safety supervision without the direct provision of ADL task assistance is not a covered service.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by home care / personal care HHC - level 2 personal care services (PCS), per 15 minutes 35 hours per week and shared responsibility of other adult living in the home.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 56 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: anterior cruciate ligament tear
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a young girl with left knee anterior cruciate ligament (ACL) and lateral meniscus tears, and left genu valgum. She is morbidly obese. She underwent arthroscopic ACL reconstruction, treatment of the meniscal tear, and osteotomy of the left distal femur. She was admitted to the hospital, received analgesia from a patient-controlled analgesia (PCA) device, and carried out physical therapy focusing on ambulation and safe transfers. She received injections of Lovenox for thromboprophylaxis.

The inpatient hospital admission was medically necessary. The patient underwent ACL (anterior cruciate ligament) reconstruction with bone-patella tendon-bone autograft, and repair of the medial meniscus. If this were the only surgery she had undergone, outpatient treatment may have been reasonable. However, she also underwent an osteotomy of the distal femur through a medial approach, which required additional dissection and surgical time, and resulted in additional pain, bleeding, and risk of complications. The patient's morbid obesity also made it likely that post-operative mobilization would be difficult. Under these circumstances, inpatient hospital admission would be justified in order to control pain, encourage mobilization, and monitor neurovascular status. An Inpatient hospital admission is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left lower limb cellulitis. 
Treatment: Continued Stay in a Skilled Nursing Facility, Level 2. 
The insurer denied Continued Stay in a Skilled Nursing Facility, Level 2. 
The denial is upheld. 

This adult female patient was admitted to a skilled nursing facility (SNF) level of care with left lower limb cellulitis. Her stay was approved for approximately 2 months. From that time forward, the patient was hemodynamically stable. She was tolerating diet. An oral medication regimen had been established. The patient's left foot, grade 2 diabetic ulcer, was healing without complications. It was being cleansed daily and as needed. Her current level of functioning was minimal assistance with standing and lower body dressing, set up with bed mobility, standby assistance with transfers and bed mobility, contact guard assistance with ambulation and upper body dressing, and supervision with toileting and personal hygiene. 

The proposed treatment is not medically necessary. 

A skilled nursing facility level of care is indicated when the patient requires skilled nursing services or skilled rehabilitation services, and the patient requires these skilled services on a daily basis, and it is practical for daily skilled services to provided only on an inpatient basis in a skilled nursing facility; and the services are reasonable and necessary for the treatment of the patient's illness or injury. 
This patient was admitted for ongoing management of cellulitis and therapy. As of the dates of service under review, the patient was medically stable. The foot wound was healing and did not require complicated wound care. The patient's current level of functioning shows that she needs minimal assistance with transfers and lower body dressing. Otherwise, she can function without assistance. Based on this patient's medical stability and functioning, it is not necessary that the patient continue to 
receive daily skilled services that can only be provided at an inpatient skilled nursing facility level of care. Continued stay in a skilled nursing facility, dates of service under review, is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Basivertebral nerve ablation
The insurer denied basivertebal nerve ablation. The health plan's determination is upheld. 

The patient is a female with complaints of low back pain. The pain began over 3 years ago. Prior treatments have included acupuncture, chiropractic care, low back injections, medications, as well as physical therapy. Pain ranges from 6-9 out of 10. Pain impacts activities of daily living (ADL). Magnetic resonance imaging (MRI) lumbar spine reported Modic type II changes at disc spaces L (lumbar)4-L5 and L5-S (sacral) 1.

The proposed Thermal Destruction of intraosseous Basi-vertebral nerve (Intracept) 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 patient has complaints of low back pain. This procedure is not recommended despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Back pain
Treatment: Basivertebral nerve ablation
The insurer denied basivertebal nerve ablation. The health plan's determination is upheld. 

This is a patient who is diagnosed with low back pain. Records note that the patient was recommended to undergo the Intracept procedure, which was denied by the health plan.
The provider noted the patient has a history of low back pain that began over 3 years ago. The patient has tried multiple treatments including acupuncture, chiropractic care, facet injections, home exercises, lumbar epidural steroid injections, medication management and physical therapy. Medications tried include CBD (cannabidiol) and non-steroidal anti-inflammatory drugs (NSAIDs). 

Intraosseous Basivertebral Nerve Ablation Procedure 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 patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes. It should be noted however that the magnetic resonance imaging (MRI) did not mention any degenerative endplate changes or Modic changes. There is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy.