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

Diagnosis: Osteomyelitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male who has a past medical history of pancreatic cancer, coronary artery disease (CAD) with stent, diabetes mellitus (DM), pulmonary embolism (PE), hypertension (HTN), and status/post (s/p) partial Right 1st and 2nd toe amputation. The patient was seen by his podiatrist for a follow up visit and the podiatrist noted a right 3rd toe with probe to the bone and was concerned about osteomyelitis and was referred to the emergency room (ER). 

The inpatient hospital admission is not medically necessary for this patient. The patient is a male who was scheduled for elective partial 3rd ray resection with little concern for residual infection. The patient was discharged the same day as the procedure. There was no clinical basis for delay of scheduled procedure and no acute facility setting needs before or after scheduled procedure. This patient could have been treated safely and successfully at a lower level of care. Thus, the requested inpatient hospital admission is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: LINX procedure
The health plan denied: LINX procedure.
The determination is: Overturned

The patient is a female who has moderate size hiatal hernia and no Barrett's esophagus. A Bravo study showed a DeMeester score of 20. At issue is whether the proposed health service or treatment LINX reflux management system is likely to be more beneficial than any standard treatment for the patient's condition.
The health plan's determination regarding the proposed health service or treatment is overturned in whole.
The LINX reflux management system is likely to be more beneficial than any standard treatment for the patient's condition.
This patient has gastroesophageal reflux disease (GERD), as per the Bravo study, and she also has a moderate size hiatal hernia. The patient is a great candidate for LINX.
As per Society of American Gastrointestinal and Endoscopic Surgeons (SAGES):
Longer-term (3-5 years) experience with the LINX Reflux Management System confirms the initial safety profile that led to Food and Drug Administration (FDA) approval of the device. The LINX device has been demonstrated to result in long-term GERD control based on symptomatic outcomes, proton pump inhibitor (PPI) utilization, and potential hydrogen (pH) studies. 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: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: LINX procedure
The health plan denied: LINX procedure.
The determination is: Overturned

The patient is a female with a body mass index (BMI) of 30, history of hiatal hernia, and gastroesophageal reflux disease (GERD) despite medication use. The patient had a normal esophageal manometry. A 24-hour potential hydrogen (pH) study documented an elevated DeMeester score consistent with GERD. An esophagogastroduodenoscopy (EGD) did not reveal a large hiatal hernia or evidence of Barrett's esophagus.
At issue is whether the proposed health service or treatment LINX reflux management system is likely to be more beneficial than any standard treatment for the patient's condition.
The health plan's determination regarding the proposed health treatment is overturned in whole.
The LINX reflux management system is likely to be more beneficial than any standard treatment. This patient has GERD (gastroesophageal reflux disease) refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The exclusions to LINX and Nissen fundoplication include BMI greater than 35, in which case treatment of obesity is thought to be important for treatment of GERD. Other exclusions for LINX include Barrett's esophagus with dysplasia, age less than 18, and prior gastric or bariatric surgery. This patient does not document any contraindication to LINX treatment. The requested treatment is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient presented with vomiting and diarrhea. She had a past history of C and S deficiency (C &amp; S are the names of proteins) and was on anticoagulation. She was on Levaquin for a sinus infection. A rectal swab was positive for Moraxella catarrhalis and she was prescribed doxycycline. The abdominal exam was benign. Stool testing was ordered. Intravenous (IV) hydration and Zofran were given. A computed tomography (CT) scan showed a large fibroid. She was then able to tolerate a diet and left the hospital against medical advice (AMA). 

Clinical indications for admission for Gastroenteritis per Milliman Care Guidelines (MCG M-170) include having a suspected severe infection, peritoneal signs, hemodynamic Instability, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had vomiting and diarrhea and appeared to have a gastroenteritis. IV hydration, antiemetics, and stool cultures could all have been done in the emergency room (ER) with observation status. She responded well to the treatment and was then able to tolerate a diet. She did not meet MCG criteria for admission for Gastroenteritis. 

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: possible meningitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
Patient is an adult with past medical history significant for asthma and marijuana abuse who presented to the emergency department with complaints of fever, sore throat, chill, and head/neck pain. 

Vitals on presentation included: Temperature. 98.6 degrees Fahrenheit, Blood Pressure-150/95, Pulse-94, Respirations-17, oxygen (O2) saturation-96% on room air. Laboratory results included the following: White blood cells (WBC)-33.6, Hemoglobin-15.9, Hematocrit-46.6, creatinine-0.69, glucose-96.

Patient was started empirically on intravenous (IV) antibiotics (vancomycin and ceftriaxone) for possible meningitis. A lumbar puncture procedure was performed; results were not consistent with bacterial meningitis. Head computed tomography (CT) scan showed changes suggestive of mastoiditis or sinusitis. Infectious Diseases consulted; antibiotics were switched to acyclovir. Patient remained afebrile and hemodynamically stable; signed out against medical advice. 

According to documentation, patient presented with severe head and neck aches.  Otherwise, he was afebrile and hemodynamically stable. Laboratory results only showed a non-specific elevation of WBC (White blood cells). Patient had no evidence for a systemic infection, was able to tolerate intake, and no significant co-morbid conditions. Based on above findings, patient met criteria for observation level of care, he did not fulfill criteria for acute inpatient hospitalization.   

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 the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary embolus
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

Patient is an adult female with a history of Migraine who presented to the emergency department (ED) with cough of 3 weeks duration and some pleuritic type of Chest pain.
The patient had been seen by her primary care physician for her cough in the previous weeks and had received courses of Antibiotics and steroids for possible pneumonia (PNA). When she did not improve with treatment she came to ED (emergency department) complaining of productive greenish sputum. She denied fever, chills shortness of breath and hemoptysis.

Vital signs at presentation were: Temperature 98.9 degrees F, heart rate 77, respirations 20 and blood pressure 123/68. Oxygen saturation was 100% on room air. The patient was in no apparent distress (NAD). Physical exam was unremarkable, lungs were clear, Heart sounds normal. She was alert and oriented with an unremarkable neurological examination.

Labs: white blood cell (WBC) count 10.3, hemoglobin (Hgb) 11.7, electrolytes, blood urea nitrogen (BUN) and creatinine (Cr) all within normal limits. Troponin was normal and D-Dimer elevated at 1.56. Chest X-ray (CXR) showed no acute infiltrates. Computed tomography angiogram (CTA) revealed a right lower lobe (RLL) pulmonary embolism (PE). There was no evidence of Right Heart Strain. Deep venous thrombosis (DVT) study was negative.

The patient was admitted to hospital for PE (pulmonary embolism) and started on Lovenox. She remained stable after admission and was switched to oral Apixaban prior to discharge home.

This patient did not need acute inpatient hospitalization and could have been placed in observation status while diagnostic testing and treatment were initiated. She was afebrile and hemodynamically stable tolerating oral food and fluids. 

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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Leakage of bloody fluid.
Treatment:  Inpatient admission.

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

The patient presented to labor and delivery complaining of leakage of bloody fluid. Evaluation was consistent with a missed abortion at 15 weeks. The patient delivered spontaneously. She was admitted for management. However, because of retained placenta she underwent a Dilatation and Curettage (D and C). 

Dilatation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration or sharp curettage. Admission to an acute level of care is not customary or medically necessary. There was no clinical reason submitted why the patient was admitted. The procedure was uncomplicated and there was no concern about a surgery complication like injury to bladder, bowel or uterine perforation. Post operatively, the patient was stable. She was voiding and tolerating oral intake.

Following the D and C, the patient could have been observed in the recovery room, and once the provider ascertained that she was stable, she could have been sent home. 

Based on all the information submitted, the inpatient admission was not medically necessary.

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: moderate maxillary and mandibular crowding
Treatment: braces/monthly visits
The insurer denied braces/monthly visits. The health plan's determination is upheld. 

The patient is a male with moderate maxillary and mandibular crowding. The patient has a class II occlusion with 4 millimeter (mm) overjet and 5mm overbite. The patient is treatment planned for Braces and Monthly Visit(s) to align the teeth and correct the bite. 

The patient has crowding but no teeth are impacted. His overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the cingulum of the upper incisors in occlusion. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior or posterior crossbites present.
While the patient has crowded teeth, there is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. The patient has a 4 mm overjet but research shows overjet would not affect oral health related quality of life unless it was greater than 6mm. If his teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, braces and monthly visits are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease
Treatment: Linx procedure
The health plan denied Linx procedure. The denial is overturned.

This patient is an adult woman with BMI (body mass index) 30. She sought surgical evaluation with her provider for the condition of GERD (gastroesophageal reflux disease), including heartburn, nausea/vomiting, and regurgitation. The records include a thoracic consultation and a follow up note that summarize a prior work up to include pH (potential of hydrogen) testing that identified a DeMeester score of 36.2 (normal < 14.7), endoscopy a year and a half ago that showed a normal esophagus and stomach with no evidence for Barrett's esophagitis, and an Esophagram that showed a small hiatal hernia with severe reflux and delayed gastric emptying. Esophageal manometry is reported to be normal. This note references a gastric emptying study that showed normal gastric emptying.

The patient has been treated with Pantoprazole and famotidine for reflux symptoms, but has breakthrough symptoms. She has had a prior median arcuate ligament repair (presumably for celiac artery compression syndrome).

The treating surgeon has requested the LINX procedure as treatment of GERD (gastroesophageal reflux disease).

The health plan rationale for denial of coverage is that the LINX procedure is considered to be investigational by the Plan. The denial is being appealed.

The patient has symptoms of chronic GERD (gastroesophageal reflux disease). She has been appropriately evaluated with pH study, motility testing, esophagram, gastric emptying study and upper endoscopy. There is confirmed pathologic esophageal acid exposure based on objective pH testing. There is no contraindicating esophageal motor condition based on the motility testing or esophagram. EGD (esophagogastroduodenoscopy) identifies no contraindicating anatomic abnormality of the esophagus or stomach. Finally, the patient does not have specific contraindication to implantation of the LINX device such as Scleroderma, suspected or confirmed esophagogastric cancer, prior esophageal or gastric surgery or endoscopic intervention, esophageal motor pathology, symptoms of dysphagia more than once per week, esophageal stricture or other gross anatomic abnormalities, esophageal or gastric varices, lactating, pregnant or plan to become pregnant, morbid obesity, or age < 21.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease
Treatment: Linx procedure
The health plan denied Linx procedure. The denial is overturned.

This patient is an adult female with BMI (body mass index) 30 and with history of GERD (gastroesophageal reflux disease) refractory to medication. The patient had a 24 hour pH (potential of hydrogen) study with elevated DeMeester score of 36.2 consistent with severe GERD (gastroesophageal esophageal reflux disease). EGD (esophagogastroduodenoscopy) did not reveal BE (Barrett's esophagus). UGI (upper gastrointestinal series) revealed small hiatal hernia and GERD (gastroesophageal reflux disease). Esophageal manometry is normal.

The requested Linx procedure is a standard treatment for GERD (gastroesophageal reflux disease).

This patient has GERD (gastroesophageal reflux disease) refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD (gastroesophageal reflux disease) in nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons (SAGES).

The patient is not responding to maximal medical management of GERD (gastroesophageal reflux disease).

This patient has GERD (gastroesophageal reflux disease) refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD (gastroesophageal reflux disease) in nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons.

This patient has no exclusion to LINX treatment (such as body mass index > 35, hiatal hernia > 3 centimeters, evidence of Barrett's esophagus with dysplasia). The requested treatment is medically appropriate and more beneficial than medication, which is not controlling this patient's symptoms.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease
Treatment: Linx procedure
The health plan denied Linx procedure. The denial is overturned.

The patient is an adult female with a history of over several years of GERD (gastroesophageal reflux disease). She has symptoms of regurgitation, heartburn, nausea, and vomiting. She was found to have a hiatal hernia, elevated esophageal acid exposure on esophageal pH (potential of hydrogen) monitor, and normal motility on manometry. She was recommended to undergo the Linx procedure. She has been on famotidine and twice daily pantoprazole.

The surgeon has requested Laparoscopic Linx procedure.  The health plan denied coverage of the request, citing that it is experimental/investigational. The denial is being appealed.

This patient suffers from GERD (gastroesophageal reflux disease) causing profound symptoms. Even with PPI (proton pump inhibitor) there is refluxing gastric contents. Surgical therapies exist that resolve this very well. Without the LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended. Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety. The side effects of LNF (Laparoscopic Nissen Fundoplication) make it a less than ideal operation. Linx is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term. It is approved by the FDA (United States Food and Drug Administration). There is published data on patients who have had the device for 12 years, showing a very low complication rate and a high resolution of GERD (gastroesophageal reflux disease).

The alternative therapies consist of Nissen fundoplication, which has a higher risk of side effects, and medical therapies that the patient has tried which are not working.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stone

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

This is an adult with past medical history of brain surgery, seizure disorder, hypertension. Patient presented to emergency department (ED) complaining of left flank pain. Imaging revealed a Left ureteral stone with hydronephrosis. Patient admitted, taken to operating room for cystoscopy and left stent placement. The patient tolerated the procedure well and recovered quickly. He was discharged home with outpatient urology follow up. 

Per Milliman Care Guidelines (MCG) Health (26th Edition):

Renal Colic + Kidney stones RRG - Patient fails to meet clinical indications for admission to inpatient care

Urologic surgery and procedure GRG - Patient meets the GRC discharge parameters within 24 hours post procedure.

As per the guidelines, this procedure is performed in the ambulatory surgery setting.

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 the inpatient admission is not substantiated.