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

Diagnosis: Gastroesophageal Reflux Disease (GERD)

Treatment: Linx procedure

The insurer denied coverage for Linx procedure

The denial is overturned

The patient had gastroesophageal reflux disease. She had a workup that included an esophagram showing a small hiatus hernia. A PH study found a DeMeester score of 29.8. An esophageal motility study was negative for achalasia. An endoscopy showed grade B esophagitis. However, there was a hiatus hernia that measured 5 centimeters (cm). 

The Linx Reflux Management System (a sphincter augmentation device) is used, according to the FDA (Food and Drug Administration), "to treat gastroesophageal reflux disease (GERD) in patients who continue to have GERD symptoms despite the use of maximum medical therapy for the treatment of their reflux." Note there is a lack of notable large trials for the surgical treatment of GERD and other indications.
 
There is growing sufficient published peer-reviewed data from well-constructed clinical studies to permit a scientific conclusion regarding the benefit of laparoscopic magnetic sphincter augmentation procedure for the treatment of GERD using the current procedural terminology code 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device) as an alternative the Nissen surgical approach.

"In this single-group evaluation of 100 patients before and after sphincter augmentation with a magnetic device, exposure to esophageal acid decreased, reflux symptoms improved, and use of proton-pump inhibitors decreased. Follow-up studies are needed to assess long-term safety. (Funded by Torax Medical; ClinicalTrials.gov number, NCT00776997. opens in new tab.)" (Ganz, R.A., et al. 2013).

"Sphincter augmentation with the Linx Reflux Management System provided long-term clinical benefits with no safety issues, as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects and no safety issues. The patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation." (Lipham, J.C., et al. 2012). Some literature is older than five years, but it is still relevant and supports this determination.

The requested procedure is likely to be more beneficial than any other standard health service/procedure without increased adverse risks.

The carrier's denial of the Linx procedure should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD)

Treatment: Linx procedure

The insurer denied coverage for Linx procedure

The denial is upheld

According to the documentation submitted this is the case of a patient with a history of gastroesophageal reflux disease (GERD). The patient's treating physician notes that the patient had a barium esophagram which showed a small hiatal hernia. Prior endoscopy showed no evidence of any Barrett's esophagus, pH study revealed a Demeester score of 29.8. He ordered an esophageal motility study which showed ineffective esophageal motility with 50% (percent) failed swallows. There was no evidence of achalasia. The patient now presented for another opinion. He discussed the advantages and disadvantages of the Linx procedure versus the fundoplication procedure. The patient's preference was for a robotic assisted hiatal hernia repair with the Linx anti-reflux system. 
 
It appears that this patient is not a good patient for this device given the fact that the patient has a 5 cm (centimeter) hiatal hernia on esophagogastroduodenoscopy (EGD) and as noted by the manufacturer "the use of the Linx device in patients with a hiatal hernia larger than 3 cm should include hiatal hernia repair to reduce the hernia to less than 3 cm. The Linx device has not been evaluated in patients with an unrepaired hiatal hernia greater than 3 cm [centimeter]." It is true that the patient has a Demeester score of 29.8 with a symptom association probability of 100, however given the large hiatal hernia the Linx is not appropriate alone. Furthermore, Schwaitzberg noted in surgical management of gastro esophageal reflux in adults, in Up-to-date, that "eligible patients must have GERD confirmed by a pH study. In addition, the manufacturer of the Linx device also suggests that the patient have no large (>3 cm) or paraesophageal hiatal hernias, severe (Los Angeles class C or D) esophagitis, Barrett esophagus, obesity (body mass index >35 kg/m2 [kilogram per square meter]), esophageal dysmotility, or prior upper gastrointestinal tract surgery." Thus, the patient does not have indications based upon his condition for an anti-reflux procedure with the Linx alone which is what it appears the provider is planning to do.

The adverse risks are not increased over standard treatment services as this procedure is less invasive that the standard fundoplication.

In this case, the Linx is not likely to be more beneficial than any standard therapies. The Linx would not be considered as good as a treatment modality as the gold standard, which is fundoplication for this patient, as the hiatal hernia was documented to be 5 cm.

The carrier's denial of the Linx procedure should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD)

Treatment: Linx procedure

The insurer denied coverage for Linx procedure

The denial is overturned

The patient had gastroesophageal reflux disease. She had a workup that included an esophagram showing a small hiatus hernia. A PH (potential of hydrogen) study found a DeMeester score of 29.8. An esophageal motility study was negative for achalasia. An endoscopy showed grade B esophagitis. However, there was a hiatus hernia that measured 5 centimeters (cm).

The Society of American Gastroesophageal and Endoscopic surgeons (SAGES) have published a review of the Linx Reflux management System. Their recommendation is that the Linx system, in patients with a hiatal hernia greater than 3 cm, should be considered on the basis of each patient's medical history and severity of symptoms. The procedure is considered safe. It is associated with improved gastroesophageal reflux disease (GERD) symptoms and freedom from proton pump inhibitor (PPI) use in 85-88% (percent) of patients for years.

The denial is overturned and the service is likely to be more beneficial than any other standard procedures without increased adverse risk.

The carrier's denial of the Linx procedure should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations, dyspnea and chest tightness
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female. She presented with palpitations, dyspnea and chest tightness.

The patient's EKG (electrocardiogram) revealed sinus tachycardia. She was admitted to telemetry. She received IVF (intravenous fluids). She underwent blood work and normal echocardiogram. She was discharged when her heart rate decreased. The discharge diagnosis was sinus tachycardia secondary to dehydration, caffeine use, and beta agonist inhalers.

No, the inpatient admission was not medically necessary.
Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care.

In this patient's case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome, but rather a response to dehydration, anxiety, and use of beta agonist inhaler. There was no evidence of any cardiac pathology. The patient's treatment was basic IVF (intravenous fluids) and telemetry.

The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added.

Milliman criteria requirements for admission were not fulfilled, as there was never any evidence of ACS (acute coronary syndrome), present nor any hemodynamic instability.

All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent to be in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay.

The denial is upheld.

The patient has a medical history notable for hypertension, anticoagulant use and paroxysmal atrial fibrillation.  He presented to the emergency room (ER) with complaint of new onset palpitations. He had prior atrial fibrillation and had intermittent symptoms despite use of Multaq. He was taking Xarelto for stroke prevention. In the ER, his vital signs were stable and his physical examination unremarkable. He was admitted to observational status, per the medical records. He remained clinically and hemodynamically stable. He was evaluated by electrophysiology and referred for electrophysiologic study with ablation of paroxysmal atrial fibrillation. There were no procedural complications, and the patient was then admitted for further monitoring. He remained on continuous telemetry monitoring. The patient remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no vascular access complications. The patient was subsequently discharged home after an uneventful, brief overnight hospital stay. 

Inpatient admission was not medically necessary. The patient presented with atrial fibrillation but was clinically and hemodynamically stable during the initial evaluation in the ER. There was no evidence of myocardial ischemia, heart failure, unstable vital signs, cerebrovascular insufficiency, or other indications for acute inpatient admission. After being evaluated by electrophysiology, the patient underwent an uneventful electrophysiology study with ablation of atrial fibrillation. There were no complications. The patient remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no hemodynamic or clinical complications or concerns noted. Per Milliman Care Guidelines (MCG) 24th Edition Guideline for Electrophysiologic Study and Intracardiac Catheter Ablation, this procedure is designated as an outpatient one, with allowance of one night in the hospital for post-procedural monitoring under observational status. Therefore, the health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient stay is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia (PNA)

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.

The denial is upheld

The patient has a history of polysubstance abuse who presented to the emergency department (ED) with complaint of dizziness, vomiting after an episode of binge drinking. The patient has history of being on Methadone.  Vital signs (V/S) at presentation: afebrile, heart rate 55, respiratory rate 18, blood pressure 152/71, and oxygen (O2) saturations 100% on room air. The patient was in no acute distress (NAD). Lungs were clear. Cardiovascular system (CVS) S1 S2 normal. Abdomen was soft.  The patient was alert and oriented to person, place and time.  Neurology exam was unremarkable.  White blood cell count (WBC) was 10.3K, Sodium (Na+) 126 blood urea nitrogen (BUN)/Creatinine 10/0.7. Liver function tests (LFT) were normal. Troponin was negative.  Chest x-rays revealed (CXR) right lower load (RLL) consolidation. EKG (electrocardiogram) show no ischemic changes. Head computed tomography (CT) reveal no acute pathology.  The patient was admitted to hospital for possible pneumonia (PNA) and alcoholic gastritis.  The patient was treated with intravenous (IV) fluids, azithromycin, Rocephin, Anti emetics and proton pump inhibitors (PPI).  As per history and physical (H&P), the patient was afebrile and hemodynamically (HD) stable.  Oxygen (O2) saturations 98% on room air. The patient was in NAD, lungs were clear with some course breath sounds (BS). Rest of physical exam was unremarkable.

The patient remained stable after admission. By the next day, the patient was feeling much better. All symptoms had resolved. The patient was tolerating oral (PO). He was in NAD.  Pulmonary exam was unremarkable. WBC 7.5K Na+ 131 The patient requested discharge and he was discharged home on oral (PO) Doxycycline. The patient was in NAD. Tolerating PO.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. Observation can last up to 48 hrs. The patient had a very mild PNA if present. The patient was HD stable. Not hypoxic.  WBC relatively Normal. Mild asymptomatic hyponatremia likely from alcohol (ETOH) abuse. Pneumonia severity index (PSI) score was low. CURB (test of pneumonia severity) 65 score was Zero. The patient was tolerating PO and improved rapidly after admission.

This patient could have been placed in Observation status and discharged home once stabilized. The patient could have been discharged on PO antibiotics with close follow up in outpatient setting. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital stay is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 
The insurer denied home health aide 140 hours a week. 
The denial is overturned in part.

The patient is a female with past medical history significant for dementia, anxiety, hypertension, urinary incontinence, gait abnormality, back pain, limited mobility, muscle weakness and fatigue and insomnia.
This review is for the medical necessity of an increase in Consumer Directed Personal Assistance Program (CDAP) from 56 hours per week to 140 hours a week. The patient currently has a home health aide 8 hours a day 7 days a week for a total of 56 hours a week. The patient is requesting home health aide 140 hours a week.

From the clinical tasking evaluation, it is noted the patient does require more services than last year due to functional decline. The patient requires an increase to 63 hours a week to meet her needs. However, the rest of the services which are medically necessary can be provided during the time period allotted. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not covered under the terms of the plan. In order for services to be considered medically necessary, the aid must be performing a service such medically necessary activities of daily living (ADL) or Instrumental activities of daily living (IADL).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Varicose Veins. 
Treatment: Radiation Services-Varicose Vein Treatment. 

The health plan denied the procedure of Varicose Vein Treatment as not medically necessary. 

The reviewer has overturned in whole the health plan's determination. 


The patient has a history of bilateral leg vein stripping and left ovarian vein embolization for pelvic congestion syndrome. Patient presents with left (L) leg varicose veins and symptoms of chronic venous insufficiency. Ultrasound of the L leg shows absent L greater saphenous vein (GSV) and normal L small saphenous vein (SSV). There is a large L calf perforator vein with reflux. The patient is recommended to undergo venography and possible embolization of this symptomatic perforator vein that is feeding multiple veins which are acting like a vascular malformation. 

The requested health service/treatment of Varicose Vein Treatment is medically necessary for this patient. 

The patient is symptomatic from a L perforator vein and the recommendation of venography and possible embolization is reasonable. There is sound peer-reviewed literature to support benefit of this approach. The peer-reviewed studies have shown benefit from the proposed procedure. The venogram and possible embolization of the L perforator vein may give patient relief of pain, as is shown in the supporting literature review. 

For these reasons, Venography and possible embolization is reasonable and medically necessary for this patient who is suffering from leg pain due to the venous malformation and reflux seen on ultrasound.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: human immunodeficiency virus.
Treatment: Cabenuva.
The insurer denied Cabenuva. 
The health plan's determination is upheld. 

The patient is a male with human immunodeficiency virus (HIV). Cabenuva was prescribed. The provider stated that the patient was previously treated with Atripla, Stribild, Genvoya, and Biktarvy. The viral load has dropped to 20 copies per milliliter. Under review is the use of Cabenuva.

A formulary exception is not indicated for this patient. The patient has not failed or been intolerant to and has no contraindication to formulary agents including Dovato, Triumeq, and Odefsey. In summary, the requested formulary drugs will not be and have not been ineffective, would be as effective as the nonformulary drug, and would not have adverse events.
Standard treatment of the patient's human immunodeficiency virus would be good viral suppression and would include the use of any of the formulary agents Dovato, Triumeq, and Odefsey. There is no Infectious Disease guideline supporting use of Cabenuva over these agents.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abnormality of gait and mobility. 

Treatment: Home care / personal care HHC (home health care) - Level 2 personal care services of 70 hours per week. 

The insurer is denied coverage for home care / personal care HHC - Level 2 personal care services of 70 hours per week. 

The denial is overturned. 

This female patient has a history of chronic bilateral intractable lower extremity lymphedema, coronary heart disease, essential primary hypertension, difficulty walking, abnormality of gait and mobility, chronic pain, hyperlipidemia, poly-osteoarthritis, shortness of breath and urinary incontinence. 

Based on the information provided for review, it is medically necessary, and in the patient's best interest, to increase personal care services (in this case CDPAS [Consumer directed personal assistance]) due to the patient's recent physical and cognitive decline, her need for weightbearing assistance for multiple ADLs (activities of daily living) , and assistance with unscheduled, recurring care needs during the day and night. The daughter's request for CDPAS 70 hours per week is reasonable and consistent with the patient's care needs as reported in the UAS (Uniform Assessment System). 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for home care / personal care HHC - Level 2 personal care services of 70 hours per week is overturned.  The medical necessity is  substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath, wheezing, slurred speech
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with history of asthma, rheumatoid arthritis, and valvular heart disease who presented to the emergency room with worsening shortness of breath, wheezing and lower extremity edema as well as a brief episode of slurred speech. In the emergency room, the patient was ruled out for acute stroke. The patient was diagnosed with asthma exacerbation and received intravenous (IV) steroids and frequent duonebs as well as oxygen. She was admitted to the acute inpatient level of care for further management. During hospitalization, the patient had difficult to treat wheezing and was seen by cardiology, pulmonology and neurology. The acute inpatient stay was denied due to lack of medical necessity. This denial is being appealed.

No, the proposed acute inpatient admission was not medically necessary.
This patient was admitted to hospital for the management of asthma and to finish the workup for stroke which included echocardiogram, magnetic resonance imaging (MRI) of the brain and carotid duplex scan. By day two, the patient was not in any distress. She did not have any signs or symptoms of acute stroke. The patient did not have active wheezing. She was able to tolerate an oral diet. The patient's oxygen levels on room air were above 90%. From the time of presentation to discharge, the patient's workup for stroke was completed which could have been done at a lower level of care since the initial emergency room evaluation ruled out acute stroke. The patient was not having wheezing and the intravenous (IV) steroid taper could have been converted to oral prednisone. Although the patient had multiple complex medical issues with chronic dyspnea, her condition stabilized and improved after the emergency room care. Therefore, the acute inpatient admission was not medically necessary.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
This patient was admitted to hospital for the management of asthma and to finish the workup for stroke which included echocardiogram, magnetic resonance imaging (MRI) of the brain and carotid duplex scan. By day two, the patient was not in any distress. She did not have any signs or symptoms of acute stroke. The patient did not have active wheezing. She was able to tolerate an oral diet. The patient's oxygen levels on room air were above 90%. From the time of presentation to discharge, the patient's workup for stroke was completed which could have been done at a lower level of care since the initial emergency room evaluation ruled out acute stroke. The patient was not having wheezing and the intravenous (IV) steroid taper could have been converted to oral prednisone. Although the patient had multiple complex medical issues with chronic dyspnea, her condition stabilized and improved after the emergency room care. Therefore, the acute inpatient admission was not medically necessary.