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

Diagnosis: Deep Vein Thrombosis.
Treatment: inpatient hospital admission.
The insurer is denied coverage for the inpatient hospital admission.
The denial is upheld.

This is a patient with a medical history of chronic back pain and atrial fibrillation. The patient was brought to the Emergency Room by ambulance. The patient had complaints of left leg swelling and inability to walk. The patient underwent a left lower extremity duplex, which was positive for deep vein thrombosis. The chest x-ray revealed no acute process. The CT angiogram of the chest revealed no pulmonary embolus. In the Emergency Room, the patient was treated with a normal saline bolus and intravenous heparin. The patient was admitted to the hospital with a diagnosis of deep vein thrombosis in the setting of atrial fibrillation not on anticoagulation. Vascular Surgery was consulted with recommendations of a hematology consult, applying a compression device to the left lower extremity, continuing a heparin drip for anticoagulation, and was to undergo a 6-month course of anticoagulation. The patient was evaluated by physical therapy. The patient was to continue oral Xarelto and avoid long distance travel. The patient was discharged when she was medically stable.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered medically necessary for this patient.

This is a patient with a history of atrial fibrillation not on anticoagulation who presented with left leg acute edema and swelling and pain and inability to walk. Appropriate workup with venous duplex and CT of the chest for pulmonary embolism (PE) protocol were ordered. The patient did not have any PE, but did have a left leg acute deep vein thrombosis (DVT). The patient was hemodynamically stable, and not on oxygen or had any respiratory difficulty, and was started on intravenous (IV) heparin and then converted to oral Xarelto and discharged the following day. Given the stable nature of this patient, and the fact the patient had no pulmonary embolism (PE), and had a low Wells score, there was no indication for inpatient stay or admission. The patient could have been treated with initiation of anticoagulation with oral Xarelto therapy in the Emergency Department and discharged.

The carrier's denial of coverage for the hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis Lung Cancer
Inpatient stay
The insurer denied the inpatient stay
The determination is overturned.

The patient was being evaluated for hydronephrosis by a computed tomography (CT) scan of the abdomen which showed a left lower lobe (LLL) lung lesion. The patient had a significant uterovaginal prolapse for which she was scheduled for colpocleisis . Workup for the LLL included a needle biopsy done which confirmed the suspicion that this was a primary lung cancer.
She was admitted for a left lower lobectomy and mediastinal lymph node dissection with robotic approach. The patient was in the intensive care unit (ICU) postoperatively. She had chest tubes to suction then water seal for 24 hour which were  removed on postoperative day (POD) number 2. The patient was discharged. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary. It is standard of care for an inpatient stay after this procedure. This patient was in the cardiothoracic intensive care unit (CTICU) postoperatively where she underwent extubation, pain management, and monitoring. Her age placed her at a high risk for possible postoperative complications. Serial chest x-rays (CXR) showed the development of a postoperative pneumothorax (PTX) on postoperative day (POD) 1, then POD 2 the CXR showed a decrease in the size of the PTX but still present.  Pain management and monitoring was continued to be needed. Chest tubes were then removed and then monitored for issues. This level of care cannot be provided at a lower level than inpatient for this type of procedure and postoperative care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian Cancer.
Treatment: Inpatient hospital stay.
The insurer denied the inpatient stay as not medically necessary. The determination is upheld in whole.

The patient has a Stage II yolk sac tumor who presented to the operating room  for resection of a pelvic mass and lysis of adhesions, performed laparoscopically. The patient was admitted to the hospital after the procedure and discharged home the following day.

The surgical procedure performed was done laparoscopically and it is defined as an ambulatory or outpatient operation. Per the medical records reviewed, the procedure was uncomplicated, it did not require conversion to a laparotomy and the patient was able to ambulate, void, and tolerate an oral diet and oral pain medications after the surgery and remained afebrile with stable vital signs. Thus, there were no medical conditions or events to justify inpatient level of care after the surgery. This service of inpatient hospital stay is not standard of care, is not supported by peer reviewed literature and it is not supported by professional organizations and thus, it was not medically necessary. The patient could have received treatment at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD); reflux esophagitis

Treatment: Blood test code 86677 antibody testing for helicobacter pylori
	
The insurer denied coverage for blood test code 86677 antibody testing for helicobacter pylori. The denial is upheld. 

This patient was a male. A progress note indicated the patient stated that his gastroesophageal reflux disease had been getting worse.  It had recently been waking him up in the middle of the night.  The patient had some regurgitation that woke him and during the day, he stated his chest felt tight.  The patient had been utilizing ranitidine over-the-counter 300 mg at night and this had been helping.  The patient did not smoke and drink alcohol, but not too much.  The patient had gained about 20 pounds in a year.  The patient had water brash.  The physician order requested a Helicobacter pylori antibody examination for the diagnosis of reflux esophagitis.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome in general; however, in this case the scientific evidence in peer-reviewed literature would not support a result of improvement in health outcome as there is a lack of evidence the test would be beneficial given the concern for reflux esophagitis. 

Blood test code 86677 antibody testing for helicobacter pylori does not have final approval from the appropriate regulatory bodies for the diagnosis of reflux esophagitis. The patient is not a good candidate for antibody testing for helicobacter pylori given the diagnosis and clinical documentation.  Antibody testing as requested for helicobacter pylori is not the best available treatment for this patient at this time given the documented diagnosis and clinical documentation.

H. pylori urease is now used as a biomarker for the infection and a variety of techniques have been developed to reliably detect its presence and thus diagnose the infection.  However, the requested Helicobacter pylori antibody examination was ordered for the diagnosis of reflux esophagitis.  The requested service would not be likely to be more beneficial than any of the standard treatments/procedures for this patient's diagnosis.

The carrier's denial of coverage for blood test code 86677 antibody testing for helicobacter pylori should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease (GERD); reflux esophagitis

Treatment: Blood test code 86677 antibody testing for helicobacter pylori

The insurer denied coverage for blood test code 86677 antibody testing for helicobacter pylori. The denial is upheld. 

This patient is a male who reported that he had gastroesophageal reflux disease (GERD) that was getting worse.  He was complaining of chest tightness.  His abdomen was reported to be soft and non-tender.  The assessment was that he had reflux esophagitis.  The plan was to treat with Protonix.  Testing for H. Pylori was negative.

The physician has submitted the American College of Gastroenterology clinical guideline for dyspepsia.  This was reported in the American Journal of Gastroenterology 2017; 112: 988-1013.  In this article dyspepsia is defined as epigastric pain associated with other upper gastrointestinal (GI) symptoms.  If a patient had dyspepsia, H. Pylori testing is an appropriate test.

The physician has also submitted an article from Gastroenterology 2005; 129: 1756-1780 titled "American Gastroenterological Association Technical Review on the Evaluation of Dyspepsia."  This review uses the Rome - definition of dyspepsia which requires recurrent upper abdominal pain.  This is a separate diagnosis from GERD.
The medical record submitted only documents GERD. There is no report of upper abdominal pain or dyspepsia.  Reflux esophagitis is the only diagnosis listed and is not caused by H. Pylori.

The scientific evidence does not support blood antibody testing for H. Pylori for GERD.  The test is FDA approved.  However, the patient is not a good candidate for it because there is no documentation of dyspepsia.  It is not the best available treatment for GERD.  If a patient has GERD that is not responsive to proton pump inhibitor (PPI) therapy, it would be standard are to consider endoscopic testing.  Since the patient only has GERD and not dyspepsia the H. Pylori blood test is not likely to be more beneficial than any other standard testing.

The carrier's denial of coverage for blood test code 86677 antibody testing for helicobacter pylori should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System 
Nursing Services (including Private Duty Nursing) 

Diagnosis: Dementia 
Treatment: Increase in Personal Care Services: 24 Hours per Day, 7 Days per Week (live-in)  

The insurer denied the Increase in Personal Care Services: 24 Hours per Day, 7 Days per Week (live-in). The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, hyperlipidemia, dementia, GERD, migraines, occipital neuralgia, osteoarthritis of the knees, lumbar spine spondylosis, shoulder impingement, urinary frequency, urinary incontinence, depression and gait disturbance with multiple falls who had been assigned PCA (personal care assistant) services. 

The Increase in Personal Care Services: 24 Hours per Day, 7 Days per Week (live-in) is medically necessary for this patient. The patient was recently diagnosed with progressive dementia and following a fall and the patient had further reduction in her physical abilities. The patient had documented shoulder impingement and knee and back osteoarthritis (OA) limiting her ability to perform self-care. The patient has incontinence of bladder with the need for help with toileting and incontinence care which she is not able to perform independently at night. The patient has had a urinary tract infection (UTI) related to not changing her diaper. The patient had a fall when she was attempting to transfer from commode recently. The telephonic assessment performed underestimated the patient's PCA care needs as the provider office notes and letters indicate the patient has higher level of assistance needs for tasks of managing finances, managing medications, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use and bed mobility. The patient does not have informal helper. PCA services are not solely for supervision, but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease.
Treatment: Descovy.
The insurer denied Descovy. 
The denial is Overturned.

The patient is a male. He has history of Crohn's disease, GERD (gastroesophageal reflux disease) on PPI (proton pump inhibitor). He engages in high risk sexual behavior, and he is an HIV negative individual. The patient's provider would like to prescribe Descovy for this. 

The provider's rationale for Descovy is that size of Truvada could potentially cause a problem in this patient with history of dysphagia. In addition, given chronic PPI use, the provider is concerned about long term bone health with concomitant Truvada. 

The health plan is denying the medication because on the basis that it is not on their approved list of medications or the US Public Health Service's recommended medications for this indication (1).

As noted in the health plan's denial, Descovy is not recommended for pre-exposure prophylaxis for HIV according to the latest guidelines published in 2017 (1). However, in 2019, Descovy was approved by the FDA for pre-exposure prophylaxis of HIV-1 infection (2). Given that the drug is FDA-approved for this indication, and the fact that the patient has dysphagia with large pills, the use of this drug for this indication should be approved. The efficacy of this medication is directly tied to adherence, and given patient's dysphagia, all efforts should be made to increase compliance, including pill size. It is recommended that this medication be approved for a duration of one year, with re-review at that point in time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive system / Gastrointestinal.
Treatment: Pharmacy/prescription drugs.
The insurer denied Entyvio (vedolizumab).
The denial is upheld in whole.

This patient has a history of ulcerative colitis. The patient  has tried and failed corticosteroids and mesalamine. She has a family history of cancer.
No, Entyvio is not medically necessary for this patient. This patient has ulcerative colitis and failed to respond to conventional therapy (corticosteroids and mesalamine). Escalation of therapy to biologics is indicated for this patient.
Entyvio is Food and Drug Administration (FDA) approved for use in the treatment of inflammatory bowel disease in adults. Despite the lack of FDA approval in pediatric patients, Entyvio is being widely used {off-label} for the treatment of pediatric Crohn's disease and ulcerative colitis. There are many peer reviewed literature reports supporting the use of Entyvio in children with inflammatory bowel disease. The safety and efficacy of Entyvio are well established in pediatric patients with inflammatory bowel disease. Per Ledder O et al, "Vedolizumab was safe and effective in this cohort of paediatric refractory (inflammatory bowel disease) IBD".
Per Schneider, Anna-Maria, et al: "In conclusion, the present study demonstrates that vedolizumab might be an effective treatment for individual pediatric patients with IBD who are unresponsive, intolerant, or experience a loss of efficacy in other therapies, including (tumor necrosis factor) TNF - antagonists."
Per the clinical practice guidelines: "Vedolizumab should be considered in chronically active or steroid-dependent patients as second-line biologic therapy after anti-TNF failure" (3). According to the records submitted for review, the patient has tried and failed corticosteroids and mesalamine.
 The other plan suggested alternatives (Cyclosporine, Azathioprine, or 6-Mercaptopurine) are not Food and Drug Administration (FDA) approved for pediatric ulcerative colitis and are associated with increased risk of malignancy. These alternatives are not appropriate for this patient. These treatments are falling out of favor due to safety concerns.
Therefore, Entyvio is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Skin Pharmacy/Precription Drugs

Diagnosis: alopecia areata 
Treatment: Xeljanz XR
The insurer denied Xeljanz XR. 
The health plan's determination is upheld.

The patient is a female with alopecia areata that has been rapidly progressing. The patient has tried and failed aggressive topical and systemic steroids. Health plan coverage of Xeljanz is under review for medical necessity.

Xeljanz is not medically necessary. 

While understandable to consider Xeljanz for this patient's condition, the requested medication is considered investigational at this time, and merits further study before being presumed acceptable for widespread clinical use. At this time, the long-term safety of this medication is not as confirmed as short-term efficacy in the use of Xeljanz for this condition.
Alopecia areata is notoriously difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, contact allergen treatment and related therapies have all resulted in variable and unsatisfactory outcomes, and self-resolution is often the only choice a patient has (along with hairpieces) for severe cases.
However, while Xeljanz has some promising preliminary results in open-label studies, the overall literature and reviews on alopecia areata mention Xeljanz only as investigational. Xeljanz was denied Food and Drug Administration (FDA) approval for use in psoriasis, in large part for safety reasons, and is not without a significant risk of side effects that preclude an acceptable risk for use outside of the investigational setting for the condition of alopecia areata.
At this time, Xeljanz is only FDA-approved for rheumatoid arthritis patients who have failed methotrexate, and for psoriatic arthritis, and for ulcerative colitis--all three conditions have indications whereby the safety risks of not using treatment are significantly greater than treatment itself. Xeljanz has recently been recommended to be used with lower dosing in rheumatoid arthritis patients.
The same cannot be said for Xeljanz in the treatment of alopecia areata, where physical/functional impairment and overall health impacts are minimal to nonexistent--despite the social/psychological impacts that can occur in some patients. The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of alopecia areata, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with a specific dosing of Xeljanz.
Therefore, as per the evidence-based literature, Xeljanz is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Issue under review: Continuous rental of Continuous Positive Airway Pressure (CPAP)
The insurer denied the Continuous rental of Continuous Positive Airway Pressure (CPAP).
The denial was overturned. 

The patient is a female with sleep apnea.  The patient is reported to have an RDI (respiratory disturbance index) of 9.5. She is reported to be using the APAP (automatic positive airway pressure) machine for 100% of nights over four hours of use, with an average use of eight hours 38 minutes documented on a data download.

Yes, the continued rental of CPAP is medically necessary.

Consistent with plan requirements and standards of care, this patient through their recent data downloads shows excellent compliance with AutoPAP therapy and efficacy in control of her apnea, with average AHI (apnea-hypopnea index) of 0.69 on her last data download.  Though the patient had compliance issues early in the use of her device, she is presently compliant, with high efficacy and the equipment remains medically necessary for her use to control her sleep apnea.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mild degenerative disease; fall; loss of consciousness
Treatment: inpatient admission
The insurer denied coverage for inpatient admission. 
The denial is reversed.

This patient is a female with a history of multiple episodes of deep vein thrombosis (DVT) presented to the Emergency Department (ED) after falling down five steps of stairs. The patient reported loss of consciousness, and hitting her head and landing on her back due to the fall. The patient rated her pain to be severe, 10 out of 10 pain severity, localized to her back, hip, right leg and head.  On exam, the patient had difficulty moving her extremities. The patient had a Morse fall scale of 45. The patient's x-ray report showed age indeterminate superior endplate fracture to L5 and mild degenerative disease. The patient was admitted to the hospital and underwent several diagnostic studies.  The patient received her home medications and physical therapy.  Cardiology consultation was completed. The patient was discharged home. 

Based on the review of the medical record, this was an elderly female patient who presented to the hospital after sustaining a fall.  The patient reported severe pain on a continual basis with visual analog scale (VAS) of 7-10.  The patient initially required Morphine, as well as oral analgesia. The patient also required several diagnostic studies to rule out intracranial pathology and other site fracture due to the impact of the fall. Although the patient's vital signs were stable, her progress was slow.  The rehabilitation records demonstrated that the patient had difficulty getting out of bed and inability to take more than a few steps, as per a progress note.  There was also report of the patient feeling dizzy after arising for her physical therapy session. Cardiology consultation was also completed for evaluation of ongoing monitoring. Due to the complexity of this patient's underlying medical condition and clinical progress, inpatient admission and length of stay was considered medically necessary to treat this patient's medical condition. 

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

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.