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

Diagnosis:  Gastroesophageal reflux disease (GERD)
Treatment: LINX Implantable Magnetic Esophageal Ring
The insurer denied the LINX Implantable Magnetic Esophageal Ring.
The determination is overturned.

This a male patient with a history of gastroesophageal reflux disease (GERD) refractory to medication. The patient has a small 2 centimeter (cm) hiatal hernia on esophagogastroduodenoscopy (EGD). A 24-hour potential hydrogen (pH) study revealed a significantly elevated DeMeester score consistent with GERD. He had normal esophageal manometry. At issue is whether the LINX Implantable Magnetic Esophageal Ring is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes. This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and the 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Gastroesophageal reflux disease (GERD)
Treatment: LINX Implantable Magnetic Esophageal Ring
The insurer denied the LINX Implantable Magnetic Esophageal Ring.
The determination is overturned.

This is a male patient who has refractory gastroesophageal reflux disease (GERD). An esophagogastroduodenoscopy (EGD) showed a 2 centimeter (cm) hiatal hernia. He has a DeMeester score of 76. The patient is on a twice a day proton pump inhibitor (PPI). The LINX procedure is under review.

The LINX Implantable Magnetic Esophageal Ring 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 as per the Bravo study and also has a 2 cm hiatal hernia. He is an appropriate candidate for the LINX procedure.
As per the 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 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, PPI utilization, and potential of 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Mental Health/Depression/MDD (Major Depressive Disorder).
Treatment:  Mental Health/Outpatient/Transcranial Magnetic Stimulation (TMS) Therapy.

The health plan denied the Mental Health/Outpatient/Transcranial Magnetic Stimulation (TMS) Therapy.  The health plan's determination is overturned.

The patient is male with history of treatment resistant depression and alcohol dependence. The patient has abstained from alcohol for approximately 2 months, and this is not an active treatment concern. The patient continues to struggle with severe depression and has failed numerous antidepressant medications. His psychiatrist has recommended transcranial magnetic stimulation (TMS therapy). The use of transcranial magnetic stimulation was denied by his insurance plan due to patient's active substance abuse problem, and it cited that TMS was in the active/experimental category for substance abuse. The following review is evaluating the medical necessity of the use of TMS to treat the patient's mental health condition.

At issue is whether the proposed health service or treatment TMS Therapy is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

I overturn, in whole, the health plan's determination regarding the proposed health plan's determination regarding the proposed TMS treatment.

The proposed health service, TMS therapy, is likely to be more beneficial than any standard treatment for the insured's life-threatening condition of depression.
The patient has failed numerous medication trials and continues to have severe depressive symptoms. The patient has abstained from alcohol for over 8 weeks and despite this continues to have significant depressive symptoms despite his sobriety. It is apparent that the insured has treatment resistant depression due to the ongoing presence of depressive symptoms despite numerous trials of medications. TMS therapy is both a safe and effective Food and Drug Administration (FDA) approved treatment for treatment resistant depression and the use of TMS is well established in the literature (Perera et al., 2016, Wang et al., 2022, and Wilson et al., 2021). Given the above, use of TMS is medically necessary and is likely to be more beneficial for the insured's depression than other standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain
treatment: inpatient stay. 
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency department with concerns for chest pain. Pertinent history included hypertension and gastroesophageal reflux disease. Initial vital signs revealed a temperature of 37.7oC (Celsius), heart rate (HR) 86, blood pressure (BP) 186/95, respiratory rate (RR) 18, and peripheral capillary oxygen saturation (SpO2) 98% on room air. Initial examination documented tenderness to palpation of the anterior chest wall. Electrocardiogram (EKG) revealed ST elevation in V1 and V2 but nonspecific. Initial laboratory testing revealed a white blood cell count (WBC) 6.5, HGB 15.0, platelets (Plt) 167, blood urea nitrogen (BUN) 11, Cr (creatinine)1.2, Glucose 96, Tbil (total bilirubin) 2.1, Troponin I 0.040, and Pro- brain (or B-type) natriuretic peptide (BNP) 1170. Chest radiograph was unremarkable. The patient was placed in the hospital with an impression of chest pain, rule out acute coronary syndrome. Treatment plan included serial cardiac enzymes, telemetry, repeat electrocardiogram, echocardiogram, and oral anti-hypertensives.

The inpatient hospital admission was not medically necessary. A lower level of care was appropriate. The patient had a history of hypertension who presented to the emergency department with concerns of chest pain. Initial examination documented the patient to be afebrile, hemodynamically stable, without hypoxia, and with tenderness to palpation of the anterior chest. Initial evaluation revealed an EKG with non-specific changes, unremarkable chest radiograph, and mildly elevated but flat / stable serial troponins. Treatment plan included oral anti-hypertensives, telemetry, echocardiography, and consultations. Following observation care, hemodynamics were stable and chest pain resolved. The echocardiogram was relatively unremarkable. Cardiology consulted and ruled out acute coronary syndrome. To note, a COVID-19 test was positive without hypoxia or chest radiographic findings. Outpatient treatment with oral Paxlovid was initiated. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits.
The determination is overturned.

This is a male patient who presented with a skeletal Class II molar malocclusion. He has maxillary and mandibular crowding. Teeth 4 and 13 are completely blocked out to the lingual. Teeth 7 and 10 are in anterior crossbite. He is treatment planned for orthodontics to correct his malocclusion. At issue is the medical necessity of braces and monthly visits.

This patient presents with an anterior crossbite of teeth 7 and 10 and severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) These problems are much more time consuming to correct than the patient's existing orthodontic problem. Teeth 7 and 10 are at high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time (4), which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia, erythema

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is overturned

This is an infant with a history of a rash erythema over the wrist for 5 days. There were vesicles noted. The infant developed fever and swelling of the hand the day prior to the admission. The infant had chest congestion, a cough and episodes of fever for 2 weeks and was previously seen in an urgicare center for fever 3 weeks prior to the admission and the infant tested negative for the influenza virus. When the mother noted that the infant had fever and swelling of the hand, she brought the infant to the emergency room (ER) for evaluation.

In the ER the child was noted have a fever of 101 degrees Fahrenheit. On physical examination the infant was noted to be weak and pale and to be crying with no tears. Physical; examination of the forearm showed a rash and swelling of the soft tissue. The child was given a bolus of intravenous (IV) normal saline. Blood testing showed an elevated white blood count of 25,400 and a chest x-ray showed right middle lobe pneumonia. The child was started on IV antibiotics. Based on the prolonged illness with the recurrence of fever, pneumonia on chest x-ray, redness and swelling of the right forearm and the elevated white blood count the decision was made to admit to the hospital for continued treatment with IV ceftriaxone and clindamycin. 

Over the next few hours, the swelling and rash spread over the right arm and a surgical consult noted localized swelling of the right forearm that was tense and edematous. The surgeon was concerned for cellulitis and compartment syndrome. The child was transferred to another institution for care and possible need for surgical intervention. 

The patient was treated appropriately in the ER for a diagnosis of fever, pneumonia and cellulitis or the right forearm following a prolonged illness. The infant had an elevated white blood count and right middle lobe pneumonia on chest x-ray. There was swelling, redness and edema of the forearm with vesicles noted. During the next few hours, the rash and swelling progressed and edema and tension developed over the right forearm which raised concern for compartment syndrome which can be a surgical emergency. The decision to admit to the hospital was consistent with the standard of care for treatment of pneumonia and cellulitis. 

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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient had a history of cholecystitis requiring a cholecystectomy and presented with abdominal pain, diarrhea, and vomiting. The patient also had a history of iron deficiency anemia. The patient was afebrile (without fever), and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The liver enzymes were elevated. An abdominal ultrasound was negative. The liver enzymes were monitored and improved. Intravenous (IV) iron was given for the chronic anemia. The patient was given histamine type 2 (H2) blockers, and a lactose free diet and the symptoms resolved. 

Clinical indications for admission for Undiagnosed Abdominal Pain are listed in Milliman Care Guidelines (MCG) guideline M-05. These include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and bacteremia. The patient did not have these conditions. 

Clinical indications for admission for vomiting are listed in MCG guideline M-370. These include having a significant metabolic derangement such as ketoacidosis, hemodynamic instability, severe vomiting that is not responsive to antiemetics, severe pain, bacteremia, acute stage 2 kidney injury, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had abdominal pain, vomiting, and elevated liver enzymes. The patient did not have intestinal obstruction or require any surgical interventions. The patient did not have acute liver failure and the liver enzymes could have been monitored as an outpatient. The iron deficient anemia was chronic and there was no sign of active bleeding. Iron infusions could have been given on an outpatient basis. The patient was stable and could have been treated with observation status. The patient did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Vomiting. The health care plan acted reasonably and with sound medical judgment. An inpatient hospital admission was not medically necessary. The denial is upheld.

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

Diagnosis: Generalized weakness, fatigue and osteoarthritis

Treatment: home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 42 hours per week

The insurer denied coverage for home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 42 hours per week

The denial is overturned

 
This is an elderly person with generalized weakness, fatigue and osteoarthritis. He lives with a friend. He currently has personal care services (PCS) from Mondays to Fridays totaling 30 hours/week. The patient is requesting an increase in PCS hours from 30 to 42 hours/week to include Saturdays and Sundays.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as modified independent. He reportedly requires extensive assistance to total dependence for much of his Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. He reportedly requires extensive assistance for bathing, lower body dressing and toilet use. Limited assistance is needed for personal hygiene, upper body dressing, locomotion, toilet transfer and ambulation. The patient is independent with bed mobility and eating. He is frequently incontinent of bladder and continent of bowel. 

The patient's functional ability has decreased when compared to the previous UAS report. The patient's condition and functional deficits are at a level or unpredictable as to support an increase PCS from 5 days/week totaling 30 hours to 7 days/week totaling 42 hours. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing home care/ personal care HHC - level 2 PCS, per 15 minutes to 42 hours per week.

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 home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 42 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic pain syndrome.
Treatment:  Pain management services/epidural steroid injection 2 units.

The insurer denied coverage for pain management services/epidural steroid injection 2 units.  The denial is upheld.
 
According to the documentation provided, this is an adult female with a history of chronic pain syndrome, post laminectomy syndrome - lumbar and cervical, lumbar radiculopathy, fibromyalgia, and irritable bowel syndrome (IBS). The patient had bilateral lumbar (L)3-4 transforaminal lumbar epidural injections (TFESIs). The patient then had a follow-up visit on with report of new pain syndrome in left foot. There is no documentation of pain score or functional improvement after TFESI performed. There is no documentation of correlation between new left foot pain syndrome and prior lumbar radiculopathy.

According to Centers for Medicare and Medicaid Services (CMS) guidelines (Epidural Steroid Injections for Pain Management), repeat epidural steroid injection (ESI) when the first injection directly and significantly provided improvement of the condition being treated may be considered medically reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using SAME scale for at least three months. If a patient fails to respond well to the initial ESI, a repeat ESI after 14 days can be performed, using a different approach, level and/or medication if appropriate, with the rationale and medical necessity for the second ESI documented in the medical record.

Based on the documentation provided, this patient does not meet the CMS recommended criteria for additional ESI (epidural steroid injection). There is no documentation in the medical record that previous ESI was of any benefit. There is no documentation of sustained improvement in pain relief and/or improvement in function after TFESI (transforaminal lumbar epidural injections) of at least three months. Based on this lack of follow-up information and CMS guidelines, there is no benefit to repeat ESI for this patient. 

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 pain management services/epidural steroid injection 2 units is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Abdominal pain with blood per rectum.
Treatment:  Current procedural terminology (CPT) code 83993 [calprotectin, fecal].
The insurer denied coverage for CPT code 83993 [calprotectin, fecal].  
The denial is overturned.

This patient has a diagnosis of chronic constipation and anxiety that now presents with abdominal pain, diarrhea and intermittent bright red blood per rectum with mucus over the last few months. Her symptoms seem prolonged but may have been actually improving. The main differential diagnosis includes infectious enteritis, allergic enteritis, irritable bowel syndrome and inflammatory bowel disease. In a review of the approach to chronic diarrhea in child greater than (&gt;) 6 months in resource rich countries from UpToDate the use of stool calprotectin is summarized in the following:

Initial laboratory testing - Perform basic laboratory screening:
1) Celiac disease - All children with chronic diarrhea should be screened for celiac disease by measuring immunoglobulin A (IgA) antibodies to tissue transglutaminase antibodies, usually in conjunction with total IgA to exclude the possibility of IgA deficiency. This screen is only valid if the child's diet includes gluten. 
2) Other tests - Other tests depend on the child's presenting characteristics and prior testing, as outlined in the table (table 5). For most children, we include a complete blood count and fecal calprotectin or lactoferrin at this stage of the workup, often with stool cultures and Clostridioides difficile testing if not already done.

Stool calprotectin is a good non-invasive marker for bowel inflammation validated in the pediatric population that can guide diagnostics and therapeutic interventions.

Given the differential for this patient, she is a good candidate for fecal calprotectin testing.

The use of fecal calprotectin testing in the setting of this patient's symptoms is supported by peer reviewed literature. 

The risk of the assay is much less than more invasive testing, like endoscopy.

For this particular patient, the results of the assay and inflammatory markers suggest no significant bowel inflammation that should prompt the treating team to delay more invasive testing.  Fecal calprotectin testing has become common place in pediatric practice as evidenced in the above recommendations, and the insurer's own policy reflects the support for the assay in the setting of diarrhea to assess for bowel inflammation. In conclusion fecal calprotectin testing is more beneficial than invasive testing in the assessment of this patient's symptoms. 

In summary, the denial of current procedural terminology (CPT) code 83993 [calprotectin, fecal] and coverage for the requested service should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankle Fracture
Treatment: Full hospital admission
The insurer denied coverage f.or full hospital admission.
The denial is upheld 

The patient presented to the hospital for surgery after a right ankle fracture. The patient had a closed bimalleolar fracture of the right ankle with delayed healing. The patient underwent an open reduction internal fixation of the right ankle. The patient received 24-hour prophylactic antibiotics postoperatively. The patient was evaluated by Physical Therapy (PT). The patient met all goals for discharge. The patient was discharged to subacute rehabilitation.

The medical records did not document a condition which would require acute admission. This person was evaluated by a case manager a week prior to admission. The recommendations after surgery were subacute admission/rehabilitation. The surgery was not complex nor extensive. The operative time was less than 2 hours with minimal blood loss. Vital signs were stable. There was no evidence of bleeding. There were no medical conditions to require acute/ongoing service. The records showed delays in mobilization. There was poor progress in PT with a remark of "anticipate rehab placement." The discharge summary did not report complications nor problems. There were no factors to substantiate the acute level of care. Services could have been completed at a lower level.

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 full hospital admission is not substantiated.