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

Diagnosis: Gastroesophageal reflux disease (GERD). 
Treatment: Transoral fundoplication (CPT code 43210). 

The insurer denied coverage for transoral fundoplication (CPT code 43210). 

The denial is overturned. 

This is a male patient who had long-term gastroesophageal reflux disease (GERD). He had been on proton pump inhibitor (PPI) therapy for years. A DeMeester score was elevated. Potential of hydrogen (pH) monitoring showed a long episode of acid reflux. 

The American Society for Gastrointestinal Endoscopy (ASGE) has published a guideline on "The role of Endoscopy in the management of GERD." The paper states that the transoral incisionless fundoplication (TIF) procedure was approved by the Food and Drug Administration (FDA) in 2007. It states that 15 studies and 550 procedures found improved GERD related quality of life scores after the procedure. Three randomized trials with at least 6 month follow up found that TIF was more effective than high dose PPI therapy in eliminating troublesome regurgitation of extra-esophageal symptoms of GERD. 

This patient had long standing GERD symptoms on PPI therapy. The pH Monitoring confirmed that he was having symptoms related to the reflux. Transoral incisionless fundoplication has been shown in the medical literature to result in improved health outcomes; and it has FDA approval. The patient is a good candidate for the procedure. TIF is one of several endoscopic treatments for GERD. It is likely to be beneficial for this patient since he has remained with symptoms on long-term PPI therapy. 

The insurer's denial of coverage for transoral fundoplication (CPT code 43210) is overturned.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cellulitis and post-surgical seroma. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is modified. 

This male patient has a history of hernia, gout and hypothyroidism, status-post surgery for left inguinal hernia repair. The patient was sent by his physician to the emergency department (ED) on for evaluation of surgical wound infection and fever of 104 degrees. Bloodwork showed white blood cells (WBCs) were 16.9. There was concern for sepsis and the patient was admitted to surgery for further monitoring and care. He was diagnosed with cellulitis and post-surgical seroma. Interventional Radiology and Infectious Disease specialties were consulted; the patient received intravenous (IV) antibiotics and underwent image-guided percutaneous drainage with moderate sedation. The patient was then discharged home. 

Per MCG Health Wound and Skin Care: Common Complications and Conditions, inpatient admission is necessary for clinically significant infection with vital sign abnormality or when procedure or treatment is required, such as percutaneous placement of closed-suction drains. [1] Surgical site infections complicate the course of recovery and increase postoperative morbidity and mortality. Management may include hospital admission, IV antibiotics, and sometimes surgical reintervention. [2] Early management and intervention has been shown to decrease inpatient length of stay and morbidity and mortality rate. [3, 4] The patient met criteria for initial inpatient admission due to a clinically significant infection with abnormal vital signs. However, there is no clinical documentation regarding surgical intervention and/or plans between the date of admission and the date of Interventional Radiology drainage. There is no documentation that notes the patient's wound was not improving, and that continued inpatient admission was necessary. Temperatures recorded are generally in the normal range or showed minor elevations. WBC was noted as 12.1. There is a consult note by interventional radiology with note saying "tentatively scheduled for today pending international normalized ratio (INR)". WBC was 7.2. There does not appear to be an INR in the submitted records. The INR was 1.0. The drainage yielded 60 cc of serosanguinous fluid.  The patient was discharged within 24 hours after percutaneous drainage. Although the inpatient admission was medically necessary, the length of stay is not justified based on the provided clinical notes. Based on the submitted records, it is unclear why the drainage by interventional radiology was delayed. Based on the submitted records given that it appears the drainage could have been done and discharged. Therefore, the requested inpatient stay should be modified to approve the admission, but deny the last day. 

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 the inpatient hospital admission is modified.  The medical necessity is substantiated for admission, but not the last date of service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer/Colon Cancer. 
Treatment: Surgical Services. 

The health plan denied the requested procedure as not medically necessary. The health plan's determination is upheld. 

The patient is a male under evaluation for a significant neoplastic lesion in his proximal ascending colon. The patient had a tubulovillous adenoma in the same location removed by polypectomy with laparoscopic assistance but apparently there was residual polyp tissue. The serosa was oversewn in that area. Biopsy results from the current, residual lesion were not included in the information provided for review. 
The patient's provider has suggested a full thickness endoscopic resection as treatment. This was denied by the plan. 

At issue is the medical necessity of the requested procedure. 

The health plan's determination of medical necessity is upheld, in whole. 

No. The technological development of the new full-thickness resection device (FTRD) system allows complete resection of the wall of the gastrointestinal tract, cutting and suturing in a one-step procedure. In a recent paper by Albrecht et al., a case series about the FTRD system showed good results in resecting non-lifting lesions of the colon with a high rate of (margin negative resection) R0 resection (I am presuming this lesion is malignant without evidence to the contrary), nearly 90%. [1] While a bloc resection allows a better histopathological evaluation at present, with available data, if a lesion invades the deep submucosal layer, even a full-thickness resection cannot change the nodal risk. This patient's lesion is on a scar. Lesions on a scar are less elastic, and this may decrease the size of the resected area representing a limit in achieving R0 histology. Moreover, there is a reduction in the R0 resection rate of FTRD when the lesion size is over 2 centimeters (cm) (such as in this case), including non-scar lesions. [2,3]. Another issue that we need to clarify is the risk of complications of this new technique. When a technique spreads in the real world, there is usually a decrease in efficacy and an increase in the complication rate. According to Albrecht et al., the FTRD technique is associated with a complication rate of about 15%, significantly higher than that of an endoscopic mucosal resection (EMR) [1].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension.
Treatment: Bystolic.

The insurer denied Bystolic.  The determination is upheld.

The patient has hypertension. Per the appeal letter written by a nurse practitioner, he has been treated with nebivolol (Bystolic) for hypertension, with good control of his blood pressure. A patient visit note was provided.  At that time, the patient was on telmisartan, hydrochlorothiazide (HCTZ) and Bystolic for blood pressure control.  The note does not provide any information as to whether or not the patient has had a trial of the formulary alternatives.  The medical necessity for Bystolic is at issue.

The requested Bystolic Tab 5 milligrams (mg) is not medically necessary.

No documentation that the patient has had a trial of the formulary alternatives (metoprolol, atenolol, bisoprolol) was provided. In addition, no medical information that would indicate that a trial of the formulary alternatives would be inappropriate was provided.  

Bystolic (nebivolol) is a cardioselective beta-blocker with additional vasodilating properties mediated through nitric oxide. Given its vasodilatory properties, some studies have shown that a higher percentage of patients achieve blood pressure control with nebivolol than with earlier generation beta-blockers. In addition, the incidence of drug-induced erectile dysfunction (ED) is lower and, in fact, pre-existing erectile dysfunction (ED) may improve with nebivolol therapy. However, there is no documentation that this patient suffers from ED or has had ED in the past due to beta-blocker therapy. A significant percentage of patients with hypertension do respond to earlier generation beta-blockers, such as carvedilol and metoprolol, when added to other agents. Per the Joint National Committee (JNC)-8 Guideline for the Management of Hypertension in Adults, beta-blockers are not recommended as first-line treatment of hypertension, except when indicated for another purpose (such as heart failure). Otherwise, they are recommended as "add-on" agents to first-line antihypertensive medications. The guideline does not specify a preference for nebivolol over other beta-adrenergic blockers in this situation. Therefore, in the absence of documented failure of formulary alternatives, or intolerable side effects, the literature would not support the use of nebivolol in this instance.

In summary, based on the limited information provided, nebivolol cannot be determined to be medically necessary in this instance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal Valve Collapse.
Treatment: Vestibular Stenosis Repair, Pre-service.

The insurer denied the Vestibular Stenosis Repair, Pre-service.  The denial is overturned.

The patient is a female. She had prior nasal septal surgery and has nasal valve collapse.  Cartilage graft reconstruction was recommended by the provider.

Yes, the Vestibular Stenosis Repair is medically necessary.

The proposed procedure is not cosmetic as suggested in the prior determination. It is rather a procedure designed to reconstruct the nasal valve region, which is creating airway collapse in the patient.  This is a functional procedure and not an aesthetic procedure. Therefore, the proposed treatment is medically necessary.

The plan's determination was to deny the proposed procedure as a cosmetic procedure, which was not in the patient's best interest.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Actemra subcutaneous (SQ). 
The denial is upheld. 

The patient is a female with rheumatoid arthritis (RA). The patient has taken methotrexate (MTX) and Rituxan. The provider is requesting treatment with subcutaneous (SQ) Actemra. This was denied by the health plan has there is no documentation of an inadequate response or intolerable adverse event to the plan preferred alternatives. The subject under review is the medical necessity for Actemra. 

The health plan's determination is upheld. 

The requested health service/treatment of Actemra SQ 162 milligrams (mg) syringe/autoinjector is not medically necessary for this patient. She has not tried or had an intolerance to the plan alternatives Kevzara, Rinvoq, Xeljanz/Zeljanz XR. There is no medical reason that the patient cannot try the alternative plan medications. Therefore, SQ Actemra is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Adenocarcinoma of the esophagus. 
Treatment: PET/CT scan. 

The insurer denied the PET/CT scan. 
The health plan's determination is overturned. 

This is a female with moderately differentiated adenocarcinoma of the esophagus. A positron emission tomography (PET)/computed tomography (CT) has been ordered for staging; this is under review. 

The Positron Emission Tomography and Computed Tomography (PET CT) is medically necessary for this patient. 

This patient has at least T1 adenocarcinoma of the esophagus. In this setting, consideration is given for treatment with curative intent when possible. A PET/CT is recommended for patient without evidence of M1 disease by the National Comprehensive Cancer Network (NCCN) Guidelines. 

The authors of UpToDate state "...FDG (fluorodeoxyglucose)-PET is more sensitive than contrast-enhanced CT or endoscopic ultrasound (EUS) for the detection of distant metastases...The addition of PET to the preoperative assessment alters management in 5 to 20 percent of cases, mainly by detecting occult metastases (i.e., upstaging) that reduces the number of patients who undergo needless surgery... The improved sensitivity of PET for the detection of metastatic disease makes it potentially the most effective method of identifying patients with occult metastases for whom curative therapy should not be pursued...". 

A major drawback of PET for the evaluation of the primary site and nodal metastases is its poor spatial resolution that makes it difficult to localize the anatomic location of the FDG (fluorodeoxyglucose) uptake. This limitation is significantly reduced by the use of integrated PET/CT imaging, which is the service under review and recommended by the NCCN. This approach is recommended by the authors of Up-to-date and in the peer-reviewed literature. The use of PET/CT for initial staging of patients with potentially resectable disease is not the subject of ongoing investigation. For these reasons, medical necessity has been established for this service.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis. 
Treatment: Humira. 

The insurer denied Humira. The health plan's determination is overturned. 

The patient is a male with Ulcerative Colitis complicated by perirectal abscess. He has failed prednisone, Pentasa, and Remicade. He has failed Humira every other week. Testing showed Humira level of 11 and lack of anti-Humira antibodies. He has been stabilized on Humira 40 milligrams (mg) weekly. Under review is the medical necessity Humira 40 mg weekly for the treatment of Ulcerative Colitis. 

Humira 40 mg (Weekly) is medically necessary for this patient. 

This patient has a history of active Ulcerative Colitis requiring biologic therapy. In the high-quality ULTRA 2 trial used for Food and Drug Administration (FDA) approval, it was part of the protocol to change patients to weekly Humira if response was not adequate on Humira every 2 weeks. The trial advanced non-responders at week 8 to weekly therapy as well as week-8 responders - both groups contained a fraction that responded to dosing frequency increase. In the ULTRA 3 trial, weekly Humira was started for inadequate response, or for flare. In a subset analysis of ULTRA 2 patients, those on weekly therapy had week-52 response rate of 25% after failing therapy given every 2 weeks. Current medical literature supports the use of dose escalation to regain lost response. 

In this case, the patient has reportedly failed Humira every other week (the standard dose of Humira) and required dose escalation; he has been stabilized on Humira every other week. Decrease to Humira 40 mg every other week or changing to a different medication may result in disease flare, disease complications, and hospitalization. 

Therefore, continuation of Humira 40 mg every 7 days is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pannus
Treatment: Panniculectomy
The insurer denied a panniculectomy. The health plan's determination is upheld. 

This female patient complains of a hanging abdominal pannus associated with lower back and hip pain and painful malodorous rashes aggravated by walking, running, exercise, climbing stairs, prolonged sitting and reaching overhead. A 40 pound weight loss did not provide relief. Nystatin and triamcinalone prescribed provided temporary relief. At examination, there was a reducible umbilical hernia and a hanging abdominal pannus but there was only mention of a rash under the breasts. Photos show a grade 1 infraumbilical pannus. Another set of photos show a grade 2 pannus that hangs over the inguinal folds touching the upper thighs and covering the upper half of the mons. Close up views of the suprapubic crease show normal skin without rashes or open areas. There are photos with total torso application of topical medication. No keloid scars are visible in any of the photos. 

Panniculectomy (Surgery to Remove Excess Skin and Fat from Belly) is not medically necessary for this patient.

InterQual criteria are a first level screening tool to assist in determining if proposed services are clinically indicated and provided in the appropriate level or whether further evaluation is required. They are based on medical literature and updated yearly. Their criteria for massive weight loss without bariatric surgery and panniculus extends below the level of the symphysis pubis AND
1) Weight stable for 6 or more months [NOT MET because the documentation only covers 3 months] AND
2) A) Inability to maintain hygiene of lower abdominal and genital area [MET by history] OR
B) Nonhealing ulceration under panniculus [NOT MET by submitted photos] OR
C) Chronic maceration or necrosis of overhanging skin folds [NOT MET by submitted photos] OR
D) Recurrent or persistent skin infection under panniculus [NOT MET records describe rashes treated under the breasts] OR
E) Intertriginous dermatitis or cellulitis or panniculitis [NOT MET by submitted photos] AND
3) A) Local or systemic antibiotic treatment for 12 or more weeks did not work [NOT MET because duration of medical treatment of the pannus is not documented and differentiated from inframammary fold treatment] OR
B) Topical or systemic corticosteroid treatment for 12 or more weeks do not work [NOT MET because duration of medical treatment of the pannus is not documented and differentiated from inframammary fold treatment] OR
C) Topical antifungal medication treatment for 12 or more weeks do not work [NOT MET because duration of medical treatment of the pannus is not documented and differentiated from inframammary fold treatment]
Therefore, the Panniculectomy (Surgery to Remove Excess Skin and Fat from Belly) is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/Migraine Headaches
Treatment: Nurtec: Pharmacy/Prescription Drugs

The health plan denied the requested prescription drug Nurtec as not medically necessary.

The health plan's determination is upheld.

This is female who was prescribed Nurtec. The medical necessity determination indicated that there was confirmation of a Sumatriptan trial in pharmacy claims, but not of any other formulary Triptans, and chart notes dated not document any additional trials. While the appeal request indicated prior trials of Sumatriptan, Eletriptan and Zolmitriptan, there were no chart notes, documenting medication trials with and intolerance to or an inadequate response to Eletriptan, or Zolmitriptan, or another Triptans. A communication with the physician indicated that the patient had been treated for chronic migraines. She tried and failed Zolmitriptan and Eletriptan but did not provide any dates of treatments. She was treated with prophylactic medications and was placed on Sumatriptan that helped her breakthrough pain for a little while was no longer working for her. Continuation of Nurtec ODT was recommended.

At issue is the medical necessity of the requested prescription medication Nurtec.

The prior health plan's determination of medical necessity is upheld, in whole.

No, based on a lack of adequate trials of Triptan medications. While the patient claims prior treatment was Zomig, Zolmitriptan and Eletriptan, there is no documentation of the dates and durations of this in office notes, and there is only evidence of a trial of Sumatriptan. The physician did not request notes from the patient's prior headache specialist to determine the duration of treatment of these or any prior migraine medications and why they were stopped. The failure of response to one Triptan does not imply failure of another Triptan, and there is no rationale why the patient cannot have another trial of a trial of a different Triptan. In the absence of clear evidence that the patient has had trials and failures of more than one Triptan and in the absence of any evidence that of any contraindication to Triptans, the use of Nurtec is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dementia
Treatment: personal care aide
The insurer denied the personal care aide hours, 24 hours per day 7 days a week split shift. The health plan's determination is upheld.

The patient is a female with multiple medical problems including dementia, cerebrovascular disease, breast cancer with metastatic disease and generalized debility.

Personal Care Aide Service Hours: 24 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week is not medically necessary for this patient.

Per a skilled observation note, the patient is able to reposition herself in bed. The Patient is able to walk 40 feet with a walker with hands-on assistance.
Uniform Assessment System (UAS) State of New York dated notes that the patient is dependent on others for all activities of daily living (ADL) and Instrumental activities of daily living (IADL). It recommended total of 62 hours a week. The patient is currently approved for 24 hour live-in services.
The amount of services currently being provided are adequate to meet the patient's medical needs in the time noted. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not indicated. In order for services to be considered medically necessary, the aid must be performing a service such medically necessary ADL or IADL.
The documentation provided including the UAS, physician notes, and an appeal letter failed to demonstrate medical needs above and beyond a 24-hour live-in aide could provide. In specific, there was no reason noted why a live-in aid could not perform these services. There is no notation of why the patient would need more than 16 hours a day of care and that the aid could not get proper rest defined as at least 5 hours of interrupted sleep.