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

Diagnosis: Gastric Adenocarcinoma.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has a history of gastric adenocarcinoma. He presented to the hospital for a scheduled right subclavian Medi port placement, staging laparoscopy, omental biopsy, and hyperthermic intraperitoneal chemotherapy (HIPEC). A Foley catheter was placed, and the patient was admitted to the hospital. He was discharged the following day.

The patient presented for a scheduled right subclavian Medi port placement, staging laparoscopy, omental biopsy, and HIPEC. Chart reflects an uncomplicated course following the procedure. This individual could have been managed at an alternative level of care; specifically observational status as less than 24-hour stay was expected for these minor surgical procedures. Therefore, the inpatient admission is not considered medically necessary for this patient. 

The health care plan did act 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.

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

Diagnosis: Symptomatic Atrial Flutter. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient is a gentleman that presented to the hospital with complaints of shortness of breath, lightheadedness and diaphoresis and palpitations. Past medical history was significant for myocardial infarction, CABG (coronary artery bypass, graph) diabetes mellitus, COPD (chronic obstructive pulmonary disease), TIA (transient Ischemic attack) and ulcerative colitis.  Upon arrival to the hospital, physical examination revealed hypertension (133/104mmHg [millimeters of mercury]) and tachycardia with a pulse of 150 beats per minute. No other pertinent physical findings were noted.  A 12-lead electrocardiogram (EKG) was significant for atrial flutter with 2:1 conduction and a rapid ventricular rate of 150bpm. T wave (interval on EKG) inversions and ST (interval on EKG) depressions were noted in leads I, aVL (augmented vector left) and V4 (lead 4) through V6. Serum blood testing was significant for mild hypokalemia with potassium of 3.4 meq/L (milliequivalents per liter). Serum troponin was not elevated (<0.015ng/ml [nanogram per liter]).  The patient was treated with intravenous diltiazem and atrial flutter terminated within 20 minutes.    Echocardiogram demonstrated an LV (left ventricular) ejection fraction of 45% (percent) and mild left ventricular hypertrophy.  The patient was admitted to the hospital for observation and treatment. He remained in sinus rhythm and was discharged. 

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.  This patient presented with symptomatic atrial flutter and following treatment with AV (atrioventricular) nodal blocking agents reverted to normal sinus rhythm.  Following evaluation and additional testing, the patient was released from the hospital.  Bellew et. al. studied patients presenting to the hospital with rapidly conducted atrial fibrillation and atrial flutter and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department.  In this study of almost 600 patients, there was no difference in outcome.  AHA (American Heart Association) guidelines note that admission to the hospital for management of atrial fibrillation or atrial flutter in patients that achieve rate control do not require hospital admission (Reference 2) This patient reverted to normal sinus rhythm twenty minutes after presentation.  In conclusion, this patient could have been managed at a lower level of care.  Inpatient hospital admission was not medically necessary. 

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 admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (Gastroesophageal Reflux Disease).

Treatment: procedure code 43284, surgery to place an esophageal sphincter augmentation device.

The insurer denied coverage for procedure code 43284, surgery to place an esophageal sphincter augmentation device.

The denial is overturned.

This case involves a male diagnosed with GERD.  According to an encounter, the patient was seen via telemedicine regarding gastroesophageal reflux disease and a small hiatal hernia.  Endoscopy showed a small hiatal hernia.  Pathology showed no evidence of Barrett's esophagus.  pH (potential of hydrogen) study showed a DeMeester score of 17 while on high-dose acid suppressive therapy.  Manometry showed normal motility.  Esophagram showed gastroesophageal reflux disease with a very small hiatal hernia.  The patient continued to maintain on daily Nexium, Carafate, and famotidine with little relief.  The patient was recommended for a LINX procedure.

The patient has refractory GERD with no hiatal hernia or Barrett's esophagus.  Maximal medical treatment has not been able to correct his reflux. A surgical or endoscopic procedure to control reflux is the next appropriate step. LINX procedure was approved by the Food and Drug Administration (FDA) and is no longer considered experimental. It does require careful selection of patients as noted below.

In addition to confirmed gastroesophageal reflux disease (GERD), initial guidance provided by the manufacturer also suggested that patients should have:
No hiatal hernia >3 cm (centimeters) or a paraesophageal hernia
No esophagitis worse than Los Angeles (LA) class A or B
Adequate esophageal motility with >70 percent of effective swallows and a distal wave amplitude >35 mmHg (millimeters of mercury)
Body mass index (BMI) <35 kg/m2 (kilograms over height in meters squared)
No Barrett esophagus
No prior esophageal or gastric surgery

He fulfills these criteria. Therefore, LINX procedure is appropriate, and the prior determination is overturned.

The carrier's denial of procedure code 43284, surgery to place an esophageal sphincter augmentation device should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease).

Treatment: procedure code 43284, surgery to place an esophageal sphincter augmentation device.

The insurer denied coverage for procedure code 43284, surgery to place an esophageal sphincter augmentation device.

The denial is overturned.

The patient has a history of esophageal reflux disease. He had a previous workup including endoscopy, esophageal manometry, esophagram, and pH (potential of hydrogen) testing. He has been on treatment with Nexium, Carafate, and famotidine with little relief. His physician has advised the LINX procedure.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Efficacy Analysis of the LINX Reflux Management System With regards to safety, the conclusion was that long term follow up supports the FDA (Food and Drug Administration) conclusion that the device is safe. With regards to efficacy there were several conclusions. The LINX implant results in pH (potential Hydrogen) normalization, improved quality of life, and cessation of regular PPI (proton pump inhibitor) use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating GERD (gastroesophageal reflux disease) symptoms and dysphagia are similar following LINX. The long term follow up data demonstrates that the LINX Reflux Management System is effective in the management of GERD.

The LINX Reflux Management System has been shown in the peer-reviewed scientific literature to result in improvement in health outcomes. It has approval from the FDA and patient is a good candidate because he has a long history of continued GERD symptoms on high dose acid suppressive therapy. There are several options available for the treatment of GERD, but the LINX procedure has been shown to be safe and effective. The patient has had an extensive workup for GERD and is a good candidate for the LINX procedure.

The carrier's denial of procedure code 43284, surgery to place an esophageal sphincter augmentation device should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back and leg numbness after a trauma
Treatment: Back Surgery (anterior lumbar interbody fusion) and Inpatient Hospital Admission
The insurer denied the Back Surgery (anterior lumbar interbody fusion) and Inpatient Hospital Admission.
The denial is upheld.

The patient is a female with back and leg numbness after a trauma. The patient has attempted PT (physical therapy), NSAIDs (nonsteroidal anti-inflammatory drugs), chiropractic care, Neurontin, ESI (epidural steroid injection). MRI (magnetic resonance imaging) shows L3-4 (third lumbar spine vertebra-fourth lumbar spine vertebra) foraminal narrowing, lateral recess narrowing at L5-S1 (fifth lumbar spine vertebra-first sacral vertebra) with severe bilateral foraminal narrowing and central disc herniation. X-ray does not show subluxation.

No, the requested Back Surgery (anterior lumbar interbody fusion) and Inpatient Hospital Admission was not medically necessary.

The patient has attempted an adequate trial of nonsurgical management, but the imaging does not demonstrate a significant pathology that would warrant the fusion recommended. The patient has stenosis without evidence of instability or other finding that warrants fusion. Therefore, this is not considered medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

This patient does not have any pathology that warrants fusion. This patient has stenosis which could be resolved with a simple decompression. There is no clear indication or evidence to support the need for fusion in this setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure and COPD exacerbation
Treatment: Skilled Nursing Facility Admission
The insurer denied the skilled nursing facility admission.
The health plan's determination is overturned. 

The patient is a male with past medical history of diabetes, chronic obstructive pulmonary disease (COPD), hyperlipidemia, atrial fibrillation, who presented for shortness of breath. Review of system was negative for additional clinical symptoms. The patient was febrile upon admission. His blood pressure was 124/73, pulse rate of 44, respiratory rate of 19, and oxygen saturation of 98% (percent) on room air. Physical examination was remarkable for erythematous area of the right axilla and right gluteal fold. The patient was admitted to a skilled nursing facility for congestive heart failure and COPD exacerbation. 

The skilled nursing facility admission was medically necessary. The patient was observed to have reduced ADLs (activities of daily living) participation and increased need for OT (occupational therapy) services. The patient was deemed to benefit from skilled PT (physical therapy) intervention to address impairments for potential to improve functional status and mobility for improved quality of life and decrease fall risk.

The patient was admitted for acute congestive heart failure and COPD exacerbation requiring IV (intravenous) diuretics and nebulizers. More importantly, the patient was noted to have impaired ADLs, increase risk of fall, and overall functional impairment. The patient required the skilled nursing facility admission for establishment of safe discharge plan of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems-Class II Malocclusion.
Treatment: Dental/Orthodontic Procedure- Comprehensive Orthodontic Treatment.
The insurer denied Comprehensive orthodontic treatment.
The denial is overturned. 

The patient is a male with a buccal (reverse) crossbite on number (#)5. He has maxillary spacing and mandibular crowding. He presents with a Class II malocclusion. He has treatment planned for orthodontics to correct the malocclusion, but the health plan has denied treatment due to lack of medical necessity. The family is appealing.
At issue is the medical necessity of Comprehensive orthodontic treatment.

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

Yes, the requested health service/treatment of Comprehensive orthodontic treatment is medically necessary for this patient.
Because tooth #5 is in buccal crossbite, it has no antagonist. As a result, it is extremely likely that this tooth will over-erupt. Once this overeruption occurs, it is very difficult to treat. Buccal crossbite (also known as scissor-bite in the literature) can negatively affect mandibular growth and should be treated as early as possible to eliminate the potential growth disturbance. If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem.
Therefore, the requested health service/treatment of Comprehensive orthodontic treatment is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Subarachnoid hemorrhage
Treatment: Inpatient hospital admission 
The insurer denied the inpatient hospital admission. 
The denial is overturned.

The patient is a male who was hit in the head by his surfboard while surfing. In the emergency department, the patient was found to have a small right temporal subarachnoid hemorrhage. He was admitted to the surgical intensive care unit (SICU) for hourly neurological checks, neurosurgery consultation, and repeat head computed tomography (CT). A repeat head CT did not show any worsening of the bleed. Neurosurgery cleared the patient for discharge to home with outpatient follow up. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is overturned in whole. 

This is a medically necessary inpatient hospital admission. This patient had an acute traumatic subarachnoid hemorrhage and the surgical team determined that the patient required vital sign monitoring every hour and SICU admission. Subarachnoid bleeds can progress, leading to rapid neurologic deterioration and death. It is essential to have inpatient Intensive Care Unit (ICU) nursing staff or staff from a dedicated neurosurgery unit monitoring a patient with a subarachnoid bleed. Milliman Care Guidelines (MCG) guidelines were cited by both the plan and facility. Of note, MCG guidelines state that inpatient hospital admission is appropriate if an intracranial injury requires neurologic monitoring more frequently than every 4 hours. The care team determined that the patient required inpatient care at the ICU level and that was provided to the patient. Given the devastating consequences of missing progression of the patient's neurologic injury, this was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose veins
Treatment: Endoluminal radiofrequency ablation of the left great saphenous vein CPT (current procedural terminology) code 36475 x 1.
The insurer denied coverage for an endoluminal radiofrequency ablation of the left great saphenous vein (CPT code 36475 x 1).
The denial is overturned.

The patient presents with left leg symptomatic varicose veins. Her main symptoms include aching, tenderness, and fatigue. Her provider clearly documents that her symptoms interfere with her activities of daily living. She has attempted and failed conservative therapy with graded compression stockings without symptomatic relief. Conservative therapy has included elevation, compression, exercise and over the counter medications without relief. Her duplex ultrasound demonstrates reflux in her left great saphenous vein. Her provider is recommending endovenous ablation of her left great saphenous vein for treatment of her condition.

A landmark study was conducted by Nordon and colleagues, comparing the efficacy of both radiofrequency and laser ablation. This was a double-blind, randomized controlled trial. The authors wrote that endovenous ablation of varicose veins using radiofrequency ablation (RFA) and endovenous laser therapy (EVLT) has reported advantages over traditional open surgical treatment. There is little evidence comparing the efficacy and patient-reported outcomes between the 2 endovenous solutions. RFA is associated with less periprocedural pain, analgesic requirement, and bruising.

A recent study by Puggina and colleagues demonstrated excellent results following radiofrequency ablation for patients with venous ulcers. The aim of the study was to investigate whether radiofrequency endovenous ablation (RFA) of saphenous and perforating veins increases venous leg ulcer (VLU) healing rates and prevents ulcer recurrence. This prospective, open-label, randomized, controlled, single-center trial recruited 56 patients with VLU divided into: compression alone (CR (complete response)), N = 29) and RFA plus compression (RF (radiofrequency), N = 27). Primary endpoints were ulcer recurrence rate at 12 months; and ulcer healing rates at 6, 12, and 24 weeks. Secondary endpoints were ulcer healing velocity; and Venous Clinical Severity Score (VCSS). Recurrence was lower in the RF group (p (probability) < .001), as well as mean VCSS after treatment (p = .001). There were no significant between-group differences in healing rates. Healing velocity was faster in the RF group (p = 0.049). In the RF group, 2 participants had type 1 endovenous heat-induced thrombosis (EHIT). RFA plus compression is an excellent treatment for VLU because of its safety, effectiveness, and impact on ulcer recurrence reduction and clinical outcome.

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

The insurer's denial of coverage for an endoluminal ablation of varicose veins (procedure code 36475) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Remicade. 
The denial is overturned. 

This is a male patient who has been on Remicade therapy. He had severe, fistulizing Crohn's disease with chronic pain, diarrhea, weight loss and failure to thrive. He failed several medications. Since commencing Remicade therapy, his life has changed dramatically for the better. He is virtually asymptomatic, completed college and is gainfully employed. He has continued to do well on infliximab 10 milligrams (mg) /kilograms (kg) for years without adverse effects. For years he was treated unsuccessfully with a number of conventional therapies for inflammatory bowel disease (IBD) with poor results.
At issue is the medical necessity of Remicade.

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

The requested health service/treatment of Remicade is medically necessary for this patient.
This request is for continuation of therapy not a new start, thus a switch to a formulary preferred medication at this time is not advised. Generally, medicines are not switched in a patient who has been stabilized for several years on a prior medication. The patient has been on this medication with a good response, switching medicine for a non-medical reason is not advisable per American College of Rheumatology (ACR) guidelines.
The formulary medicine has a different mechanism of action which might worsen the patient's Crohn's control. The tumor necrosis factor (TNF) agents are not freely interchangeable and there is individual variability in response. This is a continuation of therapy that the patient has already improved on this medicine. Switching his medicine can worsen the disease state and destabilize the patient.
Therefore, the requested health service/treatment of Remicade is medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Pulmonary hypertension

Treatment: Personal care assistance (PCA) services 56 hours per week

The insurer denied coverage for PCA services 56 hours per week.

The denial is modified.

This is a patient with chronic medical problems including pulmonary hypertension requiring nasal oxygen. She currently has PCA services 30 hours/week. Under review is the requested increase PCA services 56 hours per week.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is intact. She is "alert and oriented to person, place and time". The patient is able to articulate safety precautions; "able to verbalize an emergency preparedness plan for example in the event of a fire in the home; member reports she would try to leave the home and then call 911 and seek further assistance; member is also aware that her oxygen is highly flammable and requires need for her to exit immediately in the event of a fire." The patient requires limited assistance for activities of daily living (ADL) tasks including bathing, personal hygiene, dressing and toilet transfers/use. She is frequently incontinent of bladder and continent of bowel. The patient is independent with bed mobility. She uses a (hybrid; manual/motorized) wheelchair or cane for functional mobility. Due to her underlying pulmonary condition, the patient uses a portable oxygen tank with oxygen concentrator. The combination of the patient's intact cognitive status, ability to perform ADL tasks with only limited assistance and her functional mobility, do not support the medical necessity of the requested increase PCA services 56 hours per week. However, increasing PCA to 35 hours/week (5 hours/day) would allow for more consistent daily care and allow the patient the ability to continue living safely at home.  

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

The insurer's denial of coverage for personal care assistance (PCA) services 56 hours per week is modified. Medical Necessity is substantiated for 35 hours/week.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankylosing spondylitis 
Treatment: Cosentyx 
The insurer denied Cosentyx. 
The determination is upheld. 

The patient has ankylosing spondylitis (AS). Prior treatment included non-steroidal anti-inflammatory drugs (NSAIDs) and topical therapies. The health plan denied the requested Cosentyx as the patient has not tried 2 preferred drugs: Enbrel, Humira, Taltz and Xeljanz/extended release (XR). The issue under review is the medical necessity of Cosentyx 300 milligrams (mg). 

The requested health service/treatment of Cosentyx pen is not medically necessary for this patient. There is no medical reason the patient cannot try 2 of the preferred drugs, Enbrel, Humira, Taltz and Xeljanz/XR, which are all indicated to treat AS. A study published in Arthritis Rheumatology in 2019 concluded that "ixekizumab (taltz) treatment for 16 weeks in patients with active radiographic axial spondyloarthritis (SpA) and previous inadequate response to or intolerance of 1 or 2 tumor necrosis factor (TNF) inhibitors yields rapid and significant improvements in the signs and symptoms of radiographic axial SpA versus placebo." Another study in Expert Opinion Biological Therapy in 2018 concluded that "beyond the clear efficacy of anti-TNF inhibition, interleukin (IL)-17 offers an alternative therapeutic target and there is promise from inhibition of the IL-17/IL-23 pathway and small molecules, such as Janus kinase (JAK) inhibitors." In summary, there are many options for the treatment of AS and there is no medical reason the patient cannot try one of drugs on the health plan's formulary.