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

Diagnosis: CVA (cerebrovascular accident), COVID-19
Treatment: Long-term care facility admission 
The insurer denied the Long-term care facility admission.
The denial is upheld. 

The patient is a male with history of Left CVA (cerebrovascular accident) and Right hemiplegia with slurred speech with acute infarct in Left MCA (middle cerebral artery) and who also later developed COVID-19 (coronavirus disease 2019) pneumonia.

The patient has a relevant past history of marantic endocarditis, polysubstance/cocaine abuse, Diabetes Mellitus, Prostate cancer, hypertension, coronary artery disease, hypoparathyroidism, etc.

Prior to admission, the patient was independent and living in a shelter.

The patient was admitted to a Long-Term Acute Care (LTAC) facility. A couple of weeks later he was medically stable, requiring minimum assistance with most ADLs (activities of daily living) including transfer, dressing/bath and independent with feeding.

No, the continued stay in LTAC (long term acute care) is not medically necessary.

The patient was admitted to a Long-Term Acute Care (LTAC) facility. He was medically stable, requiring minimum assistance with most ADLs (activities of daily living), including transfer, dressing/bath and independent with feeding a few weeks later. Therefore, continued stay in LTAC (long term acute care) was not medically necessary, as his ADLs (activities of daily living) level had improved to a level such that he did not need further stay in LTAC (long term acute care) while he remained medically stable. His needs could be met at a lower level of care such as outpatient PT/OT (physical therapy/occupational therapy) or Home therapy.

As stated above, the continued stay in LTAC (long term acute care) was not medically necessary. The clinical evidence was showing improvement such that further stay in LTAC (long term acute care) is not reasonably expected to be health beneficial for the patient, and/or withholding it in whole or in part, is not reasonably expected to affect the patient's health adversely, as the patient requires mostly contact-guard for most ADLs (activities of daily living).
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Restless Leg Syndrome.
Treatment: Horizant 300MG OR TBCR
The insurer denied Horizant 300MG OR TBCR.
The determination is overturned.

The patient has with restless leg syndrome. The patient has been taking Horizant 600 MG (milligrams) or TBCR (tablet controlled release) nightly since approximately 2018 with good response. The documentation also indicates that the patient has tried and failed opioids, gabapentin, pregabalin, and pramipexole. 
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, Horizant or would have adverse effects. All of the formulary drugs [pramipexole, ropinirole, pregabalin, and gabapentin] will be or have been ineffective or would not be as effective as the non-formulary drug, Horizant 300 MG(milligrams)  OR TBCR (tablet controlled release). The patient has previously tried and failed 3 formulary drugs including gabapentin, pregabalin, and pramipexole. The other dopamine agonists ropinirole would not be expected to be as effective as the requested Horizant because the dopamine agonist pramipexole was not effective  The mechanism of action is the same and pramipexole is regarded as the more effective drug as compared to ropinirole. Additionally, the patient has been on the requested drug for several years with noted improvement in the restless leg syndrome as documented in the provider's note.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Gynecological. 
Treatment:  Pharmacy/Prescription Drug. 
The insurer denied Makena. 
The denial is upheld in whole.

The patient is a female who is pregnant with diamniotic dichorionic twins as a result of In Vitro Fertilization (IVF). She has a prior history of prior preterm deliveries due to suspected preeclampsia at 36 weeks and a prior pregnancy with preterm, premature rupture of membranes at 33 weeks gestation with a twin gestational age. She had suspected preeclampsia in two prior pregnancies. The patient was offered Makena at 16 weeks and accepted this therapy as a preventative agent for preterm birth given her history. The subject under review is consideration for Makena (hydroxyprogesterone caproate) for the indication of supervision of pregnancy with history of preterm labor, second trimester.

The health plan's determination is upheld in whole.

In this case, there is no formulary alternative to Makena in the prevention of preterm birth. Current guidelines in the United States by the American College of Obstetrics and Gynecology (ACOG)  and supported by one of the two randomized controlled trials of this intervention recommend the use of progesterone supplementation in a singleton gestation by 17-hydroxyprogesterone caproate 250 mg from 16 to 36 weeks gestation in women with prior, singleton spontaneous preterm birth or preterm rupture of membranes between 20 0/7 weeks gestation and 36 6/7 weeks gestation. In this case, the history to support that the patient has a prior spontaneous preterm birth or singleton prior affected gestation is not clearly found. There are two prior pregnancies that are complicated by preeclampsia. The use of Makena would not be recommended in these cases. The patient in this case is also carrying a twin gestation for which Makena has been studied and found to be ineffective in prevention of preterm birth when used in twins. Thus, again, Makena is not indicated in this presentation. For this reason, there would be no recommendation for the use of Makena in this case. There would be no indication for the use of the non-formulary drug Makena in this case given this patient does not have a current singleton gestation and this agent is not approved for use in twin pregnancy and has been specifically shown not to be effective in twin pregnancy as an agent for reduction of preterm birth risk.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck Pain (s/p cervical discectomy and fusion)
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female who underwent anterior cervical discectomy and fusion C5-6 and C6-7. Intraoperative durotomy was noted during surgery.  The patient had a history of axial neck pain radiating to her shoulder blades and arms with numbness and tingling.  She had reportedly failed conservative treatment.  She was treated with intravenous (IV) antibiotics, intravenous (IV) Solu-Cortef, post-operatively.  Her drain was removed and she was discharged home. 

Yes, the inpatient admission and extended hospital stay were medically necessary.  

This patient had a dural tear (durotomy) or complication during surgery that should be monitored closely for symptoms including neck swelling and the drain was appropriate.  It would not be medically appropriate to send the patient home with a drain in the setting of a dural tear/leak.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is a male with diabetes, hypertension, and chronic kidney disease who presented with blurry vision, paresthesia in extremities, increased thirst, and polyuria. Blood pressure (BP) was 106/71, and heart rate 110. Glucose was 630 mg/dL. PH was 7.405, Bicarbonate (HCO3) was 25.5, ketones negative, and osmolality 307. He was treated with intravenous fluids. He was given 8 units of regular insulin intravenously and subcutaneous Lantus and lispro in the emergency department. 

The inpatient hospital admission was not medically necessary. This patient presented with hyperglycemia and dehydration in the setting of known type 2 diabetes. He had mild tachycardia that resolved with hydration. His heart rate improved to 78. He was hemodynamically stable. He did not have evidence of sepsis or infection. He had hyperglycemia but his pH was in the normal range at 7.405. Therefore, he did not have acidosis to support a diagnosis of diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar state. His glucose improved with hydration and insulin therapy. His glucose improved to 233 mg/dL on subcutaneous insulin. His insulin doses could have been titrated at a lower level of care. Therefore, the requested inpatient stay was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: Surgical Services (LINX Reflux Management System)
The health plan has denied the requested procedure. 
The health plan's determination is upheld.

This patient is a male Body Mass Index (BMI)(not included with review material) who sought surgical evaluation for the condition of heartburn. The submitted records do not include a surgical history and physical that provides clinical detail on his symptoms, prior treatment efforts, past surgical history, and comorbid health conditions. The records do not indicate if the patient has symptoms of dysphagia.

He has been evaluated for this condition with:
Esophagram showed normal esophageal motility and a tiny sliding hiatal hernia.

Esophagogastroduodenoscopy (EGD)  that showed grade B esophagitis in the gastroesophageal (GE) junction and a small hiatal hernia.

Esophageal motility showed adequate peristalsis of the esophagus. There was a no manometric hiatal hernia and normal distal contractile integral.

A potential hydrogen (pH) study  identified an elevated esophageal acid exposure with a composite DeMeester score of 51.4 over 24-hours of study (nl < 14.7).

The treating surgeon has proposed the LINX procedure as treatment of gastroesophageal reflux disease (GERD).

Uphold in whole the health plan's determination regarding the proposed LINX.

No, based on the records sent for review, it cannot be said that the proposed LINX procedure will be more beneficial than standard treatment for the insured's condition. The submitted records do not include a surgical history and physical that provides clinical detail on his symptoms, prior treatment efforts, past surgical history, and comorbid health conditions. While this patient has proven and pathologic esophageal acid exposure based on endoscopy and pH testing and has adequately preserved esophageal function based on motility testing and esophagram, the absence of a recent surgical H&P that details symptoms, prior treatment efforts, past surgical history, and comorbid health conditions precludes determination as to the benefit of the proposed treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: Surgical Services (LINX Reflux Management System)
The health plan has denied the requested procedure. 
The health plan's determination is overturned.

The patient is a male evaluated for epigastric abdominal pain. Upper gastrointestinal (GI) endoscopy showed upper third and middle third of the esophagus were normal, Los Angeles Grade C esophagitis with no bleeding seen in distal esophagus (biopsies taken), a 2 centimeter (cm) hiatal hernia, patchy/severely erythematous mucosa without ulcer or bleeding in prepyloric region of stomach (biopsies taken), gastric fundus and gastric body were normal, (biopsies taken), duodenal bulb and second portion of the duodenum were normal (biopsies taken). Instructions were to resume trigger foods, avoid eating within 3 hours of bedtime, minimize nonsteroidal anti-inflammatory drug (NSAID) use, use Prilosec 40 mg po twice daily (BID) for 8 weeks and then taper to once daily, repeat upper endoscopy in 12 weeks to evaluate response to therapy. Follow-up endoscopy was performed which showed Los Angeles Grade B esophagitis with no bleeding in the distal esophagus (biopsies taken), upper third and middle third of the esophagus were normal, Z-line(squamocolumnar mucosal line) appeared regular and was found 38 cm from incisors, gastric fundus and gastric body were normal, patchy mild erythematous and congested mucosa without bleeding in gastric antrum, duodenal bulb and second portion of duodenum normal (biopsies taken.)
 
I overturn in whole the health plan's determination regarding the proposed health service or treatment.

Yes. The proposed health service or treatment LINX Reflux Management System 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 chronic gastroesophageal reflux disease (GERD) that is not responding to medical therapy. In recent years, there have been a growing number of publications describing potential adverse effects of chronic proton pump inhibitor (PPI) treatment. These include increased risk of hip and spine fractures, community-acquired pneumonia, Clostridium difficile colitis, vitamin and mineral deficiencies, gastric fundic gland polyps, rebound acid secretion, and inhibition of the antiplatelet effects of Clopidogrel. Due to these potential long-term complications, as well as common side effects, such as headache, abdominal pain, diarrhea, and nausea, patients are referred for surgical management to avoid long-term PPI use. When medical therapy is insufficient (as in this patient), surgical therapy is indicated, and Laparoscopic fundoplication has constituted the gold-standard method. However, magnetic sphincter augmentation (MSA) using the LINX Reflux Management System has emerged and disputes the standard therapeutic approach.The Linx Reflux Management System was designed for the treatment of GERD.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: Surgical Services (LINX Reflux Management System)
The health plan has denied the requested procedure. 
The health plan's determination is overturned.

The patient is a man with gastroesophageal reflux and heartburn symptoms refractory to medical management. Evaluation has shown a small sliding hiatal hernia, otherwise normal esophagram without gastroesophageal reflux noted. An upper gastrointestinal (GI) endoscopy showed a Grade B esophagus with no bleeding. The Z line (the squamocolumnar mucosal line) was regular at 38 centimeters (cm) with normal gastric fundus and gastric body normal. Biopsies were taken without significant findings.

The treating surgeon has requested esophageal sphincter augmentation with the LINX system (Reflux Management System) current procedural terminology (CPT) 43284. The issue under review is the use of the LINX system.

The health plan's determination is overturned, in whole. 

Yes, the proposed health service or treatment LINX Reflux Management System is likely to be more beneficial than any standard treatment or treatments for the insured's disabling/life threatening condition or disease.

The proposed health service, esophageal augmentation/LINX procedure has been shown to be safe and effective for gastroesophageal reflux disease (GERD) in multiple studies including randomized clinical trial and propensity matched studies as well as received Food and Drug Administration (FDA) clearance and societal approval for patients with this condition in a subset of patients.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of hypertension, gastroesophageal.
reflux disease (GERD), anemia and chronic. kidney disease. Chronic Urticaria.
Treatment: Xolair 150MG/ML SC Sosy.
The insurer denied the Xolair 150MG/ML SC Sosy.
The denial is overturned. 

The patient is a female with a history of chronic idiopathic urticaria unresponsive to H1 (histamine 1) and H2 (histamine 2) antihistamines. The request is approval for Xolair.

Yes, the treatment with Xolair is medically necessary.

The patient is older than 12 years of age. The patient experienced inadequate response or intolerance to second generation H1 (histamine 1) antihistamines with cetirizine 10mg (milligrams) twice a day. The patient tried dose advancement of H1 (histamine 1) antihistamine, as cetirizine was increased from once a day to twice a day. The patient tried addition of another H2 (histamine 2) antihistamine in the form of famotidine. The patient tried leukotriene receptor inhibitors for at least six weeks in the form of montelukast. The patient tried first generation H1 (histamine 1) antihistamines at bedtime in the form of hydroxyzine 25mg (milligrams) at night. The patient tried dose advancement of H1 (histamine 1)  antihistamines. The patient therefore meets guidelines for Xolair for the indication of chronic idiopathic urticaria.

The patient has shown persistent refractory symptoms of hive on face, body despite treatments with multiple H1 (histamine 1)  antihistamines in combination with H2 (histamine 2) antihistamines and montelukast.  The patient is a young person with active lifestyle. Overmedication with multiple antihistamines can lead to excessive drowsiness, which can further impact school and work.  

Omalizumab (Xolair) has received FDA (Food and Drug Administration) approval for the treatment of patients with chronic Idiopathic Urticaria in adults and adolescents (12 years of age and above) who remain symptomatic despite H1 (histamine 1) antihistamine treatment.   Based on the clinical information provided, the patient has remained symptomatic with urticaria despite H1 (histamine 1) and H2 (histamine 2) antihistamine treatment and will benefit from omalizumab treatment.

Therefore, given the above, the treatment with Xolair is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Possible seizure.
Treatment:  Inpatient admission for Video Electroencephalogram (VEEG) Monitoring.

The insurer denied Inpatient Video Electroencephalogram (VEEG) Monitoring.  The health plan's determination is upheld. 

The patient is a girl with a history of tics and obstructive sleep apnea.  She has recently started having paroxysmal events consisting of cough and hiccups, along with episodes of eye blinking and eye spasms.  Her neurologist suspected that the spells might be epileptic in nature and ordered an electroencephalogram (EEG).  The EEG was abnormal, as it revealed left occipital spike-wave activity, which was epileptiform in nature.  To better determine whether the spells are actually epileptic, the provider ordered a video EEG (VEEG) to be conducted on an inpatient basis.  The health plan has approved the VEEG but has not approved the inpatient hospital admission for the VEEG.

The Inpatient Video Electroencephalogram (VEEG) Monitoring is not medically necessary for this patient.  VEEG is a technique that combines video recording with EEG technology to assess the nature and frequency of paroxysmal events, including seizures.  The patient has paroxysmal events of an unclear nature.  It is possible that they are epileptic in nature, but this is not known for certain.  It is reasonable for the patient to undergo VEEG monitoring at this time.  However, it is not medically necessary for the patient to be admitted at an acute level of care for the VEEG to be conducted.  The patient is currently medically stable, and she is at her baseline and on no medications.  The VEEG could be conducted at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory
Home Health Care

Diagnosis: Atrial fibrillation/hypertension
Treatment: Consumer and Self-Directed Personal Care Services
The insurer denied the Consumer and Self-Directed Personal Care Services - 56 Hours a Week. The health plan's determination is upheld. 

The patient is a female with past medical history of hypertension, atrial fibrillation, chronic pain, osteoarthritis, permanent pacemaker, abnormal gait, and urinary incontinence who had been assigned 42 CDPAS (Consumer and Self-Directed Personal Care Services) hours/week. The patient's PCP (primary care provider) wrote a letter stating the patient needs help with activities of daily living (ADL) and has been assigned 6 hours/day, 7 days/week but continues to be at risk when alone. The PCP letter further states the patient was told to request 8 hours/day, 7 days/week and needs the additional hours to avoid being alone given her fall risk. With this request for increase CDPAS hours the patient underwent telephonic assessment tool and was assessed at maximal assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs, transportation, bathing, dressing lower body, and toilet use. The patient was assessed at limited assistance with tasks of managing finances, managing medication, personal hygiene, dressing upper extremity, walking, locomotion, transfer toilet, and bed mobility while set up only with task of phone use. The assessment noted the patient lives alone, is using a cane, declined CDPAS, and has an informal helper of a child/child in law. 

The Consumer and Self-Directed Personal Care Services - 56 Hours a Week is not medically necessary for this patient.

The patient's provider indicated the patient needed increase in CDPAS hours to prevent her from being alone due to fall risk. The plan recommended discussing her medical conditions of hearing and vision decline with her provider. The plan also recommended physical therapy for the patient as well as rearranging allotted hours to better meet her care needs. There was not sufficient evidence provided that the patient has increased care needs with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) outside of the time she has an informal helper, other than the need for safety and supervision monitoring. The services allotted by the health plan are sufficient to meet the patient's needs.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorder
Pharmacy/prescription drugs

Diagnosis: Rosacea
Treatment: Soolantra
The insurer denied Soolantra.
The health plan's determination is upheld. 

The patient is a female with rosacea, for which Soolantra 1% cream is under review for medical necessity. Doxycycline (50 mg/day) has been prescribed and utilized but was not utilized for a 12-week consecutive trial as per the history. Topical Metrogel has been prescribed and filled. The use of Soolantra is under review for medical necessity.

Soolantra Cream is not medically necessary for this patient.

The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line topical therapies (such as sustained topical Metrogel, Finacea, or Permethrin) or systemic therapies such as either Minocycline or Doxycycline. Furthermore, Doxycycline previously utilized was at a low dose (50 mg/day) that would not be anticipated to benefit this patient. Therefore, consistent with current literature and standards of care, the requested 1% Soolantra cream is not medically necessary.