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

Diagnosis: GERD
Treatment: LINX procedure
The insurer denied the LINX procedure. The health plan's determination is upheld. 

This patient is a woman (body mass index (BMI) 23.6)) who sought surgical evaluation for the condition of gastroesophageal reflux disease (GERD) characterized by heartburn, chest/epigastric pain. Her symptoms are partially responsive to treatment with daily proton pump inhibitor (PPI) medications and she has been taking these medications for the past one year. Per the recent consultation, the patient has undergone sleeve gastrectomy in the past as treatment of morbid obesity.

Considering the submitted documentation, the published literature, and the clinical details of this case, the requested LINX is not likely to be more beneficial than any standard treatment for the insured's condition.
While LINX is not experimental or investigational in the setting of pathologic esophageal acid exposure documented by potential hydrogen (pH) testing and in the absence of specific contraindication to the LINX device, in this case there is a history of prior gastric surgery (sleeve gastrectomy). This is a listed precaution/contraindication to the application of the LINX device. There is very limited published data regarding LINX in the post sleeve gastrectomy setting. While the publications listed below describe a favorable result in terms of decreased reflux symptomatology in two small series of patients, these are small sample size case reviews that are retrospective analyses with short term follow up. They do not provide enough support for the widespread application of LINX in this clinical circumstance.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD
Treatment: LINX procedure
The insurer denied the LINX procedure. The health plan's determination is upheld. 

This patient is a female who is 5 feet 7 inches tall, weighs 151 pounds giving a body mass index of 23.6. The patient has a history of morbid obesity status/post (s/p) laparoscopic sleeve gastrectomy in 2016. The patient has gastroesophageal reflux disease (GERD) with esophagitis despite medication intake.

The LINX Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
At this time, there is limited published data on the safety, efficacy and durability of LINX procedure after sleeve gastrectomy for the treatment of GERD. There are no long-term or high level studies done to support its use. A total of fewer than 30 patients have been treated. Ongoing evaluation in clinical trials should be considered to determine long term efficacy and safety. Bariatric surgery remains a relative exclusion to LINX treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trouble swallowing, eosinophilic esophagitis
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This is a male who was hospitalized. The patient has a history of eosinophilic esophagitis and alcohol (EtOH) use disorder. He presented with dysphagia. The ear nose and throat (ENT) doctor was consulted but deferred management to gastroenterology. Gastroenterology recommended nothing by mouth (NPO) with progression of diet as an inpatient. On day six, the patient choked on a piece of chicken at dinner. Repeat neck computed tomography (CT) scan showed calcification which was present on imaging and therefore the decision was made not to pursue esophagogastroduodenoscopy (EGD). Alcohol use disorder was managed with Gabapentin, multivitamin (MVI), thiamine, folate, and electrolyte depletion. The patient did not require sedation or benzodiazepine use.  

Day three, the patient was tolerating a full liquid diet. Day four, the patient's swallowing improved but the patient had mild neck pain. He was tolerating a full liquid diet.

No, the proposed inpatient hospital admission was not medically necessary.

The patient was clinically stable days three and four, tolerating a full liquid diet. The patient was not actively withdrawing from alcohol and did not require any sedation of benzodiazepine use. Based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question, as it exceeded in scope and intensity the level of care necessary to provide safe, adequate, and effective treatment for this patient's condition.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: schizophrenia.
Treatment: Personal Care Services: 24 Hours per Day (Two 12-Hour Shifts), 7 Days per Week - Total of 168 Hours per Week. 
The insurer denied Personal Care Services: 24 Hours per Day (Two 12-Hour Shifts), 7 Days per Week - Total of 168 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with a past medical history of vascular dementia, coronary artery disease, chronic obstructive pulmonary disease (COPD), urinary incontinence, bowel incontinence, gastroesophageal reflux disease (GERD), mild intermittent asthma, psoriasis, hypothyroidism, transient ischemic attack (TIA), schizophrenia, constipation, insomnia, osteoarthritis, hypertension, and diabetes mellitus type 2 who had been assigned PCA (personal care assistant) services.

Personal Care Services: 24 Hours per Day (Two 12-Hour Shifts), 7 Days per Week - A total of 168 Hours per Week are medically necessary for this patient.
There is documentation from the patient's PCP (primary care provider) and psychiatrist of worsening cognitive and physical functioning. This worsened following initial admission and subsequently worsened on the second admission when discharged. Due to the patient's cognitive decline and schizophrenia, the patient has insomnia. The patient wakes frequently with the need for help with eating, bed mobility, toileting, transfer toilet, and incontinence care.
The patient also requires encouragement to increase fluids because of her medications which can cause kidney damage which in turn causes her to urinate more. The patient would need prompting to drink more and with increased urination more help with incontinence care. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's request for an increase in PCA services is not solely for safety and supervision but to assist the patient with the safe completion of activities of daily living (ADL) / Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cavitary pneumonia
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female who presented to the emergency room with hemoptysis, fevers, chills, and weight loss. The computed tomography (CT) of the chest showed cavitary pneumonia and was concerning for tuberculosis. The patient was admitted to the acute in-hospital level of care for the management of cavitary pneumonia. The acute in-hospital level of care is denied due to medical necessity. This denial is being appealed.

No, the proposed treatment was not medically necessary.

The patient had cavitary pneumonia which caused a small amount of hemoptysis. The patient was treated with intravenous antibiotics. The patient had three sputum samples collected for tuberculosis. The patient was awaiting bronchoscopy which was performed. The patient was discharged home with antibiotics. 

The patient was hemodynamically stable and did not require supplemental oxygen. The patient was tolerating diet. The patient's hemoptysis was mild. The sputum acid-fast bacillus (AFB) stains were negative. The patient could have been treated at a lower level of care and the proposed treatment is not medically necessary.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

Since the patient was hemodynamically stable, and the treatment included antibiotics as well as sputum collection, it would have been reasonable to expect the patient's treatment course would have been safe and effective at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis Vulgaris. 
Treatment: Humira (cf) pen psor-uv-adol (psoralen and ultraviolet A therapy) hs (high-sensitivity) 80mg (milligrams) - 40mg (milligrams) pen ij (injection) Kit. 
The insurer denied the Humira (cf) pen psor-uv-adol (psoralen and ultraviolet A therapy) hs (high-sensitivity) 80mg (milligrams) - 40mg (milligrams) pen ij (injection) Kit. 
The denial is upheld. 

The patient is a female diagnosed with moderate to severe psoriasis. She has been prescribed Humira, which was denied coverage by the health plan. The treating provider is appealing the denial. 

No, the requested Humira is not medically necessary. 

The provider has stated that the patient cannot take methotrexate due to an interaction to pantoprazole, however the patient has no documented contraindication to alternatives cyclosporine or acitretin. These systemic alternatives have demonstrated safety and efficacy in treating moderate to severe psoriasis. There is no indication that the patient could not do well on one of these alternatives. There is no indication that taking an alternative would cause a barrier to patient adherence. 

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

There are safe and effective systemic treatment alternatives for the patient's disease and there are no documented contraindications to these alternatives. There is no documentation supporting that patient adherance would be an issue in taking a preferred medication. 

Per Choi, C. et al.,  "The use of cyclosporine at doses of 2.5 to 5 mg/kg [milligrams/kilogram] per day for 3 to 4 months showed significant improvement of psoriasis in up to 90% of patients." 

Zurita, C et al. concludes "MTX [methotrexate] is an effective and safe option for the treatment of psoriasis in the real-world clinical practice." 

Per Menter, A. et al , "low-dose methotrexate (< [less than] 25 mg [milligrams] per week) decreases proliferation of lymphoid cells, and this direct immunosuppressive effect is considered to be the mechanism by which methotrexate improves psoriatic disease."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:. Uncontrolled diabetes, uncontrolled hypertension, hyperlipidemia and substance abuse.
Treatment:  Inpatient admission.

The insurer denied the Inpatient admission.  The denial is overturned.

The patient is an adult female with a past medical history of uncontrolled diabetes, uncontrolled hypertension, hyperlipidemia and substance abuse. She was admitted for vertigo.

The patient's workup was significant for lacunar infarcts. Given the need to be on prolonged telemetry and hypertensive urgency requiring IV (intravenous) therapy, she was switched from observation to admission status.

Coverage for the admission was denied by the health plan, as it was not determined to be medically necessary. The denial is being appealed.

The inpatient admission was medically necessary.

Given multiple lacunar infarcts on CT (computed tomography) scan, as well as hypertensive emergency, there was a need for continuous telemetry monitoring, as well as permissive hypertension. A stroke cannot be treated in the outpatient setting. Furthermore, a stroke increases the chances of additional strokes in the next few days following onset.

Therefore, given the above, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic pain, epilepsy, depression, and anxiety. 
Treatment: Alternate Level of Care Stay (in Nursing Home). 
The insurer denied: Alternate Level of Care Stay (in Nursing Home). 
The denial is upheld. 

The patient is an adult male with chronic pain, epilepsy, depression, and anxiety. He was recently admitted to the hospital with breakthrough seizures, status epilepticus and respiratory failure and was discharged. He was readmitted to the hospital with altered mental status after possible overdose to his Seroquel. 
The patient refused to be discharged to the shelter from the Alternate Level of Care (in Nursing Home). The patient had no alternative safe discharge locations. The patient was discharged from the Alternate Level of Care (in Nursing Home) with family/friend; however the patient was unable to be discharged earlier for not having safe discharge locations and an ongoing psychiatry barrier. 

The patient had reached the highest functional level in the skilled rehabilitation program. The patient had anxiety and depression, and was on fluoxetine and quetiapine. He was to follow-up with psychiatry as outpatient. 

The request is for Alternate Level of Care Stay (in Nursing Home). 

The requested Alternate Level of Care Stay (in Nursing Home) was not medically necessary. 

The patient has chronic pain, epilepsy, depression, and anxiety. Based on the records attached, the patient was admitted to the skilled nursing facility. The Alternate Level of Care Stay (in Nursing Home) was initially utilized to treat his condition. However, physical therapy had maximized his level of care and activity. The patient refused to be discharged to the shelter. The patient did not have any skilled nursing facility care needs. The patient was independent with activities of daily living and did not need ongoing physical therapy or nursing needs. The patient could have followed with psychiatry and psychology as an outpatient for his anxiety. The patient did not meet requirements for the requested Alternate Level of Care Stay (in Nursing Home).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy
The insurer denied Gastric Restrictive Procedure, Sleeve Gastrectomy, by Laparoscopy. The health plan's determination is overturned. 

The patient is a woman who has medically complicated morbid obesity. Her weight was 250 lbs. She is 66 inches tall. This corresponds to a body mass index (BMI) of 40.4. The records indicate that the patient has been significantly overweight for many years. She has attempted weight loss with conventional diet programs. The patient has comorbid health conditions of high cholesterol, sleep apnea treated with continuous positive airway pressure (CPAP), and hypertension.

Gastric Restrictive Procedure, Sleeve Gastrectomy by Laparoscopy is medically necessary for this patient. The current standard of care for successful candidacy for bariatric surgery such as laparoscopic sleeve gastrectomy are: BMI of 40 or a BMI of 35 in association with weight related comorbid illnesses such as hypertension, diabetes, sleep apnea, osteoarthritis, etc. There must also be documentation of prior nonsurgical attempts at weight loss, nutritional counseling/education, mental health clearance for the proposed surgery, and commitment for long term follow up post bariatric surgery.
In this case, the patient has a body mass index of 40.4 with comorbid, weight related conditions of high cholesterol, sleep apnea, and hypertension. She has successfully completed a comprehensive multidisciplinary evaluation that includes surgical, medical, psychological and nutritional components. The proposed bariatric operation is medically necessary for this patient and is consistent with nationally recognized standards.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Protruded teeth
Treatment: Braces (D8080)
The insurer denied: Braces (D8080)
The denial is upheld

The patient is a preteen female with Class I skeletal bite. She has severe protrusion of her upper anterior teeth due to a finger sucking habit. The health plan's prior denial of coverage of the requested braces was due to a Salzmann index score of 7. The denial is being appealed.

The requested braces are not medically necessary.
The patient only scored a 7 on the handicapping index scale. This is insufficient to qualify for braces. Additionally, the patient has no automatic qualifiers for treatment.

Therefore, given the above, the requested braces are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial Flutter
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is an adult male with a past medical history of B-cell lymphoma for which he has been on systemic chemotherapy. He presented to the hospital as a direct admission from chemotherapy infusion center after having a witnessed syncopal episode upon receiving intravenous (IV) magnesium and calcium given that he had had hypomagnesemia and hypocalcemia. The patient responded to a sternal rub and had some vomiting shortly after waking up.  

On arrival to the emergency department (ED), the patient was afebrile, blood pressure was 140/77, heart rate was 61 beats per minute and oxygen saturation was 100% (percent) on room air. While in the ED, the patient did have a drop of his systolic blood pressure to the 70's which required a bolus of IV fluids. Initial labs were notable for a blood urea nitrogen (BUN) of 41, creatinine of 1.39, magnesium of 1.4, hemoglobin of 8.3, troponin of 61, and calcium of 7.5. The patient's initial electrocardiogram demonstrated atrial flutter. The patient was admitted to the inpatient unit and received IV fluids. Cardiology was consulted and given that there was evidence of volume overload, he was also started on diuretic therapy. The patient's electrolytes were replenished, he was hydrated and transfused with improvement of his bradycardia. He was discharged with outpatient follow up.

The proposed inpatient hospital admission was medically necessary.

This patient presented with a syncopal episode and was found to have new onset atrial flutter with variable AV (atrioventricular) block. Furthermore, he was bradycardic and had intermittent episodes of hypotension. Consequently, this presentation was consistent with hemodynamically unstable atrial flutter. To make the clinical course even more complicated, he was bradycardic, which in the setting of atrial flutter is concerning for sinus node dysfunction from which he was symptomatic (syncope and lightheadedness). The patient needed close hemodynamic monitoring, possible pacing, and aggressive electrolyte repletion. Furthermore, given that there was evidence of volume overload, he required diuresis during this hospitalization. Looking at the totality of the evidence, there is sufficient clinical data to support medical necessity for admission to inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dental issue. 
Treatment: Alternate Benefit (D5213) for Pontic (D6241) on Tooth Number #4. 

The insurer denied: Alternate Benefit (D5213) for Pontic (D6241) on Tooth Number #4. 
The denial is partially overturned. 

The patient is an adult female requesting a three-unit bridge from tooth #3 to tooth #5 to replace missing tooth #4. The prior denial for the pontic crown on tooth #4 was due to the missing tooth clause and need for alternate benefit. 

The pontic crown on tooth #4 is medically necessary. The Alternate Benefit (D5213) is not medically appropriate for this case. 
The pontic crown for tooth #4 should be approved. The patient is only missing two teeth in her upper jaw, teeth #'s 4 and 13. To fabricate a partial denture for just these two teeth (with one tooth being on the upper right and the other missing tooth on the upper left) is not proper. There will be a lot of metal across the patient's palate to stabilize the denture. It is much better for the patient to place a bridge on teeth #3 through #5, rather than have a lot of unnecessary metal across the roof of her mouth to hold up two small teeth. Also her ability to taste food, speak and keep her teeth clean will be somewhat compromised with a partial denture. If the patient was missing more teeth in her upper jaw, the partial would be justified, but not for just two teeth with one being on either side. The letter also states that if less than three teeth are missing in an arch, the bridgework would be justified. The three unit bridge on teeth #3 through #5 with the pontic being #4 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epigastric pain, vomiting. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient is an adult male.  The patient presented with a three-day history of epigastric pain accompanied with multiple episodes of vomiting. He "vomited approximately 10 times" described as "dark green (bilious) vomitus", "decreased appetite" and "last used cannabis greater than 1 month ago".  
The patient's physical exam showed guarding, exquisite epigastric tenderness, and dry mucus membranes (DMM).  Abnormal laboratory results included high potassium (K+) 5.3, lactate acid 2.5, and a white blood cell (WBC) count of 15.9.  The patient's electrocardiogram (EKG) was completed which demonstrated "ST & Nonspecific - wave abnormalities."  
The patient failed emergency department therapy with multiple fluid boluses, intravenous (IV) antiemetics, and multiple doses of intravenous protein pump inhibitors (PPI).  
The patient was diagnosed with Poisoning By Cannabis, Accidental (Unintentional), Acidosis, Asthma, Dehydration, and Gastritis and was discharged after improvement the following day. 

The proposed inpatient hospital admission was medically necessary. 
This patient presented with severe symptoms that failed initial emergency department management.  The patient was found to have significant metabolic abnormalities including the following: 
1 - lactic acidosis and leukocytosis due to significant dehydration warrants further intravenous fluid therapy until resolution. 
2- hyperkalemia with electrocardiogram abnormalities warrant further monitoring to prevent potentially fatal cardiac arrhythmia. 
Both lactic acidosis and hyperkalemia with electrocardiogram abnormalities warrant inpatient monitoring therapy and cannot be managed in less than the acute care setting.