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

Diagnosis: Multiple trauma. 
Treatment: Inpatient admission. 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

This is female patient who was brought in by ambulance for status post assault with knife. Upon evaluation in the Emergency Department (ED), the clinical impression was right thigh stab wound; left scapula fracture; status post assault. The stab wound was washed out and stapled in the ED. The patient received wound care with dry gauze dressing. Computed Tomography (CT) revealed non-displaces left scapula fracture. The patient was admitted to trauma services. Orthopedics was consulted and the recommendation was non-weight bearing of the left upper extremity with sling for the scapula fracture. Social work was consulted for domestic violence. The patient was discharged home with Orthopedic follow-up and the instruction to keep arm elevated in sling for comfort. 

The medical record demonstrated an isolated stab wound to thigh and closed fracture to left scapula. There was no evidence of an unstable condition (i.e. No bleeding from wound). The patient's vital signs were stable with pulse oximeter over 98. There was no evidence of infection. The physician record reported pain was manageable. The person did not require additional imaging nor treatment for other underlying problems. Diagnosis and emergent management were provided. There were no extenuating circumstances to substantiate necessity of ongoing acute admission and care. 

The health plan did 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 upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient Hospital

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

The patient is a man who presented to the hospital. He had a history of repeated head trauma and injury at work that required back surgery and knee surgery, and he presented to the hospital with headache and photophobia. He was planned for admission but subsequently eloped from the emergency department. He returned hours later with family members. He stated that he had three days of constant severe frontal headache with photophobia. The headache worsened with standing and bending of the neck. He also reported loss of appetite, nausea and fatigue. He denied fevers and chills. Review of systems was negative for chest pain and shortness of breath. Past medical history also included depression, suicidal ideation and lumbar fusion. Vital signs showed temperature 98.2 Fahrenheit, blood pressure 122/74, heart rate 71, and respiratory rate 18. On physical exam, heart was regular, breath sounds were normal, and he had photophobia. Labs showed white blood cell (WBC) 6.06, hemoglobin 13.9, platelets 250, sodium 141, potassium 4.8, and creatinine 0.9. Alcohol level was 55.0. Head computed tomography (CT) demonstrated a left lamina fracture and diffuse white matter abnormalities. The patient was admitted with a headache/migraine, photophobia, and cerebral edema. 

The acute inpatient stay was not medically necessary for this patient's symptoms. The patient did require further management given his photophobia, potential migraine, and more pain. However, there was no evidence of infection, no evidence of meningitis, no evidence of acute stroke, and no acute neurologic deficits. He left against medical advice but even in the absence of him leaving against medical advice, there was no need for acute inpatient management.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Digestive System/Gastrointestinal-Other-Gastroenteritis
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in part the health plan's determination.

At the time of his admission, the patient was a previously healthy toddler, brought by his parents to the emergency department (ED) with vomiting and diarrhea since the morning. At triage, the patient was noted to be alert and active and drinking from a bottle. He was afebrile with normal vital signs. The ED physician notes state the patient had about 15 episodes of non-bloody, non-bilious vomit and 6 episodes of non-bloody diarrhea. The ED physician documented that he was active, in no distress, non-toxic, well hydrated, well appearing, attentive and interactive and appropriate for age, smiling and playful, crying tears when upset but quickly consolable. The exam was normal. Electrolytes showed bicarbonate (bicarb) of 13 and potassium of 5.1 with a notation that it was a hemolyzed specimen. He was given Zofran, a 20 milliliter(ml) /kilogram( kg) normal saline bolus, then started on an infusion of Dextrose(D)5% and 1/2 normal saline(NS). He was admitted to the pediatric ward late in the evening for gastroenteritis, continued on intravenous (IV) fluid and oral fluid (no vomiting), and discharged. He continued to have diarrhea during the hospitalization, but was otherwise well. Follow up electrolytes showed a potassium of 2.6 and bicarb of 16 without a comment about specimen hemolysis. He was given supplemental IV potassium to correct the hypokalemia and later the potassium was 3.5 and bicarb 15 without comment about specimen hemolysis.  The physician notes explained the low bicarb and potassium as being due to diarrheal losses. 
The inpatient stay was medically necessary for this patient, in part.
Although the notes all indicate the baby did not appear clinically dehydrated, the laboratory values suggested a mild to moderate dehydration based on the low bicarbonate level. The morning after admission, the potassium was 2.6 and required correction for a safe discharge. The follow up potassium of 3.5 later in the evening showed the baby was heading in the right direction, and the baby could have been safely treated at a lower level of care at this point. So, the first night was medically necessary due to the electrolyte abnormality not able to be corrected with IV fluid in the observation/ED setting; the second night was not medically necessary because the electrolyte abnormality was corrected.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Inpatient Detoxification Services.
The insurer denied the Inpatient Detoxification Services.
The denial is upheld. 

The patient is a male. He has a history of heroin, marijuana, and non-prescription methadone use. The patient presented for detoxification.

The patient was alert and oriented x 3. He complained of symptoms of withdrawal including nausea, trouble sleeping, anxiety, sweats, tremors, irritability, and joint pain. His past medical history was significant for Hepatitis C and insomnia. His VS (vital signs) were as follow: Temperature 98.3, pulse 88, respiration rate 128, blood pressure 117/79. His COWS (clinical opiate withdrawal scale) score was 14. His exam was unremarkable. His drug screen was positive for opiates and methadone. His CBC (complete blood count) and CMP (comprehensive metabolic panel) were unremarkable.

The patient was admitted with a diagnosis of opioid dependence with plans for Methadone Tapering Protocol.

The patient's condition was stable with no distress. The plan was to continue methadone protocol. There was no significant change through discharge.

No, the Inpatient Detoxification Services were not medically necessary.

Medically necessary services are those which are:
safe
effective
generally accepted national standard of medical practice
not provided primarily for convenience of the patient or the practitioner
the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

This patient was admitted for opiate detoxification. The patient was hemodynamically stable and afebrile. He had tachycardia but no evidence of arrhythmia. He complained of symptoms including nausea, tremor, sweats, and irritability. There were no physical signs of withdrawal. Labs were unremarkable. He did not have comorbid conditions. The patient was admitted for methadone tapering protocol. The patient was clinically stable and did not have severe findings. He did not have symptoms that required an acute inpatient level of care. He had not failed management in a lesser level of care. The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine Bleeding.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient underwent a robotic assisted laparoscopic hysterectomy, retroperitoneal dissection, bilateral ureterolysis, bilateral salpingectomy and cystoscopy. She had a history of uterine bleeding, fibroids, adenomyosis and endometriosis. She had extensive adhesions and a general surgeon was consulted for adhesiolysis. She was admitted as an inpatient to the hospital on the day of surgery. She progressed well postoperatively and was given non-steroidal anti-inflammatory agents for pain control. She was discharged the following day. At issue is the medical necessity of an inpatient stay.

The inpatient hospital stay is not medically necessary for this patient.

The patient had a laparoscopic surgery and the medical documentation does not support the need for acute, high-level inpatient hospitalization. Her surgery was without complications and blood loss was not excessive. She had no intraoperative nor postoperative hemorrhage that required monitoring nor transfusions. She had no anesthesia complications nor signs/symptoms of infection after her surgery. She had no comorbid conditions including cardiovascular, respiratory nor renal complications. She progressed well after her surgery with normal vital signs. There were no cardiopulmonary concerns. She had no abnormal laboratory tests to show any hepatic concerns. She did not require inpatient admission and could have received care at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose veins. 
Treatment: Phlebectomy. 

The insurer is denied coverage for phlebectomy. 

The denial is upheld. 

This male patient has a history of left leg painful varicose veins and swelling.  The patient is 6 feet, 3 inches tall, 400 pounds and has a body mass index of 50.  The patient has had multiple areas of superficial clots in his legs with redness.  He denies any non-healing wounds or ulcerations, and he does not wear compression socks regularly.  The patient reports pain in his left leg throughout the course of the day, especially after working on his feet for many hours.  There is also pain in the areas of the varicose veins over his left anterior thigh and knee.  The patient has scattered varicose veins and spider veins of the left leg, but they do not bother him.  Over the counter medication and elevating his legs every day have not provided any relief for his pain. A lower extremity venous reflux duplex ultrasound report did not have evidence of significant great saphenous vein or small saphenous vein (SSV) reflux.  The patient's veins measured 9.9 millimeters to 4.6 millimeters off of the great saphenous vein and long saphenous vein.  Per the provider, the lower extremity pulse volume recording stated the right and left are both within normal limits.  Treatment options were discussed with the patient, and he wants to proceed with a left leg stab phlebectomy to relieve the pain in his leg. 

The current medical literature notes that correction is indicated documented reflux of greater than 0.5-second duration.  The current medical literature supports that the majority of patients will achieve good to excellent relief of their symptoms following treatment of a dominant refluxing vein, which in this case, would be the greater saphenous vein (GSV). The current medical literature also indicates that phlebectomy and ablation are necessary when performed together. 

The left leg venous reflux study did not include the branch varicosities being interrogated to see if the branch vessels off the GSV and SSV have reflux or incompetency. Therefore as there is a lack of the above in the submitted documentation the prior determination remains upheld. 

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

The carrier's denial of coverage for the phlebectomy is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease (GERD).
Treatment: Surgical Services (LINX procedure).

The health plan denied the requested surgical service as not medically necessary. 
The health plan's determination is overturned.

This patient is a man (body mass index (BMI) 32) who sought surgical evaluation for the condition of heartburn and a family history of colorectal cancer. These symptoms are partially responsive to proton pump inhibitor (PPI) medication (Pantoprazole), but he does have breakthrough symptoms. Symptoms have been present for at least 3-years. He has no dysphagia.

The patient has been evaluated for this condition with:  1) An esophagogastroduodenoscopy (EGD) that showed esophagitis in the area of the gastroesophageal (GE) junction and no hiatal hernia. No intestinal metaplasia was noted on biopsy, 2) An esophageal motility showed adequate peristalsis of the esophagus. There was a no manometric hiatal hernia and 100% of swallows were normally peristaltic, and 3) A potential hydrogen (pH) study identified an elevated esophageal acid exposure with a composite DeMeester score of 43.2 over 48-hours of study. Symptom correlation was strong for heartburn. The study was positive on both days of the 2-day study.

The health plan's determination regarding the proposed health service or treatment is overturned, in whole.

Yes. Based on the current evidence-based literature and the patient-specific objective clinical evaluation in this case, the LINX procedure is medically necessary and is likely to be more beneficial than any standard treatment for this patient's condition of proven gastroesophageal reflux disease (GERD).

The LINX procedure is a minimally invasive procedure for the treatment of GERD and the recently published body of literature includes conclusions of ongoing clinical trials that support the long-term safety and efficacy of this procedure. There has been completion of ongoing clinical trials NCT00776997 and NCT01624506 that provide the necessary long term follow up regarding LINX. These studies, in conjunction with previously published data, support the long-term safety and efficacy of the LINX and reinforce that this procedure has withstood appropriate scrutiny and should be included in the armamentarium of proven-effective therapy for the treatment of GERD in selected patients.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease (GERD).
Treatment: Surgical Services (LINX procedure).

The health plan denied the requested surgical service as not medically necessary.  The health plan's determination is overturned.


This patient is a male with a body mass index (BMI) of 32 and history of symptomatic gastroesophageal reflux disease (GERD) despite medication with proton pump inhibitors (PPIs). An esophagogastroduodenoscopy (EGD) showed findings of esophagitis. A 24-hour potential hydrogen (pH) study revealed an elevated DeMeester score of 43 consistent with GERD. An esophageal manometry was normal.

At issue is the medical necessity of the requested surgical service of a LINX placement.

The health plan's determination regarding the proposed health service or treatment is overturned, in whole.

This patient has GERD, refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX (a Food and Drug Administration (FDA) approved) procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The FDA exclusions to LINX and Nissen fundoplication include a BMI > (greater than) 35, in which case treatment of obesity is thought to be important for treatment of GERD. Other exclusions for LINX include Barrett's esophagus with dysplasia, age < (less than) 18 and prior gastric or bariatric surgery. Given that this patient has no exclusion to treatment, symptomatic GERD with normal motility, the medical necessity of LINX is determined to be as or more beneficial than other standard surgical treatments (lap Nissen fundoplication) for GERD with less morbidity and mortality.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Gastroesophageal Reflux Disease (GERD).
Treatment: Surgical Services (LINX procedure).

The health plan denied the requested surgical service as not medically necessary.  The health plan's determination is overturned.

The patient is a male with a history of Barrett's and a family history of colorectal cancer. He has a body mass index (BMI) of 31, essential hypertension, obstructive sleep apnea (OSA), esophagitis, hereditary hemochromatosis, hyperlipidemia, fatty liver, and chronic allergic rhinitis. He was referred for a LINX device. The medical plan denied the use of this magnetic sphincter augmentation (MSA) device because they deem it investigational.

In this patient it is imperative that his reflux be controlled given his Barrett's (a premalignant condition). He has failed proton pump inhibitor (PPI) therapy, so his treatment needs to be scaled up to the next level.

At issue is the medical necessity of the requested LINX device placement.

The health plan's determination regarding the proposed health service or treatment is overturned, in whole.

Yes, the proposed LINX device in this patient is likely to be more beneficial than PPI or than a laparoscopic Nissen fundoplication. This patient meets the criteria for this device- including a BMI < (less than) 35. He has failed medical therapy. A laparoscopic Nissen is a much longer procedure and permanently alters the configuration of the stomach by pulling it around the esophagus. The LINX has fewer side effects, including less gas-bloat. Studies show that very few patients need to have the device removed for side effects. There have been randomized control trials and 5-year outcome data, so it is unclear why the health plan is taking this stance.

In addition, a recent observational study has shown that LINX has beneficial effects on esophageal motility [7]. Maintaining esophageal motility is important for long term quality of life, heart burn, feeling of getting things "stuck".

Finally, a recent 3-year study in a registry has demonstrated effectiveness in the MSA when compared to the lap fundoplication with shorter operative time [8].

The results from trials reporting on this device (LINX) show that in the right patient, it is safe, and it has great results with less side effects and less operative time. The Anthem policy Lower Esophageal Sphincter Augmentation Devices for the treatment of GERD. SURG.00131 needs to be updated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumothorax
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

This is a female patient who developed a left pneumothorax after computed tomography (CT) guided lung biopsy requiring a chest tube and inpatient admission.

Yes, the proposed inpatient admission was medically necessary.
An increasing pneumothorax after computed tomography guided biopsy would warrant chest tube placement and admission for further management. The patient may develop persistent air leak, continued pneumothorax , hemothorax or subcutaneous emphysema that require management.  This level of care is most consistent with inpatient level of care.  Therefore in this patient admission for management of the pneumothorax was appropriate.

Admission for management of this complication of lung biopsy would be standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Alopecia Areata (AA).
Treatment:  Xeljanz.

The insurer denied Xeljanz as experimental/investigational. The denial was upheld.

This is a female patient with alopecia areata. The patient has been treated on Xeljanz with improvement. The request is for Xeljanz.

At issue is whether the health treatment of Xeljanz is likely to be more beneficial than any standard treatment.

Xeljanz is not likely to be more beneficial than any standard treatment or treatments for the patient's condition.

According to the U.S. Department of Health & Human Services, National Institutes of Health (NIH) and Genetic & Rare Diseases Information Center (GARD) (2017), "No therapy has been found to work for everyone who has alopecia universalis (AU) which makes managing AU challenging. Although multiple treatments have been explored, no therapy is currently approved by the United States Food and Drug Administration (FDA). Some promising therapies include: diphenylcyclopropenone (DPCP), squaric acid dibutyl ester (SADBE), photodynamic therapy, steroids, cyclosporine in combination with methylprednisolone (a steroid). There are several recent studies showing that a class of medication known as Janus kinase (JAK) inhibitors, which includes Tofacitinib and Ruxolitinib, are effective in alopecia areata, including AU. However, JAK inhibitors have not yet been approved by the FDA for use in skin conditions."

Per Ibrahim et al. (2017), "Tofacitinib citrate (Xeljanz) is a Janus kinase 1/3 inhibitor approved for the treatment of rheumatoid arthritis, but it has recently been used to treat alopecia areata (AA). To truly assess efficacy, therapeutic trials should continue in the clinical setting for a minimum of 4 months and potentially up to 1 year. Patients should be informed of the lack of durability of effects after the treatment is discontinued. Future studies, including those using other Janus kinase inhibitors, such as ruxolitinib phosphate, are needed and should continue to elucidate these medications' efficacy, safety, and durability in the treatment of AA."

In a retrospective study of 90 patients by King et al., Xeljanz was studied and shown to have possible efficacy in treating patients with alopecia. However, there is insufficient evidence by way of large randomized controlled cohort prospective trials showing the long-term safety and efficacy of Xeljanz in treating this patient population. As such, there are no clinical guidelines with regards to optimal dosing and duration of therapy. There is also a lack of consensus with regards to the optimal patient scenario. It has been well documented in the medical literature of the inability of Xeljanz to maintain long-term efficacy. Therefore, at this time, a medical exception for Xeljanz has not been established.