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

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

This patient is an adult female for whom an inpatient hospitalization is under review. There was a history of diabetes, hypertension, and CAD (coronary artery disease). She had a defibrillator. She presented with chest pain. The patient was noted to be in no acute distress. The electrocardiogram was reported as non-acute. A chest X-ray was normal. Blood pressure was mildly elevated. Other vital signs and oxygen saturation was essentially normal. Troponins were minimally elevated. Cardiology was consulted, and the patient had a normal exercise test. There was a known catheterization with normal coronary arteries 8 months ago and a known left ventricular ejection fraction (LVEF) of 55-60% (percent).

The Inpatient admission was not medically necessary.

This patient presented with chest pain and remained stable. There was no congestive heart failure, respiratory distress, or ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, or another serious cause for chest pain, such as a pulmonary embolism or aortic dissection, need for prolonged intravenous (IV) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or acute coronary syndrome. In the setting of this case, an acute inpatient level hospitalization, compared to for example observation, has not been established as standard of care toward improved cardiac outcomes. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Periodontal disease 

Treatment: white glass with gold crown for teeth 10, 6, and 7

The insurer denied coverage for white glass with gold crown for teeth 10, 6, and 7

The denial is upheld overturned


Based on the submitted documentation which includes copies of post endodontic therapy periapical radiographs, narrative letter from Dr. Carlos Ovalle, dental treatment record and insurer correspondence, it appears that this patient presented to the dentist for comprehensive dental care. Endodontic therapy was recommended and completed on teeth numbered 6, 7 and 10 with additional recommendation of full coverage crown restoration on these teeth. The insurer has denied the full coverage crowns stating that the service is not medically necessary as the documentation did not demonstrate medical need to support the treatment. The patient is appealing the decision. 

Upon review of radiographs, it supports the recommended treatment. Review of radiographs indicates completed endodontic therapy on teeth numbered 6, 7 and 10. There is ample coronal structure remaining on each of these teeth after the endodontic therapy. These teeth will have adequate residual coronal structure for support of crowns and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of crowns on endodontically treated teeth which would have an excellent long-term prognosis with the recommended treatment. 

White glass with gold crown for teeth numbered 10, 6 and 7 as medically necessary as the radiographic documentation supports this service, and this service would be a standard of care in general dental practice.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for white glass with gold crown for teeth 10, 6, and 7 services is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/ Gastrointestinal/Gastroesophageal Reflux Disease/GERD
Surgical Services  (All)/LINX  Reflux Management System
The health plan denied the requested treatment, LINX  Reflux Management System, as they consider it to be experimental/investigational. The health plan's determination is overturned.

This is a male with gastroesophageal reflux disease (GERD) that is refractory to medical management. He meets all criteria for surgical management including a DeMeester Score of 27.4, normal manometry, no Barrett's esophagitis by endodoscopy, and only a small (< 3cm) hiatal hernia by esophogram. His surgeon has offered him a LINX device based on well-documented safety, efficacy, side-effect profile, and maintenance of native gastroesophageal anatomy, all of which have been appropriately explained to the patient and to which he consents.
At issue is whether the proposed treatment (LINX Reflux Management System (LINX)) is likely to be more beneficial than any standard treatment for this patient's condition.

I overturn, in whole, the health plan's denial of the proposed service to use the LINX device for this patient. It is not experimental or investigational and should be a covered benefit as a well-conceived and well-supported management option for this patient.

The proposed treatment of LINX is likely to be more beneficial than fundoplication or other acceptable options for this patient's specific situation.

First, this patient's specific pathology meets all criteria for which the LINX is deemed an acceptable option. Then, based on the surgeon's statement that he wants to offer this patient a minimally invasive option that has a well-documented safety and efficacy track record, a well-documented side-effect profile that preserves ability to belch or vomit, and that preserves the native gastro-esophageal anatomy and, finally, based on the consent and trust of this patient in his surgeon's skill and experience, the LINX is the best option for this patient.

The attached supporting peer-reviewed literature adequately documents a track-record that categorically refutes a claim that the LINX can still be considered experimental and investigational, particularly under the definition in the health plan's policy, also provided for review here, which includes criteria that the product or procedure is not proven safe or effective, is not Food and Drug Administration (FDA) approved, and is not as beneficial as established alternatives.
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/ Gastrointestinal/Gastroesophageal Reflux Disease/GERD
Surgical Services  (All)/LINX  Reflux Management System
The health plan denied the requested treatment, LINX  Reflux Management System, as they consider it to be experimental/investigational. The health plan's determination is overturned.

The patient is a male who has refractory gastroesophageal reflux disease (GERD). A potential hydrogen (pH) study showed a Demeester score of 27. The patient's esophageal manometry test was normal. An esophagogastroduodenoscopy (EGD) showed no Barrett's esophagus. An upper gastrointestinal (UGI) study showed the patient had a small hiatal hernia.
At issue is whether the proposed treatment (LINX  Reflux Management System (LINX )) is likely to be more beneficial than any standard treatment for this patient's condition.

I overturn the denial, in whole.

LINX Reflux Management System is likely to be more beneficial than any standard treatment or treatments for the insured's condition.

This patient has GERD per the bravo pH study, and also has a small sized hiatal hernia. The patient is a great candidate for LINX.

As per Sages:

"Longer-term (3-5 years) experience with the LINX Reflux Management System confirms the initial safety profile that led to Food and Drug Administration (FDA) approval of the device. The LINX device has been demonstrated to result in long-term GERD control based on symptomatic outcomes, proton pump inhibitor (PPI) utilization, and pH studies. LINX is a reasonable treatment option for appropriately selected patients with GERD who meet indications for antireflux surgery. The LINX procedure is part of the armamentarium in the treatment of GERD. As such, it should be performed by surgeons familiar with the workup and different management alternatives of GERD and not offered in isolation. Implantation of the LINX device should be covered and reimbursed by insurance for appropriate patients who meet the selection criteria as described above." [2]
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/ Gastrointestinal/Gastroesophageal Reflux Disease/GERD
Surgical Services  (All)/LINX  Reflux Management System
The health plan denied the requested treatment, LINX  Reflux Management System, as they consider it to be experimental/investigational. The health plan's determination is overturned.

The patient is a male with a body mass index (BMI) of 23 kilograms per square meter (kg/m2). He has a history of long-standing gastroesophageal reflux disease (GERD) despite medication use. An esophagogastroduodenoscopy (EGD) performed in 2021 did not reveal Barrett's Esophagus (BE). An upper gastrointestinal (UGI) endoscopy revealed a small hiatal hernia. A 24 hour potential hydrogen (pH) study revealed a DeMeester score of 27.4 consistent with GERD. 
At issue is whether the proposed treatment (LINX  Reflux Management System (LINX )) is likely to be more beneficial than any standard treatment for this patient's condition.

I overturn, in whole, the health plan's determination.

The LINX  Reflux Management System is more beneficial than any standard treatment for this patient's condition.

This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX  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.

This patient has no known exclusion to LINX  treatment, such as BMI > 35, hiatal hernia > 3 centimeter (cm), or BE with dysplasia. The requested treatment is medically necessary and standard treatment for GERD.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/ Musculoskeletal
Inpatient Hospital

Diagnosis: ACL rupture, subsequent ACL reconstruction.
Treatment: Outpatient Physical Therapy3
The insurer denied outpatient physical therapy.
The health plan's determination is upheld.

The patient is a male who is status/post knee anterior cruciate ligament (ACL) reconstruction and meniscectomy. He has attended 30 sessions of skilled physical therapy. He has improved functionally and is independent.

At issue is the medical necessity of Outpatient Physical Therapy.
The health plan's determination is upheld, in whole.

Outpatient physical therapy is no longer medically necessary for this patient.

The patient's pain has improved. The range of motion of the left knee is full actively and passively (0-140 degrees). His motor strength for knee extensors is 4/5 and symmetric. He should continue to exercise independently with a home program. He needs a foot orthotic for overpronation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever. 
Treatment: Inpatient admission. 
The insurer denied: Inpatient admission. 
The denial is upheld. 

The patient is an adult female. She is an otherwise healthy, nonsmoker who presented to an outside hospital with a history of fevers. She was identified to have severe left hydronephrosis and a 4-millimeter stone. The patient underwent nephrostomy tube placement with resolution of the hydronephrosis. Renal scan demonstrated 30% function on the left. The patient underwent uncomplicated cystoscopy, retrograde study, ureteroscopy, stent placement, and robotic-assisted laparoscopic Y-V pyeloplasty on the left. The patient's pain was controlled with as needed (prn) pain medications and by postoperative day (POD) #1, the patient's pain was controlled on oral analgesics. The drain was removed after drain fluid creatinine assessment confirmed consistence with serum and not urine. The patient was noted to be tolerating oral intake without nausea or vomiting and was ambulating. Her maximum temperature (tmax) was 99. The patient was discharged to home on postoperative day #1. The acute inpatient care was denied as not medically necessary. 

The acute inpatient admission was not medically necessary. 

The treatment the patient received did not need to be carried out at the acute inpatient level of care; acute inpatient level of care was not medically necessary. This patient is an otherwise healthy woman with no documented medical comorbidities. She underwent an uncomplicated pyeloplasty, stent placement, cystoscopy and retrograde study, and ureteroscopy. She remained hemodynamically stable, was afebrile, tolerated medication by mouth, and was able to control her pain with oral pain medications. She could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Other- Hypotension
Treatment: Inpatient hospital stay 
The health plan denied: Inpatient hospital stay
The determination is: Upheld 

The patient is a female with a past medical history of gastroparesis, chronic kidney disease (CKD), migraines, and hypertension (HTN) who was admitted with complaints of headache and poor intake by mouth (PO). Her vital signs were notable for a blood pressure (BP) of 76/45. Her physical exam was unremarkable. She was non-toxic appearing with normal mentation. Her lab work was notable for a creatinine level of 1.1. Her electrocardiogram (EKG) showed normal sinus rhythm without ischemic changes. She was diagnosed with failure to thrive and treated with intravenous fluids (IVF), to which her BP responded appropriately, intravenous antibiotics, which were discontinued on admission due to low suspicion for sepsis, and the withholding of oral anti-hypertensives, with resolution of hypotension. The patient was discharged in stable condition.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient hospital stay was not medically necessary for this patient. This patient presented to the emergency department with headache and poor PO intake. The patient was admitted with a low suspicion for sepsis, and the patient's hypotension resolved with the administration of IVF and the withholding of anti-hypertensives.
The patient was diagnosed with failure to thrive and deconditioning. There were no marked electrolyte abnormalities associated with the elevated creatinine and the migraine was treated with continuing home medications. There was no evidence of increased intracranial pressure, tumor, hydrocephalus, intracranial bleed, acute or subacute cerebrovascular accident, acute central nervous system (CNS) infection (encephalitis, brain abscess) or bacterial meningitis. In addition, the patient did not require immediate surgical intervention, have a hypertensive emergency or acute alteration in mental status, co-existing seizures, nuchal rigidity, acute visual loss, new focal neurologic deficits, abnormal pupils, apnea, abnormal respiratory pattern, or significantly abnormal vital signs.
The patient was diagnosed with failure to thrive; an alternative level of care would have provided an ideal setting for care coordination and discharge planning and an opportunity for assessment by a physician, physical therapist, social worker, and care manager. These types of patients receive focused interventions in mobility, gait training, and functional status improvements. Overall, this patient had neither severe acute pathology nor the need for acute surgical intervention. She was diagnosed with failure to thrive for which they were treated with non-surgical treatment modalities, including physical therapy, gastrointestinal (GI) consultation, IVF, and medication management. These interventions could have been safely and appropriately provided at an alternative level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is upheld.

The patient is an adult male. He had a history of being an active smoker with alcohol use. He presented to the emergency room with cough, shortness of breath, and pleuritic chest pain. The patient's emergency workup included Duonebs, intravenous antibiotics, and computed tomography (CT) scan. The CT (computed tomography) scan showed pulmonary nodular infiltrates concerning for pneumonia or malignancy. The patient was admitted to hospital for further workup. The patient was started on Duonebs, Symbicort (budesonide / formoterol), and Spiriva (tiotropium). The patient was also referred to interventional radiology for lung biopsy. The patient was placed on alcohol withdrawal watch. The patient was seen by pulmonary consultation as well. The acute hospitalization was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The inpatient admission was not medically necessary.

The patient was admitted to the hospital for abnormal radiology and chronic obstructive pulmonary disease (COPD) exacerbation. The patient was started on inhalers and did not require intravenous or oral steroids. The computer-tomography (CT)-guided biopsy was arranged while he was admitted to the hospital. The patient was ambulatory and was able to tolerate oral diet. The patient was not on any invasive drips or supplemental oxygen. The patient did not receive any treatment that could not have been safely and effectively provided at a lower level of care. The acute hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Full braces and monthly brace adjustment visit
The insurer denied: Full braces and monthly brace adjustment visit
The denial is overturned.

The patient is an adolescent male. The request is for orthodontic treatment with monthly visits. The health plan denied coverage of the request as not medically necessary. The denial is being appealed.

The full braces and monthly brace adjustment visit are medically necessary.

The patient has an impacted upper left permanent canine (tooth #11 (number 11)) that needs to be moved into its proper position. When there is an impacted permanent anterior tooth where extraction is not indicated, this is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem, and the case has medical necessity.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Other keratoconjunctivitis (right eye). 
Treatment: Acthar Gel. 

The insurer denied: Acthar Gel. 
The denial is upheld. 

The patient is a teenage female with keratoconjunctivitis for whom coverage of Acthar Gel is the subject of review. Coverage was previously denied as the current plan approved criteria does not allow for coverage unless the patient has a diagnosis of infantile spasms or multiple sclerosis. Additionally, failure, intolerance or contraindication to at least three of the formulary medications (dexamethasone, prednisolone, methylprednisolone, hydrocortisone, prednisone) had not been documented. Upon appeal, the provider states that the patient has been using Acthar since last year and it has been effective in the treatment of other conjunctivitis and vernal keratoconjunctivitis of the right eye. The patient has tried and failed Lotemax, Maxitrol, FML Tobradex, PF dexamethsone, prednisolone, Restasis, Xiidra, and oral doxycycline as well as amniotic membrane placement. Additionally, it is noted that the etiology of the patient's keratoconjunctivitis is staphylococcal hypersensitivity. An exam note dated last month documents the patient being treated for vernal keratoconjunctivitis of the right eye with doxycycline, Acthar and Verkazia (cyclosporine). The noted states that Acthar was started 5 months ago. 

Based on the information provided, the health plan should not cover the proposed treatment. 

It is not established that the remaining formulary alternatives have been ineffective, would not be as effective as the requested Acthar, or have caused adverse effects for this patient. This patient is identified as having vernal keratoconjunctivitis. According to Singhal et al, the management of vernal keratoconjunctivitis is challenging. Although an acute episode can be well managed with the help of currently available topical agents, the major challenge lies in preventing recurrences and their consequences. Steroids are highly effective in controlling both an acute episode and chronic disease; however, the long-term complications of steroid use often prevent their continued use. Immunomodulators such as tacrolimus and cyclosporine may be used as steroid-sparing agents. This patient has reportedly used drops containing loteprednol, dexamethasone, prednisolone, (two formulary alternatives) as well as Restasis (cyclosporine), Xiidra (lifitegrast) and amniotic membrane graft. The patient has not demonstrated failure of the remaining formulary alternatives, methylprednisolone, hydrocortisone, or prednisone. A review of the peer reviewed medical literature does not identify support for the safety and efficacy of repository corticotropin (Acthar) in the treatment of vernal keratoconjunctivitis and no head-to-head studies with these remaining formulary alternatives are identified.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes Mellitus
Treatment: Mounjaro
The insurer denied Mounjaro.
The determination is upheld.

This is a female patient diagnosed with type 2 diabetes mellitus with hyperglycemia. This request is for Mounjaro 15 milligrams (mg). As per a visit note, she is on Jardiance 25 mg every day, Ozempic 2 mg every day, metformin immediate release (IR) 2000 mg, and Novolog 6-12 units. She is off Levemir because she had hypoglycemia. As documented, she is on continuation therapy of Mounjaro. Her hemoglobin A1C about 2 years ago was 8.5 percent (%) and about 10 months ago was 7.4%. Formulary alternatives are Victoza and Trulicity. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The formulary alternatives would be as effective as the requested medication.

The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss. (1-3)

There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 receptor agonists as a first line agent. There is no preference for the requested medication over GLP-1 receptor agonists. (4) The patient can try two more formulary alternatives. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary.