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

Diagnosis: Hypertension, pulmonary emboli, End Stage Renal Disease
Treatment: Sub Acute rehabilitative (SAR) services in a skilled nursing facility
The insurer denied coverage for Sub Acute rehabilitative (SAR) services in a skilled nursing facility
The denial is overturned

This is a patient with multiple medical problems including hypertension, pulmonary emboli and end stage renal disease on dialysis. The patient was admitted for shortness of breath, hypoxia, right leg pain and weakness. The patient received physical therapy and subacute rehabilitation was recommended. Under review is the medical necessity for Sub Acute Rehabilitative (SAR) services in a skilled nursing facility (SNF).

The patient is an appropriate candidate for the SNF subacute rehabilitation care. When the patient was initially evaluated by the physical therapist, the treatment notes were consistent with the patient being nearly at the pre-morbid functional level. The patient was independent with bed mobility and transfers. The patient was ambulating short distances (20 feet x2). The physical therapist recommended a treatment frequency of only "1-2x (times)per week" and anticipated the patient would be ambulating "50 feet with the least restrictive device independently" in "3-4 sessions."  However, subsequent notes document patient's limited functional progress and ability due to fatigue, weakness, and pain. The updated physical therapy note, documents the necessary assistance needed for the patient's functional mobility (partial assistance for ambulating 15 feet with a rolling walker/poor standing balance); and supporting the medical necessity for Sub Acute Rehabilitative (SAR) services in a skilled nursing facility (SNF).

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 Sub Acute rehabilitative (SAR) services in a skilled nursing facility is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Orthopedic/Musculoskeletal/Back Pain/Spinal Stenosis, Lumbar Region with Neurogenic Claudication; Low Back Pain
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient stay as not medically necessary. The health plan's determination is partially overturned.

This patient with low back and leg pain underwent a (lumbar) L4-5 TLIF (transforamal lumbar interbody fusion) without complications. The patient is a female presenting with low back pain and radiculopathy due to the left 4-5-disc herniation. She obtained imaging and medical clearance as well as oral steroids and was taken to surgery.
At issue is the medical necessity for the inpatient stay.

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

The health plan acted appropriately. Per Milliman Care Guidelines (MCG) Lumbar Fusion, 2 post operative days are allowable after lumbar fusion, which is the standard.
Post operatively, the patient remained neurologically and hemodynamically stable, no infection or active bleeding was noted, no drips were noted, her pain was under control medically, and no further surgery was necessary.
In this case, there was no need for the inpatient stay from the date of admission to the surgical date, as the patient could have presented on the day of surgery for elective outpatient surgery with 2 post operative days as inpatient stay, followed by discharge. Therefore, only 2 days are allowable for inpatient stay, without any further inpatient care needs noted.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Orthopedic/Musculoskeletal/Back Pain/Spinal Stenosis, Lumbar Region with Neurogenic Claudication; Low Back Pain
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is partially overturned.

This patient with low back and leg pain underwent a (lumbar) L4-5 TLIF (transforamal lumbar interbody fusion) without complications. The patient is a female presenting with low back pain and radiculopathy due to the left 4-5-disc herniation. She obtained imaging and medical clearance as well as oral steroids and was taken to surgery.
At issue is the medical necessity for the inpatient stay.

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

The health plan acted appropriately. Per Milliman Care Guidelines (MCG) Lumbar Fusion, 2 post operative days are allowable after lumbar fusion, which is the standard.
Post operatively, the patient remained neurologically and hemodynamically stable, no infection or active bleeding was noted, no drips were noted, her pain was under control medically, and no further surgery was necessary.
In this case, there was no need for the inpatient stay from the date of admission to the surgical date, as the patient could have presented on the day of surgery for elective outpatient surgery with 2 post operative days as inpatient stay, followed by discharge. Therefore, only 2 days are allowable for inpatient stay, without any further inpatient care needs noted.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Severe Dry Eyes.
Treatment: Eysuvis.
The insurer denied: Eysuvis.
The denial is: Overturned.

The patient is a female with history of severe dry eyes. The patient was tried on prednisolone, Xiidra, and Occusoft lid scrubs without lasting effect. The patient has severe dry eye syndrome and keratitis that affects her on a daily basis. The treating doctor is requesting Eysuvis as an alternative to current failed therapy.

The health plan's determination is overturned.

The patient has tried and failed multiple prior treatments including but not limited to prednisolone, Xiidra, and occusoft lid scrubs, but the effect has diminished overtime. The patient has severe dry eye syndrome and keratitis sica. Chronic symptoms of burning, itching, and tearing occur daily.

Eysuvis would be considered an appropriate next line of therapy for this patient's current eye condition.

Dry eye flairs are rapid-onset, inflammation-driven responses to a variety of triggers, which may not be adequately managed with a patient's ongoing maintenance therapy, such as artificial tears and daily, chronic prescription (Rx) therapies. Most patients with dry eye suffer from short term, episodic exacerbations, many patients do not suffer from continuous symptom. Eysuvis can be used to help patients during the acute flare ups.
Because of the failure of previous ocular therapy, including prednisone, Xiidra, and occusoft lid scrubs, it would be appropriate to consider ophthalmic alternatives. Eysuvis 0.25% eye drops would be considered an appropriate alternative to current failed therapy to the patient's current eye disease.

In summary, the non-formulary drug would be more effective than the formulary alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dysphagia and recurrent abdominal pains
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient presented with abdominal pain, nausea, and vomiting. She had previous gastric sleeve surgery. This was complicated by a leak at the gastroesophageal junction and recurrent stenosis requiring balloon dilatation. An endoscopy was performed and showed a normal esophagus and stomach. Stenosis was present at the gastroesophageal junction. A stent was placed at the gastroesophageal junction. The patient tolerated the procedure well and no complications were reported. The diet was then advanced. 

In the Milliman Care Guidelines (MCG) for Gastroenterology, severe dysphagia is an indication for admission if certain criteria are met. These include severe dehydration, inability to manage secretions, hemodynamic instability, severe electrolyte abnormalities, and acute renal failure stage 3. The patient did not have these conditions. 

This patient had dysphagia and recurrent abdominal pains. The patient had previous surgery with complications and a stricture. The patient required an endoscopy and stent placement. They were able to tolerate a liquid diet. The endoscopy with stent placement could have been done on an ambulatory basis. MCG criteria for admission for Gastroenterology were not met. 

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

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

Diagnosis: Hiatal hernia; GERD (gastroesophageal reflux disease). 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is an adult male with DeMeester Score 80 with some esophageal dysmotility with refractory GERD (gastroesophageal reflux disease). The patient underwent 270 degrees Fundoplication. The health plan denied coverage of the inpatient admission. The denial is being appealed. 

The Inpatient Hospital Admission was not medically necessary. 

Per the records, the patient underwent robot-assisted hiatal hernia repair. The patient had an NG (nasogastric) tube overnight, and esophagram was normal. The patient was started on clears and discharged the following day. 

The patient did not meet criteria for inpatient admission, even though the admission stated that because of the NG (nasogastric) tube and pending esophagram, the patient's situation did not meet ambulatory criteria. 

Standard hiatal hernia pathways include esophagram the next day, and many times NG (nasogastric) tube is not necessary for POD (post-operative day) #0 management. The patient did not demonstrate any additional findings in the operative report to need an NG (nasogastric) tube as well. Given the findings in the medical records, inpatient level of care is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal surgical wound and protruding wound mass
Treatment: Inpatient hospital stay
The insurer denied coverage for the inpatient hospital stay.
The denial is upheld.

The records document that the patient had a wound breakdown following spine surgery. The patient was admitted. Inpatient plan of care included plastic surgery and neurosurgery consult, would care, trend blood cultures, intravenous (IV) fluids and hemodynamic monitoring. Once all risks were addressed and the patient achieved hemodynamic stability, they were cleared for discharge with outpatient follow-up instructions. The records do not document that the patient was hemodynamically unstable or septic. The patient could have been managed at an observation level of care while the physicians performed the workup. According to Milliman Care Guidelines (MCG) General Admission Criteria: General Criteria: Observation Care: "Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations."

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

The insurer's denial of coverage for the inpatient hospital stay is upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease)
Treatment: TIF (transoral incisionless fundoplication)
The insurer denied TIF (transoral incisionless fundoplication).
The denial is overturned.

The patient is an adult male with chronic GERD (gastroesophageal reflux disease), manifested by regurgitation, belching, heartburn and nausea and vomiting despite proton pump inhibitors. He has a 1 cm (centimeter) hiatal hernia. His pH (Potential of Hydrogen) study noted a DeMeester score of 56.4. His provider is requesting transoral incisionless fundoplication (TIF).

The health plan should cover the requested TIF.

The requested TIF is more beneficial than any standard treatment.

Per the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the TIF can be performed with an acceptable risk in appropriate patients. The medical literature indicates that the safety profile of TIF and its effectiveness in eliminating typical and atypical GERD supports the adoption of this treatment as an alternative treatment for selected patients with inadequate symptom control on proton pump inhibitor (PPI) therapy. TIF can be used to achieve long-term control of chronic GERD symptoms, healing of esophagitis, and improvement in esophageal acid exposure (EAE).

Per Trad, K. S., et al (2017), at 3-year follow-up, elimination of troublesome regurgitation and all atypical symptoms was reported by 90 percent (%) (37/41) and 88% (42/48) of patients, respectively. This study demonstrates that TIF can be used to achieve long-term control of chronic GERD symptoms, healing of esophagitis, and improvement in EAE.

Per UpToDate (2018), "TIF [transoral incisionless fundoplication] can be performed in patients with typical GERD [gastroesophageal reflux disease] symptoms, no or only low-grade erosive esophagitis (grades A and B)."

Per Hunter, J. G. (2015), "Transoral esophagogastric fundoplication (TF) can decrease or eliminate features of gastroesophageal reflux disease (GERD) in some patients whose symptoms persist despite proton pump inhibitor (PPI) therapy. We performed a prospective, sham-controlled trial to determine if TF [transoral esophagogastric fundoplication] reduced troublesome regurgitation to a greater extent than PPIs (proton pump inhibitors) in patients with GERD (gastroesophageal reflux disease). TF [transoral esophagogastric fundoplication] was an effective treatment for patients with GERD (gastroesophageal reflux disease) symptoms, particularly in those with persistent regurgitation despite PPI (proton pump inhibitor) therapy, based on evaluation 6 months after the procedure."

The scientific evidence and peer-reviewed literature supports a result of improvement in health outcomes of TIF, and it is as beneficial as a surgical fundoplication, a standard treatment for the patient's disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease)
Treatment: TIF (transoral incisionless fundoplication)
The insurer denied TIF (transoral incisionless fundoplication).
The denial is overturned.

The patient is an adult male who sought surgical evaluation for the condition of GERD (gastroesophageal reflux disease) associated with heartburn and regurgitation of 20-years duration. The symptoms are partially controlled with medicinal therapy (Nexium). The patient has been evaluated for this condition with the following: EGD (esophagogastroduodenoscopy) showed a 1-cm (centimeter) hiatal hernia and distal esophagitis. There was short segment intestinal metaplasia without dysplasia. Potential of Hydrogen (pH) study confirmed abnormal esophageal acid exposure with a DeMeester score of 56.4 (normal less than 14.7). The treating surgeon has proposed the transoral incisionless fundoplication (TIF) procedure. The health plan rationale for denial is that the TIF procedure is considered to be investigational by the plan.

The health plan should cover the requested TIF.

In this case the TIF procedure is medically appropriate and would be expected to be health beneficial for the condition being treated. It is an endoscopic intervention for GERD and therefore does not require surgical access as is required for laparoscopic fundoplication. 

In 2017, Trad published the results of the TEMPO trial. This was a multicenter randomized study at 7 community hospitals that compared TIF to maximal dose PPI (proton pump inhibitor) therapy in partial responders to PPI therapy. At six-month follow up, troublesome regurgitation was eliminated in 97% (percent) of TIF patients versus 50% of PPI patients and 90 % of TIF patients had completely stopped PPI use. Follow up endoscopy was performed at six-months and complete healing or reduction in reflux esophagitis was achieved in 90% of TIF patients versus 38% of medicinally treated patients. The median total Reflux Symptom Index score in the TIF group decreased significantly from 23 on PPIs before the procedure to 3 off PPIs at six-month follow up. Longer term follow-up has been reported to 3-years. 

Based on the volume of peer-reviewed clinical data, FDA (United States Food and Drug Administration) approval of the procedure (11), and affirmative society statement from the American Gastroenterology Association and The Society of American Gastrointestinal Surgeons (SAGES), the TIF procedure is medically appropriate. Indications for the TIF  procedure include: adult over 18 years old, experiences chronic symptomatic GERD, requires and responds to pharmaceutical therapy, has a hiatal hernia less than or equal to 2 cm in size, has a Body Mass Index (BMI) less than 35, has preserved esophageal motility. This patient is an appropriate candidate for the TIF procedure and has none of the contraindications for TIF. Based on the submitted clinical data, the body of peer-reviewed literature, and the manufacturer listed indications and contraindications, the TIF procedure is medically appropriate and likely to be more beneficial than alternative reflux therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease)
Treatment: TIF (transoral incisionless fundoplication)
The insurer denied TIF (transoral incisionless fundoplication).
The denial is upheld.

The patient is an adult male with chronic GERD (gastroesophageal reflux disease) with high DeMeester score and with small hiatal hernia. The plan is for transoral incisionless fundoplication (TIF).

The health plan denied coverage of the request, noting that it is experimental/investigational for GERD. The denial is being appealed.

The health plan should not cover the requested TIF.

While TIF has been shown to be effective in the short term, papers have demonstrated that this therapy produces short term outcomes, and many patients resume PPIs (proton pump inhibitors). One paper from Richter demonstrated that laparoscopic Nissen fundoplication produced longer term control of reflux versus TIF. Laparoscopic reflux procedures remain the gold standard in surgical treatment of reflux. Therefore, the health plan should not cover the requested transoral incisionless fundoplication.

The requested transoral incisionless fundoplication is not more beneficial.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Admission
The insurer denied: Inpatient Admission
The denial is: Upheld

The patient is a female with an unremarkable past medical history who presented to the hospital with complaints of abdominal pain and distention. She went to the emergency room at Mount Sinai hospital where she had an x-ray that was consistent with constipation, and she was given treatment with an enema. In the hospital, the patient was seen by a general surgery service. There were no indications for acute surgical intervention. The general surgery service recommended a bowel regimen as well as a consultation with a gastroenterology service.
Computed tomography (CT) scan of the abdomen and pelvis with contrast was interpreted as a negative study for acute intraabdominal etiology including bowel obstruction. It demonstrated a large uterus. Transvaginal ultrasound was performed and demonstrated fibroids and myomas.
Obstetrics/Gynecology (OB-GYN) service was consulted. They stated that the patient had a known history of fibroids. They recommended outpatient follow-up with OB/GYN. A gastroenterologist evaluated the patient and recommended treatment with MiraLAX and an outpatient colonoscopy.
The discharging physician felt that the abdominal distension was most likely related to constipation. The patient was transitioned to outpatient care.

The health plan's determination is upheld.

The inpatient admission was not medically necessary for this patient.
The patient did not need admission at the acute inpatient level of care. The abdominal pain and distention were not associated with hemodynamic instability or peritoneal signs. There was no evidence that it was severe enough to justify admission at the acute inpatient level of care.
There was no evidence that the abdominal pain and distention were the result of serious medical conditions such as aortic dissection, bowel perforation, bowel ischemia, visceral organ torsion, or intestinal obstruction. There was no mention that the abdominal pain was associated with bacteremia or toxic megacolon.
The evaluation of the abdominal pain did not require the patient not to eat or drink for an extended period of time.
The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headaches.
Treatment: Nurtec.
The insurer denied Nurtec.
The determination is upheld.

The patient has chronic migraines and is prescribed treatment with Nurtec oral disintegrating tablet (ODT). This was denied because she has not tried and failed Aimovig, Ajovy and Emgality. The provider indicates that the patient has needle phobia. At issue is the medical necessity of Nurtec.

No. The provider indicates that the member has chronic migraine in a progress note (see active problems: headache, chronic migraine without aura). Nurtec ODT is not Food and Drug Administration (FDA) approved, compendia supported, or literature supported for the prevention of chronic migraine. As such, the requested service is not medically necessary. The requested drug is not medically necessary over the alternatives of Ajovy, Aimovig, or Emgality as these drugs are FDA approved for prevention of chronic migraine. Needle phobia is not an absolute contraindication to the use of these medications. The provider also notes that the patient has constipation. As such, Emgality or Ajovy may be preferred over Aimovig.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer
Treatment: Electrical Stimulation Device (Optune)
The insurer denied: Electrical Stimulation Device (Optune)
The denial is overturned

The patient is an adult male with glioblastoma (GBM) treated with Temodar plus radiation therapy (XRT). The attending physician (AP) has now requested Optune plus Temodar. The patient is enrolled in a clinical trial evaluating Optune with radiation.

The proposed treatment is medically necessary.

While Optune used with concurrent radiation is experimental, and the subject of this study, this patient was on the control arm and did not receive Optune with radiation. While this patient is participating in a clinical trial, the use of Optune plus Temodar following Temodar plus radiation therapy (XRT) is standard of care as therapy for glioblastoma. Based on the EF-14 trial that showed an improvement in overall survival (OS) to the use of this device following Temodar plus radiation therapy (XRT), this has Food and Drug Administration (FDA) approval and National Comprehensive Cancer Network (NCCN) support in this setting.