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

Diagnosis: Dental Problems/Other/Malocclusion.
Treatment: Dental/Orthodontic Procedure.
The health plan denied the requested service/treatment of braces as not medically necessary. 
The health plan's determination is overturned.

The patient in question is a female presenting with a skeletal Class II malocclusion and mild spacing. She has an anterior open bite. Tooth #10 is in anterior crossbite. The patient is treatment planned for 30-36 months of orthodontics including palatal expansion to address the spacing and open bite.
At issue is the medical necessity for the requested health service/treatment of braces.

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

Anterior open bite patients are among the most difficult patients to treat.[1] One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite.[2]
Studies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with normal occlusion.[3] However, it has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion.[3] Given the patient's malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux and Barrett's Esophagus.
Treatment: LINX Procedure.
The insurer denied the LINX Procedure.
The denial is upheld.

The patient is a female with history of GERD (gastroesophageal reflux disease) and reflux symptoms that have been present for a while.

The patient was seen for persistent reflux symptoms. DeMeester 40, normal motility, and EGD (esophagogastroduodenoscopy) showed irregular Z line and hiatal hernia. The patient has had prior history of Barrett's.

No, the health plan should not cover the LINX procedure.
After reviewing the medical record, and the attached documentation, there are no good studies to validate the use of LINX system in large hiatal hernias and Barrett's esophagus. There is one study citing regression of intestinal metaplasia, however this was a small study. There is one study that prospectively looked at large (> {greater than] 3cm [centimeters]) hernias with LINX system that found no correlation with increased complications. However, there is not enough data to demonstrate utility in these cohorts for the LINX system.

No, the LINX procedure is not more beneficial.
Laparoscopic hiatal hernia repair with fundoplication can give equally as good results and can be used in patients with Barrett's esophagus.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux and Barrett's Esophagus.
Treatment: LINX Procedure.
The insurer denied the LINX Procedure.
The denial is overturned.

The patient is a female with Barrett's esophagus and GERD (gastroesophageal reflux disease). The request is for LINX fundoplication.

The patient has had complete workup, including pH testing showing a Demeester score of 40 and manometry showing normal motility.  She has a small hiatal hernia as well.

The request for LINX was previously denied coverage by the health plan as experimental/investigational.  The reason for appeal is that it is felt to be medically indicated in this patient.

Yes, the health plan should cover the LINX procedure.
There are good data supporting the use of magnetic sphincter augmentation for medically refractory GERD (gastroesophageal reflux disease) (see references).  Thus, this procedure can no longer be considered experimental/investigational.  Additionally, major foregut societies recommend its use, as outlined below:

Per the Sages technology and value assessment committee "safety and effectiveness analysis of the LINX reflux management system posted": "The LINX device has been demonstrated to result in long-term GERD [gastroesophageal reflux disease] control based on symptomatic outcomes, PPI [proton pump inhibitor] utilization, and pH studies," and, "should be covered and reimbursed by insurance for appropriate patients."

Per ASGS (American Society of General Surgeons) "LINX statement in support from ASGS [American Society of General Surgeons]": "based on currently available information and the experience of our members with the procedure, we do support the LINX procedure as a mechanism for controlling GERD [gastroesophageal reflux disease] when it is placed by properly trained laparoscopic surgeons with experience in foregut surgery in the management of GERD [gastroesophageal reflux disease] patients."

Yes, the LINX procedure is more beneficial.
LINX is more beneficial than standard fundoplication in this patient.  LINX fundoplication is associated with less gas bloat, quicker/immediate diet progression, and is less invasive when compared to standard fundoplication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overdose
Treatment: Inpatient psychiatric hospital treatment
The insurer denied coverage for inpatient psychiatric hospital treatment.
The denial is overturned.

This female reportedly was admitted to an inpatient hospital in the psychiatric unit due to an overdose. It was reported that she had limited coping skills and insight, and emotional reactivity and acute emotional distress as well as impulsivity. She reportedly had a diagnosis of Unspecified Mood Disorder, Borderline Personality Disorder, and rule out PTSD (post-traumatic stress disorder). 
    
This reviewer disagrees with the decision to deny coverage for continued inpatient psychiatric hospital treatment and the medical records provided enough specific evidence to support that she required inpatient hospitalization still. The MCG (Milliman Care Guidelines) Behavioral Health Inpatient Level of Care Adult criteria reports that a patient needs to present as an imminent danger to self, imminent danger to others, with severe psychiatric or behavioral symptoms, have a severely dysfunctional living situation including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible to meet criteria for inpatient behavioral health level of care. The InterQual Behavioral Health-Adult Psychiatry-Inpatient medical necessity criteria reports that if one has assaultive behavior within 24 hours, catatonia, command hallucinations to harm self or others, destruction of property with poor impulse control within 24 hours, disorganized behavior, unstable eating disorder, fire setting, homicidal or suicidal attempt within 24 hours, suicidal or homicidal ideation with high risk for an attempt, mania, risk of harm to self or others, non-suicidal self-injury and continued danger to self, positive psychotic symptoms with risk of harm to self or others, PTSD with risk of harm to self or others, psychomotor agitation and potential for violence, severe social withdrawal and refusing treatment, unavailable support or inability to provide needed care and supervision and there is acute deterioration, then one still meets criteria for hospital treatment. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with past suicide attempts are at high risk for suicide and this patient had past reported suicide attempts including the attempt prompting this admission. The APA Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports also that patients may require more time in the hospital to better assess suicide because they sometimes do not tell the truth regarding their suicidal thoughts in order to leave the hospital and that observation in the hospital is appropriate to better ensure their safety. 

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for continued inpatient psychiatric admission is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ear/Nose/Throat/Sinusitis/Sinus Infections
Treatment: Surgical Services (All)
The health plan denied the requested procedure as experimental/investigational. 
The health plan's determination is upheld.

Records indicate this patient has chronic sinusitis. There is a computerized axial tomography (CAT) scan showing pansinusitis. There is an appeal letter from the physician noting that the client has had aggressive medical management and the swell bodies were necessary to be done. The operative report is present, noting balloon dilation of all sinuses along with ethmoidectomy and turbinectomy and swell bodies. The office notes include that the client had nasal congestion on both sides of the nose which are described as severe. The office visit noted that the physical exam showed inside the nose "nasal mucosa within normal limits, vestibule within normal limits, middle meatal narrowing turbinate hypertrophy and discharge purulent deviated septum to the right ". No mention of nasal swell bodies other than the turbinate hypertrophy is noted. The subject of the appeal is the excision of the nasal septal swell body.
At issue is the whether the proposed health service or treatment is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

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

No. This patient has documented sinusitis on the CAT scan in the medical records and he underwent sinus surgery septum and turbinate surgery. The issue at hand is nasal swell bodies. During the procedure, the client had a turbinectomy and the swell bodies are noted a separate procedure but:
1. It would typically be consistent with while operating the turbinates if there are any areas of swelling, these will be dealt with at the same time and a separate procedure is not consistent with being necessary and should be part of the turbinate procedure.
2. The physical exam from the office visit noted "nasal mucosa within normal limits, vestibule within normal limits" and mention of swell bodies or other abnormalities other than the turbinate hypertrophy could not be located.
3. Radiofrequency ablation of swollen areas are procedures that have been done for many years and are now being done with new instruments such as Vivaer or Rhinaer. Although the literature supports the use of radiofrequency ablation there is less literature, and it is not consistent with being well-documented and well proven that the newer techniques using instruments such as Vivaer or Rhinaer are shown to be effective or more likely to be beneficial than standard treatments.
4. The insurance policy considers the procedure as unproven.
Therefore, it is not consistent with stating that the procedure done is more beneficial than standard treatment or that it is medically necessary or that it is proven.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ear/Nose/Throat/Sinusitis/Sinus Infections
Treatment: Surgical Services (All)
The health plan denied the requested procedure as experimental/investigational. 
The health plan's determination is upheld.

The patient is a gentlemen who was seen in the clinic complaining of severe nasal congestion, nasal discharge and postnasal drainage. He had no improvement with nasal steroids in the past. An examination including a nasal endoscopy showed bilateral turbinate hypertrophy, right septal deviation and purulent discharge in the middle meatus bilaterally.
A computed tomography (CT) of the sinuses showed bilateral chronic pansinusitis.
The patient underwent surgery- bilateral balloon dilation of the frontal, maxillary and sphenoid sinuses; bilateral anterior ethmoidectomies; bilateral inferior turbinate submucosal reduction; and bilateral transmucosal radiofrequency reduction of septal nodular swelling.
At issue is whether the proposed health service or treatment is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

I uphold, in whole, the health plan's determination regarding the proposed treatment.

The proposed treatment was not more likely to be beneficial than any standard treatment for the patient's condition.
The patient was noted to have a right septal deviation on physical exam, but there was no note of enlarged, obstructive septal swell bodies in this clinical note. The standard procedure to correct a septal deviation is a septoplasty. Transmucosal radiofrequency reduction of nodular septal swelling (using the Vivaer device) will not correct a septal deviation. It is not clear in the provided documentation what the nodular swelling was exactly, or that it was contributing to this patient's symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ear/Nose/Throat/Sinusitis/Sinus Infections
Treatment: Surgical Services (All)
The health plan denied the requested procedure as experimental/investigational. 
The health plan's determination is upheld.

The patient is a male with chronic sinusitis and nasal obstruction. Medical management has included nasal steroids, oral antibiotics, antihistamines, and oral steroids.
The patient underwent sinus surgery, septoplasty, turbinate reduction and septal swell body reduction. Septal swell body reduction is the topic of this review
At issue is whether the proposed health service or treatment is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination regarding the proposed health service is upheld, in whole.

No. Septal swell body reduction has not been shown in well-designed studies to be an effective treatment for nasal obstruction.
This treatment is not considered standard of care and is not routinely done in the United States. [1-5]
This procedure is unlikely to have had any additional benefit to the patient's nasal obstruction symptoms which were treated with septoplasty and turbinate reduction.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive/Gastrointestinal System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a female who presented to the emergency department (ED) with severe, generalized, worsening, abdominal pain and nausea. At the time of presentation, the patient was without fever, heart rate was 82 and blood pressure was elevated at 189/103 millimeters of mercury (mmHg). She was tender and had peritoneal signs of guarding. The white blood cell (WBC) count was 7.1 thousand (K). The complete metabolic panel identified low potassium (3.1). Diagnostic considerations per the ED records initially included small bowel obstruction, biliary disease and kidney stones. Abdominal computed tomography (CT) scan showed findings consistent with organoaxial gastric volvulus. The patient was treated with nasogastric (NG) tube decompression. Gradually, her symptoms of pain did improve while she was in the ED.

She was admitted to the hospital and a surgical consultation was obtained. The nasogastric tube was continued, and her electrolyte abnormalities were corrected. Gastroenterology consultation was obtained. The NG tube was removed. The patient underwent diagnostic laparoscopy. The operative dictation describes that there was no active gastric volvulus. She was clinically stable following surgery and was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. Post-operative day #1 following surgery, the patient had stable vital signs. Pain was controlled with oral medications. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting. The subject under review is the medical necessity for the inpatient stay.

This patient is a female who presented to the hospital with acute onset abdominal pain. Based on the presenting lab and imaging data that identified gastric volvulus, it was reasonably anticipated that the medically necessary care would span a period of greater that 48-hours. An inpatient stay was medically necessary in this case and consistent with the diagnosis of gastric volvulus. In this case, the submitted documentation does support that these clinical conditions (failure to achieve discharge status criteria) existed to warrant an inpatient level of care. The diagnosis of gastric volvulus as was identified by CT scan is a surgical emergency that carries the significant risk for rapid clinical deterioration. The records support that the patient was treated in an expeditious and efficient manner. Her condition required the coordinated, inpatient care, of the gastroenterology and surgery services. She required surgical intervention as performed. Inpatient care was appropriate, consistent with medical standards and a lower level of care would not have satisfied the clinical needs of this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine.
Treatment: Ubrelvy.
The insurer denied the Uberlvy.
The determination is upheld.

The patient has a diagnosis of acute migraine. Treatment with Ubrelvy is the subject of this review. The drug was denied because the member has not tried and failed other formulary alternatives. There is only documentation of the member has tried and failed Imitrex for acute treatment of migraine. The provider appealed the determination. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Ubrelvy 100 milligram (mg) tablet or would have adverse effects.

All of these drugs are safe and effective for treatment of acute migraine. The patient does not have an absolute contraindication to the use of triptan drugs. Failure to sumatriptan tablets does not indicate that the patient will not respond to any other triptans. The formulary contains triptans that can be taken via different routes of administration including disintegrating tablets, nasal sprays, and injections. Additionally, there is no peer reviewed literature to show that Ubrelvy is more effective than these triptan alternatives for treatment of acute migraine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic brain injury (TBI).
Treatment: Skilled nursing facility (SNF) admission.
The insurer denied coverage for a skilled nursing facility admission.

The denial is upheld.

According to the medical records, the patient is a male who fell off a ladder and had a subarachnoid hemorrhage; he had hydrocephalus and exterior shunt. He had a percutaneous endoscopic gastrostomy (PEG) tube, was aphasic, and had a stay at a rehabilitation and was transferred to a skilled nursing facility and has a decubitus ulcer. Later, he was admitted to the hospital for hypernatremia and fevers. He was treated with antifungals and antibiotic and got a new suprapubic catheter. He was suspected of having a urinary tract infection and had a wound vac placed. He was denied readmission to SNF.

Lueckel, S. N. et al. conclude "Our results suggest that among patients with traumatic brain injury admitted to skilled nursing facilities, the likelihood of adverse outcomes varies significantly by key demographic and clinical characteristics. These findings may facilitate setting expectations among patients and families as well as providers when these patients are admitted to skilled nursing facilities for rehabilitation after their acute episode." (2019).

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

He requires supportive care and 24-hour nursing.  He is severely cognitively impaired. He was noted to open eyes to sound some spontaneous movement. No information regarding progress during prior SNF stay or goals achieved or the number of days he previously had. There was only one therapy session, and it was more of a brief assessment rather than an actual visit. Therefore, a skilled nursing facility admission at is not considered medically necessary for this patient.

The insurer's denial of coverage for skilled nursing facility admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain .
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient has a history of hypertension, hyperlipidemia, prediabetes, coronary artery disease (CAD) with a previous myocardial infarction (MI) and drug-eluting stent (DES) placement, and heart failure with reduced ejection fraction (HFrEF)  ejection fraction 26-30%), on a LifeVest, who presented to the emergency room (ER) with chest pain. He had left-sided chest pain, non-radiating, which started after he had walked for 20 minutes. The pain worsened with movement. In the ER, his blood pressure was 147/121 millimeters of mercury (mmHg), pulse 59 beats per minute (bpm), and respirations 16. The troponin was 0.01. An electrocardiogram (ECG) showed sinus bradycardia.
The patient was admitted and ruled out for myocardial infarction (MI) with negative serial troponins and ECGs. He was seen in cardiology consultation. He had previously had a negative stress nuclear study for ischemia. His pain was felt to be atypical for angina and possibly musculoskeletal in origin. An echocardiogram (ECHO) was recommended and performed. It showed an EF of 31%, and segmental wall motion abnormalities consistent with previous studies. He was discharged home. At issue is the medical necessity of an inpatient stay.

Inpatient admission is not medically necessary/indicated.
This patient with multiple comorbidities as noted above, presented with chest pain, but was hemodynamically stable, had initial negative cardiac enzymes and no ischemic electrocardiogram (EKG) changes. Based on his clinical symptoms and objective findings, he would be considered an intermediate risk patient for MACE (major adverse cardiac event) for whom a lower level of care is indicated, per current the American College of Cardiology (ACC) guidelines (reference 2 below). Inpatient admission was not indicated for this patient with chest pain but no objective evidence for acute coronary syndrome or other acute potentially life-threatening cardiac disease.