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

Diagnosis: Memory Issues
Treatment: Home care/personal care HHC (home health care)- level 2 personal care services, per 15 minutes increase to 50 hours per week
The insurer denied home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 50 hours per week
The determination is upheld.

This is a female patient with a medical history notable for poor memory and incontinence. The patient is approved for 30 hours per week of level 2 personal care services. The patient and her care team requested an increase to 50 hours per week, and this request was denied by the health plan. There were no letters of medical necessity or medical records provided as part of this review. The member's care plan notes were provided and reviewed in detail.

A Uniform Assessment System (UAS) was completed and was available for review. The patient lives with her husband in a private home. Her Consumer Directed Personal Care Assistance Services (CDPAS) caregiver is her daughter. The patient is a mutual case with her husband. The patient was recently discharged home from a skilled nursing facility after a planned hospitalization for a knee replacement. The patient's cognition was minimally impaired; she was alert and oriented to person and place only, but able to direct her own care. For her instrumental activities of daily living (IADLs), she requires total dependence for meal preparation and housework. She requires maximal assistance for finances, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for hygiene, dressing upper body, toilet transfer, and toilet use. She requires limited assistance for walking, locomotion, bed mobility, and eating. She ambulates with a walker with a slow and unsteady gait. She needs extensive assistance with transferring including toileting. She is frequently incontinent of urine and uses pullups for incontinence care. Compared with a UAS (prior to the knee surgery), the patient's functional status improved modestly. A task tool associated with the most recent UAS recommended 35 hours per week to address her personal care needs, a decrease from the 43 hours recommended on prior assessment. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 50 hours per week.

The requested health service/treatment of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 50 hours per week has not been demonstrated to be medically necessary for this patient.

The patient has functional limitations as outlined in the UAS. She showed improvement over earlier this year after receiving knee replacement surgery, which is expected to improve the patient's mobility. The patient appears to have adequate formal and informal support. There is no documentation regarding what personal care needs, if any, are not being met at the current allotment of CDPAS hours.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Migraine
Treatment: Sphenopalatine ganglion (SPG) blocks
The insurer denied Sphenopalatine ganglion (SPG) blocks.
The determination is upheld.

This is a male patient with chronic migraines. The patient is not currently on a Food and Drug Administration (FDA) approved preventative therapy for migraine prevention. Sphenopalatine ganglion (SPG) blocks are requested for acute treatment of migraine. At issue is whether outpatient SPG (Sphenopalatine Ganglion block) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Large controlled trials or perspective studies are lacking to demonstrate the efficacy of sphenopalatine ganglion blocks for treatment of acute and/or chronic migraine. SPG blocks have not been compared to Food and Drug Administration (FDA) approved therapies such as analgesics, triptans, ditans for treatment of acute migraine. Thus, it cannot be stated that the SPG block is more beneficial than any standard treatment for the member's condition. Additionally, there is no literature supporting the proposed treatment plan for SPG blocks for three days in a row.

It is noted that the patient has tried and failed sumatriptan, naratriptan, and zolmitriptan. The member has had a partial response to rizatriptan. The patient has not tried and failed frovatriptan, eletriptan, or almotriptan. There is no documentation that the patient has tried and failed ergotamines, which are also approved for treatment of acute migraine. The patient has tried and failed the gepants, Ubrelvy and Nurtec oral disintegrating tablet (ODT). There is not documentation that the member has tried and failed Reyvow, a ditan drug that is FDA approved for treatment of acute migraine. Thus, it cannot be said that treatment with SPG blocks is likely to be more beneficial for treatment of the member's condition than FDA approved medications.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Migraine
Treatment: Sphenopalatine ganglion (SPG) blocks
The insurer denied Sphenopalatine ganglion (SPG) blocks.
The determination is upheld.

This is a male patient with a listed diagnosis of migraine. However, the headaches are reported as daily/continuous, bilateral, dull and throbbing. Medication overuse headaches do not appear to have been ruled out.
Limited documentation reports trials of the following:
-	amitriptyline, propranolol, Botox, Emgality, Ajovy - unknown doses, unknown duration of trials
-	"nerve blocks", trigger point injections, magnesium, riboflavin, gabapentin, paroxetine, cyclobenzaprine, rizatriptan, zolmitriptan, Ubrelvy, which are not generally accepted as proven migraine prophylactic agents.
-	Nurtec, which is given unclear doses and it is unclear if it is taken as abortive or prophylactic.

At issue is whether the proposed health service or treatment outpatient SPG (Sphenopalatine Ganglion block) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment outpatient SPG (Sphenopalatine Ganglion block) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

There is insufficient evidence from high-quality peer-reviewed literature, large, well-designed, blinded, randomized trials to support long term safety and efficacy of the requested procedure, sphenopalatine ganglion block, for the requested indication in this patient, as documented. There is similarly no high quality evidence that such procedure would be superior to other, standard of care alternative treatment options. This reviewer could also not identify a single widely accepted guideline recommending such treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Migraine
Treatment: Sphenopalatine ganglion (SPG) blocks
The insurer denied Sphenopalatine ganglion (SPG) blocks.
The determination is upheld.

This is a male patient who has been under the care of a headache center for a history of migraines and myofascial pain. Notes from a follow-up visit indicated that the patient had daily headaches with migrainous features and 10-12 severe migraines/month. The patient reported the onset of headaches had been following sinus surgery.

For acute therapy at the time of the visit, the patient was noted to be using naratriptan in combination with ibuprofen 400 milligrams (mg). Prior acute therapies trialed by the patient were said to have included: sumatriptan (tablets), rizatriptan, zolmitriptan, Ubrelvy and Nurtec.

At the time of the follow-up visit, the patient was referred for sphenopalatine (SPG) blocks for the acute treatment of his migraines. A request for prior approval of the SPG blocks was made. The health plan denied the request for and at issue is whether outpatient SPG (Sphenopalatine ganglion block) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

It is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
According to the current expert consensus of the American Headache Society (AHS), the authors concluded "With the exception of cluster headache, there is a paucity of evidence, and further research may result in the revision of these recommendations to improve the outcome and safety of these interventions" (3)

Since the publication of the AHS guidelines there has been at least one early/pilot randomized trial performed involving SPG blockade with bupivacaine delivered repetitively for 6 weeks with the Tx360 device. The trial found a significantly greater short-term (up to 24 hours) reduction in pain severity after active treatment versus placebo. However, there were no significant longer term effects on other outcomes (ie, 1 and 6 months after 12 treatments over 6 weeks). The trial was also underpowered to detect outcomes at 1 and 6 months. It had risks of bias due to a high rate of dropouts The authors of the study noted that "further research on sphenopalatine ganglion blockade is warranted."(8).

The requested service/procedure has not otherwise been readily validated for efficacy in adequately sized/powered clinical trials (4).

There otherwise have not been any studies done to date comparing the efficacy of the proposed intervention with other validated acute therapies for the management of migraine headaches.

In as much, based on the weakness of the literature available regarding the proposed procedure/service, it cannot be said to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Weakness.
Treatment:  Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), included microprocessor, sensors, all components and accessories, custom fabricated.
The insurer denied Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), included microprocessor, sensors, all components and accessories, custom fabricated.
The determination is overturned.

This is a male patient with a history of left upper extremity weakness following a stroke. He has a history of diabetes, hypertension, gastroesophageal reflux disease (GERD), and psoriatic arthritis. The patient was seen by an orthotic specialist for evaluation of a powered upper extremity range of motion assist device. He had a modified Ashworth Scale spasticity score of 1 in the biceps, 1 in the triceps, 2 in the wrist/Finger flexors and 2 in wrist finger extensors. At issue is whether the proposed health service or treatment powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), included microprocessor, sensors, all components and accessories, custom fabricated is likely to be more beneficial than any standard treatment.
The the proposed health service or treatment powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), included microprocessor, sensors, all components and accessories, custom fabricated is likely to be more beneficial than any standard treatment.
Multiple studies demonstrate the feasibility of a myoelectric elbow-wrist-hand orthosis resulting in improved range of motion during use and efficacy at remediating upper extremity impairment after stroke. Most patients could operate the device in at least one mode, and most could lift and hold weights representative of some everyday objects using the device with no significant adverse events including an absence of joint hyperextension or mediolateral instability. Given that stroke increasingly affects younger individuals with long life expectancies, it is critical to encourage the use of advanced orthotic technology to enhance motor performance while next generation clinical and pharmaceutical interventions are developed.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Weakness.
Treatment:  Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), included microprocessor, sensors, all components and accessories, custom fabricated.
The insurer denied Powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), included microprocessor, sensors, all components and accessories, custom fabricated.
The determination is upheld.

This is a male patient with a history of diabetes mellitus (DM), hypertension (HTN), aortic valve replacement (AVR), ankylosing spondylitis, status/post (s/p) cerebrovascular accident (CVA) with left hemi who has applied for authorization of a Myopro. This device is an elbow/wrist/hand/finger orthosis custom fabricated with a microprocessor. At issue is whether this is likely to be more beneficial than standard treatment or treatments.

There is not convincing evidence that the MyoPro microprocessor upper limb orthosis would be beneficial for this patient. The patient has a chronic cerebrovascular accident (CVA) with left hemiparesis and contractures (per the documentation). This would limit the efficacy of the electromyography (EMG) activated device and limit the functional benefits. The custom powered elbow/wrist/hand/finger orthosis is not standard of care and would be no more beneficial than a standard orthosis. With any tone or contracture, the efficacy of a powered orthosis will be reduced. The patient is not a good candidate for this device and the supporting documentation does not explain why this patient would benefit.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Acute Inpatient Hospital Admission:
The insurer denied: Acute Inpatient Hospital Admission:
The denial is Overturned.

This patient is an adult female who presented to the emergency room (ER) with complaints of abdominal pain, nausea and vomiting. The patient had a temperature of 100.7 with tachycardia. Labs were significant for leukocytosis of 15.84. Computed tomography (CT) scan revealed distended gallbladder with wall thickening and pericholecystic fluid consistent with acute cholecystitis but recommended consideration of ultrasound. Ultrasound revealed gallstones, sludge with thickened wall. The patient was made nothing by mouth (NPO) and supported with intravenous fluid (IVF) and intravenous antibiotics. A decision was made to proceed with surgery. The patient was taken for laparoscopic cholecystectomy on day two of the admission. The procedure was uncomplicated. The patient was continued on intravenous antibiotics after the procedure and the white blood cell (WBC) count was normalized on post-operative day one (POD#1). The patient was tolerating a diet and oral medication and was discharged home on post-operative day one.

The proposed treatment was medically necessary.

This patient was denied treatment for not being medically necessary as lack of need. Unlike symptomatic cholelithiasis or elective interval cholecystectomy which generally does not require inpatient admission, this patient presented acutely to the emergency room after being discharged from a separate emergency room one day prior. The patient had pain, low grade fever, tachycardia and leukocytosis. The patient was treated with nothing by mouth (NPO) / intravenous fluid (IVF) / intravenous (IV) antibiotics. As this was not a scheduled elective case, 
the patient was supported with intravenous antibiotics until she could be taken to the operating room. The patient had leukocytosis, and this was not documented to have down trended or normalized until post-operative day one (POD#1). The patient's care could not have been managed at an observation or ambulatory level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD)
Treatment: LINX device (procedure code 43284)
The insurer denied coverage for LINX device (procedure code 43284).
The denial is overturned.

The patient has a history of gastroesophageal reflux disease (GERD). A workup including endoscopy, upper gastrointestinal (UGI) series, a pH (acid or alkaline) study off proton pump inhibitors (PPI), and manometry was done. The DeMeester score was 39.1. He had reflux on testing which correlated to his symptoms. He was advised to have a LINX procedure to control his reflux symptoms. 

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the Linx Reflux Management System in March 2017. With regards to safety, the conclusion was that long-term follow-up supports the Food and Drug Administration (FDA) conclusion that the device is safe. With regards to efficacy, there were several conclusions. The LINX implant results in pH normalization, improved quality of life, and cessation of regular PPI use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating GERD symptoms and dysphagia are similar following LINX. The long-term follow-up data demonstrates that the LINX Reflux Management System is effective in the management of GERD. 

The Annals of Surgery 2019 Aug 270(2):302-308 has an article titled "Objective Evidence of Reflux Control After Magnetic Sphincter Augmentation: One Year Results From a Post Approval Study." The conclusion was that both safety and effectiveness of magnetic sphincter augmentation has been demonstrated outside of an investigational setting to further confirm the procedure as treatment for GERD. 

The scientific literature supports the use of the LINX system as a treatment for GERD. The 2019 study in the Annals of Surgery confirms the long-term safety and efficacy of the procedure. 

The LINX system has been approved by the FDA.

The patient is a good candidate since he has chronic GERD and has concerns about long-term PPI therapy. 

There are multiple options for treating GERD, but the LINX system has been shown to be both effective and safe. The procedure has been shown to be beneficial for chronic reflux.

In summary, the denial of LINX device (procedure code 43284) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD)
Treatment: LINX device (procedure code 43284)
The insurer denied coverage for LINX device (procedure code 43284).
The denial is overturned.

Gastroesophageal reflux disease (GERD) results from incompetency of the lower esophageal sphincter (LES) that allows the contents of the stomach to reflux into the esophagus, airways, and mouth. The LINX Reflux Management System was developed to provide a permanent solution to GERD by augmenting the sphincter barrier with a standardized, reproducible laparoscopic procedure that does not alter gastric anatomy and is easily reversible. [1] The LINX Reflux Management System is a permanent, drug-free treatment for GERD that consists of a small band of magnetized titanium beads that are wrapped around the LES. This is performed under sedation using a laparoscopic technique. This band helps prevent gastric acids from pushing back up into the esophagus from the stomach yet also safely allows the LES to open when required to allow for easy swallowing. Sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits with no safety issues, as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on proton pump inhibitors (PPIs), with minimal side effects and no safety issues. [2] The LINX system is intended for use in GERD patients with abnormal pH (acid or alkaline) testing who continue to have chronic symptoms despite anti-reflux therapy. [3] LINX Reflux Management System should be considered a safe and efficacious alternative to the more technically difficult and infrequently used Nissen fundoplication, with lower complication rates as well as the unique option for easy removal. This procedure should be considered a standard of care option for the treatment of GERD.

This is an adult male patient with a history of GERD. The patient presented with persistent belching, heartburn, and regurgitation. Symptoms are not controlled despite the use of three different PPIs. An esophagogastroduodenoscopy (EGD) demonstrated an irregular Z line (squamocolumnar junction). Pathology demonstrated findings consistent with reactive gastropathy. A pH study demonstrated abnormal reflux events and an elevated DeMeester score of 39.1. An upper gastrointestinal study demonstrated reflux. 

LINX obtained Food and Drug Administration (FDA) approval in 2012 and has been demonstrated to be safe and effective in patients with GERD. Per provided clinical documentation, the requested procedure is medically necessary and is likely to be more beneficial than other standard treatments.

In summary, the denial of LINX device (procedure code 43284) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fracture teeth x 2
Treatment: Post and hard material under cap (post and core) for tooth # (numnber) 8 and tooth colored cap for teeth #'s 8 and 9
The insurer denied coverage for post and hard material under cap (post and core) for tooth #8 and tooth colored cap for teeth #'s 8 and 9.
The denial is upheld.

Upon review of the submitted documentation which includes copies of panoramic radiograph and periapical radiographs and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment presumably secondary to fracture of teeth # (number) 8 and 9 with pain. Based on the documentation, post and crowns were recommended. The insurer has denied the services stating that these services are not medically necessary treatment as the clinical documentation does not support the requested services. The patient is appealing.

Based on the submitted objective information for review, which consists solely of the radiographic examinations, it is difficult to discern any radiographic issues as the quality of the radiographs is poor/inadequate. As this is the case, and there is no other objective clinical documentation provided for review, the radiographic documentation does not support the dental treatment recommended by the dentist. There are no dental treatment notes, no dental charting, nor periodontal charting provided for review. As the documentation is inadequate to support the treatment, these services are considered not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient.

The medical necessity for post and hard material under cap (post and core) for tooth #8 and tooth colored cap for teeth #'s 8 and 9 is not substantiated.