Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease).
Treatment: LINX Reflux Management System.
The insurer denied the LINX Reflux Management System.
The denial is overturned.

The patient is a male with medically refractory GERD (gastroesophageal reflux disease). The request is for magnetic sphincter augmentation.  The patient has a history of GERD (gastroesophageal reflux disease) symptoms for over 5 years that are uncontrolled despite being on Prilosec 40mg (milligrams) BID (twice daily), famotidine, and carafate QID (four times per day).  He had a GES (gastric emptying scintigraphy) that was normal, an EGD (esophagogastroduodenoscopy) that showed gastritis, an UGI (upper gastrointestinal series) showing a small hiatal hernia and reflux, manometry that was normal with 93% normal peristalsis, and a pH (potential of hydrogen) study showing GERD (gastroesophageal reflux disease) with a Demeester score of 17.2.  Previously, the case was denied stating it was experimental/investigational, that it has not been proven medically effective, and it does not "have enough proof in the medical information or research by specialists that describe safety, value, or effectiveness."

Yes, the insurance plan should cover magnetic sphincter augmentation.
Magnetic sphincter augmentation should be a covered treatment for this patient.  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:

Sages (Society of American Gastrointestinal and Endoscopic Surgeons) technology and value assessment committee "safety and effectiveness analysis of the LINX reflux management system": "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 (potential of hydrogen) studies, and "should be covered and reimbursed by insurance for appropriate patients."

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.
The patient has failed maximal medical therapy with max dose PPI (proton pump inhibitor), H2 (histamine H2-receptor) blocker, and Carafate.  Surgery with magnetic sphincter augmentation is indicated here, and it has a lower side effect profile than traditional fundoplication (see references).
Appeal type: Medical necessity
Decision: Overturned

Cardiac/Circulatory
Pharmacy/Prescription drugs

Diagnosis: Coronary artery disease/Hyperlipidemia
Treatment: Praluent
The insurer denied Praluent. The health plan's determination is overturned.

The patient is a man with a history of hypertension, hyperlipidemia and coronary artery disease. His baseline low density lipoprotein (LDL) cholesterol level is greater than 300. He had an ST segment elevation myocardial infarction. He was on high intensity statin therapy at the time. Recently, on atorvastatin 80 milligrams (mg) daily, his LDL cholesterol level was 92. Coverage for Praluent is under review.

Praluent is medically necessary for this patient.
This man has marked hyperlipidemia (most likely heterozygous familial hypercholesterolemia) and atherosclerotic cardiovascular disease (ASCVD). Despite treatment with high intensity atorvastatin, his LDL cholesterol level remains above his goal level of less than 70.
Praluent (alirocumab) is a member of a class of lipid lowering drugs called PCSK9 (Proprotein convertase subtilisin/kexin type 9) inhibitors. In clinical trials, these drugs have proven to be superior to conventional lipid lowering therapy in reducing LDL cholesterol levels and in improving cardiovascular outcomes. Current guidelines, including the 2017 National Lipid Association Update on the Use of PCSK9 Inhibitors in Adults and the 2016 American College of Cardiology (ACC) Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk, endorse the use of this medication in patients with clinical ASCVD whose LDL cholesterol level remains above goal despite maximally tolerated statin therapy. This patient meets this indication and Praluent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg swelling. 
Treatment: Compression pump. 

The insurer is denied coverage for compression pump. 

The denial is upheld. 

This female patient has no documented history. 

This board-certified physical medicine and rehabilitation/pain management practicing physician relied upon clinical experience and a medical literature review regarding pneumatic compression systems in making the determination.  The clinical records submitted do not support the requested durable medical equipment (DME) E0650x1, E0667x2- compression pump as medically necessary.  The patient and/or her medical provider(s) do not provide any specific clinical information regarding the underlying diagnosis, result of alternative treatments or response to the requested treatment.    
From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, based on the clinical information submitted for review, durable medical equipment (DME) E0650x1, E0667x2- compression pump is not medically necessary. 

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

The carrier's denial of coverage for compression pump is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse. 
Treatment: Residential inpatient care. 

The insurer is denied coverage for residential inpatient care. 

The denial is upheld. 

This male patient has a history of attention deficit hyperactivity disorder (ADHD) with severe executive function deficits, cannabis use disorder, depression and anxiety. 

The Interqual 2019 Child and Adolescent Psychiatry Behavioral Health Residential Treatment guidelines reports that interventions should include weekly psychiatric evaluations in addition to behavioral contract or symptom management plan clinical assessment at least 1 time per day, individual or family psychoeducation, individual or group or family therapy at least 3 times per week, as well as school or vocational program. 

According to the American Academy of Child and Adolescent Psychiatry (AACAP) Principles of Care for Treatment of Children and Adolescents with Mental Illness in Residential Treatment Center June 2010, it states that residential treatment should include a mental health professional to lead the treatment team but states that a psychiatrist with training and experience consistent with the age and problems of the children served should inform and monitor this process. There was not sufficient evidence to support that proper supervision and evaluation by a psychiatrist was done for this 24 hour treatment as there were no reports of weekly psychiatric evaluations.  She reportedly was seen by a social worker. Also, this wilderness program was not accredited by JCAHO or CORF. Wilderness programs are considered an adventure based therapy and this is not considered a standard treatment for an adolescent with a primary diagnosis of ADHD, substance use disorder, Anxiety Disorder, or Dysthymic  Disorder.  The medical records did not provide enough specific evidence to support that he required only this wilderness treatment program or that this wilderness program provided weekly psychiatric evaluations. 

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

The carrier's denial of coverage for residential inpatient care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent: Dose - 300mg Every Week, Pre-service
The insurer denied the Dupixent: Dose - 300mg Every Week, Pre-service.
The denial is overturned.

The patient is a male with atopic dermatitis to the neck, trunk and extremities with up to 50% BSA (body surface area). He has been treated with multiple topical steroids, prednisone, protopic, Eucrisa and phototherapy. The patient has been treated with Dupixent for several years. His provider is requesting weekly dosing.

Yes, weekly Dupixent is medically necessary.
The health plan denied the request for weekly dosing because only bi-weekly dosing is covered.

Randomized controlled trials for Dupilumab did not find a significant difference in response to weekly dosing compared with that to every other week (EOW) dosing.  The article by Gao et al performed a cohort study to examine the real world experience for recurrence of AD (atopic dermatitis) prior to the next dose of dupilumab and how patients on weekly dosed dupilumab did in the cohort, all of whom were inadequately controlled on the approved dosing.  This was a small study with only 23 patients.  The 23 patients who had tried weekly dupilumab were called, with 17 patients completing the survey.  It was observed that 12/17 patients (71%) reported recurrence prior to their next dupilumab dose, and all of them (100%) claimed that increasing EOW (every other week) dosing of dupilumab to EW (every week) dosing helped control their symptoms, this benefit was worth the effort of injecting oneself twice as often, and they planned to remain on weekly dosing.  From this study, weekly dosing of dupilumab may be beneficial to some patients with AD (atopic dermatitis), particularly those experiencing a recurrence of AD (atopic dermatitis) symptoms on the standard dosing.

The randomized, double-blind, phase 3 clinical trial (Worm et al) showed that continued response over time was most consistently maintained with dupilumab administered weekly or every 2 weeks. Longer dosage intervals and placebo resulted in a diminution of response for both continuous and categorical end points. No new safety signals were observed. The approved regimen of 300 mg (milligrams) of dupilumab every 2 weeks is recommended for long-term treatment.

Given the severity of disease and potential for improved control on weekly dosing, the request is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung Nodule. 
Treatment: Positron Emission Tomography (PET) Scan. 

The insurer denied the PET scan. The health plan's determination is upheld. 

The patient is a male with a known 7 millimeter (mm) irregular nodule in the left upper lobe as demonstrated on a computed tomography (CT) chest. He subsequently had a fludeoxyglucose (FDG) positron emission tomography (PET) scan, and it demonstrated the 7 mm left upper lobe nodule that was beyond PET resolution, a new subsegmental atelectasis, and a mildly avid 8 mm nodule in the right upper lobe. 
Under review is the medical necessity of a PET scan. 

A Positron Emission Tomography (PET) Scan is not medically necessary for this patient. The recommendations from the Fleischner Society for the management of multiple subsolid nodules (non-pure ground glass opacities) the dominant lesion or lesions determines further management. The patient should first have an initial follow-up CT examination in 3 months that confirms persistence. In addition, the American College of Chest Physicians (ACCP) evidence-based guidelines recommended "In the individual with a solid, indeterminate nodule that measures >8 mm in diameter and a high pretest probability of malignancy (>65%), we suggest that functional imaging should not be performed to characterize the nodule". The ACCP guidelines favored surveillance when the probability of malignancy was >3%, and surgical diagnosis was preferred when the probability was >68% and biopsy was the recommended strategy when the probability of malignancy fell between 3% and 68%. Therefore, based on the prevailing guidelines, this patient would have been more appropriately with a repeat surveillance CT chest in 3 months.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Skilled Nursing Facility. 
The insurer denied Long term custodial care. 
The denial is upheld in whole.

The patient is a female with a past medical history significant for hypertension, diabetes, seizure disorder, bipolar disorder, chronic obstructive pulmonary disease (COPD) with current tobacco use, obesity, sleep apnea and left below knee amputation (BKA) years prior. She had a recent coronavirus (COVID-19) infection and completed Remdesivir.
At issue is the medical necessity of long-term custodial care.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Long term custodial care is not medically necessary for this patient.
The patient is a female with multiple medical problems along with psychiatric illness. Care was denied stating that there is no change in her ambulation, or activities of daily living. She has not had any documented falls in the last month. The progress note by neurology documented the tremors were improved. It was noted she would have follow-up once she was discharged from the facility.
There are no noted physical disabilities that would necessitate inpatient custodial care. The patient is able to ambulate, she is able to transfer and toilet without assistance. The patient does have an above knee amputation (AKA) with recent stump infection which is healing. The AKA was several years ago. There does not appear to be any other associated new medical conditions or disabilities which would necessitate ongoing inpatient care. From a psychiatric standpoint she was able to direct her own care. Alternate living arrangements are reasonable and appropriate.
Therefore, Long term custodial care is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis/frequent falls. 
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services: 70 Hours per Week. 

The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services: 70 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of diabetes mellitus type 2, hypertension, hyperlipidemia, congestive heart failure (CHF), chronic kidney disease, severe arthritis with chronic pain, osteoporosis, neuralgia, urinary retention and recurrent falls who had been assigned personal care services. 

The patient underwent another assessment tool via telephone assessing patient at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with tasks of shopping, bathing, and toilet use. With tasks of managing finances, managing medication, stairs, transportation, dressing lower body, transfer toilet, and bed mobility the patient was assessed at extensive assistance while limited assistance with tasks of phone use, personal hygiene and dressing upper body. The patient was assessed at supervision with tasks of walking, locomotion, and eating. Notes from this assessment stated patient had a Foley catheter in place and was using pull-ups to manage leaks. In addition, the report stated the patient had unsteady gait and ambulated using a cane supported by daughter when transferring and changing positions. 

Home Care / Personal Care HHC - Level 2 Personal Care Services: 70 Hours per Week are medically necessary for this patient. 
There is documentation of worsening physical functioning following hospitalization. There is documentation of recurrent falls. The patient's medical provider requested an increase in Home Care / Personal Care services. The assessment tools show an increased need for assistance with tasks of meal preparation, phone use, bathing, dressing upper body, toilet use, bed mobility and eating. The patient did have improvement with walking and locomotion as well as personal hygiene but patient was still noted to require at least some assistance for these tasks. 
As the patient requires at least some assistance with all activities of daily living (ADL)/ Instrumental activities of daily living (IADL) and the requested increase in Home Care / Personal Care Services is not solely for safety and supervision but to assist the patient with safe completion of ADLs. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet the patient's care needs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services: 70 Hours per Week are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a past medical history significant for schizophrenia, bipolar disorder, and glucose intolerance who presented to the emergency department after he sustained a fall.

In the hospital, the patient was seen by orthopedic surgery. Based on the evaluation, there were no acute fractures or tendon ruptures. There were no interventions recommended during this hospital stay.
During the hospital stay, the patient remained in stable clinical condition. He was transitioned to outpatient care, with a recommendation to follow up with psychiatry and orthopedic surgery. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. This patient presented to the hospital after he sustained a fall. However, the fall did not result in any significant injuries that would require admission at the acute inpatient level of care. The patient was seen by orthopedic surgery. He did not need any inpatient stabilization and had no signs of limb-threatening injuries. There were no complaints of severe pain requiring acute inpatient management. There was no evidence that the patient had any significant laboratory abnormalities, or any unstable comorbid conditions requiring admission at the acute inpatient level of care. Overall, the patient hospital stay was short and could have been conducted at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is upheld. 

This female patient has a history of hypertension (HTN), and stage 4 chronic kidney disease on hemodialysis.

The patient was admitted for hyperkalemia and hypertensive urgency. She did not have persistent severe hyperkalemia, no signs of severe volume overload or hypoxia, nor documentation of severe uremia such as encephalopathy or uremic bleeding.  She had established dialysis access and did not require emergent vascular intervention.
Her condition could have been treated safely under lower level of care such as observation.

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

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

Diagnosis: Restless Leg Syndrome
Treatment: Fentanyl (in the dosage of 75mg (milligram) patches)
The insurer denied the Fentanyl (in the dosage of 75mg patches)
The denial is upheld.

The patient is a woman with restless legs syndrome who has tried and failed
multiple medications including multiple dopaminergic agents, gabapentin, baclofen
and tizanidine. She is currently taking 120 tablets of tramadol and 300 tablets of
codeine every month. Her prescriber would like to start her on Fentanyl patch.

This request was previously denied by the health plan, as the request did not meet plan's opioid management health and safety program which requires the following to be met: 
1)	diagnosis of chronic pain (pain that lasts for more than 3 months) which has required around-the-clock opioid treatment; 
2)	prior trials of non-opioid methods of treating pain;
3)	requirement of prescriber to confirm that he or she checks a prescription drug monitoring program and that risks and benefits of opioid therapy have been discussed and that the patient has a signed pain contract and treatment. 

The patient has not met the requirement of her condition being a chronic pain syndrome and that she would be using it in conjunction with non-pharmacological therapies.

No, the requested Fentanyl is not considered medically necessary.
The proposed treatment is not considered medically necessary due to lack of safety
data. Although multiple studies have indicated that opioids are effective for treating
RLS (restless leg syndrome) symptoms, there is lack of data establishing the
safety of opiates. Furthermore, the studies have looked at other opiates and not
Fentanyl, which is more powerful.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the
best interest of the patient.
Given the lack of safety data, the health plan acted reasonably, with sound medical
judgement and in the best interest of the patient, given that Fentanyl is a very
strong narcotic.