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

Diagnosis: GERD
Treatment: LINX Procedure
The insurer denied the LINX Procedure
The determination is overturned.

The patient has a body mass index (BMI)of 32.5 kilograms per square meter (kg/m2) and symptomatic gastroesophageal reflux disease (GERD) with regurgitation despite medication use. A 24-hour potential hydrogen (pH) study revealed an elevated DeMeester score of 72.4. An esophagogastroduodenoscopy (EGD) revealed no significant esophagitis or hiatal hernia. A biopsy did not reveal evidence of Barrett's esophagus. Esophageal manometry was normal. At issue is whether the proposed health service or treatment Laparoscopy and esophageal sphincter augmentation procedure (LINX procedure) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes. The laparoscopy and esophageal sphincter augmentation procedure (LINX procedure) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and the LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The exclusions to LINX and Nissen fundoplication include body mass index (BMI) greater than (>) 35 kilograms per square meter (kg/m2) in which case treatment of obesity is thought to be important for treatment of GERD. Other exclusions for LINX include Barrett's esophagus with dysplasia, age less than (<) 18 and prior gastric or bariatric surgery. This patient does not document any exclusion to treatment at this time. The requested procedure is a standard treatment for symptomatic GERD without any obvious contraindication for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The health plan's determination is upheld.

This is the case of a male who presented to the emergency department (ED) with a 3 day history of left forearm pain, rash, and swelling. Pain occurred on extension of the left elbow and redness and swelling of the left forearm had increased over the past 3 days. Review of symptoms (ROS) was negative for fever, recent trauma, or similar swelling in the past. Patient problem list includes obesity, eczema, and acanthosis nigricans.
ED vitals were temperature (T) 37.2 Celsius (C), heart rate (HR) 99, respiratory rate (RR) 18, blood pressure (BP) 120/80, oxygen (O2) saturation 100% on room air. The patient's weight was 275 lbs., and the pain score was 5/10. Physical exam was notable for 8-10 centimeter (cm) x 3-5 cm erythema, tenderness, and indurated swelling of the ventral aspect of the left forearm. Pain was elicited with extension of the left elbow. There was no associated lymphadenopathy. Complete blood count (CBC) showed white blood cell (WBC) count = 13.7 with normal differential, C-reactive protein (CRP)=6.3. The patient was given a dose of intravenous (IV) clindamycin and was admitted for intravenous (IV) antibiotics to treat a diagnosis of cellulitis.
At issue is whether this inpatient admission was considered medically necessary.

The health plan's decision is upheld.

The requested inpatient hospitalization is not considered medically necessary. This patient could have been adequately treated at a lower level of care. He was an otherwise healthy teenager with stable vital signs and ability to tolerate and oral diet.
He presented with 3 days of left forearm redness, pain, and swelling. There was no fever, vomiting, or history of trauma. The patient did not have immune compromise or other underlying medical condition. Laboratory evaluation showed elevation of WBC and CRP, consistent with skin infection.
Per Milliman Care Guidelines (MCG) Pediatric Cellulitis criteria, this patient did not meet criteria for inpatient level of care. Additionally, per Infectious Disease Society of America (IDSA) Guidelines cited below, "Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability (mild nonpurulent; Figure 1) (strong, moderate). Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing (moderate or severe nonpurulent; Figure 1) (strong, moderate)."
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Alopecia areata

Treatment: Xeljanz 10 milligrams (mg), 10 mg PO (by mouth) two times a day (BID) for one year

The insurer denied coverage for Xeljanz 10 milligrams (mg), 10 mg PO two times a day (BID) for one year

The denial is overturned

The patient is a female who has a history of alopecia areata. She has previously failed topical and oral steroids. The provider is requesting Xeljanz.

Xeljanz has recently been shown to be safe and effective in the treatment of extensive therapy resistant alopecia areata/totalis/universalis (Liu et al., Ibrahim et al.). In Liu's study, 65 patients with extensive alopecia areata were treated with Xeljanz. 77% (percent) of these patients achieved clinical response with 58% achieving greater than 50% changes in Severity of Alopecia Tool (SALT) score (Liu et al). No serious adverse events were noted. This patient has alopecia areata failing various systemic therapies and topical and local therapies. She has tried and failed guideline recommended therapies. Alopecia areata has extensive psychosocial impact and has a significant impact on quality-of-life scores (Liu et al).

Xeljanz is not yet FDA (food and drug administration) approved for the treatment of alopecia areata.

The patient is a good candidate for Xeljanz 10 milligrams (mg), 10 mg by mouth (PO) two times a day (BID) for one year to treat alopecia areata.

This treatment is the most effective treatment available for this patient. There are no standard treatments/services. Xeljanz is the most effective treatment for alopecia areata and in studies, it was shown to be very well tolerated without significant side effects.

Xeljanz 10 milligrams (mg), 10 mg by mouth (PO) two times a day (BID) for one year to treat alopecia areata is the best available treatment for this patient at this time. It is likely to be more beneficial than any therapies without increased adverse risks.

The carrier's denial of Xeljanz 10 milligrams (mg), 10 mg by mouth (PO) two times a day (BID) for one year to treat alopecia areata should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Alopecia areata

Treatment: Xeljanz 10 milligrams (mg), 10 mg PO (by mouth) two times a day (BID) for one year

The insurer denied coverage for Xeljanz 10 milligrams (mg), 10 mg PO two times a day (BID) for one year

The denial is overturned

The patient is a female who has a diagnosis of alopecia areata affecting 40% (percent) of scalp hair. The patient has failed therapy with topical, intra-lesional, and oral steroids.  The patient has also failed minoxidil topical therapy. The requested medication is Xeljanz.  

The patient has extensive disease involvement of alopecia which necessitates systemic therapy. No FDA (food and drug administration) approved systemic therapies are available for treating alopecia areata. There is sufficient peer-reviewed data to demonstrate the likelihood of efficacy of the Xeljanz with a reasonable side effect profile which can be monitored by the providing physician.  

The patient is not documented to have any other medical conditions and no relevant allergies which would prohibit the use of Xeljanz. In this clinical situation, Xeljanz is an appropriate treatment option for the patient's alopecia areata and is likely to be more effective than other alternatives. The adverse risks are not increased over standard therapies  

The carrier's denial of Xeljanz 10 milligrams (mg), 10 mg by mouth (PO) two times a day (BID) for one year to treat alopecia areata should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left finger trigger. 
Treatment: Assistant surgeon services during musculoskeletal surgery. 

The insurer denied coverage for assistant surgeon services during musculoskeletal surgery. 

The denial is upheld. 

This case is a patient with a history of left index finger trigger finger, left long finger trigger finger, left ring finger trigger finger, who presented to the surgical center for trigger finger release of the affected fingers.  A physician assistant (PA) assisted with the procedure. The patient subsequently received a denial of coverage for the assistant surgeon given that there was a lack of supporting documentation to justify the need for an assistant for a minimally invasive procedure. There was no indication of any complications or unusual circumstances requiring the presence of an assistant surgeon. 

The assistant surgeon services during the musculoskeletal surgery were not considered medically necessary for this patient. 

Literature notes that trigger finger is a common issue with a variety of acceptable treatments. Surgical options include open surgical release and percutaneous release of the A1 (flexor tendon pulley) sheath. Trigger point release is a minimally invasive procedure and does not require an assistant. Records did not indicate that there were any additional complexities to the surgery that would warrant the PA assistant. There were no exceptional factors or extenuating circumstances to support this request. It was therefore determined that the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

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

The insurer's denial of coverage for assistant surgeon services during musculoskeletal surgery is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Admission. 

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

This patient is a male with a history of alcohol related cirrhosis, colon cancer status post resection and chemotherapy, and anemia of chronic disease who presented for ecchymosis over the abdomen.  His alcohol level was 250, potassium was 3.2, white blood cell (WBC) count was 2.77, hemoglobin was 9.0, and platelet count was 43.  Abdominal imaging showed fatty liver and small volume ascites. The patient was treated with intravenous (IV) fluids, Ativan, Valium per Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.  The patient received treatment with potassium repletion, antibiotics, thiamine, multivitamins, and folic acid.  The patient was stated to have no acute events overnight, and no complaints.  The patient did not require 'as needed' (PRN) Ativan.  Valium was tapered.  The patient was on day four of five of antibiotics. 

No, the proposed inpatient stay was not medically necessary. 

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. 

An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be 'nothing by mouth' for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have liver failure, did not have gastrointestinal bleeding, did not have acute kidney injury, did not have fevers, did not have an elevated white count, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.  The patient did not require 'as needed' (PRN) Ativan since day two. 

The patient required intravenous (IV) antibiotics, but the antibiotics could have been administered at a lower level of care. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female, smoker who underwent a radical mastoidectomy for left cholesteatoma. She subsequently presented to the emergency room with complaint of dizziness intolerance to oral intake and nausea and vomiting. She complained of pulsatile pain and constant vomiting since the time of surgery. She was unable to tolerate her medications and although she drank Pedialyte she regurgitated it. She was given intravenous (IV) fluids and her dizziness and nausea resolved. She was given Zofran while in the hospital and fluids intravenously. Hospital notes say, "states the unsteadiness and vertigo have been progressive but not acute in onset or worsening." She had nausea and vomiting. The ear did not show any abnormalities and the exam in the emergency room was with "mild abdominal tenderness diffuse upper," along with further notation of rotational torsional nystagmus. The hospital notes state the patient reported "constant vomiting since surgery... Unable to tolerate any by mouth (p.o.) Feels dehydrated imbalanced." She was given IV fluids on admission as well as heparin for deep vein thrombosis (DVT) prophylaxis. Overnight the records noted "continues to have nausea...Attempting soft p.o. diet today." The second day post admission records state "nausea improved...Tolerating p.o." She was discharged home post admission day #2 tolerating oral intake.
At issue is the medical necessity of Inpatient Stay.

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

The requested health service/treatment of Inpatient Stay was medically necessary for this patient.

This client was admitted for intractable vomiting. The records indicate she had persistent vomiting since surgery which was 3 days prior. She was unable to tolerate Pedialyte. She had abdominal tenderness and the hospital note stated, "constant vomiting since surgery unable to tolerate any p.o. feels dehydrated and imbalance." Additionally, the records indicate that the day of admission she had abdominal tenderness along with nystagmus. She required IV fluids and Zofran the day of admission and the next day and was discharged home on post admission day #2 when she was able to tolerate liquids. Virtually any area of surgery can result in postop vertigo. A client who has 3 days of persistent nausea and vomiting and cannot keep down any liquids, has constant vomiting since surgery and requires 2 days of IV fluids and Zofran, is not hemodynamically stable until she is able to tolerate p.o. intake. The records indicate she was unable to tolerate p.o. intake consistently until post admission day #2. It is medically necessary for an admission for this patient due to the persistent vomiting, need for IV hydration and until she was stable and able to tolerate oral intake.
Therefore, the Inpatient Stay was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fetal Demise.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


The patient presented with fetal demise secondary to trisomy 13. She was admitted for an induction of labor. Misoprostol was provided vaginally and she delivered 12 hours after the medication. She was discharged home the next day. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.
The patient was provided medication to induce delivery of a second trimester fetal demise. She passed the fetus without complication and this is typically performed in an outpatient or clinical setting. There was no hemorrhage, infection, nor anemia noted. There was no abnormal physical exam nor any post-procedure complications. The patient had no abnormal vital signs nor any hemodynamic instability. She had no renal, hepatic nor cardiac comorbidities. She had no pulmonary complaints or concerns. She could have been treated at a lower level of care. There are no medical records to support the need for acute, inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Iron Deficiency Anemia
Treatment: Feraheme (Q0138)
The insurer denied the Feraheme (Q0138)
The denial is upheld

The patient in this case is a female that has iron deficiency anemia. Her iron deficiency anemia is secondary to menorrhagia. Records indicate that she has tried treatment with oral iron, but that it was ineffective. She was prescribed treatment with Feraheme.

No, the requested Feraheme (Q0138) was not medically necessary.
This patient is noted to have a history of iron deficiency anemia.  However, no documentation of her hemoglobin or iron studies obtained before she was treated with Feraheme is provided. Therefore, while she may have a history of iron deficiency anemia there is no documentation showing that she had active iron deficiency anemia when she was treated with Feraheme.  Given that lack of supporting evidence, use of Feraheme in this case cannot be considered medically necessary

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cancer
treatment: Genetic Testing: CDKN2A Deletion Studies 
The insurer denied Genetic Testing: CDKN2A Deletion Studies. The health plan's determination is overturned. 

The patient is a female with a history of World Health Organization (WHO) grade IV IDH (isocitrate dehydrogenase) mutant glioma, status/post (s/p) resection, status/post (s/p) radiation and chemotherapy. The patient's provider is requesting genetic testing for better prognostications.

Genetic Testing: CDKN2A (cyclin-dependent kinase inhibitor 2A) Deletion Studies is medically necessary for this patient.
The proportion of CDKN2A homozygous deleted gliomas ranged from 9 to 43%, with a median incidence of 22%. Typically, the presence of this mutation carries a shorter progression free survival (PFS) and shorter overall survival (OS).
This mutation also carried clinical implication, as it has been shown that patients with homozygous CDKN2A mutation have a better OS when treated with bevacizumab. In this case, the results of the mutation will help to determine the treatment and help with prognosis. The mutation will predict the response to further therapy. It is proven that CDKN2A mutation predicts response to bevacizumab.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck and Back Pain. 
Treatment: Chiropractic Services. 

The insurer denied chiropractic services. 
The denial is upheld. 

The patient is a male who began chiropractic treatment for neck and back pain, of unknown duration or cause. Neck pain Visual Analog Scale (VAS) was 5-6/10; 6-7/10 for the low back, with examination findings of spasm, subluxation and reduced ranges of motion. Treatment included spinal and extraspinal manipulation, mechanical traction and therapeutic exercise. VAS was 2-4/10, with the same examination findings. VAS was 3/10, with spasm, tenderness and subluxation. VAS was 3/10 and 2/10. The subject under review is the medical necessity for the chiropractic services in question. 

The requested chiropractic services is not medically necessary for this patient. The patient did not reach the stated short or long-term goals and showed signs and symptoms of fluctuating improvements and regressions over a number of months, as also reported in the treating chiropractor's letter to the carrier. As such, maximum therapeutic benefit had been achieved. There were no ongoing, objective clinical signs of improvement. There were no details as to what therapeutic exercises were being utilized, and no documented non-supervised home rehabilitation program, which would make treatment more efficacious. There was also no ongoing Oswestry scoring, to better document clinical improvements, if any. There was no ergonomic advice documented, to improve the patient's recovery while working. The patient showed some initial improvement, but this hit a plateau, and in alignment with accepted chiropractic standards of care, continued treatment after such a medical endpoint is reached is not recommended or supported as medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus
Treatment: Dexcom continuous glucose monitor
The insurer denied Dexcom continuous glucose monitor.
The determination is upheld.

The patient has type 2 diabetes on a Dexcom continuous glucose monitor. She has an A1C of 6.7%. The patient is appealing the denial because use of continuous glucose monitoring has improved her diabetic health and her A1C improved from 10.7% to 6.7% with use of the device. A Dexcom continuous glucose monitor is under review for medical necessity.

The request is for a Dexcom G6 transmitter for monitoring of glucose for this patient with type 2 diabetes. Long-term continuous glucose monitoring has been shown to be safe and effective for people with type 2 diabetes on multiple daily insulin injections and basal insulin therapy. No documentation was provided to support that the patient is on insulin therapy. The use of continuous glucose monitoring in the absence of insulin therapy is not supported by the Endocrine Society guidelines [1] or the American Diabetes Association clinical guidelines [2]. Therefore, the requested Dexcom G6 continuous glucose monitor is not medically necessary for this patient.