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

Diagnosis: Acute Exacerbation of Asthma

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a female with history of asthma, obstructive sleep apnea (OSA,) Morbid Obesity, Lymphedema, Covid, Seizures. She presented to the emergency department (ED) with a 3-day history of worsening shortness of breath (SOB), chest tightness, cough with whitish sputum. 

In the emergency department (ED), the patient was afebrile, Heart Rate was 110, oxygen (O2) saturations 99% (percent), peak expiratory flow (PEF) was approximately 200L (liters) /Minimum (Min) (No baseline known).  Lung exam revealed decreased air entry (AE) 

White blood cell count (WBC) was 6.5, Electrolytes within normal limits (WNL), Chest x-ray (CXR) revealed no acute infiltrates.
 
The patient was treated with intravenous (IV) Steroids, bronchodilators (BD), and intravenous (IV) Magnesium. The patient did note some improvement with treatment. She was admitted to hospital for Acute Exacerbation of Asthma.

As per the history and physical (H&P), the patient was in no acute distress (NAD). The patient spoke in full sentences. O2 saturations 99% on room air. PEF around 200L /Min. Breath sounds (BS) were noted to be decreased. The patient was alert and oriented (A X O X 3) [person place and time].  The patient remained stable after admission.

The patient was described to be A x O X 3. In no acute distress (NAD). Temperature 37.1 F (Fahrenheit), Heart Rate 113, Blood Pressure 128/78, Respiratory Rate 20. O2 saturations 99% on RA (room air). The patient signed out against medical advice (AMA).

This patient did not need acute inpatient hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated.

The patient had started improving with treatment in ED. As per the history and physical the patient in no acute distress. The patient was not hypoxic and was tolerating oral intake (PO). WBC was normal. 

No pneumonia (PNA) or pneumothorax (PTX) or Pleural Effusion on CXR. The patient could have been discharged home on PO steroids and BD the next day with close follow up (FU) in outpatient setting.

Admission was not necessary for this patient. She could have been treated in Observation setting. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Seizure

Treatment: Inpatient hospital admission

The insurer denied coverage for an inpatient hospital admission.

The denial is overturned.

This case involves a male with a history of diabetes who presented to the hospital with a suspected seizure witnessed by another individual. The patient reportedly dropped a cutlery and started seizing - general shakiness, twitching of the face, and bit his tongue. The episode lasted for approximately 2 minutes with postictal confusion. The patient was therefore admitted in the stepdown unit for a new onset generalized seizures. He had a positive family history of seizures. A work-up was completed and treatment was administered. The patient had no prior history of seizure but did have a mood disorder. Upon arrival to the emergency department, the patient had altered mental status, he was notably febrile with a temperature of 100.2 F (degrees Fahrenheit) and was started on intravenous Levetiracetam. The patient reportedly continued to suffer from postictal confusion status post onset seizures. He remained on inpatient status for one day and then he left against medical advice. He was initially denied coverage of the inpatient hospital admission as not medically necessary. A final adverse determination letter stated that the patient had a seizure, but sugar level was normal with no repetitive seizures noted and no other findings warranting an inpatient hospital admission. 

The inpatient hospital admission was considered medically necessary for this patient. Literature titled, "Short-term risk of relapse after a first unprovoked seizure in an adult population" states that most patients with a first unprovoked seizure diagnosed in the emergency department did not present seizure recurrence within the first month, especially if no specific risk factors were present. [1] However, this patient had a new onset seizure with altered mental status in the emergency room and was febrile. These are medical issues which would qualify for inpatient evaluation. 

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 is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: gastroesophageal reflux disease (GERD)

Treatment: LINX procedure

The insurer denied coverage for the LINX procedure

The denial is overturned.

According to the documentation submitted this is the case of a female who has a history of Crohn's disease, gastroesophageal reflux disease (GERD), hypertension (HTN), hyperlipidemia, and IBS (irritable bowel syndrome). According to the thoracic surgeon's note the patient was previously referred for GERD along with a small hiatal hernia. Endoscopy showed no evidence of Barrett's esophagus. The esophagram showed severe reflux up to the level of the clavicles along with a small hiatal hernia. He noted that a motility study was normal and a Bravo pH (potential hydrogen) capsule showed a Demeester score of 39.6. He feels that she would be an excellent candidate for the LINX system. In a prior note the provider noted that the patient has had worsening symptom of reflux and was currently taking Omeprazole 20 mg (miiligrams) daily and Famotidine 40 mg bid (twice daily).

Esophagram revealed tiny sliding type hiatal hernia with associated severe GERD to the level of the clavicles.

The insurer has denied coverage for the LINX procedure. They stated in in a final adverse determination letter that the treating physician indicated that the patient has GERD and is being treated with medications but still has symptoms. The insurer noted that they are upholding the previous determination to not cover the LINX procedure as it is considered experimental and investigational. 

It appears that this patient is a good candidate for this device given the fact that the patient has Demeester score of 39.6 with symptom associated probability of 100% (percent) with severe reflux up to the level of the clavicles. In addition, esophageal motility study is normal. Thus, the patient does have indications based upon her condition with persistent symptoms. 

The LINX is a good available treatment for this patient as this patient has GERD with a Demeester score of 39.6 and severe reflux up to the level of the clavicle and as such does require treatment. It is the least invasive and would provide durable results for this patient and as noted by the provider she is a good candidate fort the LINX. There is no reason to do a very invasive procedure such as a Nissen fundoplication when one can get a durable result with the LINX. The LINX offers several advantages over the fundoplication approach; the fundus wrap is extremely invasive and is non-reversible; the fundoplication often leaves the patient with the inability to vomit and vent their stomach. 

The adverse risks are not increased over standard treatment services as this procedure is less invasive that the standard fundoplication.

The requested procedure is likely to be more beneficial than any standard service.

The carrier's denial of the LINX procedure should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: gastroesophageal reflux disease (GERD)

Treatment: LINX procedure

The insurer denied coverage for the LINX procedure

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 (Torax Medical, St. Paul, MN, USA) 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 PPIs (proton pump inhibitor), with minimal side effects and no safety issues. [2] The LINX system is intended for use in GERD patients with abnormal pH testing who continue to have chronic symptoms despite antireflux 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 a female patient with a history of GERD. The patient presented with persistent heartburn and reflux. Symptoms are not controlled with proton pump inhibitors. An esophageal motility study was normal. An esophagram demonstrated severe reflux and a tiny hiatal hernia. A pH (potential of hydrogen) study demonstrated abnormal reflux events and an elevated DeMeester score of 39.6. LINX obtained FDA (food and drug administration) approval in 2012 and has been demonstrated to be safe and effective in patients with GERD. The requested service is likely to be more beneficial than standard medical management without increased risk. 

The carrier's denial of the LINX procedure should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: gastroesophageal reflux disease (GERD)

Treatment: LINX procedure

The insurer denied coverage for the LINX procedure

The denial is overturned.

The patient has a history of chronic reflux disease. An endoscopy was negative for Barrett's esophagus. Her symptoms were not controlled on omeprazole and famotidine. Bravo pH (potential of hydrogen) testing was done. The DeMeester score was 39.6. Her doctor has recommended the LINX antireflux system.

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 FDA (Food and Drug Administration) 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 (proton pump inhibitors) use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating gastroesophageal reflux disease (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 LINX procedure has been shown to be more beneficial for patients with GERD who have not responded adequately to proton pump inhibitor (PPI) therapy. The scientific literature supports the use of the LINX procedure and results in improvement of health outcomes. The procedure has FDA approval. There are several procedures available for the treatment of GERD but the LINX procedure has been shown to be safe and effective. The LINX Reflux Management System has been shown to be beneficial in patients with chronic reflux who have not responded to PPI therapy.

This procedure is likely to be more beneficial than any other standard services without increased risk. The carrier's denial of the LINX procedure should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Below the knee transtibial amputation.
Treatment: addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system; lower extremity prosthesis- right pro-flex pivot foot.
The insurer denied addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system; lower extremity prosthesis- right pro-flex pivot foot. 
The determination is upheld.

The patient has a diagnosis of right transtibial amputation (below the knee amputation). Available records include a letter from patient, written order for prosthetic limb, office visit, patient notes, amputee mobility predictor assessment tool, and medical articles pertaining to vacuum suspension limbs. According to documentation submitted, the patient's ambulation level is K3. At issue is whether the proposed health service or treatment addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system; lower extremity prosthesis- right pro-flex pivot foot 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 addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system; lower extremity prosthesis- right pro-flex pivot foot is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Although the patient requires a prosthetic limb for her right below the knee amputation, it is not necessary to include a vacuum socket and pro-flex pivot foot. The patient currently has a vacuum pump, however, current use of the device does not mean that the device is necessary. A standard socket would be appropriate for this patient's needs. There is a lack of evidence to support that the proposed suspension system is superior to standard.  A standard socket would be appropriate for this patient's needs. The function of a suspension system of a prosthetic limb is to hold the prosthetic onto the residual limb of the patient. There are alternate methods of doing this including vacuum pump which is proposed but there is no evidence that they provide a superior endpoint of function or ambulation. The Pro-Flex Pivot Foot is manufactured by Ossur.  It is a multi-blade prosthetic foot featuring a pivot mechanism.  Per the manufacturer website it provides a 95% (percent) increase in peak ankle power and 82% increase in range of ankle motion when compared to a conventional energy storing and return foot. This increase in range of motion and ankle power is not required in order to allow the full range of normal activities including the activities specified for this patient which includes active lifestyle.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Below the knee transtibial amputation.
Treatment: addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system; lower extremity prosthesis- right pro-flex pivot foot.
The insurer denied addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system; lower extremity prosthesis- right pro-flex pivot foot. 

The determination is overturned.

The patient is a right traumatic transtibial amputee. She has had issues with volume management in her right residual limb since her amputation. At issue is whether the proposed health service or treatment addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system; lower extremity prosthesis- right pro-flex pivot foot likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The current proposed prescription for the patient's transtibial amputation prosthetic prescription including all mentioned components for moisture and volume management suspension system are considered standard of care and would be clinically indicated for a K3 functional level amputee as in this case.  The patient lives a very active lifestyle and frequently ambulates on uneven surfaces. She therefore requires all the components for prosthetic prescription in question. The recommended prescription therefore falls within the recommended standard of care practice management in order to maximize quality of life and function. Vacuum suspension systems have been shown through randomized controlled trials to help reduce residual limb ischemia and prevent choke syndrome [1]. Pivot foot and ankle prosthetic devices have been shown through thorough level 1 scientific evidence to reduce ground reaction forces and therapy helps preserve joint health and reduce incidence of osteoarthritis in amputees [2].  Thus, scientific evidence supports the use of the prescribed prosthetic device components in question as explained by the referenced literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sarcoidosis
Treatment: Humira 80 mg on day 1, followed by Humira 40 mg weekly
The insurer denied the Humira 80 mg on day 1, followed by Humira 40 mg weekly.
The denial is overturned.

The patient is a female with sarcoidosis. The request is for Humira (adalimumab) 40 mg (milligrams) weekly. The patient was diagnosed with sarcoidosis. The patient was treated with prednisone initially, but she developed side effects. The patient has tried and failed infliximab and methotrexate. The patient has been successfully treated with adalimumab. After initiation with adalimumab, the patient was weaned off prednisone, as well as adalimumab. The patient now has worsening symptoms, and adalimumab 40 mg weekly is requested.

The Humira is prescribed as 80 mg SC (subcutaneous) on day 1 followed by 40 mg SC every 7 days. The request was denied coverage by the health plan as not medically necessary, with the position that they would cover 40 mg every other week. This denial is being appealed.

Yes, the requested Humira 80 mg on day 1, followed by Humira 40 mg weekly is medically necessary.

The anti-tumor necrosis factor agents (anti-TNFs) have been recommended as third-line therapy for sarcoidosis due to positive outcomes and reduced systemic steroid use. Available evidence suggests the efficacy and safety of Humira in pulmonary, cutaneous, ocular, neurologic, and multisystem sarcoidosis, and in cutaneous and ocular sarcoidosis. The use of Humira is medically necessary, as the patient had been treated with it in the past with good clinical outcomes.

When the patient was tapered off this medication, the sarcoidosis symptoms returned. Although the plan is approving Humira 40 mg every other week, the current clinical practice guidelines recommends the use of Humira SC 40 mg every 1 to 2 weeks for the treatment of sarcoidosis. The one time dose of 80 mg SC is also considered standard of clinical practice as the loading dose. The proposed treatment is medically necessary, as it is considered the current standard of clinical practice.

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

Diagnosis: Pulmonary Artery Stenosis.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient presented for an elective right pulmonary artery intervention. Her vital signs and  oxygen saturation were normal. She was in no distress. She underwent angioplasty and stenting of the right pulmonary artery without complication. She remained stable and was discharged.

At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. This patient underwent successful and uncomplicated intervention of the right pulmonary artery stenosis. She remained stable. There was no hemodynamic instability, severe procedure complication, need for urgent repeat procedure, requirement for prolonged in-hospital intravenous medications, or high risk medication administration requiring ongoing inpatient hospital surveillance. In this setting, an inpatient hospitalization, compared to for example outpatient, has not been established as standard of care towards improved cardiovascular outcomes. Therefore, the inpatient stay is considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Disorder/Genitourinary - Female Infertility. 
Treatment: pharmacy/Prescription Drugs. 
The insurer denied infertility services (menotropins). 
The denial is upheld.

The patient is a gravida 0 who presents with the diagnosis of Polycystic ovary syndrome (PCOS) and anovulation. It is noted that her partner has a normal semen analysis but there is no result given. No hysterosalpingogram (HSG) was done. Patient is requesting the use of menotropins (Human Menopausal Gonadotropin [HMG], Menopur) for ovulation induction. She has been denied as she has been responsive to Clomid in the past and per her plan the use of Menopur or gonadotropins (Gonal-f) is not medically necessary if ovulation occurs with the use of oral medication. The patient is appealing this decision.

The health plan's determination is upheld.

Since the patient ovulates on oral medication, switching to menotropins will not increase her chances of pregnancy and therefore is not medically necessary. Given her history, this patient ovulates better with Clomid than she does with low dose menotropins or gonadotropins. Given her elevated AMH, giving higher doses of menotropins or gonadotropins would put her an increased risk of producing multiple follicles which could result in twins or higher order multiple gestations. At that point, in vitro fertilization (IVF) would be preferable to ovulation induction with gonadotropins. The use of menotropins is only indicated when there is failure to ovulate on both Clomid and Letrozole which is not met by the patient.