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

Diagnosis: Venous insufficiency.
Treatment: Open Revascularization with Percutaneous Stent.
The insurer denied the Open Revascularization with Percutaneous Stent. 
The health plan's determination is overturned. 

The patient is a man with bilateral thoracic outlet syndrome and longstanding lower extremity venous insufficiency who is status post venogram and stenting of the inferior vena cava (IVC), left CIV (common iliac vein), right CIV, and right EIV (external iliac vein).

The patient followed up with his provider for recurrent upper extremity symptoms and recurrent bilateral lower extremity swelling and bilateral leg and foot pain. A venous duplex exam showed dilated right greater saphenous vein (GSV) and left GSV with reflux. Under review is the medical necessity of Open Revascularization with Percutaneous Stent.

The Open Revascularization with Percutaneous Stent is medically necessary for this patient.

The patient had recurrent bilateral lower extremity swelling and bilateral leg and foot pain due to iliac vein obstruction. The patient has a longstanding history of venous insufficiency and was found to have iliac vein compression syndrome. He had recurrence of symptoms and subsequent treatment of his venous insufficiency and iliac vein compression syndrome. Iliac vein compression syndrome is a known cause of venous insufficiency. The standard of care for the treatment of iliac vein compression syndrome is venography, intravascular ultrasound and venoplasty and stenting of the iliac veins.
The requested procedure is medically necessary in this patient with lower extremity venous insufficiency.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease
Treatment: Stelara
The insurer denied Stelara. The denial is upheld.

The patient is a male with a history of Crohn's disease. He tried and failed corticosteroids. He received one dose of Stelara. There is no history of treatment with infliximab (Remicade) or adalimumab (Humira).

The subject under review is the medical necessity for the treatment with Stelara.

Stelara is not medically necessary in this case. Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with Crohn's disease.

Chavannes M, et al reported a multi-centered cohort study supporting the safety and efficacy of Stelara in pediatric patients with refractory Crohn's disease.

A recent report by Dayan JR, et al showed that ustekinumab (Stelara) is efficacious and safe in pediatric patients with inflammatory bowel disease (IBD).

Therefore, Stelara use in children with refractory Crohn's disease is appropriate and well supported by peer reviewed evidence.

However, this patient does not have refractory Crohn's disease and has not yet tried and failed the available and FDA approved therapies (such as Remicade and Humira). These treatments are much more established than Stelara and have been extensively studied. There is no evidence that Stelara is superior to Remicade or Humira in treating children with Crohn's disease. The use of Stelara (off-label) is appropriate, but only after trying and failing the available FDA approved treatments or when the patient has contraindications to using these treatments.

The clinical practice guidelines and available evidence endorse using Remicade or Humira in pediatric Crohn's patients who fail corticosteroids. This patient has no contraindications to using Remicade or Humira. Therefore, the plan's determination to deny Stelara is appropriate. Medical necessity of Stelara cannot be established.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis:  GERD.
Treatment:  Esophageal surgery and inpatient stay.  

The insurer denied the Esophageal surgery and inpatient stay.  The denial is overturned.

The patient is a with longstanding gastroesophageal reflux disease (GERD).  He has failed medical therapy.  He takes daily famotidine and lansoprazole.  He has tried multiple other medications.  He remains symptomatic despite twice a day (BID) proton pump inhibitors (PPI) and famotidine in the evening.  He has a normal esophageal manometry.  He has a DeMeester Score of 127.6, indicating very abnormally high esophageal acid exposure due to Gastroesophageal Reflux Disease.  Upper endoscopy revealed a small hiatal hernia, mild inflammation in the gastric antrum.  Esophagram revealed severe Gastroesophageal reflux.  
 
This patient suffers from GERD.  Even with BID PPI and H2 blocker, there is refluxing gastric contents.  Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  LINX is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA.  There is published data on patients, who have had the device for six years, showing a very low complication rate and a high resolution of GERD.  The standard of care is to perform this operation as an inpatient stay in order to provide adequate anti emetics, pain control, hydration, to ensure the safe recovery of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis:  GERD.
Treatment:  Esophageal surgery and inpatient stay. 

The insurer denied the Esophageal surgery and inpatient stay.  The denial is overturned, in part. 

The patient is a male.  He is 6 feet tall and weighs 191 pounds, giving a body mass index (BMI) of 25.9 kg/m2.  He has symptomatic GERD (gastroesophageal reflux disease) despite medication use.  Manometry revealed normal esophageal peristalsis with low LES (lower esophageal sphincter) tone.  24-hour pH study revealed a significantly elevated DeMeester score consistent with GERD.  EGD (esophagogastroduodenoscopy) revealed small hiatal hernia and normal esophagus.  UGI (upper gastrointestinal series) revealed GERD to level of clavicles and normal motility. 

Specifically, the health plan should cover the Esophageal surgery.  LINX procedure standard LOS (level of service) is generally 23-hour observation or ambulatory.  Acute inpatient admission is generally not required, unless there are other high risk co-morbid conditions, such as severe CAD (coronary artery disease), or severe sleep apnea, for example, to warrant acute inpatient admission.

LINX is considered to be a standard FDA-approved surgical treatment for GERD within the medical community and is recommended in updated published guidelines from the Society of Gastrointestinal and Endoscopic Surgeons to be a safe, effective and durable treatment for GERD for mid- to long-term outcomes based on published findings.  There are only a few exclusions to the treatment, of which the patient has none.

Specifically, the Esophageal surgery is likely to be more beneficial.  The requested procedure, however, does not require acute inpatient stay and is generally performed as an outpatient/ambulatory or 23-hour observation level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pressure and palpitations.
Treatment:  Inpatient admission.
The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male.  He presented to the hospital complaining of chest pressure and palpitations. 

Upon arrival patient, the patient's vital signs revealed an irregular irregular pulse with a rate as high as 137 BPM (beats per minute).  His BP (blood pressure) and respiratory rate were within normal limits.  No other abnormal findings were noted on physical examination.  ECG (electrocardiogram) revealed AF (atrial fibrillation) with rapid ventricular rate, a narrow QRS complex, and no ST or T wave abnormalities.  Serum blood testing revealed no elevation in troponin or CKMB (creatine kinase isoenzyme MB). 

The patient was treated with Lovenox and Cardizem, and he reverted to sinus rhythm after several hours.  The patient remained hospitalized for several days and was discharged following stress testing, which was normal.

This patient presented with chest pain and atrial fibrillation with a rapid ventricular rate and no ST or T wave abnormalities on ECG.  His pretest probability of coronary artery disease was low (Reference 1).  Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score, he was considered low risk (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. 

In addition to chest pressure, the patient was noted to have AF that reverted to normal sinus rhythm after several hours.   Bellew et al. studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department.  In this study of almost 600 patients, there was no difference in outcome (Reference 4).  

AHA guidelines note regarding admission to the hospital for management of atrial fibrillation that patients who achieve rate control do not require hospital admission (Reference 5).  This patient reverted to normal sinus rhythm several hours after presentation. 

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.  This patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cerebral Palsy.
Treatment:  Durable Medical Equipment (DME)/Motorized Wheelchair.

The health plan denied the requested Durable Medical Equipment (DME)/Motorized Wheelchair.  The health plan's determination is overturned.

The patient is a  female with a medical history significant for spastic quadriplegic cerebral palsy. She is non-ambulatory and requires her wheelchair for all mobility. In addition, she requires maximum assistance for transfers making her unable to reposition in her wheelchair - placing her at high risk of skin breakdown and, therefore, making it medically necessary that she has a power tilt & recline feature. Her current wheelchair is over 7 years old.  The patient has had significant weight gain and is no longer fitting the frame - making her at increased risk of skin breakdown and associated pain.

At issue is if the requested health service/treatment of durable medical equipment (DME) Motorized Wheelchair is medically necessary for this patient.

This reviewer overturns, in whole, the health plan's determination of medical necessity.

Yes, the requested health service of a DME Motorized Wheelchair is absolutely medically necessary for this patient.

The patient is a female with a medical history significant for spastic quadriplegic cerebral palsy. Per documentation review she is non-ambulatory and requires a power wheelchair for all her mobility needs. Her current power wheelchair is from 2013 and, per the physician who has cared for this patient since 2015, no longer appropriately accommodates the patient. "Since the patient received the chair in 2013, she has gained weight and therefore the seat has become too narrow to accommodate her hip width. While sitting in the 16-inch-wide seat, her hips push out onto the arm rests, resulting in blanchable redness and bruising on the lateral aspects of her thighs." The patient's current wheelchair is putting her at great risk of skin breakdown - not to mention pain. In addition, she requires maximum assistance for transfers and is unable to appropriately reposition herself - placing her at even greater risk of skin breakdown. She requires a customized, motorized tilt in space wheelchair for adequate pressure relief. Lastly, she is cognitively intact and able to safely navigate her wheelchair, and she lives in a wheelchair accessible home which will allow her wheelchair to be used both in and out of the home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Hypertension; Congestive Health Failure, Osteoarthritis
Treatment: Personal Care Assistance (PCA) services.
The insurer denied coverage for personal care assistance (PCA), 18-24 hours per day, 7 days week.
The denial is upheld. 

This female patient has medical history of asthma, scleroderma, finger ulcer, pulmonary arterial hypertension (PAH), Raynaud's disease with gangrene, atrial flutter, venous stasis ulcer, osteoarthritis, congestive heart failure, pulmonary embolism, and hypothyroidism. She recently had an admission for gastrointestinal bleed and another for hypoxia. As per televisit records, she is stable on home oxygen. Previously she was approved for personal care assistance (PCA) services 5 hours per day, 7 days per week (total 35 hours per week). An increase to 18-24 hours per day, 7 days per week is requested.

The patient's physician indicates that the patient has PAH and requires around-the-clock care. She has had 3 prolonged hospitalizations in the past 4 months. She is using oxygen 24 hours a day and requires monitoring of oxygenation as well as assistance with activities of daily living (ADLs), food preparation, medication administration and ambulation.

A nursing assessment noted that the patient is independent with bed mobility and eating, requires limited assistance with walking, locomotion, toilet transfers and toilet use, extensive assistance with bathing, personal hygiene, and dressing. She ambulates with a cane or rollator. She is frequently incontinent of bladder. She lives alone, and her sons visit daily after work and assist when the aide leaves. The letter notes that there has not been a significant change from an assessment. There are no nighttime needs. Turning and positioning was not required.

The issue here is whether there has been an increase in need for services that would be provided through PCA services. The patient has serious ongoing medical problems.  However, there has not been a substantial change in the patient's personal care needs in the last year. The physician visit notes and letter, and the appealer comments, do not specify what additional services are needed beyond supervision and safety needs, not covered by PCA services. The plan is providing 6 hours per day, and there is no documentation that supports a greater number of hours. 

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

Based on the above, the medical necessity for Personal Care Assistance (PCA) services at 18-24 hours per day, 7 days week is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Centralized Precocious Puberty. 
Treatment: Radiology Services/ MRI (magnetic resonance imaging). 

The health plan denied the requested MRI. 
The health plan's determination is overturned. 

This is a female diagnosed with CPP (centralized precocious puberty). This request is for a magnetic resonance imaging (MRI) of the brain. 

As reported, she had onset of right sided breast bud development prior to her 7th birthday. She describes the breast buds as tender to palpation. Her breast was at tanner 2 and GU (sexual maturity staging) was at tanner 1. On later testing her luteinizing hormone (LH) was prepubertal; follicle-stimulating hormone (FSH) was 5.1; Estradiol was 31. Her FSH peaked at 22.16; LH peaked at 11.80; Estradiol peaked at 54 (on Lupron stimulation test). 

At issue is the medical necessity of the requested MRI. 

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

Yes. The definition of precocious puberty is children who have the onset of secondary sexual characteristics younger than age 8 years in girls and younger than age 9.5 in boys [1, 2,3]. Central precocious puberty (CPP) is diagnosed using a basal LH of >0.3 or stimulation testing with a gonadotropin-releasing hormone (GnRH) analog such as Lupron showing a pubertal response defined as an LH >10 [4]. CPP is treated with GnRH agonists [5, 6, 7, 8,9, 10] such as Lupron [11] and Supprelin [12]. The FDA indication for GnRH agonists is for use in central precocious puberty. In addition, when used for CPP. the Food and Drug Administration (FDA) recommends discontinuation of GnRH agonists before age 11 years for females and before age 12 years for males [11]. This is consistent with accepted recommendations for discontinuation of GnRH agonist therapy at a bone ages of 12 years in girls and 13 years in boys [2, 4, 5, 6, 7].
An ultrasound in patients with central precocious puberty is not appropriate given the fact that the cause of puberty has already been proven to be central meaning from the brain rather than from the ovaries. When the LH level is pubertal such as in this case, the source of puberty is the brain rather than the ovaries. The ovaries merely respond to the LH and FSH levels. Pathology in the ovaries is not suspected in this case. Therefore, an ultrasound of the ovaries is not appropriate. 

The standard of care regarding imaging for central precocious puberty in girls is to do an MRI of the brain when a girl has an onset of puberty before age 7 years or there are signs or symptoms of mass effect on examination and history. This patient had onset of puberty before age 7 years in the form of breast buds. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Dental
Dental/Orthodontic Procedure.
Diagnosis: Malocclusion.
Treatment: Braces.
The insurer denied braces. The health plan's determination is upheld. 

The patient in question is a male with a Class I occlusion with appropriate overbite and 5 millimeter (mm) overjet. He has minor maxillary and mandibular crowding. He is treatment planned for 36 months of orthodontics to correct his malocclusion. This is the subject of this review.

There is no medical reason to correct this patient's malocclusion with braces. While the patient has minor crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. However, this patient presents with none of those conditions. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If his teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer.
Treatment: Radiation Therapy.

The insurer denied proton beam therapy with image guidance.  The denial is upheld.

The patient is a female with a stage IIa Hodgkin's lymphoma of the neck and mediastinum. She was treated with chemotherapy with complete response on follow up positron emission tomography (PET). She had bulky disease. Radiation therapy is recommended to this bulky region and proton beam with image guidance approach is requested. The medical necessity of this treatment is the subject under review.

The health plan's determination is upheld in whole.

The requested proton radiation treatment for Hodgkin's lymphoma phase 1 - 15 treatments of proton beam therapy with image guidance is not medically necessary for this patient. The requested proton beam radiation therapy for this patient is not considered medically necessary as very low doses of radiation are needed to have excellent results, where proton radiation therapy has not been shown to have improved outcome. There are lack of significant randomized trials showing a significant benefit or improved safety with proton radiation over standard photon radiation treatment. The radiation needed for this patient can be safely delivered without the use of proton beam radiation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of stroke. 
Treatment: Increase Personal Care (PCW) services From 7 days Per Week 3 Hours Per Day 21 Hours Per Week to Personal Care Worker (PCW) services 7 Days per Week 24 Hours per Day 168 Hours per Week; continuous, by more than one person (mutual split shift with spouse). 

The insurer denied the Increase Personal Care Worker (PCW) services From 7 days Per Week 3 Hours Per Day 21 Hours Per Week to Personal Care Worker (PCW) services 7 Days per Week 24 Hours per Day 168 Hours per Week; continuous, by more than one person (mutual  split shift with spouse).  The denial is overturned. 

The patient is an female with history of stroke, vertigo, atrial fibrillation, urinary incontinence and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 168 hours per week Personal Assistance Services to offer increased activities of daily living (ADL) support. 

Yes, the proposed treatment of 168 hours per week Personal Assistance Services is deemed medically necessary to offer increased activities of daily living (ADL) support. 

This is an female with history of stroke, vertigo, atrial fibrillation, urinary incontinence and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent correspondence from the patient's Primary Care Provider, Urologist and Physical Therapist indicate that due to worsening gait ataxia, fatigue, dizziness and overall functionality, the currently approved plan of 35 hours/week  Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 168 hours/week Personal Assistance Services is deemed medically necessary.