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

Diagnosis: Obesity, sleep apnea
Treatment: Gastric bypass surgery
The health plan should cover the gastric bypass surgery.
The gastric bypass surgery is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.
This patient suffers from severe GERD due to a hiatal hernia and incompetent lower esophageal sphincter mechanism.  GERD is a known complication of sleeve gastrectomy.  In order to properly treat her GERD, as well as her obesity and related comorbidities, the most definitive operation would be a laparoscopic RNY gastric bypass.  The patient has the rest of her life to benefit from this operation, which when done correctly, should cure GERD as the stomach is almost entirely excluded from the esophagus.  The gastric bypass will also help her to lose weight by providing restriction to solid foods and suppress her appetite, leading to decreased caloric intake, and weight loss.  The only other treatments are what she has already been doing (diet and exercise, lifestyle modification, omeprazole two to three times a day as well as tums), and they have failed to produce relief.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obesity, sleep apnea
Treatment: Gastric bypass surgery
The health plan should cover the gastric bypass surgery.
The requested health service is likely to be more beneficial than any standard treatment(s) for this patient's condition.  
An extenuating, patient-specific, clinical circumstance in this case is that the patient has GERD and she has a three-cm hiatal hernia as documented by upper endoscopy, pH testing, and contrast UGI.  She also has comorbid illnesses of GERD and obstructive sleep apnea.  She has a body mass index of 36.4 kg/m2 and has successfully completed a comprehensive multidisciplinary bariatric evaluation.  
This intervention (conversion to roux en Y gastric bypass) is the accepted standard of care among those charged with the care and treatment of patients with GERD complicating sleeve gastrectomy as exists in this case.  This therapy will provide effective control of gastroesophageal reflux, will prevent further progression of this disease and will provide ongoing treatment of the chronic condition of morbid obesity as was initiated with sleeve gastrectomy.  Due to her existing gastric anatomy, fundoplication is not an option.
Based on this supportive documentation, the proposed conversion to roux en Y gastric bypass would be anticipated to alleviate reflux symptoms and may promote additional weight loss for this patient with a current BMI of 36.4 kg/m2.  
1) The proposed bariatric surgery is consistent with generally accepted standards of medical practice in this specific case. The patient has a BMI of 36.4 kg/m2 and weight related comorbidities that would be expected to respond favorably to sustained weight loss.  She has also completed a multidisciplinary evaluation with medical and mental health clearance.
2) The available medical documentation does support that laparoscopic roux en Y gastric bypass is clinically appropriate. 
3) Laparoscopic roux en Y gastric bypass has been demonstrated through scientific evidence to be effective in improving health outcomes for a patient such as this with medically complicated morbid obesity and refractory GERD post sleeve gastrectomy.
4) Laparoscopic roux en Y gastric bypass is supported by guidelines established by The American Society for Metabolic and Bariatric Surgery (ASMBS). 

There is scientific data that supports the application of revisional gastric bypass for the treatment of refractory and severe GERD. There is ample data that supports the safety and efficacy of Roux-en-Y gastric bypass as treatment of GERD in the post gastric sleeve setting. The proposed operation is not offered primarily as a bariatric operation, but rather as a treatment of the documented complication of GERD following prior gastric sleeve.  The health plan policy recognizes the role for revisional surgery in the setting of documented complications of prior surgery.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obesity, sleep apnea
Treatment: Gastric bypass surgery
The health plan should cover the gastric bypass surgery.
The gastric bypass surgery is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.
This patient has GERD that is not controlled with medication, but is status post (s/p) prior laparoscopic vertical sleeve gastrectomy. She is therefore not amenable to standard surgical anti-reflux procedures, such as LINX or laparoscopic Nissen fundoplication (LNF). LINX is contraindicated in patients with a BMI of 35 kg/m2 and history of prior bariatric or gastric surgery, and she cannot have the LNF because her fundus has already been removed. In this setting, as long as there are no dietary or behavioral contraindications to gastric bypass- which there are not- as this patient completed an updated multidisciplinary evaluation specifically for gastric bypass, this is the most anti-reflux procedure available and would be supported. General weight loss from sleeve to gastric bypass procedures is not significant and therefore sleeve to bypass conversion for weight regain is generally not supported, however, this conversion is not recommended for weight loss but for correction of GERD, a known complication of sleeve gastrectomy, which is diagnostic based on UGI, esophagogastroduodenoscopy (EGD), and 24 hour pH study as significant. Reflux persisted despite hiatal hernia repair in 2017 and has recurred.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tooth misalignment
Treatment: Braces (comprehensive orthodontic treatment)
The braces are medically necessary.
The patient has an upper left tooth and a lower right tooth out of alignment. They are "inside" of the rest of his teeth and are both severe hygiene problems. There will be no way to keep them clean throughout the patient's life and will negatively impact the adjacent teeth by not allowing them to be cleaned properly either. In addition, the lower left canine is not in its correct position so it will not be able to properly guide the jaws during the chewing cycle. The patient needs orthodontic treatment to correctly align his teeth so they will function properly and be allowed to be cleaned properly. Medical necessity has been established.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient complained of abnormal uterine bleeding (moderate menstrual flow and spotting 7-10 days prior to menses). The patient also complained of severe cramps of 2 days duration and post-coital pelvic pain. The patient discontinued oral contraceptive pills due to having lupus. The patient stated this resulted in increased bleeding and premenstrual syndrome with cycles. The patient had a CT of the abdomen and pelvis that revealed "The uterus is bulky and heterogeneous consistent with diffuse leiomyomatous involvement." The patient had a transvaginal ultrasound examination that revealed no distinct uterine fibroids and normal endometrial thickness. The patient underwent hysteroscopy and a dilitation and curettage with NovaSure ablation.

Women with abnormal uterine bleeding have a variety of therapeutic options. Endometrial ablation has become an increasingly popular treatment since it is minimally invasive and successful ablation avoids chronic use of medications. The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.
The requested service is one of the acceptable options of the standard treatment and procedures that could be recommended for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Irregular menses

Treatment: Endometrial ablation

The insurer denied endometrial ablation and associated services as experimental/investigational. The denial was upheld as the services were not likely more beneficial than any other standard procedures/treatments.
This case involves a patient seen for her annual Pap smear.  The patient stated she has irregular menses and describes her menstrual flow as moderate.  She also complained of frequent spotting.  She states she has severe cramping of 2 days duration.  She reports post-coital pain intermittently for approximately 1 year.  The patient has previously utilized oral contraceptives. However they were discontinued due to her having lupus.  The physician detailed since discontinuation of the medication the patient has had an increase in bleeding.  An ablation versus hysterectomy was also discussed.  The patient did undergo an ultrasound in 2018 revealing an anteverted uterus with no distinct uterine fibroids identified.  There was normal endometrial thickness and the bilateral ovaries appeared within normal limits.  The physician indicated options such as oral contraceptives, IUD, and ablation were discussed.  The patient was interested in an ablation.  An endometrial biopsy was also discussed.  The physician understands there is a small risk of malignancy.  The patient was admitted to undergo the requested procedure.  It is noted the patient declined the endometrial biopsy.  The patient underwent the procedure without complication.

While there are literature sources submitted with the documentation, they are not the most recent.  According to current literature, treatment for abnormal uterine bleeding should not be initiated until the etiology of bleeding has been evaluated.  Evaluation would include a history and physical exam to look for obesity and hirsutism, pregnancy testing, measurement of thyroid-stimulating hormone, and prolactin levels.  An endometrial tissue assessment would be completed to rule out cancer.  If the biopsy is normal, ultrasound or sonohysterography would be completed to rule out structural abnormalities.  Typically, pharmacological treatment is first-line therapy which may include oral contraceptives and IUD, and/or tranexamic acid.  In cases in which the initial medical therapy is not effective, more invasive procedures may be appropriate.  

While the procedure does have the appropriate approval from regulating bodies the patient is not a good candidate.  The submitted documentation does not indicate the patient had undergone a full evaluation including lab studies prior to the procedure being performed.  Therefore, endometrial ablation performed with anesthesia services are not likely to have been more beneficial than any other standard treatments/procedures.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperlipidemia

Treatment: Repatha

Summary:
This patient with advanced multivessel CAD (coronary artery disease) requires further lowering of the LDL-C levels to below 70 mg/dL. However, as pointed out in the denial letter there are alternative preferred treatments including the use of Rosuvastatin 40 mg or addition of Zetia 10 mg to Atorvastatin 80 mg or Rosuvastatin 40 mg, which have not been attempted. Therefore the medical necessity of using specifically Repatha for LDL-C lowering in this case could not be established at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient presented with acute onset of vertigo and normal examination and vital signs. Her MRI brain was negative. The severity of her symptoms, the clinical presentation and her risk factors did not warrant acute in patient level of care.  The work-up, treatment and monitoring could have been safely and effectively completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal (Vomiting)
Treatment: Inpatient Hospital
   
Summary: This patient presented to the Emergency Department (ED) with worsening spit-up and vomiting for the last month. Nutramigen feeds and a 24 hour pH study were recommended by Pediatric Gastroenterology. The patient's mother reported his vomiting worsened overnight, and he was unable to take feeds despite changing his formula. Intravenous (IV) fluids were started and an esophageal pH probe was placed which diagnosed gastroesophageal reflux. Rice cereal was added to the feeds, and the patient was started on Zantac 12mg twice daily. He was discharged home with instructions to follow up with the Gastroenterologist in one month. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

This patient presented with recurrent emesis requiring multiple formula changes. At the time of admission, his heart rate was normal for age and electrolytes showed mild acidosis (no anion gap). The patient did not undergo fluid resuscitation, though he did have maintenance fluids ordered following admission. There was no decrease in wet diapers or stools per the mother's report. There was overall a deceleration in the baby's weight percentile. The hospitalist's expressed the reason for admission was failure to thrive and vomiting. Based on the evidence at hand, the degree of dehydration, if there was any in this infant, was mild (bicarbonate of 20). Whenever possible, oral rehydration therapy is the recommended route of management for children with mild to moderate dehydration. For such a child as in this case where vomiting was initially noted, appropriate management of such cases would typically entail repletion (orally or intravenously) followed by oral rehydration (if initial therapy were given intravenously). There is no documentation that this child received any resuscitation. The ED notes state that the infant was to be offered an oral fluid trial, but there was no documentation that this was performed. The infant was admitted, placed on maintenance intravenous fluids, and offered formula as well. There was no indication that formula was not tolerated. A pH probe was performed which confirmed reflux and the infant was treated with Zantac and cereal to thicken feeds. Further, the infant was documented as being admitted for failure to thrive. Yet, strict intake and outputs were not monitored, nor were daily weights. The infant's weight was not carefully tracked. The infant was discharged home after outpatient measures were implemented. While the baby was started on IV fluids, this was not clearly performed in the setting of dehydration, and the baby otherwise received interventions which could have been performed as an outpatient (oral feeding, pH study, anti-acid trial, formula thickening).
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with asthma and morbid obesity who presented with 2 days of increasing dyspnea and cough, no fever, but chest pain from coughing.  In the emergency department (ED) she was diagnosed with asthma exacerbation and bronchitis. 

The health plan's determination is upheld.  The inpatient admission was not medically necessary.  Based on clinical information provided, the patient has mild to moderate asthma exacerbation with no abnormal vital signs (no hypoxia, tachycardia, but mild tachypnea) or evidence of pneumonia or other process (PE or pneumothorax).
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has a history of atrial fibrillation required anticoagulation. While on a new generation anticoagulant t patient he had a severe hemorrhagic stroke. The use of the Watchman closure device is under review.

The health plan's determination is overturned. Transcatheter Closure of the Left Atrial Appendage is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.In this setting, the Watchman has been demonstrated safe and effective for attempted atrial fibrillation stroke prevention. Additionally, this individual has essentially no other treatment options. Therefore, the Watchman is indicated in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient had a large hemorrhagic stroke in Oct 2018 while on a newer oral anticoagulant (NOAC) for paroxysmal atrial fibrillation. The patient also had a history of hypertension. Transthoracic Echo on 10/16/18 did not show left atrial appendage thrombus. 

The health plan's determination is overturned. This patient has a high risk of recurrent stroke with CHADS VASC score of 3. The two major options are anticoagulation or LAAO. In this case LAAO is preferable in view of previous brain hemorrhage. Restarting an anticoagulant would place the patient at high risk for recurrent brain hemorrhage. LAAO will avoid the need for anticoagulation after a the first few months of implantation.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has a history of hypertension, atrial fibrillation and a hemorrhagic stroke while on anticoagulation who was recommended to undergo transcatheter left atrial appendage (LAA) occlusion with the Watchman device.

The health plan's determination is overturned. The transcatheter LAA occlusion is likely to be more beneficial than any standard treatments in this case. The patient is at elevated risk for stroke given history of atrial fibrillation, hypertension and a prior stroke. Additionally, the patient is at elevated risk for bleeding given hypertension, prior stroke and bleed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath and chest pain
Issue under Review: Inpatient admission
Summary: The proposed inpatient admission was not medically necessary.
This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarction (MI) was ruled out by cardiac enzymes, which were negative. A pulmonary embolism was suspected and was ruled out by a pulmonary CTA, which was unremarkable. No further inpatient ischemic work-up was planned.  There was no evidence of acute myocardial infarction, ACS, decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital 

Summary: This patient presented to the Emergency Department (ED) with a complaint of left-sided chest pain. He has a past medical history which includes coronary artery disease (CAD) status post percutaneous coronary intervention (PCI) to the right coronary artery (RCA) (proximal and mid), and left circumflex (LCx). He also has a history of hypertension and spinal stenosis. He claimed that the pain started two weeks ago and occurred intermittently since then. The pain returned this morning when he was walking out of the subway to go shopping. The pain was described as a pressure like sensation, exertional, non-radiating, not associated with diaphoresis, nausea or vomiting. The pain resolves with rest. After experiencing this pain on the morning of presentation, which was 10/10 in severity, he went to an Urgent Care Center which referred him to the ED. He reported not taking medication over the last two years and not following up with his doctors. His review of systems was negative, except for what has been mentioned above. An electrocardiogram (EKG) showed sinus bradycardia at 59 beats per minute (bpm). The report concluded by stating that the EKG showed possible anterior infarction-age undetermined with significant changes from comparison EKGs. Another note in the chart stated that the EKG showed normal sinus rhythm (NSR) with left ventricular hypertrophy and no acute changes when compared to prior EKGs. A third note in the chart described the EKG as showing NSR at 60 bpm with mild ST elevation with no reciprocal changes. This was unchanged from prior EKGs done in 2014. A coronary angiogram was performed and showed severe disease in the RCA ostium, distal RCA and LCX. PCI was performed on the mid-LCx and distal RCA. The prior stents in the RCA and LCX were patent and the left anterior descending (LAD) showed mild disease. The stents were successful as judged by intravascular ultrasound studies. The patient's discharge medications include Plavix, aspirin, Lipitor and losartan. 

The insurer denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

This patient presented to the hospital with a complaint of chest pain which had been occurring intermittently for the past two weeks. He has a history of CAD with previous PCI. His pain was present mostly with exertion and was not noted following admission to the hospital. His troponins and pro-brain natriuretic peptide (BNP) were within normal limits. The literature makes it clear that hospital admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for hypertension who presented to the emergency department with complaints of shortness of breath, chest tightness, and cough with greenish mucus for one week. The patient was seen in an urgent care center one day before admission, where she was prescribed Azithromycin and cough medications, which did not improve her symptoms. The health plan's determination is upheld.  This patient responded to treatment provided in the ER and also within the first 24 hours of hospitalization. Even though this patient was tachypneic on admission, she was afebrile, hemodynamically stable, and had no known underlying lung condition or any comorbidities that would require admission at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain; syncope
Treatment: Inpatient admission
The proposed treatment of inpatient admission is not deemed medically necessary.
This male with medical history pertinent for EtOH abuse and gastritis presented to the ER for further evaluation/management of diffuse body pain and gastritis. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen. Laboratory, ECG testing and neuroimaging was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where he received supportive care with IV fluids and continued cardiac monitoring. He responded well to the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patients hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease
Treatment: Inpatient hospital admission
The inpatient admission was medically necessary.
The patient with complex coronary anatomy, s/p CABG, presented for management of recurrent angina, and was noted to have obstructive disease of the proximal left circumflex artery (LCX) on cardiac catheterization. A coronary intervention with stent placement was performed on a bifurcation lesion in the LCX/OM branch, which is considered a complex PCI. In addition a IIB/IIIA inhibitor agent (bolus and drip) was used as a part of the procedure, increasing the risk of bleeding, thrombocytopenia, alveolar hemorrhage, etc. Patients such as this one were excluded from the studies of outpatient PCI. It would be consistent with the current standard of care that this patient, after this complex PCI with the use of IIB/IIIA inhibitor, be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.