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

Diagnosis: Heart disease, hypertension, pulmonary embolism, spinal stenosis, and arthritis
Treatment: Personal Care Level II 24 Hours Live-in 7 Days Per Week
The insurer denied the Personal Care Level II 24 Hours Live-in 7 Days Per Week.
The denial is upheld.

The patient is a female. Her conditions include heart disease, hypertension, pulmonary embolism, spinal stenosis, and arthritis. Denial of an increase in personal care level II, 24 hours, live-in, 7 days per week is being appealed. The health plan approved an increase from 35 to 49 hours/week.

The increase in hours was requested because the patient needs 24 hour care and cannot be left alone. Uniform Assessment System (UAS) evaluation completed shows cognition is modified independent and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, lower body dressing, and toilet use; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toilet transfer; and independent with bed mobility and eating. She has infrequent bladder incontinence. Clinical note states the patient fell in her kitchen a week ago and has an unsteady gait.

No, the requested Personal Care Level II 24 Hours Live-in 7 Days Per Week is not medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of an increase in PCA (personal care assistance) level II, 24 hours, live-in, 7 days per week, is being appealed. The health plan approved an increase to 49 hours/week.

This patient has multiple chronic medical conditions. UAS evaluation completed shows the patient requires assistance with all ADLs, except bed mobility and eating. She requires limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toilet transfer. She has infrequent bladder incontinence. The appeal statement notes the patient cannot be left alone. The information provided does not support that the patient has needs that requires 24-hour assistance. She does not require repositioning/turning or need for transfers and toileting throughout the day. PCA is not indicated when no tasks are being performed or for supervision. The approved PCA 49 hours per week is appropriate and medically necessary to meet the patient's needs for assistance with ADLs and personal care. The proposed increase in PCA 24 hours, live-in, is not medically necessary.

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

Diagnosis:  Diabetes.
Treatment:  Continuous Glucose Monitoring System.

The health plan denied the requested continuous glucose monitoring system.  The health plan's determination is overturned.

This is a female with type 2 diabetes. She is on 4-6 insulin injections per day. She is checking glucose 4-6 times per day. Her glucose values range from 60-450 mg/dL. The patient's HbA1c is 9.5%. 

The request for Freestyle Libre 2 continuous glucose monitor is under review for medical necessity.

I overturn, in whole, the health plan's determination of medical necessity.

In a randomized controlled trial, continuous glucose monitoring was shown to lower HbA1c (Hemoglobin A1c) in patients with uncontrolled type 2 diabetes on multiple daily insulin injections [1]. In a second study of 101 patients with type 2 diabetes on two or more injections per day, use of the continuous glucose monitoring system significantly improved HbA1c levels. The changes in HbA1c were -0.82% vs. (versus) -0.33% in the intervention group using the continuous glucose monitoring system and control group, respectively (P = 0.005)(p=probability value concept), and 68.6% of the patients in the intervention group using the continuous glucose monitoring system had their HbA1c reduced by 0.5% compared with 30.2% in the control group (P < 0.001), and 39.2% had their HbA1c reduced by 1.0% vs. 18.6% in the control group without an increased frequency of hypoglycemia [2]. This patient has uncontrolled type 2 diabetes with a HbA1c of 9.5% and she is on multiple daily insulin injections. In this clinical situation, as outlined above, the use of continuous glucose monitor (CGM) has been shown to reduce hyperglycemia. Without CGM, this patient will be at ongoing increased risk of hyperglycemia which increases her risk for retinopathy, neuropathy, and nephropathy. Therefore, yes, the requested Freestyle Libre 2 continuous glucose monitoring system is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Syncytial Virus (RSV) prophylaxis 
Treatment: Synagis 100 milligrams/milliliter (mg/ml) intramuscular (IM)

The insurer denied coverage for Synagis 100 milligrams/milliliter (mg/ml) intramuscular (IM).
The denial is upheld.

This is an infant with a history of tricuspid atresia, transposition of the great arteries (TGA), and pulmonary stenosis. He presented to the Pediatrician's office with complaints of upper respiratory congestion and coughing. The patient was noted to have an acute respiratory infection. There were minimal problems. The treating physician recommended Synagis to prevent RSV. 

Guidelines for Evidenced-Based Synagis Prophylaxis:

Infants younger than 12 months at start of season with a diagnosis of: 

1.	Prematurity - born before 29 weeks 0 days gestation.

Infants in their first year of life with a diagnosis of:

1.	Chronic Lung Disease (CLD) of prematurity (defined as birth at less than 32 weeks 0 days gestation and requiring greater than 21 percent oxygen for at least 28 days after birth).
2.	Hemodynamically significant acyanotic heart disease (CHD), receiving medication to control congestive heart failure, and will require cardiac surgical procedures.
3.	Moderate to severe pulmonary hypertension.
4.	Neuromuscular disease or pulmonary abnormality that impairs the ability to clear secretions from the upper airways because of ineffective cough.

Note: Infants with cyanotic heart disease may receive prophylaxis with cardiologist recommendation. 

Infants less than 24 months of age with a diagnosis of:

1.	Profound immunocompromise during RSV season.
2.	CLD of prematurity (see above definition) and continue to require medical support, supplemental oxygen, chronic corticosteroid or diuretic therapy during the six-month period before start of second RSV season.
3.	Cardiac transplantation during RSV season.

Synagis is effective as shown in CHD and also beneficial and improves outcomes in neuromuscular disease or congenital anomaly that impairs ability to clear respiratory secretions from the upper airway. There is no evidence that shows beneficial effects nor toxic effects/adverse effects in children above 24 months. Hence denying the request and could not fulfill the medical necessity.

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

The insurer's denial of coverage for Synagis 100 milligrams/milliliter (mg/ml) intramuscular (IM) is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD).
Treatment: Linx Reflux Management System.

The insurer denied coverage for Linx Reflux Management System.
The denial is overturned.

The patient has had symptomatic GERD (gastroesophageal reflux disease) for many years. He has continued to have symptoms while on proton pump inhibitor (PPI) therapy. An endoscopy showed a hiatus hernia with reflux esophagitis. An esophagram did not demonstrate a hiatus hernia. A motility study was negative for a motility disorder. There was an elevated DeMeester score of 20.8.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the Linx Reflux Management System. 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 (potential of hydrogen) normalization, improved quality of life, and cessation of regular PPI use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating 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.

Two hundred patients were studied who had large hiatal hernias and underwent the Linx procedure. The study found that complete PPI independence was achieved in 94% (percent) of patients. There were no device explants, erosions, or migrations, it was concluded that doing this procedure with a hiatus hernia resulted in favorable outcomes. (Buckley, et al.)

The scientific literature supports the use of the Linx Reflux Management System for patients with chronic reflux. It has FDA approval. The patient is a good candidate since he is having chronic reflux symptoms while on PPI therapy. There are several options for both surgical and endoscopic treatment of GERD, but Linx has been shown to be an effective treatment with a good safety profile. A minimally invasive treatment such as the Linx system is appropriate for patients with continued GERD symptoms after treatment with a PPI.

The carrier's denial of Linx Reflux Management System should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Ureteral Stone/ Hydronephrosis
Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.
The denial is upheld.

This patient who has a past medical history of type 2 diabetes, hypertension, and chronic pancreatitis presented to the emergency department complaining of chills and left flank pain radiating to left groin. The patient had been to the same emergency department 2 days before and was diagnosed with 5 millimeter (mm) obstructing left ureteral stone. The patient was discharged then on Flomax and pain medications but returned with worsening symptoms. Exam was positive for left costovertebral angle tenderness, left upper quadrants / left lower quadrants abdominal tenderness. The patient was admitted with diagnosis of left ureteral stone/ hydronephrosis and scheduled for cystoscopy, left ureteroscopy with laser lithotripsy left stent placement. The patient was given intravenous fluids, intravenous antibiotics, Flomax, pain medications as needed. The patient's symptoms improved; it was determined that he was stable for discharge home on Flomax/Bactrim with outpatient follow up care. 

Per Milliman Care Guidelines (MCG) Health (25th) Renal Colic and Kidney Stones RRG: patient fails to meet clinical indications for admission to inpatient care.

These include:

-	Hemodynamic instability 
-	Acute renal failure (Stage 3 AKI [acute kidney injury])
-	Bilateral obstruction 
-	Urinary Tract Infection
-	Severe pain requiring acute inpatient management 
-	Obstruction with a single functioning kidney or a transplanted kidney

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

The inpatient hospital stay was not medically necessary for this patient.

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

Diagnosis: Idiopathic Short Stature

Treatment: Nutropin AQ (somatropin)

The insurer denied coverage for Nutropin AQ

The denial is overturned

This is a teenage male diagnosed with idiopathic short stature (ISS). This request is for Nutropin 2 mg (milligrams) daily. As reported; he started on growth hormone (GH) therapy several years ago. Before GH therapy began, his GH stimulation test with clonidine and arginine peaked at 11.60. His insulin-like growth factor (IGF1) was 148. His pretreatment height velocity is reported to be 3.4 centimeters (cm)/year (yr). His height velocity on therapy is reported to be 8.1 cm/yr. 

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines  [4, [5, [6, [7, [8, [9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS (standard deviation score) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient had a pretreatment height less than or equal to -2.25 SD (standard deviation). The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The patient is a continuing therapy patient who has benefited from growth hormone. Continuation is consistent with the standard of care and is therefore medically necessary. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medication Nutropin AQ is considered medically necessary for this patient.

The insurer's denial of coverage for the medication Nutropin AQ is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Inflammatory Neuropathy

Treatment: Intravenous immune globulin (IVIG) (codes J1561, 96365 and 96366) (pre-service)

The insurer denied coverage for intravenous immune globulin (IVIG) (codes J1561, 96365 and 96366) (pre-service)

The denial is overturned.

This patient has a history of progressive right upper arm weakness. His neurologist stated the patient's magnetic resonance imaging (MRI) test results showed evidence of proximal right arm denervation, and the cerebrospinal fluid protein was significantly elevated. The neurologist determined the patient has an inflammatory neuropathy, either a motor neuropathy or a motor variant of chronic inflammatory demyelinating polyneuropathy (CIDP). The neurologist stated the sooner the patient can be treated with intravenous immune globulin (IVIG) the more likely he is to have improvement in his weakness. The treatment plan includes initiating IVIG therapy with a loading dose of 140 grams over 4 days, followed by 35 grams every 2 weeks. 

The patient has an inflammatory motor neuropathy based on EMG [electromyogram]/NCS [nerve conduction studies], CSF [cerebral spinal fluid] analysis and clinical exam.  IVIG is the most appropriate treatment.  This is a rare disorder, so it is not specifically listed in the insurer's guidelines as a condition for which IVIG is typically used.  IVIG is medically necessary for this patient to prevent further weakness. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for intravenous immune globulin (IVIG) (codes J1561, 96365 and 96366) (pre-service) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Kidney disease (idiopathic membranous
glomerulonephritis)
Treatment: Rituximab injection (J9312)
The insurer denied the Rituximab injection (J9312).
The denial is overturned.

The patient is a female with history of membranous nephropathy, nephrotic syndrome treated with steroids, treated with Rituxan in the past with induction of sustained remission.  The Plan denied the Rituxan as not prescribed for a Plan approved diagnosis. The physician is appealing the determination.

Yes, the requested Rituxan is medically necessary.
The requested medication is medically necessary as supported by current medical literature. The requested Rituxan would be considered safe, effective, a generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner, the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient has been treated with steroids in the past but attained prolonged remission with Rituxan from nephrotic syndrome related to membranous nephropathy. The patient is now again noted with nephrotic range proteinuria and query regarding necessity of Rituxan. 

In a randomized controlled trial of rituximab versus cyclosporine in the treatment of idiopathic membranous nephropathy, Fervenza's group randomized people from 25 participating institutions to receive cyclosporine or rituximab and found that B-cell targeting with rituximab reduced the number of relapses and increased the time to relapse when compared with cyclosporine. Rituximab also had fewer adverse events compared with cyclosporine.  

Dahan et al. in the GEMRITUX multicenter, randomized, controlled trial at 31 hospitals noted a positive effect of rituximab on proteinuria remission after six months.

Based on Kidney Disease Improving Global Outcomes (KDIGO) for patients with membranous nephropathy, they recommend using rituximab or cyclophosphamide and steroids for six months as first line therapy. Use of Rituxan would be considered standard of care as first line therapy for membranous nephropathy.   

With past response with good result, and based on medical literature, continuation of Rituxan would be standard of care treatment in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right pontine cryptogenic stroke.
Treatment: Subcutaneous Cardiac Monitor (33285).
The insurer denied the Subcutaneous Cardiac Monitor (33285).
The denial is upheld.

This female was referred for Subcutaneous Cardiac Monitor (33285) as part of evaluation of her right pontine cryptogenic stroke. During her stroke hospitalization, she was diagnosed with dissecting pseudoaneurysm of the right internal carotid artery (RICA) and subsequently underwent endovascular stent repair. The requested coverage for the service has been denied by her Plan and the patient is appealing the decision.

No, the proposed treatment, Subcutaneous Cardiac Monitor (33285) was not medically necessary.
There is insufficient relevant published evidence to conclude that net health outcome will be improved and so Subcutaneous Cardiac Monitor (SCM) is considered unproven for this patient's medical condition and not medically necessary. The use of a Subcutaneous Cardiac Monitor is considered medically necessary for individuals with a history of cryptogenic stroke and previous non-diagnostic trial of external ambulatory event monitoring (AEM). The current peer-reviewed published medical literature is inadequate to conclude that the information gained is only possible with an implantable Subcutaneous Cardiac Monitor or that standard cardiac monitoring techniques, like a conventional patient-activated or auto-triggered cardiac ambulatory event monitoring have been unsuccessful or could not have been utilized due to the patient being incapacitated or mentally challenged and unable to activate the ambulatory event monitoring.  It has not been determined that a Subcutaneous Cardiac Monitor is safe, effective and results in better health outcomes and is medically necessary for this patient's medical condition, cryptogenic stroke. Therefore, the proposed treatment, Subcutaneous Cardiac Monitor, is not medically necessary, based on the submitted information provided and  the current published medical literature.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder-Seizure
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has a history of one episode of status epilepticus, who was in her usual state of good health when she developed a mild subjective fever, which was treated with Tylenol. The following day, she had a seizure, consisting of generalized shaking of her arms and legs. The seizure had a duration of 5 minutes and stopped spontaneously. Post-ictal, she was sleepy for 30 minutes. For this seizure, she was taken to the emergency room, where she was noted to be postictally sleepy, but had no further seizures. She was slightly tachycardic with a heart rate of 160 beats per minute (bpm), but was clinically stable, and her other vital signs were normal. Laboratory testing, including complete blood count (CBC) and comprehensive metabolic panel (CMP), were unremarkable. She was then transferred to an outside Hospital, where she was admitted. While in the hospital, she developed a rash, runny nose, and fever to 101.8 degrees Fahrenheit. For her previous seizure, she was started on Keppra. Throughout the hospitalization, she remained seizure-free. She was discharged to home on the following day.
This patient has a history of status epilepticus. This occurred four months previously. At that time, she had a single prolonged seizure, which lasted about four hours and required multiple anticonvulsants to make it stop. Head computed tomography (CT) scan and electroencephalogram (EEG) were both normal at that time. She was discharged on a tapering dose of phenobarbital.

The inpatient stay was not medically necessary. When a young child has a generalized seizure that stops on its own within a few minutes, then that child can be observed  at a lower level of care. This is true whether the child has a fever or not. This patient had a generalized seizure that lasted five minutes and stopped spontaneously. In the emergency department, she fully recovered after 30 minutes of postictal lethargy. She had no concerning vital signs abnormalities or abnormal lab tests that required inpatient investigation or treatment. This patient could have been safely treated at a lower level of care.
The patient had a single, brief, generalized seizure that stopped spontaneously. She did not have a complex febrile seizure, complex metabolic disorder, brain tumor, recurrent seizures, status epilepticus, brain trauma, cerebral swelling, stroke, or any of the other criteria listed in the Milliman Care Guidelines for admission of a child with seizures. She could have been safely treated at a lower level of care.