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

Diagnosis:  Dental Problems (skeletal Class II retruded mandible, maxillary and mandibular crowding, deep impinging overbite and severe overjet).
Treatment:  Braces and monthly visits.

The insurer denied coverage for braces and monthly visits.  The denial is overturned. 

This is a male child, who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class II retruded mandible, maxillary and mandibular crowding, deep impinging overbite and severe overjet.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining a score of 17 points on the HLD index where 26 points is required. 

Regarding the validity of the HLD index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies.  Peer reviewed articles conclude that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the HLD index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system, if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage.  This automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

The healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for braces and monthly visits is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Trelegy Ellipta.
The insurer denied coverage for Trelegy Ellipta.
The denial is upheld. 

This is a female with history of gastroesophageal reflux disease (GERD), hearing loss and cough. The patient presented for follow-up appointment with a pulmonologist for asthma. The patient continued to have issues with cough despite maximized asthma treatment. The patient utilized Dupixent. The patient was also utilizing Trelegy as well as Singulair, albuterol, and Allegra. The patient's cough was ongoing, but was controlled. The patient denied sputum production and has not been hospitalized for asthma. The patient's physical examination revealed her oxygen saturation was 99% and the patient's blood pressure was 130/68. The patient was alert and oriented and the patient was breathing comfortably and there were no wheezes on her lung examination. The recommendation was made to continue with multiple medications. The request has been received for Trelegy Ellipta. This request was previously denied because the pharmacy criteria are not met for Trelegy because the individual components of this medication are on the preferred drug list. 

Consideration can be made using two separate prescriptions for Arnuity Ellipta in combination with Anoro Ellipta, which are the components of Trelegy Ellipta. Thus, if the patient is getting meaningful benefits from Trelegy, the patient would get the same benefits from this combination of two inhalers. This determination is supported by literature review. Therefore, the request for Trelegy Ellipta is not considered medically necessary for this patient.

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

The carrier's denial of Trelegy Ellipta should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Abuse
Treatment: Inpatient Hospital 
The health plan denied the inpatient hospital stay. 
The health plan's determination is overturned.

The patient is a male who was admitted to the hospital  The patient was found via Emergency Medical Services (EMS) intoxicated. He was found in a hotel room with multiple alcohol bottles around. The patient was tachycardic, hypertensive and with an elevated alcohol level of 406.8. He has a past medical history of hypertension, type 2 diabetes, chronic back pain and alcohol abuse. The patient was discharged from the hospital.
Significant findings were heart rate of 103 beats per minute (bpm), an ethanol level of 408.8 mg/dl, an aspartate aminotransferase (AST) of 73, and an alanine aminotransferase (ALT) of 64.
The patient was admitted for alcohol intoxication and withdrawal. He was started on the Clinical Institute Withdrawal Assessment (CIWA) protocol, thiamine, and folic acid supplementation with as needed (PRN) Ativan. He was found to be thrombocytopenic likely secondary to chronic bone marrow suppression from his alcohol use history. Work up and treatment plan consisted of CIWA protocol, intravenous (IV)fluids, IV thiamine and folic acid, PRN Ativan and Zofran.
The day after admission the patient had a blood pressure of 170/102 millimeters of mercury (mmHg).The patient reported feeling drowsy and nauseated. He was continued on the CIWA protocol, PRN Zofran, thiamine/ folic acid. He had a CIWA score of 8. His blood pressure medication was adjusted. The patient was discharged home.
At issue is the medical necessity of the inpatient hospital stay.

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

Yes, the inpatient hospital admission was medically necessary. The patient was still showing signs of withdrawal on day two. He was still on PRN IV Ativan and had a CIWA of 8. A CIWA score greater than or equal to 8 is not safe to discharge. [5] The patient was still drowsy, nauseated and hypertensive and required continued hospital care. Other conditions to include hospitalization " admissions include liver disease, acute pancreatitis, congestive heart failure, heart arrhythmias, aspiration pneumonia, and uncontrolled hypertension because of the risk of stroke or heart attack." [6] This patient was also tachycardic and had uncontrolled hypertension, which are additional reasons for his hospitalization and continued care. The patient could not safely be discharged on day two. He was still at an increased risk of going into a coma, seizure or acute respiratory distress.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The health plan's determination is upheld in whole.

The patient is a female who was diagnosed with Graves Disease. There were no cervical mass lesions, and no hyperthyroid or hypothyroid symptoms. She elected total thyroidectomy. She underwent an unevenly total thyroidectomy and was admitted postoperatively. She did well with no complications intraoperatively or postoperatively. Her vital signs were stable, she was afebrile, her surgical wound was clean dry and intact, she tolerated liquids, she was able to ambulate and void and there was no documentation of respiratory distress, Chvostek's test was negative, and there was no documentation of dysphagia or hoarseness. She was discharged. The subject under review is the medical necessity for the inpatient hospital admission. 

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

The requested health service/treatment of Inpatient Hospital Admission medically necessary for this patient. Clinically this is a patient with asymptomatic Graves Disease who underwent an uneventful total thyroidectomy. She was admitted as an inpatient and had an uneventful postoperative course. Her vital signs were stable, she was afebrile, her surgical wound was clean dry and intact, she tolerated liquids, she was able to ambulate and void and there was no documentation of respiratory distress, Chvostek's test was negative, and there was no documentation of dysphagia or hoarseness.
According to Reinhart (2018), in a review of 1460 patients there was no difference between outpatient and inpatient complications including symptomatic hypocalcemia or postoperative hematomas and they concluded a that same day discharge after thyroidectomy is safe and effective. Balentine et al. (2016) states that multiple studies in the evidence based literature have now demonstrated that careful patient selection combined with surgeon experience can result in successful and safe surgery without a full inpatient admission. Lee et al. (2018) found fewer complications in outpatient than inpatient thyroidectomy and suggested that inpatient thyroidectomy may be as safe as inpatient thyroidectomy in appropriately selected patients. Clinically there are no documented comorbidities or complications that would have necessitated an inpatient thyroidectomy. Based upon the evidence based literature, an inpatient hospital admission is not clinically appropriate and medically necessary. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid arthritis

Treatment: 40 hours/week, Consumer Direct, 1 Client

The insurer denied coverage for 40 hours/week, Consumer Direct, 1 Client.

The denial is overturned. 

This is a female patient with rheumatoid arthritis, lupus, prothrombin mutation, fibromyalgia, cervical disc degeneration, chronic obstructive pulmonary disease, lumbosacral spondylosis without myelopathy, lumbar radiculopathy, myofascial pain, migraines, inflammation of sacroiliac joint, bicipital tendinitis right shoulder, inflammatory poly-arthropathy, asthma, hypertension, gastroesophageal reflux disease, depression, anxiety, and seizure disorder. A Person Centered Service Plan (PCSP) notes that the patient lives with an adult son and daughter. There were no recent falls. The patient reported it was taking longer to get dressed and use the bathroom because of increased swelling. She was having more difficulty with household chores. A Physician Care Note, at the time of a visit, notes recent increased morning stiffness and generalized pain. The patient's right leg recently gave out, causing her to fall. She reports dependence on aide for activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The assessor noted that scripts were sent for a cane, bath chair and grab bars, and a referral was made for physical therapy for strength training exercises. The patient was felt to need more assistance at home with her ADLs and IADLs.  According to a recent Uniform Assessment System (UAS) report, the patient now needs extensive assistance with bed mobility. 

The recent UAS report noted that extensive assistance with bed mobility was needed, a change from the previous UAS. The patient already needed extensive assistance with other ADLs. The physician notes also indicate that the patient's rheumatoid arthritis is more active. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for 40 hours/week, Consumer Direct, 1 Client is substantiated. The insurer's denial is overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Surgical Procedure. 
The insurer denied LINX procedure. 
The denial is upheld in whole

The patient is a female with a history of gastroesophageal reflux symptoms. On endoscopy, there is a 2 centimeter (cm) hiatal hernia with mild esophagitis. She has undergone a Bravo pH evaluation which indicates a DeMeester score of 28 indicating abnormal esophageal acid exposure. Manometry is normal.
This review concerns whether the proposed LINX system for treatment of gastroesophageal reflux disease (GERD) is likely to be more beneficial for this patient than standard treatment.

The health plan's determination is upheld.
The LINX system is not more likely to be more beneficial than standard medical and surgical therapies. The LINX system, magnetic bead sphincter augmentation device placed laparoscopically, has been used in limited centers with limited follow-up analysis. Evidence supporting the LINX has stemmed primarily from cohort studies with inadequate control groups and not of long term.
There is currently insufficient evidence that the LINX treatment is more beneficial than standard medical and surgical therapies. As Kirkham's 2020 metanalysis concluded, "Most studies on magnetic sphincter augmentation (MSA) lacked information about patient selection, governance, expertise, techniques and outcomes, or varied between studies. Currently, MSA is being used despite a lack of robust evidence for its effectiveness." (2)
Guidozza's 2019 review and pooled analysis included 6 comparative studies but only one of these had duration of follow-up beyond 12 months. The authors conclude, "The safety of MSA also appears acceptable with only 3.3% of patients requiring device removal. There is an urgent need for randomized data directly comparing fundoplication with MSA for the treatment of GERD to truly evaluate the efficacy of this treatment approach." (1) The lack of such randomized data, and the lack of long term evaluation for erosion, reinforces the finding that the LINX is not the standard of care at this time.
Concerns of erosion of the LINX system have not been adequately resolved due to the time course of esophageal erosion for past devices and the relatively short duration of follow-up of the LINX series. Short term follow up such as that reported by Aiolfi have not answered the question of efficacy and safety over a longer time period. (4)
Concerns remain about long term erosion potential, and as Asti reports, LINX removal in such cases can be fraught. (3)
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Surgical Procedure. 
The insurer denied LINX procedure. 
The denial is upheld in whole

This patient is a female (body mass index [BMI] 35 kilograms per square meter [kg/m2]) who sought surgical evaluation for the condition of heartburn, chest pain and regurgitation. These symptoms are partially responsive to proton pump inhibitor (PPI) medication (Omeprazole), but she does have breakthrough symptoms. She has no dysphagia.
She has been evaluated for this condition with:
Esophagogastroduodenoscopy (EGD) that esophagitis in the area of the gastroesophageal (GE) junction and a 2-centimeter (cm) hiatal hernia.
Esophageal motility showed adequate peristalsis of the esophagus. There was a no manometric hiatal hernia and 100% of swallows were normally peristaltic.
A pH study identified an elevated esophageal acid exposure with a composite DeMeester score of 28.2 over 48-hours of study (nl less than [<] 14.7). Symptom correlation was strong for heartburn, chest pain and regurgitation. The treating surgeon has proposed the LINX procedure as treatment of gastroesophageal reflux disease (GERD).

The subject under review is whether the procedure is likely to be more beneficial for this patient than standard treatment.

Based on the current evidence-based literature and the patient-specific objective clinical evaluation in this case, the LINX procedure is medically necessary and is likely to be more beneficial than any standard treatment for this insured's condition of proven GERD.

Based on the current evidence-based literature and the patient-specific objective clinical evaluation in this case, the LINX procedure is medically necessary and is likely to be more beneficial than any standard treatment for this insured's condition of proven GERD.

Based on the status of peer reviewed literature and adequate long-term follow up, specialty surgical society position statement affirmation regarding LINX and FDA approval, the LINX procedure likely to be more beneficial in this case. 
This patient's evaluation confirms that an anti-reflux procedure is warranted. Standard of care treatment options include ongoing medicinal treatment, laparoscopic fundoplication, transoral incisionless fundoplication (TIF), and the LINX magnetic sphincter augmentation procedure. The LINX procedure offers benefits over traditional surgical fundoplication with equivalent reduction in esophageal acid exposure with preservation of the ability to belch / vomit. LINX offers improved symptom control compared to ongoing medicinal therapy with reduction in need for anti-acid medications and reduction in regurgitation. It also avoids the need for ongoing PPI therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal 
Treatment: Surgical Procedure. 
The insurer denied LINX procedure. 
The denial is upheld in whole.

The patient is a female with a body mass index (BMI) 35.61 kilograms per square meter (kg/m2) with history of long standing gastroesophageal reflux disease (GERD) refractory to medical management. Esophageal manometry was documented to be normal. Esophagogastroduodenoscopy (EGD) revealed class 1 esophagitis, 2 centimeter (cm) hiatal hernia. 24 hour pH monitoring revealed an elevated DeMeester score of 28.2 consistent with significant GERD.

The subject under review is whether the proposed LINX system is likely to be more beneficial than any standard treatment for this patient's condition.

The health plan's determination is upheld in whole.

The LINX reflux management system is not likely to be more beneficial for this patient than any standard treatment. Although this patient has GERD, and LINX is a standard treatment option for GERD, this patient also has an elevated BMI consistent with morbid obesity (BMI greater than [>] 35 kg/m2) with hypertension (HTN) which is a relative contraindication to the LINX procedure, as general outcomes after any surgical anti-reflux procedure such as lap Nissen fundoplication or LINX have not been shown to be as durable in this population with a higher incidence of failure. Bariatric surgery with subsequent weight loss has been shown to be a better treatment for GERD in patients with a BMI of 35 kg/m2 or greater. Relative Food and Drug Administration (FDA) exclusions to LINX include age less than (<) 18, BMI of 35 or greater, findings of Barrett's esophagus or prior history of gastric or bariatric surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stage IIIC squamous cell carcinoma of the cervix 
Treatment: Proton Beam Therapy
The insurer denied the Proton Beam Therapy.
The denial is upheld. 

The patient is a female with a diagnosis of stage IIIC squamous cell carcinoma of the cervix involving the left common, internal and external iliac nodes.  Definitive chemotherapy and radiation therapy were recommended, and proton beam radiation therapy was requested.  

No, the proposed treatment with Proton Beam Therapy is not medically necessary.

The patient is a female with a diagnosis of stage IIIC squamous cell carcinoma of the cervix involving the left common, internal and external iliac nodes.  Definitive chemotherapy and radiation therapy were recommended, and proton beam radiation therapy was requested.  However, the clinical data from well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature is inadequate to conclude that proton beam radiation therapy is superior to photon-based radiation for the treatment of cervical cancer.

Proton beam radiation therapy is a type of very precise external radiation treatment in which protons are used to treat cancer and other conditions.  Compared to photon, a proton beam that is delivered with sufficient energy has a low "entrance dose". A proton beam also has a high dose "Bragg peak" region, which is designed to cover the entire tumor and there is no "exit dose" beyond the tumor involved in proton radiation therapy.  Because of this unique property, proton beam therapy is highly successful in minimizing damage to normal tissue and surrounding organs, resulting in fewer side effects.  It is a Food and Drug Administration (FDA) approved procedure and it is not subject to Institutional Review Board (IRB) review.

Although proton beam radiation therapy has been shown to be safe and effective for certain tumors that are adjacent to critical structures such as central nervous system (CNS) lesion, there is insufficient clinical peer-reviewed literature for supporting its use for the definitive treatment of cervical carcinoma.  There are clinical trials still evaluating the role of proton therapy for the treatment of gynecologic cancers.  There are other established alternatives available such as conventional conformal or intensity modulated radiation therapy (IMRT) that have been shown to be safe and effective for the treatment of cervical cancers.  Proton beam radiation therapy, therefore, is not a medically necessary trial due to insufficient clinical data in well conducted trials supporting its use for cervical cancer.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic procedure. 
The insurer denied braces and monthly visits x12. 
The denial is overturned in whole. 

The patient in question is a female with an anterior crossbite on tooth 11. She presents with a skeletal Class I malocclusion with minor crowding in the maxilla and moderate crowding in the mandible. She is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

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

The requested treatment of braces and monthly visit (x12) is medically necessary for this patient. This patient presents with an anterior crossbite on tooth 11, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.1,2,3 If left untreated the damage that will likely occur to the patients teeth will be much more difficult to correct than the patient's existing orthodontic problem. Treatment is deemed medically necessary.