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

Diagnosis:  GERD (gastroesophageal reflux disease).
Treatment:  LINX Procedure.

The insurer denied the LINX procedure.  The denial is upheld.

The patient is a male.  He has a BMI (body mass index) of 27 kg (kilograms)/m2 (meters squared) and history of long-standing GERD (gastroesophageal reflux disease).  EGD (esophagogastroduodenoscopy) revealed a four-cm (centimeters) hiatal hernia without evidence of Barrett's esophagus.  24-hour pH (potential of hydrogen) study revealed an elevated DeMeester score of 58.8 consistent with GERD (gastroesophageal reflux disease).  Esophageal manometry was normal.  Hiatal hernia surgery is planned, as well as the LINX procedure.

No, the health plan should not cover the LINX Procedure.

LINX is considered a standard surgical treatment for GERD (gastroesophageal reflux disease) 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 (gastroesophageal reflux disease) for mid- to long-term outcomes based on published findings.

There are only a few exclusions to treatment, which include the following:  1) Age less than (<) 21, 2) Barrett's esophagus, 3) BMI (body mass index) greater than (>) 35, and
4) Hiatal hernia greater than (>) three cm (centimeters).

This patient has a hiatal hernia of 4 cm (centimeters), and the LINX device has not been formally studied in patients with hiatal herniae of this size.  Therefore, for this patient, the requested LINX procedure is not considered medically appropriate for this patient, who has a 4 cm (centimeter) hiatal hernia.

No, the LINX procedure is not likely to be more beneficial.

Although LINX is a standard surgical treatment for GERD (gastroesophageal reflux disease) based on published literature and updated national guidelines (SAGES [Society of American Gastrointestinal and Endoscopic Surgeons]), there are certain precautions and potential concerns which include age < 21, Barrett's esophagus, BMI (body mass index) > 35 and hiatal hernia > 3 cm (centimeters).  This patient has a hiatal hernia of 4 cm (centimeters), and the LINX device has not been formally studied in patients with hiatal herniae of this size.  Therefore, for this patient, the requested LINX procedure is not considered medically appropriate for this patient, who has a 4 cm (centimeter) hiatal hernia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 diabetes mellitus.
Treatment: Continuous glucose monitor supply (K0553 x 6).
The insurer denied coverage for continuous glucose monitor supply (K0553 x 6).
The denial is overturned. 

This is a female patient with Type 1 diabetes mellitus (DM). She had issues with nocturnal hypoglycemia. She currently uses a T slim and a continuous glucose monitor (CGM) for blood sugar control (Dexcom G6). Supplies for the T slim and CGM are medically necessary due to the patient's diagnosis. Her Hemoglobin A1c (HbA1c) was 6.9. The insurer has denied coverage for continuous glucose monitor supply as not medically necessary. Her Endocrinologist is appealing this decision and noted that she has been using the Dexcom G6 for over a year and the CGM is medically necessary due to frequent episodes of hypoglycemia.

Howsmon, D., & Bequette, B. W. (2015) states, "Diabetic alarm systems potentially afford more effective diabetes management and an increased quality of life to those living with diabetes. While some signals are only capable of classifying a patient's state as normal and hypo- and/or hyperglycemic, others can estimate blood glucose concentrations. Furthermore, some signals are only suitable for detection of altered glycemic states while other signals can predict these undesirable events. Although standalone alarm systems will become obsolete with the development of the artificial pancreas, alarm systems will form the core safety components and have paved the way for insulin administration algorithms of various complexities."

According to Martin-Timon, I., & Del Canizo-Gomez, F. J. (2015), Continuous Glucose Monitoring System (CGMS) "that can detect hypoglycemia, represents an important technological advance on the methods used for self-monitoring of blood glucose, and they are welcome to both patients and clinicians. The ability of CGMS systems is to advise patients when glucose levels fall too low or rise too high, and has the potential to reduce duration of hypoglycemia and hyperglycemia events."

According to Peyser, T. A., et al. (2015), "Use of an 80 mg/dL [milligrams per deciliter] threshold setting for hypoglycemic alerts on the G4 Platinum (software 505) may provide patients with timely warning of hypoglycemia before the onset of cognitive impairment, enabling them to treat themselves for hypoglycemia with fast-acting carbohydrates and prevent neuroglycopenia associated with very low glucose levels."

The health care plan did not act reasonably in the best interest of the patient. The CGM is considered medically necessary due to the patent's increase frequency of hypoglycemia. Therefore, continuous glucose monitor supply (K0553 x 6) is considered medically necessary for this patient. 
                                                         
The carrier's denial of coverage for continuous glucose monitor supply (K0553 x 6) is overturned. The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Pharmacy/Prescription Drugs (Dupixent)
The health plan denied the requested prescription drug. 
The health plan's determination is upheld.

The patient is a male with atopic dermatitis of the face, abdomen, back, and lower extremities. He has tried and failed topical Eucrisa, Hydrocortisone, Ketconazole cream, and Elidel. The patient has also tried phototherapy. The patient is on Dupixent dosed every other week, and flares right before the next injection.

Weekly Dupixent coverage is under review.

The health plan's determination of Dupixent is upheld.

The patient has no documented treatment failure with, or true medical contraindication to, either topical Tacrolimus (which, unlike Elidel or Eucrisa, is Food and Drug Administration (FDA)-approved for moderate to severe atopic dermatitis), and/or more potent topical steroids, and/or standard, first-line oral medications such as Methotrexate, Azathioprine, or Mycophenolate Mofetil. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. The patient is uncontrolled on the standard dosing of Dupixent every two weeks, and therefore alternative systemic therapies are medically necessary. The formulary alternatives are often needed concurrently with Dupixent for more severe cases of atopic dermatitis and are both usually well-tolerated and effective for this patient's clinical scenario with appropriate monitoring.

Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Indeed, standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. This review focuses on the use of systemic treatments in adult AD patients analyzing published literature. [2]

Therefore, consistent with current dermatology literature reviews [1-4], the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer has denied Cosentyx. 
The denial is upheld.

The patient is a male with moderate to severe psoriasis of the elbows, back, and legs. The patient also has joint pain and swelling of the proximal interphalangeal joints on multiple digits and morning stiffness of the hands and feet. The patient has tried and failed light therapy and topical therapies (such as Olux and Clobex and calcipotriene). The subject under review is the medical necessity for Costentyx.

The health plan's determination is upheld in whole.

Cosentyx is being requested for use out of convenience rather than true medical necessity. Alternative biologic agents, such as Tumor Necrosis Factor inhibitors (Humira and Cimzia) are first-line biologic therapies for psoriatic arthritis and are of similar efficacy to the requested Cosentyx with respect to moderate to severe psoriasis. Tremfya and Stelara are also Food and Drug Administration (FDA)-approved for both moderate to severe psoriasis and psoriatic arthritis.

The patient has no documented treatment failure with, or true medical contraindication to, either Cimzia, Humira, Stelara, or Tremfya. These four biologic agents are all FDA-approved for moderate to severe psoriasis and psoriatic arthritis. Tumor Necrosis Factor inhibitors Humira and Cimzia are among the first-line therapies recommended for psoriatic arthritis. Therefore, as per the patient's preferred alternatives, the requested Cosentyx is not medically necessary.

Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Cosentyx, particularly for a patient with a limited history of systemic/biologic psoriasis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Cosentyx is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Developmental Regression in Language
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of premature birth, solitary right dysplastic kidney with chronic kidney disease, and developmental delay. She was having some shaking spells that were suggestive of epileptic seizures. However, she underwent a routine electroencephalogram (EEG), which was normal, and the shaking spells spontaneously resolved. She demonstrated some developmental regression in her language skills, as she was previously uttering several words, but then stopped using those words. Out of concern that her developmental language regression might be due to electrographic seizures in sleep, her neurologist has ordered a video electroencephalogram (VEEG). The neurologist has ordered that the patient be admitted for the VEEG on the basis that the patient would not tolerate an ambulatory EEG as an outpatient. The insurance company has approved the EEG to be conducted at the ambulatory level of care, but has denied the request for admission to the hospital on the basis that admission is not medically necessary. At issue is the medical necessity of inpatient hospital admission for VEEG.

Although it is medically reasonable for this patient to undergo a video EEG, it is not medically necessary for an inpatient hospital admission for a video EEG. Although rare, electrographic seizures in sleep can lead to developmental language regression in children. It is especially rare for this condition to affect children as young as this patient. However, it is possible that the patient's developmental language regression is due to electrographic seizures in sleep. Therefore, it is reasonable for her to undergo an EEG. However, there is no reason why she needs to be admitted to the hospital for this EEG to be conducted. Prolonged EEGs, which include recordings during sleep, are commonly and customarily acquired on an outpatient basis. The medical records contain no information demonstrating that the patient would not tolerate an outpatient EEG. Outpatient EEGs are routinely obtained on young children, like this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Relapsing Remitting Multiple Sclerosis
Treatment: Ocrevus
The insurer denied the Ocrevus.
The determination is overturned.

The patient has a history of relapsing remitting multiple sclerosis who was recently treated with Tysabri; however, he is John Cunningham virus (JCV) antibody positive. Ocrevus is requested as therapy. There are no other medication's tried and failed. At issue is the medical necessity of the Ocrevus.

The Ocrevus is medically necessary. The patient has a diagnosis of relapsing remitting multiple sclerosis. The patient has previously been treated with Tysabri. On Tysabri, the patient has been relapse free for several years. However, the patient cannot continue Tysabri because he has antibodies to the JCV. The continued use of this medication may result in a life-threatening condition called progressive multifocal leukoencephalopathy. As such, the provider has requested a change to Ocrevus. Ocrevus is appropriate for this patient as the drug is Food and Drug Administration (FDA) approved for treatment of relapsing remitting multiple sclerosis. The drug is not being used as a first line agent. The patient is neurologically intact. The use of this medication is medically necessary as it is considered the standard of care for treatment of multiple sclerosis and is also supported by the FDA, literature, and compendia. There are no other treatment options that are as likely to be as effective or beneficial for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned. 

This is a male patient with a past medical history of Crohn's disease. The patient presented to the Emergency Room (ER) with subjective complaints of abdominal pain.  The patient had abdominal pain for 1 hour and had associated nausea. The patient's pain level was rated 10 out of 10 in severity. The patient noted that he had been having mild Crohn's symptoms/flare over recent days. Approximately 1 hour into the arrival at the ER, the patient had a sudden onset of severe upper twisting abdominal pain with nausea and vomiting. The patient's last bowel movement was the morning of this ER presentation.  The patient's X-ray showed a dilated loop of small bowel in the right upper quadrant and right lower lobe infiltrates. The patient's computed tomography (CT) scan revealed transverse colitis with fever. The patient's laboratory results revealed an aspartate aminotransferase (AST) of 117 and increased alanine transaminase (ALT). The patient was admitted for intravenous (IV) antibiotics and pain/nausea control and to rule out gallbladder pathology. The patient was to receive nothing by mouth. The gastroenterologist ordered an abdominal ultrasound to assess the patient's gallbladder and recommended trending liver function tests. The patient's abdominal ultrasound showed multiple gallbladder polyps without acute cholecystitis. The impression was acute exacerbation ileocolonic Crohn's disease. The patient was subsequently stabilized and discharged.

Based on medical record and literature review, the inpatient hospital admission was medically necessary for this patient. The patient presented to the ER with severe abdominal pain requiring IV pain relief. The patient had multiple comorbidities with elevated liver enzymes and possibility of acute cholecystitis as well as CT- documented colitis. Given this patient's history of active Crohn's disease and clinical presentation, there was a clinical possibility of bowel obstruction and need for flare control. These multiple pathologies are best managed in the acute hospital setting.
  
The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The inpatient hospital admission was medically necessary for this patient.

The carrier's denial of coverage for the inpatient hospital admission should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness Of Breath (status post s/p cardioversion)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a gentleman. He presented with intermittent lightheadedness and mild dyspnea lasting for several minutes.  Upon arrival to ED (emergency department), the patient had a low-grade fever 100.5, and he denied exposure to COVID-19 (coronavirus disease 2019) virus.  His past medical history included recent onset atrial fibrillation, obstructive sleep apnea, hypertension and anal fissure on antibiotics and pain medication.  

The patient's vital signs were P (pulse) 90, BP (blood pressure) 152/98, and physical examination was within normal limits.  Laboratory testing revealed no elevation of serum troponins, negative D-Dimer, negative COVID (coronavirus disease) antigen test, and CT (computerized tomography) pelvis demonstrating anal fissure without abscess.  ECG (electrocardiogram) revealed AF (atrial fibrillation) with rapid ventricular conduction up to 140 bpm (beats per minute).

The patient was treated with IV (intravenous) metoprolol.  He was admitted to the hospital. TEE (transesophageal echocardiogram) and cardioversion were performed, however sinus rhythm was not restored.  Given symptoms persistent AF (atrial fibrillation) with rapid ventricular conduction, the patient was scheduled for EP (electrophysiology) study with radiofrequency ablation of AF (atrial fibrillation) the following day.  

Pulmonary vein isolation and posterior wall isolation was successfully performed, and the patient was discharged the following day.

Yes, the Inpatient admission was medically necessary.

Patients presenting with atrial arrhythmia with rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. 

In this case, the patient was treated with cardioversion that was unsuccessful. He required additional treatment, and he underwent catheter ablation one day after his sinus rhythm could not be restored.  Following catheter ablation, the patient required additional monitoring and care. 

An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of three days (Reference 1). This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. A second analysis also reported an average length of stay for AF (atrial fibrillation) management was three days (Reference 2).  The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. Given the stepwise and logical treatment course that transpired with this patient, a higher level of care was indicated.

Therefore, given the above, the Inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable vomiting.

Treatment: Inpatient stay.

The insurer denied coverage for the inpatient stay.

The denial is upheld. 

This is a female with a history of gastroesophageal reflux disease (GERD), hypertension, osteoarthritis (OA), tobacco abuse, and marijuana abuse. She presented to the emergency room with complaints of a one month history of abdominal pain, nausea, and vomiting. Symptoms were worse on the day of arrival. The patient was admitted with intractable vomiting. The impression was recurrent gastroenteritis versus intermittent cannabis hyperemesis syndrome.

The patient presented with abdominal pain and vomiting, with a history of daily marijuana use. She had hypertension but was hemodynamically stable. There was no abdominal rebound or guarding. A computed tomography (CT) scan was negative for acute disease. The patient's lactate level was 1.6. The Blood urea nitrogen (BUN) level was 19 with a creatinine level of 0.80. She was treated with intravenous hydration, Reglan, and Zofran. It was felt that she had cannabis hyperemesis syndrome.

This patient required intravenous hydration and antiemetics. She could have received this treatment with observation status. She did not meet Milliman Care Guidelines (MCG) criteria for an inpatient admission for vomiting. Clinical indications for admission - vomiting (M-370) include gastrointestinal obstruction, a significant metabolic derangement, severe vomiting which persists after treatment, severe electrolyte abnormalities, and acute renal failure. The patient did not have these conditions. She did have recurrent vomiting in the emergency room. However, by the following morning she was able to tolerate a liquid breakfast.  

The healthcare plan acted reasonably and with sound medical judgment. An inpatient stay was not medically necessary. The denial is upheld.

The medical necessity for the inpatient stay is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital.
The insurer denied inpatient hospital admission for medical necessity.
The denial was overturned. 

The patient is a boy who fell and sustained a left type 3 supracondylar humerus fracture with wide displacement. He was transferred from the emergency room where he initially presented to another hospital, where he was admitted.

The following morning, he was taken to the operating room (OR) where he underwent a closed reduction and percutaneous pinning of the fracture. He was monitored for a period of time after that in the hospital, and then he was discharged.

At issue is the medical necessity of the inpatient hospital admission.

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

The requested health service/treatment of an inpatient stay was medically necessary for this patient.

This patient sustained a type 3 supracondylar humerus fracture with wide displacement. Children who sustain this type of fracture are at risk of nerve and vascular injury and need to be monitored closely for evidence of ischemia or compartment syndrome. Pain accompanies this type of fracture and must be treated. However, the level of pain must also be repeatedly assessed, as an unusual degree of pain is the most common indication of an impending compartment syndrome. This type of monitoring requires inpatient admission and inpatient level of care and should not be considered equivalent to an outpatient procedure.

Therefore, the inpatient hospital admission was medically necessary.