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

Diagnosis: Gastroesophageal reflux disease (GERD). 

Treatment: Surgery

The insurer denied the LINX Reflux Management System and the related inpatient hospital admission. That denial was reversed. It was determined the requested procedure is likely to be more beneficial than any other existing standard health service.

Reviewer #1:

The patient has a history of gastroesophageal reflux disease (GERD).  She has remained symptomatic in spite of medical therapy.  Esophageal pH testing revealed an elevated DeMeester score.   A barium swallow showed significant regurgitation.  Due to the extent of the reflux, she was felt to be an excellent candidate for the LINX procedure.

In March 2017 the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the LINX Reflux Management System.  With regard to safety, the conclusion was that long term follow-up supports the FDA conclusion that the device is safe.  With regard to efficacy, there were several conclusions.  The LINX implant results in pH normalization, improved quality of life, and cessation of regular proton pump inhibitor (PPI) use on a consistent basis.  

Gastrointestinal Endoscopy 2019 Volume 89 Page 14 has an article titled "Laparoscopic Magnetic Sphincter Augmentation versus double dose PPI for management of moderate to severe regurgitation in GERD: a randomized controlled trial."  The conclusion was that patients with moderate to severe reflux, especially if on PPI therapy, should be considered for minimally invasive treatment rather than increased PPI therapy.

The scientific evidence shows that the LINX system results in improvement in health outcome.    LINX has Food and Drug Administration (FDA) approval.  The patient has documented reflux and persistent symptoms, so she is a good candidate for LINX.  There are several options for both surgical and endoscopic treatments, but LINX has been shown to be an effective treatment.  A minimally invasive treatment such as LINX is appropriate for patients who have continued GERD symptoms on medical management and do not want to have more extensive surgery.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who was admitted for residential mental health treatment of persistent depressive disorder together with diagnoses of neuro-developmental coordination disorder, autism spectrum disorder, borderline intellectual disability disorder, and major neurocognitive disorder associated with aggressive and disruptive behaviors with co-occurring addiction to the internet.  The patient had received mental health treatment with various levels of care including extensive treatment in the past that included therapy and medication with family support and involvement.  The patient was treated immediately prior to her referral with an outdoor behavioral health (Wilderness) program with recommendations for the admission for extended residential treatment.  The health plan's determination of medical necessity is overturned.  The patient's clinical history,  presenting features and persistent symptoms together with safety concerns did warrant the continued structure and monitoring of a residential setting with the intensity, scope, and duration of residential level services in order to effectively address the patient's risk of self harm, continue to learn adequate coping skills to engage in an ongoing therapeutic process, and prevent treatment failure, while the treatment team and family worked toward a clinically appropriate disposition with continued mental health services to address the severe and persistent symptoms of the multiple diagnosed disorders and the associated disturbances of mood, attention and functioning.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted for low-intensity residential mental health treatment of neuro-developmental and autism spectrum and intellectual disability disorders associated with aggressive and disruptive behaviors and persistent depressive disorder and co-morbid features of attention deficit hyperactivity disorder (ADHD).  The patient had received mental health treatment with various levels of care including extensive treatment in the past that included therapy and medication with family support and involvement.  Despite the best efforts of community providers with supports within the educational system with an individual educational program and specialized education services, the patient worsened with a decline in functioning and social isolation and aggressive behaviors. 

The patient presented with anxiety, depression, hopelessness, and affective instability with limited insight and fair judgment associated with anxiety symptoms that were prominent; the patient exhibited coping and personality traits that reflected poor control of impulses with high risk for repeated violations of boundary issues and problems with maintaining emotional control in the context of the developmental disorder (autism spectrum disorder) and the addiction to the internet.

There were no acute general medical conditions or substance use disorders in this case. The patient was prescribed mood stabilizing and antidepressant medication to address anxiety, depression, and her aggressive outbursts:  Luvox and Trileptal, as well as N-acetylcysteine (NAC) and vitamin supplements.

The health plan's determination is overturned.

The patient required the admission and the continued structure and monitoring of a residential setting through date of discharge.  The residential level services and transitional living were medically necessary in order to effectively address the patient's risk of self-harm and problematic behaviors, continue to learn adequate coping skills to achieve better control of impulses and boundaries with peers and family, and prevent treatment failure, while the treatment team and family worked toward a clinically appropriate disposition with continued mental health services to address the co-occurring mood and developmental disorders and ADHD, including the aggressive and disruptive behaviors associated with autism spectrum disorder and persistent depressive disorder.  The patient had a history of failing to benefit from prior treatment episodes and demonstrated residual symptoms and behaviors that had persisted despite multiple treatment episodes; the patient lacked the insight and control of impulses to remain engaged in treatment in a less restrictive setting during the time frame under review.  These factors support the assertion that the patient could not have been effectively treated at a lower level of care through discharge, at which time the patient was working on the remaining psychological issues with improved insight, impulse control, and coping skills, per the health plan's case notes and submitted documentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient hospital admission
The inpatient hospital admission was not medically necessary.
Syncope is not an uncommon occurrence in childhood, with up to 35% of children experiencing at least one episode. Because of the decreased risk of underlying heart disease in the pediatric population, most syncope is benign. The yield of diagnostic studies is therefore quite low. The current guidelines recommend increased use of the electrocardiogram to screen for underlying cardiac abnormality because it provide the highest yield, and modified use of imaging studies. "The goal of the evaluation is to identify high-risk patients with underlying heart disease, which may include identifiable genetic abnormalities such as the LQTS [long QT syndrome], Brugada syndrome, or hypertrophic cardiomyopathy." (4) Syncope is an unusual presentation of patients with neurological problems. Such causes should be pursued only if suggested by the history or physical exam. Seizure would be the most common neurologic cause of unconsciousness or unresponsiveness, and electroencephalogram (EEG) would be the diagnostic study of choice, followed by imaging studies to identify structural abnormalities.
This boy was taken to the ED after having a second episode of syncope in a week, and upon further inquiry, was having multiple episodes of syncope every month. His mother had history of an aberrant pathway requiring ablation. His evaluation in the ED was unremarkable. While it was reasonable to monitor him pending cardiology consultation, he was overall stable and did not require acute inpatient admission. He could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fish allergy

Treatment: Inpatient admission 

Summary:
The inpatient admission  was medically necessary.   
This patient had a severe anaphylactic reaction to food, which is a life threatening illness. In addition, the patient has history of severe asthma - requiring intubation in the past. This patient was at risk of biphasic reaction and should have close monitoring, which can only be done in the ICU.   This patient was at risk of requiring intubation given history of asthma and should have been in a setting where close monitoring and intervention are possible.  Outpatient setting is not appropriate for this pediatric patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Excessive skin and subcutaneous tissue, weight loss post bariatric surgery 

Treatment:  Surgical excision

The insurer denied coverage for surgery to remove excess skin and fat from the thighs (CPT code 15832- Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh). That denial was upheld

This patient has a past medical history of massive weight loss following gastric bypass, and panniculectomy.  She complains that he thigh skin rubs against each other and she is unable to run due to the irritation.  The patient has lost 80lbs after the weight loss surgery.

The thigh dermatolipectomies were performed as a treatment for recurrent infections, but the records do not include objective evidence to verify the accuracy of the patient's history.  The patient does not have medical record documentation over time (e.g., series of office notes, dermatology consultations, pharmacy prescription records) of infections in the thigh folds, and photographs documenting cellulitis, ulcerations or rashes are not submitted.  The medical records do not provide any documentation in the form of frequent physician visits to the patient's primary care physician (PCP) or dermatologist for the management of ongoing clinically significant dermatologic problems that have either 1) never responded to topical therapy given or 2) despite initial response, have recurred and caused significant functional impairment.  

The patient is not sick from her excess skin, and has not had ulcerations or sepsis from her infections.  She has not required hospitalization or treatment with IV or oral antifungal or antibiotic medications.  Her excess thigh skin has not jeopardized her health.  There are no evaluation or treatment notes from a dermatologist or internist with appropriate, physician directed skin care.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.  Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.
Appeal type: Medical necessity
Decision: Overturned

The patient has type 2 diabetes, HIV with AIDS.  Patient is on Basaglar 75 units at bedtime and Humalog insulin 2-3 times daily.  Patient also takes Trulicity 1.5mg weekly.  The patient has fluctuating glycemia with blood sugars ranging from 57-500 and also noted low blood sugars in the mornings.  The patient checks blood sugars 4 or more times per day.  The patient's caregiver checks the blood sugars and administers insulin injections. 
The health plan's determination is overturned.

The requested health service of glucose monitoring device is medically necessary for this patient. Continuous interstitial fluid Glucose Monitoring (CGM) is considered safe and effective for Type 2 diabetes. CGM devices are Food and Drug Administration (FDA) approved for monitoring Interstitial glucose values(1).

In a meta-analysis by Gandhi et al., there was a significant reduction in A1C with use of CGM in adults with type 2 diabetes (2). CGM device offer the additional benefit of understanding Glycemic patterns for a continuous period of time and thereby avoiding hypoglycemia (3). In a study of patients with type 2 diabetes on multiple daily injections for 24 weeks, there was an improvement in hemoglobin A1c compared to the control group (4).

The American Association of Clinical Endocrinologists (AACE) published a consensus statement stating that CGM in Type 2 Diabetes can be useful in patients with unappreciated hyperglycemia, hypoglycemia unawareness or those at risk for hypoglycemia, and those using intensive insulin therapy, regardless of type of diabetes (5).

In the 2017 Standards of Diabetes Care, the American Diabetes Association recommends CGM use for all patients with diabetes who have hypoglycemia unawareness and/or frequent hypoglycemia (6).
In March 2017, Medicare announced therapeutic CGM coverage for patients with both Type 1 Diabetes and Type 2 Diabetes on intensive insulin therapy.

For this subject who has fluctuating glycemic control with hyper and hypoglycemia, CGM is medically necessary to improve  glycemic control and also avoid hypoglycemia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces (D8080)
The proposed braces are medically necessary. 
The patient has a "deep, impinging overbite with soft tissue damage to the palatal tissues". This is an "automatic qualifier" for treatment benefits on the Salzmann scale. The patient needs to have orthodontic treatment for correct the severely deep bite he has and prevent further damage to his tissues.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with tooth #7 in crossbite. Tooth #6 is being pushed labially through the mandibular arch. Tooth #26 has wear developing from the anterior crossbite with #7. She is treatment planned for 24-30 months of orthodontics with extraction of four first premolars to correct her malocclusion. The health plan's determination of medical necessity is overturned.  This patient has significant crowding, with #7 in crossbite. Teeth #7 and #26 are at high risk for restorative problems in the future due to their traumatic occlusion. Studies have shown that even the untreated dentition shows increased anterior irregularity with time [4], which will make treating this occlusion at a later time more difficult.
Appeal type: Medical necessity
Decision: Upheld

Diagnoses: Malocclusion

Treatment: Comprehensive orthodontics

The insurer has denied coverage for D8080-Comprehensive orthodontic services. This denial was upheld.

This patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, Class III malocclusion, vertical growth pattern, deep bite, maxillary and mandibular crowding and has recommended orthodontics. The orthodontist has completed the HLD index attaining 7 total points to support orthodontic care. 

The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 8 points on the HLD index. The Handicapping Labio-Lingual Deviation Index Report 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 7 points to
justify orthodontic care. 

This reviewer concurs with the index completed by the orthodontist, attaining a total of 7 points on the HLD index (2 overjet, 2 overbite, 3 ectopic eruption) which is below the
threshold of 26 points to support orthodontic care. Of note, in this case,
the patient's own orthodontist does not attain 26 points on the HLD index as
required for orthodontic approval. In this case the patient's own orthodontists completed HLD index total score of 7 points remains below the threshold of 26 points to justify
orthodontic care. The D8080- comprehensive orthodontic services are not considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a skeletal class I, mandibular deviation to the right, moderate maxillary spacing, mild mandibular spacing, moderate overbite and overjet. The treatment proposed is braces for 18-24 months with possible interproximal reduction and at least 3 months of retention. The health plan's determination of medical necessity is upheld in whole. The malocclusion in question does not meet the criteria used in most programs to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 13 with no auto qualifier present. Most programs using these evaluation methods require a score of 26 or more for treatment to be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Issue under review: Braces

Determination:
The braces are medically necessary.

The patient has a "deep impinging overbite with severe soft tissue damage." This is an automatic qualifier for orthodontic benefits.
Appeal type: Medical necessity
Decision: Upheld

The patient has sickle cell disease (S-beta that) and presented for care at the Emergency Department (ED) with severe, progressively worsening, lower extremity pain. The patient tried taking pain medications at home but they were not effective. The patient was noted to have no fever, a respiratory rate of 24, blood pressure of 105/66 and heart rate of 80. The patient had 99% oxygen saturations on room air and his labs showed a hemoglobin of 9.8 g/dL. The patient was treated with intravenous (IV) fluids, IV Toradol and IV Morphine. However, the patient continued to have pain and was admitted for further treatment and monitoring.

The health plan's determination is upheld. This patient has a past medical history of sickle cell anemia (sickle beta that), with presentation of pain crisis without other concerning symptoms or concerns. While he continued to have pain after his treatment in the ED, there was no need for continuous IV pain medications (patient controlled analgesia (PCA)), or other types of therapy that could only have been safely provided at the inpatient level of service. His counts were stable, he had no need for transfusion support, no fevers, no oral intake concerns and no other complicating features. He was clinically stable throughout the hospital stay, appeared to be at his baseline level of function, and had no concerning physical exam or evaluation findings other than those directly related to his pain.
This patient did not meet the typical criteria required for acute admission related to his sickle cell disease. There was no concern for acute chest syndrome, no clear aplastic or hemolytic crisis, no increasing splenomegaly, no fever / infection concerns, and no elevation in the serum bilirubin. While he had pain, the treatments being provided could also have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe cognitive impairment
Treatment: Increase in CDPAP services to Live-in Per Diem, 24 hours per day, seven days per week

The proposed treatment of an increase in CDPAP services to Live-in Per Diem; 24 hours per day, seven days per week is deemed medically necessary. 

This female patient has a history of severe cognitive impairment rendering her moderate (mod)/maximum (max) assist for all activities of daily living.  Specifically, she is mod/max assist with bed mobility, transfers, ambulation, eating, bathing and toileting.  For these reasons, an increase in CDPAP services to Live-in Per Diem; 24 hours per day, seven days per week is deemed medically necessary and indicated to better assist this patient with her daily needs and to provide enhanced safety and fall prevention.
Appeal type: Medical necessity
Decision: Upheld

This is a patient  who presented to the hospital with a past history of diabetes, obesity, hypertension, hypercholesterolemia, peripheral vascular disease, and coronary artery disease. He presented with shortness of breath. He also reported right shoulder pain that he rated as four out of 10 in severity. The health plan's determination of medical necessity is upheld in whole.
 The patient had chest pain and a significant history of CAD but cardiac enzymes were negative, EKG was not reported to be consistent with acute ischemia, and he was hemodynamically stable. He did have a complicated past medical history of a cardiac catheterization and peripheral vascular disease (PVD) but overall, he was stable during this admission and ultimately no intervention was performed during the cardiac catheterization. There were also no other aggravating factors, such as acute heart failure, acute kidney injury, pericarditis, or acute pulmonary embolism.
Appeal type: Medical necessity
Decision: Overturned

The patient presented with fever and multiple episodes of diarrhea. Patient was found to be febrile. Patient was admitted for dehydration, indicated by decrease in wet diapers, initial lack of tears and prolonged capillary refill, and low bicarbonate level. Patient also was found to have fever and white blood cells in  urine, raising concern for urinary tract infection. In the hospital, patient was continued on intravenous fluids as well as ceftriaxone while cultures were pending, with monitoring of intake and output. Patient was kept on intravenous fluids until  oral intake was felt to be adequate. Laboratory values improved, and urine culture and blood culture showed no growth. The HP decision is overturned. The decision making at the time of admission for this patient was consistent with young age, the presence of dehydration in the context of significant fluid loss from diarrhea and inadequate oral intake, and concern for potentially serious urinary infection and the need for prompt initiation of treatment and monitoring in a controlled setting.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with MM (malignant melanoma) to the R (right) mid back, Breslow depth is 0.3 millimeter (mm).  This is a review for the use of the DecisionDx Melanoma Gene Expression Profile assay.

The health plan's determination is upheld.  The requested service is not likely to be more beneficial than any standard treatment for the patient's condition.  There is insufficient evidence to determine how gene expression profiling may be used to guide clinical decisions related to the diagnosis and treatment of cutaneous melanoma.  Specifically, it is not known how or whether decisions concerning treatment and surveillance are improved over the current standard of care, and it is unknown whether health outcomes are improved as a result of those decisions.