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

Diagnosis: Fever, possible sepsis
 
Treatment: Inpatient admission, medications, monitoring

The insurer denied the inpatient admission. The denial was reversed.

The patient is a young female with sickle cell (HGB SC) disease presenting with fever and neck pain. Physical exam in the Emergency Department (ED) was relatively benign and the patient was described as without distress and no significant respiratory findings. However, the patient was febrile in the ED and notably had high fever (102.5F. degrees) at home. The patient had tachycardia in the ED. The labs demonstrated mildly elevated white blood cell (WBC) count of 11.8 K.  The patient was tolerating fluids by mouth even though not eating normally.

It is well supported in the literature (see references below, especially "1. Practical Algorithms in Pediatric Hematology and Oncology") that patients with sickle cell disease with fever need to be evaluated for sepsis when presenting with fever greater than 101.3 F. Depending on the age, clinical appearance, vital signs and/or lab findings, hospitalization for patients with sickle cell disease is often supported as within standard of care.

In this child, tachycardia is concerning for dehydration, significant pain and/or severe infection/sepsis. Based on the child's sickle cell disease, fever >101.3, tachycardia and poor feeding, it was within standard of care to consider this child at high risk of sepsis when taking into account this constellation of pertinent clinical findings. Patients with sickle cell disease are considered functionally asplenic and are at increased risk for life-threatening infection. In the setting of fever, tachycardia and leukocytosis, hospitalization for intravenous antibiotics and management is the standard of care given the risk of life-threatening infection. Thus, the admission of this patient was within standard of care.

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

Diagnosis: Hypoglycemia with possible seizure activity
Treatment: Inpatient admission
The inpatient admission was medically necessary. 

This patient was admitted after a fall in the setting of hypoglycemia complicated by rhabdomyolysis. Given his case was complicated by rhabdomyolysis with a creatinine kinase level of 4,985 and severe metabolic acidosis with a pH of 7.1, he required inpatient admission for aggressive hydration and monitoring of electrolytes and renal function which would not be appropriate for observation management. He also experience recurrent hypoglycemia which required discontinuing of medication. Therefore, the proposed inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of hypertension and supraventricular tachycardia who was brought to ED with palpitations, sweating, nausea and weakness while walking outside and he felt sudden onset of sweating and chest tightness. It lasted for 25 minutes. Paramedics arrived, they recorded rhythm strip which showed supraventricular tachycardia. Paramedics administered adenosine. The first injection of 6 mg was not effective, and second injection of 12 mg converted the patient back to sinus rhythm.

In ED, the patient was comfortable in sinus rhythm. The rest of his vitals were normal. His physical examination was unremarkable. His chest x-ray (CXR) was normal. His electrocardiogram (ECG) was normal. A brain (or B-type) natriuretic peptide (BNP) was normal and the rest of his labs were normal. D-dimer was normal. His first troponin was normal, 0.012. A repeated troponin went up to 0.046. The patient was admitted to the hospital to a telemetry bed. The patient was consulted by cardiology and electrophysiology. He underwent an electrophysiology study on hospital day 4. The patient was discharged home with medications prescribed and follow up was arranged. The health plan denied the inpatient admission as not medically necessary. 

The health plan's determination is upheld. The patient suffered an episode of paroxysmal supraventricular tachycardia, which was recurrent. It was broken by intravenous (IV) Adenosine in the field.
Upon arrival to ED, the patient was back to his baseline, stable. However, his troponin went slightly up, reflecting a very high heart rate during episode. The patient was appropriately observed overnight due to troponin "bump." However, there were no indications for the electrophysiology study needed to be done in house. The patient could have been treated at a lower level of care. An inpatient level of care was not indicated.
Appeal type: Step Therapy
Decision: Upheld

This is a patient with opioid use disorder and chronic pain (dorsalgia and neuropathy).  The patient was prescribed Zubsolv 5.7/1.4 milligram (mg) tablets at a dose of one and one-half tab daily as maintenance medication to assist in the substance use disorder treatment of opioid use disorder; however, this medication failed to address cravings and post-acute withdrawal symptoms of the opioid use disorder.  A previous trial of Suboxone Film resulted in more effective control of craving and withdrawal symptoms.  Moreover, the patient has not been compliant with the treatment plan while taking Zubsolv in that he has used opioids affirmed with a urine drug screen.  The health plan's determination is upheld.  The health plan formulary has the availability of Suboxone tablets which provides the same benefit of Suboxone Film.  The documentation does not indicate that the patient has tried and failed Suboxone Tablets.  Thus, Suboxone is available for this patient as a different formulation with the likelihood of equivalent benefit, as cited in the references below.
The patient has not reported trial and failed treatment with this formulary alternative.  Medical necessity for the requested non-formulary medication is not met in keeping with the instruction for this review and is not consistent with the scientific literature or published guidelines that supports the use of the formulary alternative in this case.  This answer is also consistent with prevailing standards of medical practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness; Chest pain
Treatment: Inpatient admission
The inpatient hospital admission was not medically necessary.
This patient presented for evaluation of chest pain and dizziness. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. The patient was hypertensive on presentation due to non-adherence to the medical therapy, and his pressure improved with therapy within 24 hours. There was no plan for an inpatient ischemic work-up (stress test, CTA [computed tomographic angiography] or catheterization). Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Substance abuse
Treatment:  Inpatient Substance Use Rehabilitation Treatment
The proposed treatment, inpatient substance use rehabilitation treatment, was not medically necessary for this patient in keeping with NY State OASAS LOCADTR 3.0 Guidelines/Criteria.

The inpatient substance abuse rehabilitation treatment, in this case scenario, was amenable to treatment at a lower level of care.  The patient was externally motivated and able to effectively engage in rehabilitation services, and the patient did not need the structure or 24-hour monitoring of an inpatient setting in order to safely and effectively participate in rehabilitation substance abuse treatment.  There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment.  Moreover, the patient demonstrated his motivation for continued involvement in the substance use disorder treatment during his detoxification, as noted in the clinical summary.  Thus, the requested benefit of inpatient substance use rehabilitation treatment was not medically necessary for this patient.

This answer is consistent with prevailing standards of professional practice, ASAM Criteria, and the scientific literature, referenced below, as well as New York State instruction for medical necessity reviews together with the NY State OASAS LOCADTR 3.0 Criteria, applicable in this case.

The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment can be/could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports.  There is no evidence that inpatient level structure and 24-hour monitoring is medically necessary for a successful outcome with regard to the dates of service under review.  And, there were no biomedical, psychiatric or general medical issues that warranted the admission and the continued inpatient level treatment in this case scenario.
 
Thus, as the health plan asserts, the patient's alcohol and tobacco/nicotine use disorders were amenable to treatment at a lower level of care in this case scenario, and the health plan's determination of medical necessity was consistent with the application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below, as well as ASAM Patient Placement Criteria and the scientific literature also referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient detoxification services, medication, monitoring

The insurer denied continued inpatient detoxification services. The denial was reversed.

This male was admitted to inpatient substance detoxification treatment for detoxification.  He had withdrawal symptoms including tremors, sleeping problems, irritable mood, anxiety, teary eyes and sweats. He had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 11.  He had a positive toxicology screen for cocaine and Oxycodone.  He was drinking several pints of alcohol per day.  He had a history of seizures, asthma, hypertension, and bipolar-depression.  He had prior substance inpatient treatments with relapses.  He was put on a Librium taper and was discharged with a referral to inpatient substance rehabilitation. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  This patient was using large amounts of alcohol and had a history of seizures.  He had a positive toxicology screen, and as such, he was at risk for overdose. He required the entire detoxification Librium protocol as he was at risk for withdrawal symptoms if he stopped the detoxification treatment prematurely.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require 24-hour treatment as he needed and received detoxification medication to modify withdrawal and prevent severe and complicated withdrawal.  He had relapsed after past inpatient substance treatments; therefore, he was at high risk for relapse again. He likely would have had withdrawal symptoms and been at risk for more severe withdrawal if he did not have the full detoxification stay. 

The carrier's denial of continuation of coverage for inpatient detoxification services is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient admission

The inpatient admission was medically necessary for this patient.

The requested benefit of inpatient admission could not have been effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol on a daily continuous basis together with cannabis that did warrant inpatient level detoxification and withdrawal management and monitoring. The patient's social environment was not conducive to an effective detoxification, and the patient struggled with withdrawal symptoms initially with continued risk for withdrawal symptoms in the context of a history or frequent blackouts. The patient displayed limited to fair insight, impaired judgment and poor control of impulses with regard to the substance use disorders.

Thus, the adult inpatient stay for detoxification treatment of this patient's substance use disorders did necessitate the continued structure of an inpatient level setting with 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder in this patient. Again, the clinical features and treatment dimensions in this case do warrant and support the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to have been attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and, consistent with New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria/Guidelines.

The requested benefit of inpatient admission is clinically appropriate, medically necessary and warranted, and should therefore be covered in this case scenario. The Substance abuse detoxification and continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to the substance use disorder services including ASAM Criteria and the application of the NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer # 3:
This is a female patient with a past medical history of non-valvular atrial fibrillation on Eliquis. She reported having the side effect of lower extremity edema. The patient verbalized concerns of the long term usage of the medication. She was evaluated by her cardiologist for inpatient admission for a Watchman device.

According to Homes, D. R., Jr. et al. (2014), "In the PROTECT AF (Watchman Left Atrial Appendage Closure Technology for Embolic Protection in Patients With Atrial Fibrillation) trial that evaluated patients with nonvalvular atrial fibrillation (NVAF), left atrial appendage (LAA) occlusion was noninferior to warfarin for stroke prevention, but a periprocedural safety hazard was identified". They go onto conclude, "In this trial, LAA occlusion was noninferior to warfarin for ischemic stroke prevention or SE >7 days' post-procedure. Although noninferiority was not achieved for overall efficacy, event rates were low and numerically comparable in both arms. Procedural safety has significantly improved. This trial provides additional data that LAA occlusion is a reasonable alternative to warfarin therapy for stroke prevention in patients with NVAF who do not have an absolute contraindication to short-term warfarin therapy".

The carrier's denial of CPT code 33340 (Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation; "Watchman Device") and inpatient admission should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer # 2:

This is a female patient with non-valvular atrial fibrillation who is currently on Eliquis and presents for evaluation of the watchmen device. The note states that she is having side effects from Eliquis including lower extremity edema. She is seeking an alternative to oral anticoagulation and is worried about being on blood thinners for a long period of time. She has a past medical history includes thyroid nodule, hyperlipidemia, obesity, bronchitis, G.I. reflux, asthma, gallstones and atrial fibrillation. Her past surgical history includes sinus surgery and a remote history of hysterectomy. It was reported that the patient had a CHADS-VASc score of 3 and, an HAS-BLED score of 2. 

The FDA approval of the WATCHMAN states the therapy to be recommended for all patients eligible for oral anticoagulation but who have an appropriate reason to seek a non-pharmacological alternative to warfarin. LAA occlusion therapy was also demonstrated to be cost-effective after around 4 years both with the background of the US health system as well as the European perspective when compared both to NOAC therapy (high cost of drug) and warfarin (high cost for INR measurements and dose adjustments). These data confirm LAA closure therapy to be an established part of the current treatment algorithm in patients with atrial fibrillation. (3) 
The use of the Watchmen device may be considered for the prevention of stroke in patients with atrial fibrillation when the following criteria are met; there is an increased risk of stroke and systemic embolism based on CHADS2 -VASc score and systemic anticoagulation is recommended and the long-term risks of systemic anticoagulation outweigh the risks of the device implantation. The use of the device in patients who do not meet these criteria is unproven. There has been no evidence submitted describing why this patient cannot be put on long-term anticoagulation. It is also not clear how a HAS BLED score of 2 was calculated. This reviewer calculated her score as 1 because of her age.

The carrier's denial of CPT code 33340 (Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation; "Watchman Device") and inpatient admission should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Paroxysmal Atrial Fibrillation
 
Treatment: Percutaneous Transcatheter closure of the Left Atrial Appendage with Endocardial Implant, including fluoroscopy, Transseptal Puncture, Catheter Placement(s), Left Atrial Angiography, Left Atrial Appendage angiography, when performed, and Radiological Supervision and Interpretation; "Watchman Device") and Inpatient Admission

The insurer denied the Percutaneous Transcatheter closure of the Left Atrial Appendage with Endocardial Implant, including fluoroscopy, Transseptal Puncture, Catheter Placement(s), Left Atrial Angiography, Left Atrial Appendage angiography, when performed, and Radiological Supervision and Interpretation; "Watchman Device") and Inpatient Admission. The denial was upheld. 

Reviewer # 1:

This is a female patient who presented to her cardiologist office for evaluation for a left atrial appendage closure device. She has a past medical history of non-valvular paroxysmal atrial fibrillation. She had a CHA2DS2-VASc risk score of 3. It was noted that the patient was taking Eliquis for stroke prevention and she was worried about the long term side effects of the medication. 

The use of the Watchman left atrial occlusion device is FDA approved for patients in whom anticoagulation is contraindicated, for prevention of strokes attributable to atrial fibrillation, in particular patients with CHA2DS2-VASc risk scores higher than 3. There are no contraindications to anticoagulation in this patient, such as inability to take anticoagulant or at risk for significant bleeding complications while on full anticoagulation. Per the patient's clinical evaluation, she requested a left atrial appendage closure device out of concern for being on an anticoagulant, which is not a FDA approved nor clinically studied indication for such use. Therefore, she is not a good candidate for this procedure and this is not the best available treatment for this patient at this time. 

The carrier's denial of CPT code 33340 (Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation; "Watchman Device") and inpatient admission should be upheld, as this is not likely to be more beneficial than any of the standard treatments / procedures.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain, Lower Back pain and Vertigo
 
Treatment: Physical Therapy

The insurer denied the Physical Therapy. The denial was upheld.  

This is a female patient who presented to her primary care physician with complaints of vertigo, and neck and lower back pain. She has a history of spondylosis; cervicalgia; aural vertigo, bilateral; myalgia; endometriosis and gastroesophageal reflux disease (GERD).   She had a magnetic resonance imaging (MRI) of her lumbar spine that revealed central disc extrusion at lumbar vertebrae (L4 and L5) with cranial migration causing increased effacement greater in the left subarticular recess. Physical Therapy (PT) was implemented. The patient reported feeling less pain while engaged in PT; her pain was described to be mild to moderate. She reported that her sleeping patterns had improved and she was more involved with her activities of daily living. Her plan of care was to continue with PT allowing her to continue to strengthen her muscles. This would improve her balance and circulation which would aid in the management of her pain reduction.

The medical literature does support that physical therapy/exercise therapy is an appropriate method of treating patients with musculoskeletal conditions that are related to a functional deficit. Per literature, ongoing documentation in relation to the patient level of function should be performed throughout the patient's therapy to include the patient's initial functional deficits, as well as any improvement or plateau that follows with ongoing therapy. The documentation indicated that the patient had previously attended physical therapy with improvement in activities of daily living and an improved ability to walk. There was a decrease in pain, a better sleeping pattern and an ability to enjoy social recreational activities.  However, it is unclear the total number of physical therapy visits the patient previously attended.  This patient should be well versed in a home exercise program.  Therefore, continued physical therapy would not be considered standard of care.

Based on the above, the medical necessity for Physical Therapy (PT) is not substantiated.  The insurer's denial is upheld.