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

Other
Inpatient Hospital

This case involves a male who underwent laparoscopic appendectomy for perforated appendicitis followed by a prolonged admission for management of intra-abdominal sepsis. He was discharged on oral antibiotics but presented again to the hospital with abdominal pain with some abdominal distention, tenderness and mildly elevated inflammatory markers. On admission his temperature was normal his heart rate 132 blood pressure 125/96 respiratory rate 28 connection saturation 98% on room air. Ultrasound (U/S) suggested the possibility of a thin abscess near the bladder. On admission the patient was placed on intravenous antibiotics which improved, and he was advanced to a regular diet. He had minimal tenderness on palpation and his white blood cell count normalized from 14 to 9 with a C-reactive protein (CRP) that went from 5 to 2.4. During admission, a magnetic resonance imaging (MRI) scan of the abdomen demonstrated no evidence of a drainable abscess. MRI showed there was inflamed and matted small bowel in the right lower quadrant along with mild dilation of loops of small bowel proximal to this region which is likely what the U/S was seeing. The MRI also identified normal appearing kidneys with no hydronephrosis or other renal abnormalities. There was a small pleural effusion on the left. They placed the child under general anesthesia for the MRI so that interventional radiology could drain any collection of fluid.

The health plan's determination is upheld.

No, the inpatient stay was not medically necessary. For the reasons cited above, mainly, he was not suffering from an acute new illness. This admission was simply due to the inadequacy of response to oral antibiotics in a patient who was able to recover with IV antibiotics. There was no ileus or intolerance of by mouth (PO) diet. His care could have been managed at a lower level of care status. If there was medical necessity for acute inpatient care, it would have been documented in the chart in the form of hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition.
Appeal type: Medical necessity
Decision: Upheld

This is a patient  with a skeletal Class II malocclusion, mild maxillary crowding, mild mandibular crowding, moderate overbite and severe overjet. The proposed treatment is braces with monthly visits. 
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 14 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9mm or greater and underbite 3.5 millimeters (mm) or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, hypertension, diabetes
mellitus and osteoarthritis
Treatment: Increase in PCW services from six hours/day, seven days/week to 12 hours/day, seven days/week

This is a female with a history of Alzheimer's dementia, hypertension, diabetes mellitus and osteoarthritis. Due to her advanced age and multiple comorbid conditions, she requires assistance with completion of the majority of her activities of daily living (ADLs). A recent correspondence from the patient's physician indicates that due to worsening functional status and the progressive nature of her multiple comorbid conditions, the patient is at increased fall risk, she needs continuous supervision, her communication is severely limited, and she requires assistance with transfers, standing and ambulation. For these reasons, the proposed treatment of an increase in PCW services from six hours/day, seven days/week to 12 hours/day, seven days/week is deemed medically necessary. PCW at six hours/day, seven days/week is not sufficient to meet the patient's needs.
Appeal type: Medical necessity
Decision: Overturned in Part

Other
Inpatient Mental Health 
The patient is a woman with a diagnosis of schizoaffective disorder (SCZAD). Case notes document that the patient was experiencing auditory hallucinations (AH) for about two weeks prior to admission. She received an intramuscular (IM) dose of Haldol from her outpatient provider and was started on lithium. Despite the outpatient treatment, she continued to experience AH as well as depressed mood, insomnia, self-talk, low energy, and dysphoria. She went to the emergency room in distress and was admitted. She had required at least two prior psychiatric admissions due to her SCZAD, with at least one admission due to cannabis use disorder (CUD). The patient's illness under review apparently began 2 weeks prior when she again smoked Cannabis which precipitated her AH. Her treatment included increasing doses of Haldol as well as lithium. At one point in her treatment, she was given trazodone for sleep. In addition, she was treated with psychotherapy and milieu management.

The health plan's determination is overturned in part. The patient was continuing with AH. The AH distressed her and put her at risk. Schizoaffective disorders include symptoms from both the schizophrenia group of illnesses and the mood disorders/bipolar disorders spectrum. This patient had to be treated for both her psychotic and mood symptoms. Therefore, discharge based on her mental status could not have been predicted and would not be appropriate. Only in retrospect could it be determined to be safe, which is not the standard of care. She would be at risk for rehospitalization or self-harm if discharged. Her mental status did show improvement: She no longer had AH. She had no paranoia. Her mood was pleasant. She interacted freely. She stated she felt better. Therefore, she could be safely discharged for continued treatment at a lower level. This patient was chronically ill and has required two past IMHT at least one with attempted self-harm.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis

Treatment: Inpatient Hospital Admission

The insurer denied coverage for Inpatient Hospital Admission. The denial was upheld.

This patient is a female, who had a past medical history of ovarian cyst, anemia and smoking. The patient presented to the ED with complaints of right-sided lower quadrant abdominal pain with diarrhea. The pain level was assessed at 8/10. The patient complained of abdominal pain for 2 days. The blood pressure was 125/77 with a heart rate of 82, respirations 18 and temperature 97.9. Oxygen saturation was 100%. On examination, there was right lower quadrant tenderness. On ultrasound, the patient had a dilated appendix with acute appendicitis. The patient had a white blood cell count of 7.79 K, hemoglobin 10.8, hematocrit 34.8, platelets 349. The patient had a sodium 139, chloride 104, Blood Urea Nitrogen (BUN) 12, potassium 3.9, Bicarbonate (HCO3) 24, creatinine 0.90. The patient had glucose of 89. The patient underwent a laparoscopic appendectomy. The patient was doing well during surgery. The patient was discharged in a stable condition.

The Milliman Care Guidelines General Surgery, Appendectomy, without Peritonitis indicates that a laparoscopic appendectomy is considered an ambulatory procedure. An extended stay may be indicated for patients with complicated appendicitis, complication such as wound infection, wound dehiscence or enterocutaneous fistula, continue ileus and postoperative bleeding. The patient was noted to be seen for complaints of abdominal pain with diarrhea. The patient had findings on ultrasound of appendicitis. The patient underwent a laparoscopic appendectomy that went well. There was no indication that the patient had complications following surgery such as; complicated appendicitis, wound infection, wound dehiscence or enterocutaneous fistula, continued ileus or postoperative bleeding. This patient did not meet inpatient admission criteria. 

The patient's condition was appropriate for level of observational care rather than inpatient level care. As such, the inpatient hospital admission is not medically necessary. The health plan acted reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the Inpatient Hospital Admission is not substantiated. The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Type II achalasia
Treatment: Per-Oral Endoscopic Myotomy (POEM)

The health plan should not cover the proposed POEM procedure for the treatment of achalasia.

POEM has been proposed as the procedure of choice for type III achalasia because POEM can deliver a longer myotomy that is generally not possible with pneumatic dilation or the Heller procedure, and a longer myotomy might be more effective at controlling symptoms caused by the esophageal spasm of type III achalasia [4]. Although short-term results of POEM for types I and II achalasia are at least as effective (and perhaps even better) compared with pneumatic dilation and surgical myotomy, data on long-term outcomes of POEM are limited. Unlike surgical myotomy (Heller Myotomy), which often is combined with fundoplication to prevent reflux, POEM includes no antireflux procedure. Consequently, POEM can result in GERD. Most published data on POEM have come from a relatively small number of highly specialized centers. The largest single-center experience, involving 500 patients with achalasia, described no deaths, but there were adverse procedure-related events (including pneumothorax, bleeding, mucosal perforations and pleural effusions) in 3% of cases. Two months after POEM, there were significant reductions in symptom scores and LES (lower esophageal sphincter) pressures (1). However, GERD symptoms at two months and at three years were noted in 17 and 21 percent of patients, respectively. Similar results have been described in other centers. 

Surprisingly good results for POEM also have been reported in patients with achalasia conditions that often do not respond well to conventional therapies such as type III (spastic) achalasia and "end stage" achalasia (markedly dilated, sigmoid esophagus), and in patients who have failed prior endoscopic and surgical achalasia treatments [2,3].  At this time, long-term data on the efficacy of POEM are limited, and there are no randomized trials that compare POEM with the conventional achalasia treatments of laparoscopic surgical myotomy and pneumatic dilation.

Although POEM is also a reasonable option for type I and type II, pneumatic dilation or laparoscopic myotomy for patients with type I or type II achalasia is recommended for type I and type II achalasia due to lack of long-term data in this subgroup of patients (2).

The requested POEM procedure is not likely to be more beneficial than any standard treatment such pneumatic dilation or Heller myotomy for the patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Type II achalasia
Treatment: Per-Oral Endoscopic Myotomy (POEM)
The health plan should not cover the Per-Oral Endoscopic Myotomy. The POEM procedure is not likely to be more beneficial for the patient.

In a prospective case series, von Renteln and colleagues (2013) reported on outcomes of 70 patients who underwent POEM at five centers in Europe and North America. The mean followup period was ten months (range, three to 12 months). Follow-up evaluation at six months and one year showed sustained treatment success of 89% and 82%, respectively. The mean Eckhardt score pretreatment was 6.9 compared with 1.3 at six months and 1.7 at one year (p<0.001 for both comparisons). Multivariate analysis showed that neither age, previous treatment (Botox/dilatation), length of the myotomy, pre-procedure LES (lower esophageal sphincter) pressure, initial Eckardt score, sex, procedure duration, nor full-thickness dissection during POEM were significant predictors of treatment failure at one year. At three months after POEM, esophagitis was observed in 42% of cases. However, the severity of esophagitis was only minor (Grade A or B) and all patients could be managed adequately with proton pump inhibitor (PPI) therapy. At three months, 22% of patients required occasional and 12% required daily PPI therapy. The one-year follow-up evaluation showed overall rates of gastroesophageal reflux disease (GERD) of 37%, and PPI use of 29%. Other complication rates of POEM ranged from 1%-4%.

The current evidence for POEM in individuals with achalasia includes nonrandomized comparative studies and case series. Relevant outcomes are symptoms, functional outcomes, health status measures, resource utilization, and treatment-related morbidity. The comparative studies showed mostly similar outcomes with POEM versus Heller myotomy for the outcome of symptom relief as assessed by the Eckardt score. Some studies showed shorter length of stay and less postoperative pain with POEM. However, potential imbalance in patient characteristics in these nonrandomized studies may bias the comparisons between treatments. In the case series studies, treatment success at short follow-up periods was reported for a high proportion of patients treated with POEM. However, incidence of adverse events was relatively high, with POEM specific complications, including subcutaneous emphysema, pneumothorax, and thoracic effusion, reported across studies. Additionally, a substantial proportion of patients undergoing POEM developed esophagitis requiring treatment. The case series studies do not allow conclusions of the efficacy of POEM relative to established treatment. Long-term outcomes of the procedure are not well described in the literature. The evidence is insufficient to determine the effects of the technology on health outcomes at this time.  Therefore, the Per-Oral Endoscopic Myotomy is not likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Type II achalasia
Treatment: Per-Oral Endoscopic Myotomy (POEM)
The health plan should cover the Per-Oral Endoscopic Myotomy. The Per-Oral Endoscopic Myotomy is likely to be more beneficial.

Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and a defective relaxation of the lower esophageal sphincter (LES), resulting in an impaired bolus transport and stasis of food in the esophagus.[Boeckxstaens, 2005] Because its exact etiology still is unknown, current treatment options of achalasia are directed only at relieving the functional obstruction at the level of the LES. Three manometric subtypes are identified based on the residual esophageal wave pattern: type I, in which the esophageal body shows minimal contractility; type II, in which there is no peristalsis but intermittent periods of compartmentalized esophageal pressurization; and type III, in which there are spastic contractions in the distal esophagus. (1)  The patient has Type II disorder.

Rohof et al evaluated response in "patients treated with either pneumatic dilation (PD) or laparoscopic Heller myotomy (LHM).  Manometric tracings were classified according to the 3 Chicago subtypes. Forty-four patients had achalasia type I (25%), 114 patients had achalasia type II (65%), and 18 patients had achalasia type III (10%). After a minimum follow-up period of 2 years, success rates were significantly higher among patients with type II achalasia (96%) than type I achalasia (81%; P < .01, log-rank test) or type III achalasia (66%; P < .001, log-rank test). The success rate of PD was significantly higher than that of LHM for patients with type II achalasia (100% vs 93%; P < .05), but LHM had a higher success rate than PD for patients with type III achalasia (86% vs 40%; P = .12, difference was not statistically significant because of the small number of patients). For type I achalasia, LHM and PD had similar rates of success (81% vs 85%; P = .84)." (2)

As such, POEM is not investigational for the patient's indication, and is medically appropriate (with greater likelihood of benefit than available standard approaches) for treatment of the patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness and headache
 
Treatment: Inpatient admission

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

This female presented to the emergency room with complaints of severe headache, photophobia, dizziness and right-sided numbness. The patient had a history of migraines, hypertension and gastroesophageal reflux disease. The patient had a temperature of 98.6 F., heart rate 57, blood pressure 125/74 and respirations 16. The patient was alert and oriented x4. The patient also had vertigo and nausea. The patient's NIHSS score was 0. An electrocardiogram (EKG) showed normal sinus rhythm with no acute ischemic changes. The patient continued to feel dizzy despite medications. There was concern for central process.  The patient was discharged the following day.

Medical literature states inpatient admission is indicated for patients who have dizziness if there is acute bacterial labyrinthitis, cerebellar, brainstem or cerebral ischemia or hemorrhage, suspected etiology that requires admission of the treatment, hemodynamic instability, signs or symptoms that are severe and persistent, vomiting that is severe, persistent cardiac arrhythmias of immediate concern, severe neurological findings requiring inpatient care, continuous intravenous infusion of anticoagulation, platelet inhibitor, vasoactive or antiarrhythmic medications needed, cerebral bleeding, hydrocephalus or vasospasm monitoring required or increased intracranial pressure. 

The patient presented with complaints of a headache and complained of continued dizziness. A sustained "stroke" was ruled out. The Troponin value was less than 0.01. The patient did not have any of the conditions indicated for inpatient admission. The patient's condition was appropriate for level of observational care rather than inpatient level care. As such, the inpatient hospital admission was not medically necessary.  

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

Chronic Obstructive Lung Disease/COPD
Pharmacy/Prescription Drugs

The patient is a male with obesity, sleep apnea, obstructive airway disease of severe nature (post bronchodilator FEV (forced expiratory volume)-43% predicted) with prior smoking history of less than 10 pack years. The patient has recurrent symptoms and flare up of breathing symptoms diagnosed as chronic obstructive pulmonary disease (COPD) exacerbations. He has required two hospitalization. A computed tomography (CT) scan done as part of work-up has been reported to show some scattered areas of atelectasis with no reported emphysema of panacinar type.
Alpha-1 antitrypsin levels were reported at 88.8 mg/dl with MZ genotype. Specimen was collected. A previous level checked was 120 mg/dl with MZ genotype. Approval for Prolastin therapy has been requested. 

The health plan's determination is upheld. Treatment with Prolastin C is not medically necessary at this time based on current standards of practice, and available scientific literature. There is no published data demonstrating benefit of alpha-antitrypin replacement in PiMZ genotype with mildly low levels of alpha-1antitryprin.
Scientific literature supports Alpha-1 antitrypsin replacement to be only considered when level is less than 57 mg/dl with evidence of emphysema (FEV1 35-65% predicted or CT evidence) in a patient who has quit smoking. This low level is usually seen with other genotypes of alpha-1, most common being PiZZ.
The patient is a heterozygote (carrier) for z allele with PiMZ genotype with two different levels reported at >80 mg/dl each time (120 in 2017 and 88 in 2019). PiMZ genotype is noted to have slight reduction (10-15%) in alpha-1 antitrypsin levels than the normal PiMM genotypes and there is limited literature which supports development of copd in this subset of carriers. In a few cases (< 10%), the alpha-antitrypsin levels can be falsely elevated by a median number of 20 based on one study in PiMZ genotype. Even if we consider that this patient has faslely elevated levels due to his ongoing illness, it is still unlikely that his level will be below 57 mg/dl.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cataract
Treatment: Cataract surgery, right side
The 66984 - Cataract surgery, right side is medically necessary, per the standard of care.

According to the American Academy of Ophthalmology, the primary indication for surgery is visual function that no longer meets the patient's needs and for which cataract surgery provides a reasonable likelihood of improved vision. According to general standards of care as reflected by CMS guidelines, cataract surgery is indicated when a patient experiences decreased ability to carry out activities of daily living such as reading, viewing television, driving, or meeting occupational or vocational expectations, and has Snellen visual acuity of 20/40 or worse. Also, if there is a glare component, glare testing which reduces visual acuity to less than 20/40 is indicated.

In this case, the patient's vision of the right eye is best corrected to counting fingers at 6 feet is impacting his ability to carry out activities of daily living.  In the absence of retinal pathology, cataract removal would be expected to improve the patient's visual functioning. Therefore, medical necessity of right eye cataract extraction is established per standard of care.