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

This is a male patient with multiple co-morbidities (liver disease, coronary artery bypass graft, chronic obstructive pulmonary disease, HFpEF) who was referred for surgical mitral repair with severe symptomatic mitral regurgitation. The procedure was aborted due to severe pleural adhesions and a percutaneous approach (MITRACLIP) has been advised. The Society of Thoracic Surgery (STS) score, though not insignificant, still underestimates the overall risk profile of this patient, from redo open heart surgery. Furthermore, redo open heart surgery was attempted but aborted due to unavoidable and unsurpassable reasons (adhesions); leaving MITRACLIP as the only option for definitive therapy.

The scientific evidence supports CPT 33418 and 33149-Heart Valve Repair in this patient. The patient is a good candidate for this surgery and it is the best available treatment option given his history. The requested procedure is likely to be more beneficial than any other standard treatments/procedures.

The insurer's denial of CPT 33418 and 33149-Heart Valve Repair is reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient is a male with history of a liver disease, chronic obstructive pulmonary disease (COPD), current every day smoker, peripheral artery disease (PAD) status post left superficial femoral artery (SFA) stenting, carotid stenosis status post left endarterectomy, coronary artery disease (CAD) status post coronary artery bypass graft (CABG) x3, and immunocompromised. The patient presented for robotic mitral valve replacement, but it was aborted due to dense right pleural adhesions preventing entry into the right chest. He was then referred to the heart valve team for MitraClip. The patient had concerns about his therapeutic options but notes no improvement of his symptoms. Given the patient's age, comorbidities and frailty, he is intermediate risk for surgery. 
The MitraClip is FDA approved for repair of severe mitral regurgitation (both primary and secondary mitral regurgitation) in patients who are deemed non-operative candidates. 
This patient was preoperatively determined to be intermediate risk, however given that he has a history of prior sternotomy at the time of his CABG, and that a robotic mitral valve replacement was not feasible due to severe pleural adhesions, which is a corroborating factor not previously known, nor factored into his surgical risk calculation, he is an appropriate candidate for trans-catheter mitral valve repair using the MitraClip device. This procedure represents the most appropriate and beneficial procedure for the patient at this time, in light of his prior open-heart surgery, attempted minimally invasive surgery, and presence of severe mitral valve regurgitation. 

The carrier's denial of CPT 33418 and 33149-Heart Valve Repair should be reversed. The procedure is likely to be more beneficial than any other standard treatment/procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Severe mitral regurgitation

Treatment: CPT 33418 and 33149-Heart Valve Repair

The insurer denied coverage for CPT 33418 and 33149-Heart Valve Repair. The denial was reversed.


This patient is a male with a history of coronary disease coronary artery bypass surgery, chronic obstructive pulmonary disease (COPD), and peripheral vascular disease. He developed severe mitral regurgitation with NYHA class II-III symptoms. A surgical correction for the mitral regurgitation was attempted but was aborted due to severe adhesions. A MitraClip is under review.

The MitraClip is a percutaneous method to treat severe clinically significant mitral regurgitation as an alternative to a surgical approach. It has been utilized in the setting of those requiring corrective mitral valve surgery for severe symptomatic regurgitation who are high surgical risk. 

In this case the individual had a prior sternotomy surgery and an unsuccessful attempt of a surgical repair due to adhesions. Due to the adhesions from his previous sternotomy, this individual was high surgical risk. In this setting, a MitraClip has been demonstrated a safe and effective alternative procedure for attempted treatment of the severe mitral regurgitation requiring correction. Therefore, the scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. 

"The EVEREST II HRS demonstrated long-term safety and efficacy of MitraClip in high-surgical-risk patients through 5 years. The observed mortality was most likely a consequence of the advanced age and comorbidity profile of the enrolled patients, while improvements in NYHA class in surviving patients were durable through long-term follow-up." (Kar, S., Whitlow, P., Pedersen, W. et al. 2014)

"The MitraClip is a new and exciting technology for percutaneously treating disease processes traditionally managed with surgery. The future of the clip and its patient population is dependent on further studies." (Stewart, M. H., & Jenkins, J. S. 2016)

 "In patients with MR [mitral regurgitation], the MitraClip procedure achieves similar survival to surgical MV [mitral valve] repair despite higher risk profiles. Recurrent MR, however, occurs more frequently (4.8-fold) after the MitraClip than surgical repair." (Takagi, H. et al. 2017).   
   
CPT 33418 and 33149 Heart Valve Repair has final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for CPT 33418 and 33149 Heart Valve Repair. 

Surgery was not an option for this patient. Medical therapy for severe mitral regurgitation causing severe congestive heart failure is not as effective as correcting the regurgitation. Therefore, the requested service is likely to be more beneficial than any other treatment.   
  
The carrier's denial of CPT 33418 and 33149-Heart Valve Repair should be reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: MOG-related demyelinating syndrome
Issue under review: Gammaked

Determination:
The Gammaked is medically necessary.

The patient is a female child. The patient has a severe form of MOG-related demyelination.

MOG-related demyelinating syndrome in children, also known as MOG-related neuromyelitis optica, is a severe demyelinating disease with high potential for brain damage and changes in the optic nerves, eventually leading to blindness.

This condition is difficult to treat. There are no FDA-approved treatments for this particular condition. Medical literature, including case reports in serious cases, indicate extensive response to intravenous immunoglobulin, without the necessary
risk of immune suppression or other complications. Intravenous immunoglobulin prevents brain and optic nerves inflammation and improves vision and prevents relapses. Therefore, the proposed treatment is medically necessary.

There are no FDA-approved treatments for MOG-related neuromyelitis optica. Relapses of this illness caused inflammation of the optic nerve, which over time reduces the vision and allows inflammatory lesions to accumulate in the brain. Therefore, the treatment requested is medically necessary, and is in the best interest of this patient.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of chronic obstructive pulmonary disease (COPD), asthma, polysubstance use (cocaine and heroin), on methadone maintenance, current tobacco smoking, and seizures, who presented to the emergency room (ER) with shortness of breath and cough productive of green sputum after running out of his inhaled steroids.
A chest x-ray (CXR) showed no acute cardiopulmonary process. An electrocardiogram (EKG) showed a non-specific T wave abnormality without evidence of acute ischemia or arrhythmia. The patient was subsequently brought into the hospital with the assessment that he had a COPD exacerbation likely 2/2 acute bronchitis with plans for SoluMedrol, nebulizers (NEBS), and magnesium.
The next day, the patient was afebrile with RR 17, BP 129/82, and oxygen saturation 98% on RA. The patient subsequently left against medical advice (AMA).
The health plan's determination is upheld.
This is a patient who presented with concerns for respiratory distress in the setting of known COPD as well as substance use. He was never hypoxic, did not have hypercarbia, did not have leukocytosis, and had a clear CXR. He remained afebrile throughout his hospital course and was normotensive. Though he left AMA, given his normal vital signs on the day of discharge without leukocytosis and with a discharge summary that noted his wheezing had resolved, hospitalization was not medically necessary. A lower level of care was appropriate.
Though this patient presented with respiratory distress, as noted above, he was afebrile, normotensive, without leukocytosis, and with a normal CXR. Furthermore, his wheezing was noted to have resolved and he was afebrile without tachycardia, tachypnea, hypotension, or hypoxia. In the absence of hypoxia, hypercarbia, or other hemodynamic instability, and in the setting of a clear CXR, and having recently used drugs, it was reasonable to expect that this patient might improve quite quickly. Inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

 Lung Cancer
Radiation Therapy

This is a female with a history of metastatic adenocarcinoma of the lung. She has been treated with radiation therapy to the right lung and hip for palliation. She has also been on chemotherapy and immunotherapy. She now has progressing metastatic disease involving the brain and meninges with leptomeningeal involvement. Radiation therapy is recommended to the central nervous system (CNS) and proton beam approach is requested.
The subject under review is the medical necessity of the proton beam therapy.

The health plan's determination is upheld.

No, the requested treatment of proton beam therapy is not medically necessary for this patient. The recommended proton beam radiation therapy for this patient and the diagnosis of leptomeningeal metastases is not considered medically appropriate nor necessary as there is lack of any significant studies published in peer reviewed medical journals supporting the benefits or safety of this approach of treatment as compared to photon beam radiation. Additional studies are needed to determine the efficacy and safety of proton beam radiation therapy to the CNS for this clinical scenario. The standard of care treatment approach in this case is whole brain radiation or craniospinal radiation therapy.  The approach of radiation that is standard of care is photon beam approach  with three dimensional (3D) conformal or intensity modulated radiation therapy (IMRT).  This is supported by National Comprehensive Cancer Network (NCCN) Guidelines as medically appropriate and standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary.

The patient is a female with a history of diabetes, hypertension and dyspnea on exertion.  She underwent evaluation for symptoms including echocardiogram and perfusion stress testing.  Ultimately, symptoms persisted despite medical therapy and the patient was referred for cardiac catheterization.  Following percutaneous intervention of the proximal left anterior descending (LAD) artery she presented for elective staged percutaneous coronary intervention (PCI) of the middle LAD artery.  She underwent uncomplicated revascularization and was discharged the following day.

This patient presented for elective percutaneous revascularization.  She underwent an uncomplicated procedure and was discharged the following day.  Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between low risk patients that are discharged on the same day as compared to patients admitted to the hospital. (Reference 1 - 4)  Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care. (Reference 4)  In conclusion, this patient should have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension and ventricular hypertrophy who was admitted to the hospital for evaluation of dizziness and palpitations. He reported dizziness that started one week prior to presentation and stated that he felt as though the room was spinning around him. He stated that the episodes of dizziness lasted a few seconds. Review of systems was negative for chest pain, fevers, chills, headache, nausea and vomiting.  A chest x-ray showed a possible right lung nodule. An electrocardiogram (EKG) showed evidence of left ventricular hypertrophy. The patient was admitted for dizziness with a concern for a possible cardiac cause. The plan of care included intravenous (IV) fluids, telemetry, monitoring blood pressure, aspirin, echocardiogram, cardiology consult, cardiac enzymes, meclizine for possible vertigo, and continuation of other home medications. Cardiology saw the patient and noted that they had concern for aortic stenosis or mitral regurgitation and recommended consideration of cardiac stress testing based on echocardiogram results. The echocardiogram showed a normal ejection fraction and mild aortic valve stenosis. Cardiac exercise treadmill stress test results were initially concerning but subsequent nuclear medicine stress test results demonstrated normal perfusion. His symptoms improved and he later reported occasional black stools, for which he was referred to gastroenterology as an outpatient. The health plan's determination is upheld. The patient presented with dizziness and underwent a primarily cardiac workup with echocardiogram, telemetry, cardiac enzymes, and cardiac stress testing. Cardiac enzymes were not elevated and there was no evidence for ischemia based on initial testing at the time of presentation. The cardiac exercise treadmill test was concerning but he subsequently underwent nuclear cardiac stress testing that was negative. There was no evidence of acute stroke, seizures, toxic ingestion, or a cerebral malignancy as a cause of the patient's symptoms. This evaluation was medically necessary but did not need to happen at the inpatient level of care
The patient did have dizziness but his overall presentation was not acute and he had no acutely concerning abnormalities that are typically managed at the inpatient level of care. He had no evidence of cardiac ischemia, no cranial nerve deficits were reported in the emergency department, and there was no evidence of seizures.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute asthma exacerbation

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female with history of asthma who presented to the Emergency Department (ED) with complaints of shortness of breath (SOB), wheezing and chest tightness which had started that morning.  The patient took her albuterol and nebulizer treatment prior to presenting to the Emergency Room (ER).  The patient denied fever or chills. Vital signs at presentation were temperature (T) 98, blood pressure (BP) 105/72 mm Hg, heart rate (HR) 76 respiratory rate (RR) 18 and oxygen (O2) saturations 98 % on Room Air.  The patient is noted to have some increased work of breathing (WOB) and bilateral rhonchi on exam. The patient was treated with Magnesium, Decadron and Nebulized Bronchodilator. The patient was subsequently admitted as she was still noted to be wheezing.

As per the History & Physical, the patient was in no acute distress.  She was alert and oriented.  She was afebrile with vital signs stable.  She was not hypoxic.  The lung exam revealed bilateral wheeze.  Cardiovascular system S1 S2 was normal.  Abdomen was soft and non-tender.

White blood cell (WBC) count was 7.8K, hemoglobin (HB) 12.6, and electrolytes were within normal limits.  Chest x-ray showed no acute infiltrates.  Venous blood gas was 7.38/ CO2 43 PO2 40.  The patient improved with treatment overnight.  Peak expiratory flow (PEF) improved from 175 to 300 by the morning after presenting to the ED. The plan was to discharge the patient on oral Prednisone taper with follow-up by primary care physician.

This patient did not need acute in patient hospitalization.  The patient remained stable after admission and was discharged a few hours after admission.  The patient could have been placed in Observation status while diagnostic testing and treatment were initiated.  The patient was afebrile and hemodynamically stable.  She was in no acute distress after initial treatment.  Some wheezing was noted but the patient was otherwise stable.  There was no carbon dioxide (CO2) retention or hypoxia noted.  WBC was normal.  Chest x-ray showed no abnormality.  The patient's WBC did increase to 17K by the next day but was likely steroid effect as the patient did not exhibit any signs of infection.  Peak expiratory flow (PEF) improved in a short period from 175 to 300.  The patient was tolerating orally and not hypoxic.  The patient was stable for discharge on oral steroid taper, bronchodilator and inhaled steroids after a period in Observation with close follow-up in an outpatient setting after discharge.  

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

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

Anemia
Inpatient hospital

The patient is a is a female with a past medical history of hypertension, high cholesterol and brain aneurysm. She presented with a low hemoglobin. She denied any weakness, chest pain or shortness of breath. She did not want a blood transfusion. Vital signs showed a blood pressure of 127/72, pulse 84, temperature 36.7 and respiratory rate 22. Oxygen saturation was 100%. Labs showed a white blood cell count of 4.8, hemoglobin 4.8, platelets 375, sodium 139, potassium 4.3 and creatinine 1.2. Stool for occult blood was negative. Chest x-ray showed mild enlargement of the cardiac silhouette. She was given a dose of intravenous iron and admitted for further management.  During the course of the hospital stay, iron was continued. Plan was for outpatient gastrointestinal (GI) workup. She left against medical advice the next day.

The health plan's determination is upheld. The inpatient stay is not medically necessary. The patient was sent to the hospital for a low hemoglobin. She was mainly asymptomatic. She was hemodynamically stable. Hemoglobin was noted to be 4.8. Stool for occult blood was negative. She refused blood transfusion. Iron stores were low and she was started on intravenous iron. She was recommended to have outpatient workup. She left against medical advice the next day. A lower level of care was more appropriate as no procedures or interventions were needed. In addition, the patient had no hemodynamic instability, active bleeding, or cardiovascular symptoms that were severe. There were no neurologic symptoms, arrhythmia, peripheral ischemia, acute renal failure, low platelet count or ongoing transfusion for blood loss.
Appeal type: Medical necessity
Decision: Upheld

Parkinson's Disease
Nursing Services (including Private Duty Nursing)

The patient is a male with a past medical history significant for Parkinson's disease, gait abnormality, dementia and psychiatric illness. This review is for the medical necessity of continuous personal care services, split shift 24 hours a day. The patient is currently approved for a live-in aide 24 hours a day 7 days per week.

The health plan's determination is upheld. The Continuous Personal Care Services (Split Shift) is not medically necessary for this patient. Split shift medical services 12 hours a day x 2 is not medically necessary to meet the patient's needs. The patient's needs can be met through a live-in service 24 hour a day. The patient has no significant nocturnal needs that would require 2 shifts, especially one at night. It appears from the documentation provided that the aid could have adequate sleep and rest and still take care of this patient.
Appeal type: Medical necessity
Decision: Upheld

Stroke/CVA
Inpatient hospital

The patient is a female with a past medical history significant for asthma, anemia, and cerebrovascular accident (CVA) who presented to the emergency department (ED) with complaint of left arm numbness and tingling as well as left facial paresthesias. She also complained of chest pain and dizziness. She had similar symptoms a year prior but was not admitted to the hospital. In the ED, she started to have some left leg tingling. On exam, her vitals signs were normal and stable. She was in no acute distress. Lung and heart sounds were normal. Neurologic exam showed no motor or sensory deficits. Her Glasgow Coma Scale (GCS) was 15 and National Institute of Health Stroke Scale (NIHSS) was 1. Her labs were normal, and she had a normal troponin level. Her electrocardiogram (EKG) showed a normal sinus rhythm (NSR) without evidence for acute ischemia or infarct, just poor R wave progression. A chest x-ray was normal. A computed tomography (CT) scan of the brain showed no acute abnormalities.

The health plan's determination is upheld. The inpatient admission was not medically necessary for this patient. This patient had transient neurologic symptoms that lasted less than 24 hours. Her symptoms had improved within 24 hours so it is unclear why she stayed the additional day, except maybe to wait for further brain imaging.
She did not meet Milliman Care Guidelines as an inpatient for a TIA as she was hemodynamically stable, she did not have neurologic symptoms that recurred or persisted, did not have an acute stroke, did not have altered MS (mental status), was not pregnant, and did not require any procedures. While the patient's symptoms persisted in the ED, they had completely resolved by the next day. She could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbar stenosis
Issue under review: Continued Skilled Nursing Facility

Determination:
The Continued Skilled Nursing Facility was not medically necessary.

As of the day before the dates under review, he was ambulating 100 feet with contact guard and using Rolling walker, independent with upper body dressing, required supervision for bed mobility, transfers, lower body dressing/bathing, hygiene/grooming, toileting, toilet transfers, required contact guard to navigate steps, and doing nine steps with one rail, etc.

Therefore, continued stay in SNF was not medically necessary. The patient's ADLs level had improved to a level such that his needs could be met at a lower level of care. 

As stated above, the continued stay in SNF was not medically necessary. The clinical evidence showed improvement such that further stay in SNF was not reasonably expected to be health beneficial for the patient, and/or withholding it, in whole or in part, would not be reasonably expected to affect the patient's health adversely, as the patient requires mostly supervision for most ADLs.