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

Back Pain
Surgical Services  (All)

This is a male who has a long standing history of low back pain. His low back pain is constant stabbing and sharp and throbbing. His pain is relieved by prolonged rest and exacerbated by increased physical activities. The patient had underwent numerous treatments including lumbar medial branch nerve blocks, lumbar epidural steroid injections, and radiofrequency ablation of the lumbar facet joints. According to the medical records, these interventions did provide him with improvement.

The health plan's determination is upheld. The Spine Surgery (Intraosseous ablation of the basivertebral nerve) is not medically necessary for this patient.
The requested procedure was designed to treat low back pain from vertebral body by ablating intraosseous nerves. A review of the available medical records did not reveal adequate evidence that this patient has pain from his vertebral bodies. On the contrary, this patient responded well to the prior epidural injections and lumbar medical branch nerve blocks, which indicates facet joint arthritis and lumbar radiculitis are his primary pain generators. Additionally, in the clinical studies that supported the efficacy of Intracept procedure, the patients with radicular symptoms and spinal stenosis were excluded. The magnetic resonance imaging (MRI) of this patient only revealed minimal modic 2 end plate changes surrounding L5-S1 disc space, but clearly revealed multi-level degenerative disc disease, facet arthropathy and foraminal stenosis.
Given this patient's medical history, MRI reading, results of prior spinal injections, and the current clinical evidence, the requested procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Arrhythmia/Irregular Heart Rhythm
Inpatient Hospital

The patient is a man with a history of asthma and paroxysmal atrial fibrillation. He was admitted to the hospital for catheter ablation of atrial fibrillation. The procedure was uncomplicated. Post-procedure, he was admitted to the hospital for overnight monitoring. His overnight course was unremarkable. He was discharged home the next day. The inpatient admission is under review.

The health plan's determination is upheld. The Inpatient Hospital Admission was not medically necessary for this patient.

This patient underwent transcatheter pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation. Given the complexity of the procedure, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate is higher than that of catheter ablations for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge after PVI, most electrophysiologists admit patients for overnight observation post-procedure. However, this patient's procedure was uncomplicated, and he was hemodynamically stable. Accordingly, while overnight observation was reasonable and prudent, the records provided do not indicate that an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of morbid obesity who presented to the emergency room with abnormal uterine bleeding. The bleeding was nearly constant and heavy. Vital signs were stable and her hemoglobin was 4.8. She was admitted to the hospital and transfused 3 units of packed red blood cells. Her hemoglobin level rose to 7.6 and she was discharged with iron tablets and was to follow up with her gynecologist. The health plan's determination is upheld.
The patient had severe anemia with chronic heavy uterine bleeding. Her blood transfusion and observation was appropriate, however, this could have been provided at a lower level of care. There are no medical records to support the need for inpatient hospital admission. Her vital signs were stable including her heart rate, blood pressure and oxygen saturation. She was not hemodynamically unstable. She received only 3 units of blood with no documented reaction and stable vital signs throughout her course. She had no other organ failure nor surgery performed. She did not need acute, inpatient monitoring during her entire stay and was discharged one day later after extended monitoring.
Appeal type: Medical necessity
Decision: Overturned

Schizophrenia
Mental Health: Inpatient

The patient is a male with a diagnosis of schizophrenia (SCZ). Case notes document that the patient suffers from chronic SCZ. About a year before the admission under review, he was actively psychotic, disorganized, confused in his speech, and showed functional impairment. He responded to outpatient treatment with clozapine. However, he stopped taking his medications and relapsed severely. On admission, he was selectively mute, withdrawn, disoriented, disorganized in speech, and highly impaired. He was treated with clozapine which was gradually titrated upwards, with attention to maintaining an adequate blood count. He had been living in a group home. From notes toward the end of his admission, it appears that some degree of confusion was present during baseline functioning. He also received psycho-education about his medications and risk management strategies for falls.

The health plan's determination is overturned. The inpatient level of care was medically necessary for this patient. The dates of service (DOS) at the IMHL of care were medically necessary through discharge. The patient was unable to answer questions adequately, was anxious, ruminated, appeared confused, with impaired memory, and was disorganized. Days of service at the IMHL through the remaining hospital days were examined. 
Two points need to be addressed: First, he did not show a continuing improvement in crucial areas necessary for functioning in a group home up until discharge. This means he had not attained a baseline before this time. So, there is no evidence that he was kept after he had reached a baseline. Secondly, for him to function in a group home, he needed to be able to interact with staff and act is a less impaired way than when he was admitted. This was gradually achieved during hospitalization. The mild anxiety he had at discharge was either a baseline mood or could be addressed as an outpatient. Discharge before the date would have a high likelihood of resulting in rehospitalization or harm to himself by neglect and poor functioning.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diffuse Pontine Glioma
 
Treatment: Skilled Shift Nursing in the home 24hour/7 days

The insurer denied the Skilled Shift Nursing in the home 24hour/7 days. The denial was reversed. 

This is a very young patient who had a diagnosis of Diffuse Pontine Glioma. She had been treated with clinical trials and received chemotherapy. Due to the progression of her disease, she had a generalized weakness with limited body control with continued deterioration in her health. She was ventilator dependent. 

As noted in Reference 4, there are no strong-evidenced based guidelines to define the appropriate level of nursing care required for pediatric patients on a ventilator.  There are, however, consensus guidelines (Ref 5) that clearly state, "A ventilator-dependent child should always have an awake and fully-trained caregiver watching him or her."  Furthermore, "In-home caregivers are most often nurses. They must be experienced with the child's ventilator, familiar with all aspects of the child's care, and certified in infant/child CPR." (Ref 5)

24 hour/7 day home nursing care is appropriate and within standard of care for this tracheostomy and ventilator-dependent child with a progressive brain tumor.

Based on the above, the medical necessity for skilled shift nursing in the home 24hour/7 days is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Refractory anaphylaxis
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient presented to the ED with hypotension and syncope after having taken GoLytely bowel prep, as well as having diarrhea. 

This patient had symptoms of hypotension and erythema of skin thought to be possible anaphylactic reaction to a medication.  This patient was at risk of biphasic reaction and should have had close monitoring, which can only be done in the ICU.  Therefore, the Inpatient admission for 2 days was medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Hypothyroidism
 
Treatment:  Armour Thyroid 120 mg OR tabs

The insurer denied coverage for a formulary exception for Armour Thyroid 120 mg OR tabs. The denial was upheld.

This case involves a female patient with a diagnosis of hypothyroidism, unspecified.  There was documentation that the patient was prescribed Synthroid for 4 years.  The patient was then switched to Armour Thyroid 90 mg and 3 years later the Armour Thyroid was increased to 120 mg.  The rationale for the change from the formulary medication, Synthroid to a non-formulary medication, Armour Thyroid was not noted.  

Medical literature states that synthetic thyroid medications are efficacious in achieving symptom improvement with normalization of thyroid function in the vast majority of patients.  They are well tolerated, have a favorable side-effect profile, good intestinal absorption.  However, there is a significant minority of patients that may experience intolerance, allergy or adverse reactions to inactive ingredients used in the synthetic formulations.  

The clinical records submitted for review fail to provide a rationale for the change from a formulary medication, Synthroid to a non-formulary medication, Armour Thyroid.  There was no documentation of an adverse reaction to Synthroid, or documentation that the Synthroid was ineffective and there was no documentation that Armour Thyroid is more effective than the formulary drug, Synthroid.  

The carrier's denial of Formulary Exception for Armour Thyroid 120 mg OR TABS is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Otezla
The treatment with Otezla is medically necessary.

A search of phototherapy offices on aad.org revealed the nearest one is over 50 miles from the patient's home address, which makes this treatment option impractical.

Methotrexate is contraindicated due to the patient's childbearing age. Also, methotrexate carries serious side effect risk and is not expected to be more effective than the requested medication, Otezla.

Cyclosporine is not a sustainable long term treatment option due to side effects. 

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  (Celgene, 2015)  Otezla is an oral small molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene, 2016)  

The patient has moderate to severe psoriasis for which therapy with Otezla is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic constipation

Treatment: Linaclotide (Linzess)

The insurer denied coverage for Linaclotide (Linzess). The denial was reversed.

This patient is a male with chronic constipation. He has failed polyethylene glycol and citrate of magnesia. The physician's medical records also report that multiple over the counter laxatives have been tried in the past including Bisacodyl, Senokot, and psyllium with no improvement in bowel symptoms.  

An Up-To-Date article, titled "Management of Chronic constipation in adults," states that Linaclotide has been approved by the FDA for the treatment of chronic idiopathic constipation. In 2 large trials of chronic constipation the linaclotide treated groups had significantly higher rates of complete spontaneous bowel movements.

This patient has chronic idiopathic constipation. The FDA has approved Linaclotide for this condition. This is supported by the recommendation from Up-To-Date. It is a medically necessary treatment. There is no contra-indication to the over the counter treatment. However, the physician's progress note states that psyllium, Bisacodyl, and Senokot have not been effective. The patient did not have a reaction to the over the counter medications, but they are often not effective in chronic idiopathic constipation. Based on the history provided in the medical record, it has been shown that the over the counter laxative preparations that the insurance company has offered, have not worked sufficiently in this patient. The healthcare plan did not act reasonably or in the best interest of the patient.

Based on the above, the medical necessity for Linaclotide (Linzess) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
 
Treatment: Dupixent Inj. 200

The insurer denied the Dupixent Inj. 200.  The denial was reversed. 

This patient is a young female patient who presented to her doctor with complaints of dermatitis. She has a history of atopic dermatitis.  It was reported that the patient's atopic dermatitis involved at least 20% of her body and had an IGA of three. She had tried and failed various topical corticosteroids. The provider was concerned for the potential adverse effects of systemic corticosteroids, which could lead to recalcitrant facial dermatoses, cataracts, and glaucoma. It is of the provider's medical opinion that Dupixent would be a safer and more effective immunosuppressive medication for the patient.

Dupixent is medically necessary for this individual. The patient has tried and failed topical corticosteroids and other over the counter (OTC) medications. Chronic use of topical corticosteroids has the potential for significant long-term adverse effects. Systemic corticosteroids are inappropriate due to chronic adverse effects as well. Phototherapy would be difficult due to the patient's schedule at school. Dupixent has been found to be safe and effective with significant therapeutic longevity in pediatric patients. Dupixent would be considered safer than systemic corticosteroids and immunosuppressant medications in this case. Therefore, the requested treatment is medically necessary.

The FDA (2017) states, "Atopic dermatitis, a chronic inflammatory skin disease, is often referred to as "eczema," which is a general term for several types of inflammation of the skin. Atopic dermatitis is the most common of the many types of eczema; onset typically begins in childhood and can last through adulthood. The cause of atopic dermatitis is a combination of genetic, immune and environmental factors. In atopic dermatitis, the skin develops red, scaly and crusted bumps, which are extremely itchy. Scratching leads to swelling, cracking, "weeping" clear fluid, and finally, coarsening and thickening of the skin. Dupixent is administered as an injection under the skin. Dupixent's active ingredient is an antibody (dupilumab) that binds to a protein [interleukin-4 (IL-4) receptor alpha subunit (IL-4Ra)], that causes inflammation. By binding to this protein, Dupixent is able to inhibit the inflammatory response that plays a role in the development of atopic dermatitis."

Based on the above, the medical necessity for Dupixent Inj. 200 is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uncomplicated appendicitis

Treatment: Inpatient hospital services

The insurer denied coverage inpatient hospital services. The denial was upheld.

This patient is a female who was seen in the emergency department with complaints of right lower quadrant abdominal pain and nausea which had been occurring for 2 weeks. The patient had a blood pressure 110/72 with a heart rate of 67, respirations 20, temperature 97.7 F., and oxygen saturation 100% on room air. The pain level was reported as 8/10. The patient had a previous CT done as an outpatient that showed acute appendicitis. The patient was told to go to the emergency room but decided to wait because pain was mild. The patient stated that the pain had worsened. On examination, there was McBurney's point tenderness. A repeat CT revealed acute appendicitis. The patient was admitted and underwent an uneventful laparoscopic appendectomy.  The patient was in stable condition following surgery. Her diet was advanced and medication for pain control was given. The patient was discharged.

The documentation indicated that the patient underwent an uneventful laparoscopic appendectomy. In this case of uncomplicated appendicitis, the inpatient stay is not medically necessary. The literature on this is strong and supports outpatient treatment for this condition. Therefore, the requested inpatient hospital services at the acute level of care were 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 services at the acute level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Thyroid Problems
Inpatient Hospital

The patient is a female who underwent a total thyroidectomy for a symptomatic multinodular goiter. The procedure was uncomplicated with minimal blood loss. Postoperatively, the patient was monitored in the post-anesthesia care unit, and from there she was transferred to the general nursing care floor. While in the hospital, she was started on thyroid hormone replacement, was given calcium and vitamin D supplementation and her pain was controlled with intravenous (IV), followed by mouth (PO) pain medications. On postoperative day #1, the patient was discharged to home in stable condition.

The health plan's determination is upheld.

No, a hospital stay at the acute inpatient level of care was not medically necessary for this patient. The patient underwent a routine total thyroidectomy. Her procedure was uncomplicated with minimal blood loss. Postoperatively, her vital signs were within normal limits. It is routine practice to monitor patients postoperatively following a thyroidectomy in order to ensure that the patient does not develop hypocalcemia or a neck hematoma.
The care provided to the patient was appropriate, including postoperative observation, oral medications and pain control. However, the identical services could have been provided at a lower level of care status rather than an acute inpatient level of care.
There are a number of factors that would justify an acute inpatient level of care, such as a high severity of illness or co-morbid conditions that would increase the patient's need for medical services and the medical probability of a complication. This patient is a generally healthy female who underwent an uncomplicated procedure. Thus, the records do not support the need for an acute inpatient hospitalization in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart failure
 
Treatment: Inpatient admission

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

The patient was a man with a medical history notable for obesity, diabetes, hyperlipidemia, marijuana use, and tobacco use. He presented for an elective cardiac catheterization but he had a fever of 102.9F. He reported shortness of breath, fever, cough, dizziness, and chest pain which was pleuritic. He was not requiring supplemental oxygen. He was admitted for heart failure after an echocardiogram showed ejection fraction 25-30%. He was sent to the cath lab, where his coronary angiogram revealed angiographically normal coronary arteries.  There were no procedural complications. He remained clinically and hemodynamically stable during his hospital stay, and had no other evidence of end-organ dysfunction. He was discharged home with the diagnosis of non-ischemic cardiomyopathy. 

The inpatient admission was not medically necessary. The patient underwent an uneventful cardiac catheterization procedure with no complications, remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no hemodynamic or clinical complications or concerns noted. Per MCG 23rd Edition Guideline Cardiovascular Surgery or Procedure GRG: SG-CVS (ISC GRG), cardiac catheterization is an outpatient procedure. 

Based on the above, the medical necessity for the inpatient acute care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with past medical history (PMH) of diabetes mellitus (DM) on insulin end stage renal disease (ESRD) on hemodialysis (HD) 3 x week, hypertension (HTN) asthma, rheumatoid arthritis (RA) and history of (H/O) ventricular fibrillation (Vfib) arrest status/post (s/p) implantable cardioverter defibrillator (ICD) for secondary prevention, who presented with feeling weak. She was found to be hypoglycemic and was given oral dextrose with improvement of her weakness. She reported a fall from bed the night before with right shoulder pain for which x-ray did not show acute fracture. Electrocardiogram (ECG) showed normal sinus rhythm (NSR) with prolonged QTC interval. Otherwise, vital signs were stable with no orthostasis, rather hypertensive but asymptomatic. There was no significant acute metabolic derangement beyond baseline consistent with (c/w) ESRD. There was no reported or documented evidence of acute cardiopulmonary or neurological process on exam. The patient was admitted for monitoring and to rule out syncope. The hospital course was uneventful with ICD interrogation showing no acute event or arrhythmia and tele NSR with arrhythmia. Blood pressure (BP) was controlled with resumption of her home med and blood glucose (BG) remained stable once patient resumed her diet. There was no documented infection or stroke. The patient received her routine dialysis next day and was able to be discharged home in a stable condition the next day.

The health plan's determination is upheld.

The inpatient stay is not medically necessary, the patient could have been treated at a lower level of care status. Though the patient's past medical history with DM ESRD/HD and h/o VFIB arrest all are concerning for probable syncope, the clinical presentation is mostly consistent with hypoglycemia. Even if syncope was suspected, there was no clinical documentation of worrisome presenting findings such as hemodynamic instability, arrhythmia or acute cardiac ischemia or neurological signs or symptoms, and no active seizure.

Based upon the patient's presentation and her past medical history, she warranted monitoring to ensure that there was no recurrence of hypoglycemia, however this could have been completed at a lower level of care status. This is consistent with the current standard of care and scientific literature.