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

Respiratory System - Breathing problem
Pharmacy/Prescription Drugs

This is the case of a male ex-33 3/7 week preemie twin B who is on albuterol, Atrovent, and Flovent in addition to supplemental oxygen. Additional medications include gabapentin, levothyroxine, and multivitamin (MVI). According to the medical documentation submitted, the patient has x-linked congenital hydrocephalus and multiple associated anomalies with severe developmental delays. At issue is whether the requested Synagis is considered medically necessary.

The health plan's determination is overturned. 

According to the American Academy of Pediatrics (AAP) bronchiolitis guideline, "Clinicians should administer palivizumab during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease of prematurity defined as preterm infants less than (<) 32 weeks 0 days gestation who require greater than (>) 21% oxygen for at least the first 28 days of life. (Evidence Quality: B; Recommendation Strength: Moderate Recommendation)." Additionally, the guidelines further delineate "Chronic Lung Disease of Prematurity: Palivizumab prophylaxis should be administered to infants and children younger than 12 months who develop chronic lung disease of prematurity, defined as a requirement for 28 days of more than 21% oxygen beginning at birth. If a child meets these criteria and is in the first 24 months of life and continues to require supplemental oxygen, diuretic therapy, or chronic corticosteroid therapy within 6 months of the start of the respiratory syncytial virus (RSV) season, monthly prophylaxis should be administered for the remainder of the season."
Based upon the guideline excerpts quoted above, this patient meets the Level B: Moderate Recommendation ("Clinicians would be prudent to follow a moderate recommendation but should remain alert to new information and sensitive to patient preferences.") based on a diagnosis of lung disease of prematurity (BPD), greater than 21% oxygen use for more than 28 days after birth, current age < 1 year, and current continuous oxygen use. Therefore, based on both present state and past medical history, Synagis is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems - Mispositioned Teeth
Dental/Orthodontic Procedure

The patient in question is a male with an anterior crossbite between teeth 10 and 22. He presents with a skeletal Class I malocclusion and significant crowding. His treatment plan for orthodontics is to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

The health plan's determination is overturned.

Yes, a comprehensive orthodontic treatment plan is medically necessary for this patient.

This patient presents with an anterior crossbite on teeth 10 and 22, as well as severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.

If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems / Malpositioned Teeth
Dental/Orthodontic Procedure

The patient is a female with a skeletal Class II malocclusion, moderate maxillary crowding and mild mandibular crowding. Overjet and overbite are mild. The proposed treatment is braces. The subject to be determined is the medical necessity for braces.

The health plan's determination is upheld, in whole. 

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 20 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeter (mm) or greater and underbite 3.5mm 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 standard criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, fever, constipation
Treatment: Inpatient admission
While the care as provided was appropriate, the level at which the care was provided, namely the inpatient admission, was not medically necessary.

The patient is a female. She had a past medical history significant for coronary artery disease (CAD), status post stent placement in the past. She also had GERD (gastroesophageal reflux disease), hypertension and dyslipidemia. The patient presented with the complaints of abdominal pain with nausea that predated her presentation by five days; new onset constipation for two days; and a subjective fever one day prior. 

The patient had mild elevated blood pressure in the ED, and she also had severe abdominal pain. There was a mild leukocytosis and creatinine elevation. A CT scan showed acute diverticulitis. She received IV antibiotics and supportive care and pain medication. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection [acute diverticulitis]; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged NPO (nothing by mouth) status [the patient was started on clear liquids on the day after admission], need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of Wolff-Parkinson-White syndrome. He had an echocardiogram (ECHO) done at a mobile cardiac unit and was told that his ejection fraction (EF) was reduced at 35%. He was subsequently evaluated and the doctor noted that he had subtle shortness of breath while exercising or at rest and ordered a repeat ECHO and stress test. The ECHO showed normal left ventricular function, with EF 60%. A Doppler showed diastolic dysfunction. There was mild mitral and tricuspid regurgitation. A stress nuclear study showed no ischemia. There were mild fixed defects in the basal septal, inferoseptal and inferior/apical areas, likely due to diaphragmatic attenuation. Left ventricular size was normal and systolic function low normal ( EF 54%).
A computed tomography (CT) coronary angiography study was ordered by Dr. Perry Frankel. The order indicates "diagnosis: EF 35%" as the indication for the study. At issue is the medical necessity of the CTA (computed tomographic angiography) coronary arteries.
The health plan's determination is upheld. Based on Milliman Guidelines for patients with suspected ischemic heart disease, the indications for coronary CTA are: 1. symptoms ( angina, dyspnea, arrhythmia) in low to intermediate-risk patients despite prior normal stress test findings, 2. inconclusive exercise or pharmacologic stress testing, or 3. contraindications to noninvasive stress testing. As the patient he had no anginal symptoms and a normal myocardial perfusion on stress nuclear study, the CTA is not indicated. The initial ECHO showing an EF of 35% is inconsistent with subsequent studies, including a repeat ECHO and may be inaccurate. The patient had the ECHO at a mobile cardiac unit showing a reduced EF of 35%. However, this was not confirmed on repeat testing, which showed normal LV function. Also, there was no myocardial ischemia on stress nuclear testing. As he has no evidence for structural heart disease or ischemia based on symptoms or objective testing, CTA of the coronary arteries is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Heart Problem
Inpatient hospital

The patient is a man with a history of hypertension, hyperlipidemia, diabetes, morbid obesity and coronary artery disease. He presented to the hospital for scheduled, elective percutaneous coronary intervention on a left anterior descending coronary artery lesion that had been demonstrated during a previous cardiac catheterization. He denied chest pain but reported exertional dyspnea with climbing two to three flights of stairs. His cardiovascular exam was unremarkable. He had no acute electrocardiographic changes. The procedure was uncomplicated. The patient was discharged. The inpatient admission is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient presented for elective percutaneous coronary intervention (PCI). He had exertional dyspnea but no resting symptoms. His serum creatinine level was normal, there was no evidence of congestive heart failure and he had no acute electrocardiographic changes. The procedure was uncomplicated. While some period of observation immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, an inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, or unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. Most other patients can be safely discharged after a period of observation of less than 24 hours. In fact, the EPOS (Elective PCI in Outpatient Study), a large randomized trial involving 800 patients who underwent elective PCI via a femoral arterial approach found that same-day discharge after elective PCI is feasible and safe in the majority of patients and does not lead to additional complications, as compared to an overnight stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizures
Treatment:  Inpatient hospital stay

The patient was a pediatric patient with autism, seizure disorder, microcephaly, and developmental delay, whose Keppra had been discontinued three months previously. The last seizure was in 2018.
Patient was brought to the emergency department (ED) after having a witnessed seizure.  In the ambulance, patient received a single dose of Ativan.  On arrival to the ED, vital signs showed a normal blood pressure and temperature, and mild tachycardia (heart rate (HR) 114) and tachypnea (respiratory rate (RR)30).  Patient was agitated, so he was initially physically restrained, and a second dose of Ativan was given.  The agitation resolved.  A chest x-ray (CXR) was normal.  Metabolic panel was normal except for a bicarb of 8, which was 26 upon repeat measurement.  Patient was loaded with intravenous (IV) Keppra and was admitted to the hospital for "further monitoring and clinical observation," per the documentation submitted for review.  Patient was discharged the next day on oral Keppra, having had an uneventful hospital course.
The health plan's determination of medical necessity is upheld in whole.
The patient had a known seizure disorder, had been off Keppra seizure medication for three months, and had a witnessed breakthrough seizure.  Patient presented to the ED with agitation having received a dose of Ativan en route, but was otherwise well.  The agitation subsided after another dose of Ativan in the ED, and the patient was loaded with Keppra.  There is no evidence to support that the convulsions persisted despite treatment with Keppra and Ativan.  It is clear that the second dose of Ativan was given for agitation, not another seizure.  In any event, by the time the patient had received two doses of Ativan and the Keppra, the patient was back to baseline and completely stable in the ED.  The stated reason for admission provided in the documentation was for observation and monitoring, which is what the patient's condition required and was in fact the treatment the patient received.  Acute inpatient hospitalization was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left subcortical ischemic stroke 

Treatment: Inpatient hospital admission 

The insurer denied coverage for inpatient hospital admission. The denial is reversed. 

This patient is a woman with a history of hypertension, transient ischemic attacks (TIA's), cervical and lumbar spinal cord compression, and baseline right-sided lower extremity weakness.  She presented to the emergency room (ER) via ambulance with sudden onset of weakness and numbness on her right side.  Stroke Team was activated.  The patient has had multiple similar episodes in the past involving both sides and was managed as an ischemic cerebrovascular accident.  Initial ER vital signs were: blood pressure 152/57, pulse 77, respirations 18, temperature 98.1F.  Patient was noted to have slight left-sided facial droop with normal speech and sensorium.  National Institutes of Health Stroke Scale score was 2.  

The patient had rapid improvement of her symptoms so she did not meet criteria for thrombolytic therapy.  Bloodwork revealed white blood cell (WBC) count 4.6, hemoglobin 11.4, hematocrit 34.5; electrolytes were normal.  A chest x-ray showed no acute pulmonary disease.  Computed tomography (CT) scan of the head showed atrophy and white matter disease compatible with microvascular ischemia.  Magnetic resonance imaging (MRI) of the brain showed possible new left subcortical ischemic stroke, and extensive white matter disease which could be demyelinating disease versus chronic hypertension.  Magnetic resonance angiogram (MRA) of the brain showed no vascular malformation or aneurysm.  

The patient was admitted for further work up.  She was followed by Neurology and the Stroke Team.  Her numbness resolved.  An MRI of the spine showed degenerative disk disease but no cord compression or abnormal enhancement.  A lumbar puncture was done which showed mild lymphocyte elevation on cerebral spinal fluid.  The patient had no further issues and was discharged.  

This patient had focal neurological signs and highly abnormal brain imaging with evidence of an acute stroke corresponding to her deficit.  Hospitalization after an acute stroke is routine and appropriate as patients may potentially require urgent intervention as well as timely diagnostic testing.(1)  In addition, this patient's MRI was so abnormal that additional diagnostic testing - LP and MRI with contrast was appropriate.  

The health care plan did not act reasonably or in the patient's best interest in denying the admission.  

The admission was medically necessary to evaluate and treat this probable acute stroke.  

Based on the above, the medical necessity for the inpatient hospital admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Heart Problem
Inpatient hospital

The patient is a man with a history of psoriasis who presented to the hospital. He presented with a chief complaint of syncope. He reported that he was helping a friend deliver items when he felt left chest discomfort and lost consciousness. He believed that he struck his head on a bench. After he awoke, he experienced mild left chest pressure. Past medical history was notable for prior cocaine use. Vital signs showed temperature 96 Fahrenheit, heart rate 71, blood pressure 114/76, and oxygen saturation 96%. On physical examination, he was in no acute distress, heart was regular, breath sounds were normal. An electrocardiogram (EKG) showed normal sinus rhythm. The inpatient stay is under review. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was hemodynamically stable, had no evidence of acute stroke or acute seizure, had a negative head CT, had no evidence of complicating sepsis, and there were no other acute abnormalities. He was also evaluated by cardiology, with a negative evaluation for ischemia. The patient needed further care for syncope but it could have been safely and effectively provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructive sleep apnea
Issue under review: Continued CPAP

Determination:
The Continued CPAP is not medically necessary.

The patient is an adult male. Pertinent to this case review, he has a diagnosis of OSA (obstructive sleep apnea). The request is for continued CPAP (continuous positive airway pressure) coverage.

Based on the compliance data provided, on initial trial, the device was used 74% of the nights. Of those nights, for 34% of the nights, the device was used for more than four hours. The patient then had a face-to-face follow-up evaluation with the treating provider. The patient had the initial face-to-face evaluation after the first 90 days to discuss the compliance. The patient's poor compliance was addressed, and the patient meant to improve compliance.  

Subsequent to that evaluation, compliance data documents that the device was used 56% of the nights out of 30 nights. For those nights, for 30% of the nights was the device used for more than four hours.  

Per generally accepted guidelines and practice in the Sleep Medicine community, for medically indicated continuation of CPAP therapy after a 90-day trial period, the following must be demonstrated and documented:

1) Improved AHI and symptom resolution during trial period; and 2) Compliance has been demonstrated as defined by the use of the device for 70% of the nights for an average of 4 or more hours per 24 hour period during a consecutive 30 day period.

Patients who do not meet the initial 90 day trial for continuation must have a face-to-face clinical re-evaluation by the treating physician to determine the etiology of the failure to respond to CPAP therapy (e.g., documentation of failure of symptoms to resolve or improper fit of device and re-education of the patient regarding proper use of the equipment or re-fitting of masks).

After the initial 90 days, compliance was discussed with the patient. The follow-up compliance after 30 days remained poor. Therefore, the patient does not meet medical necessity for continued coverage.
Appeal type: Medical necessity
Decision: Upheld

Asthma
Inpatient stay

The patient has a history of asthma and presented to the emergency room with a chronic cough and shortness of breath for the past 1 month which had acutely worsened 3 days prior to presentation. The patient stated that the cough produced greenish to yellow sputum which is thick. The patient also had worsening shortness of breath with minimal alleviation of symptoms with routine home nebulizer and inhalers. Patient also tried Prednisone 20 milligrams (mg) for 10 days with no improvement. The patient denies any fevers or chills or change in appetite. Upon evaluation in the emergency room patient was afebrile with a pulse rate of 97 beats per minute (bpm), respirations of 20/minute, a blood pressure of 128/77 millimeters of mercury (mmHg), with an oxygen saturation of 97% on room air. A chest x-ray showed clear lungs. An electrocardiogram (EKG) showed a heart rate of 85 bpm with no acute ST or T wave changes. A white blood cell count (WBC) count was 11.4, with a sodium of 138, and a creatinine of 0.9. There was a concern for an asthma exacerbation. In the ER the patient was treated with 60 mg of oral Prednisone, intravenous (IV) Magnesium and duo nebulizers. He was admitted and started on oral Prednisone, duo nebulizers, and Montelukast. No antibiotics were given. As symptoms improved, patient was discharged home two days after admission with a steroid taper and was advised to follow-up with pulmonary in the outpatient setting. The health plan's determination of medical necessity is upheld in whole. There is no evidence of hypoxemia at presentation, reduction in peak flow. There was no need for supplemental oxygen, invasive or noninvasive ventilation. There is no evidence of hypercarbia. No evidence of cardiac ischemia or pneumonia. There is no evidence of sepsis or hemodynamic instability. The patient could have been safely evaluated and treated at a lower level of care without admission to inpatient status
according to the review of the chart, standard of care, and scientific literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not  medically necessary.

The patient is an adult female. She presented to the ED with a one-day h/o (history of) diffuse abdominal pain, nausea associated with multiple (10-20) episodes of non-bloody and non-bilious, cheesy vomiting, and profuse diarrhea (10-20 loose nonbloody BMs [bowel movements]). She endorsed eating an old bagel with cheese one day before, and eating raw seafood two days before.

In the ED, the patient was pale-appearing. She was hemodynamically stable with blood pressure of 98/60, pulse rate of 72/min, respiratory rate16/min, and she was afebrile with temp of 36.6C. Her abdominal exam was remarkable for tenderness in the right lower quadrant and no rebound tenderness. The CBC (complete blood count) revealed Hb (hemoglobin) of 17.1 and WBC (white blood count) of 28.1. The Chem panel revealed normal lytes, BUN (blood urea nitrogen) and Cr (creatinine), and normal liver function tests (LFT). The CT scan of the abdomen revealed diffuse enteritis.

The patient was admitted to the hospital, made NPO (nothing by mouth), and started on IV fluids, IV ceftriaxone, and metronidazole. She was treated with Reglan and Zofran for nausea and vomiting, and IV Morphine for pain. Over the next 24 to 48 hours, her abdominal pain, nausea and vomiting, and diarrhea improved, and she was able to tolerate liquid diet, which was then subsequently advanced to regular diet. 

The patient was discharged home in a fair and stable condition.

The patient was admitted with one-day h/o of diffuse abdominal pain, nausea, vomiting and diarrhea. In the ED, she was ill-appearing but was hemodynamically stable and afebrile. Her abdominal examination revealed right lower quadrant and no rebound tenderness. Her CBC revealed normal Hb, HCT, and marked leukocytosis. Her CT revealed diffuse enteritis but no evidence of any obstruction or perforation. She was empirically treated with broad spectrum antibiotics, and her abdominal pain was treated with IV Morphine, and nausea and vomiting were treated with Reglan and Zofran. She was initially made NPO and started with IV fluids. Over the next 24 to 48 hours, her symptoms resolved and she was able to tolerate clear to full liquid diet that was later advanced to regular diet. Given this clinical scenario, and no clinical evidence of hemodynamic instability, sepsis, bowel obstruction, bowel perforation etc, the acute level care was not appropriate and medically necessary, and she could have been safely managed at the lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Psoriasis Vulgaris
Treatment:  Consentyx

The proposed Cosentyx is medically necessary.  

The patient is a male with psoriasis, treated with topicals, methotrexate, phototherapy, and Skyrizi.  The patient has cleared on Cosentyx samples.

Cosentyx is an approved, appropriate and effective medication for psoriasis.  A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis.  Currently, the selection of the first biologic and the choice of sequential biologics in the event of efficacy/tolerability concerns is made using a limited evidence base.  It is generally considered medically necessary to continue a patient on a therapy to which they have favorably responded. 

The patient has already tried methotrexate.  Cyclosporine is not used for plaque psoriasis.