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

Diagnosis: Antiphospholipid syndrome, Factor V Leiden mutation, left posterior knee pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld. 

The patient in this case is a man with anti phospholipid syndrome and Factor V Leiden mutation.  He has a history of deep venous thrombosis and was maintained on Coumadin.  He presented to the emergency department with a one day history of left posterior knee pain.  Ultrasound was done and revealed chronic deep vein thrombosis (DVT) on the left side.  He was hemodynamically stable.  International normalized ratio (INR) was 1.8.  

The patient was admitted and started on Lovenox, for the purpose of bridging until he could achieve a therapeutic international normalized ratio (INR) on Coumadin. Acetaminophen was ordered to treat his leg pain.  Repeat labs revealed international normalized ratio (INR) of 2.1.  The patient was discharged home.

No, the inpatient admission was not medically necessary.

This patient had leg pain but ultrasound only revealed chronic venous thrombosis, not acute deep vein thrombosis (DVT). International normalized ratio (INR) was 1.8. While that is a sub-therapeutic level, it did not require hospital admission and treatment with enoxaparin. Treatment with enoxaparin can be given on an outpatient basis; also, Coumadin dose can be adjusted with a plan to repeat international normalized ratio (INR) in a few days. The patient was hemodynamically stable and did not have any concerning signs or symptoms. His leg pain was treated with oral acetaminophen. Given these considerations, acute care hospitalization was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. His medical history included diabetes mellitus, type-II; gastro-esophageal reflux disease (GERD); obesity; and tobacco-use. His surgical history included appendectomy and left inguinal hernia repair. 

The patient presented to an emergency department with a 24-hour history of epigastric and right-upper-quadrant abdominal pain. Vitals were temperature 98.4, pulse 97, blood pressure 145/85, respirations 18, and oxygenation 100%. Physical examination demonstrated tenderness-to-palpation of the epigastrium and bilateral upper quadrants of the abdomen; moreover, Murphy's Sign was elicited. Serum laboratories demonstrated elevated liver enzymes (aspartate aminotransferase [AST] 449, alanine aminotransferase [ALT] 467). Abdominal ultrasound was consistent with acute cholecystitis. 

The patient was admitted at an acute inpatient level-of-care with a diagnosis of acute cholecystitis. He was made nothing by mouth [NPO]; and provided with intravenous fluids, antibiotics, analgesics, and antacids. Magnetic resonance cholangiopancreatography (MRCP) demonstrated/confirmed acute cholecystitis. 

The following day, the patient underwent laparoscopic cholecystectomy. According to an operative report, surgery was technically challenging due to "severely acutely inflamed and thickened [gallbladder]"; "[a] 2.5 cm (centimeter) gallstone... impacted in the neck, causing a type 1 Mirizzi syndrome"; and "[an] intrahepatic gallbladder". However, there were no complications. 

Having returned to his baseline health and function, and with improving post-operative pain control and down-trending/normalizing liver enzymes, the patient was discharged home in good and stable condition with prescriptions for oral analgesics and stool softeners; and outpatient surgical follow-up.

No, the proposed inpatient admission was not medically necessary.

No, the proposed treatment -- admission at an acute inpatient level-of-care from was not medically necessary. According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [SAGES - Society of American Gastrointestinal and Endoscopic Surgeons]. Insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as surgery and recovery were uncomplicated (albeit technically challenging), the patent could have been treated at a lower level-of-care, precluding the need for admission at an acute inpatient level-of-care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history of hypertension, former tobacco abuse, hyperlipidemia, type II diabetes and coronary arterial disease status post coronary artery bypass graft (CABG), asthma and hyperthyroidism. He was referred by his cardiologist for coronary angiography given his ongoing symptoms of chest pain and exertional shortness of breath. He underwent coronary angiography with a drug-eluting stent to the diagonal vessel. The procedure was uneventful and no complications were observed. Post procedure, the patient was hemodynamically stable and he was monitored overnight and discharged home on the following day in stable condition. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay is not medically necessary.
This patient has a known history of coronary arterial disease and was referred for coronary angiography given his symptoms of stable angina pectoris. The physical exam on admission was stable. His laboratory findings did not show major abnormalities. His electrocardiogram (ECG) showed no ST changes. He underwent coronary angiography which was performed via the femoral approach. The procedure report was reviewed in detail and no intra-procedural adverse events were noted. Post procedure, the patient was hemodynamically stable with no complications. His access site did not have any bleeding. There was no change in his hemodynamics. On the next day, his physical exam was stable. Based on a review of the latest medical literature and current standard of care, this patient could have been treated safely and efficiently at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay. The health plan's determination is overturned.

The patient is a male who was admitted for investigation and management of seizures associated with fever. Emergency room records were reviewed, together with inpatient notes. The patient had had a previous unprovoked, afebrile seizure. Video electroencephalogram (EEG) telemetry had been normal. He was not started on a maintenance anticonvulsant, but his family was issued Diastat (rectal Valium) in the event of further prolonged seizures.

His mother witnessed a seizure involving tonic clonic movement of the limbs, eye rolling and loss of consciousness lasting around 1 minute. His father gave rectal Diastat, with resolution of the seizure. The patient was seen in the emergency room, where he was given an intravenous load of Levetiracetam (Keppra) and discharged home with outpatient pediatric neurology follow up.

The patient was transported back to the emergency room by paramedics after having three further seizures lasting < (less than) 30 seconds at home. In the emergency room his temperature was 102F, but he became afebrile following acetaminophen (Tylenol). A further seizure was noted in the emergency room, prompting an additional intravenous load of Levetiracetam. The patient was started on maintenance Levetiracetam. He was admitted to the inpatient service where a pediatric neurology consult was performed. He received a head computed tomography (CT) scan and EEG, both of which were normal. The emergency room physician was concerned regarding the potential for further decompensation, and for the family being unable to comply with medical recommendations, noting that the Administration for Children's Services (ACS) was involved.

The patient was initially postictal in the emergency room, but subsequently was reported to have normal general and neurological examinations. He tested positive for rhinovirus. Laboratory testing was otherwise unremarkable.

At issue in this review is whether inpatient hospital admission was medically necessary for the patient.

The health plan's determination of medical necessity is overturned, in whole.

The patient had had a previous unprovoked, afebrile seizure the previous month. There was a strong family history of epilepsy. On the day of admission, he had already been given rectal Diastat and an intravenous load of Keppra, yet had a further 3 brief seizures at home, and another seizure in the emergency room, prompting administration of a further intravenous load of Levetiracetam. By definition, he did not have simple febrile seizures (i.e., a seizure that was brief, single, associated only with fever, non-localized) [1]. His history was more consistent with an underlying epilepsy, probably genetic, with fever lowering his seizure threshold, or alternatively, with complex febrile seizures. He was at high risk of further seizures and status epileptics. Inpatient hospital admission was appropriate, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headaches
Treatment: Pain Management/Cervical Injections
The health plan denied the requested pain treatments. 
The health plan's determination is upheld.

This is a female patient who was seen with complaints of worsening headaches, and treated with cervical injections. Examination revealed normal general appearance, eye, ear, nose, mouth, neck, lung, cardiovascular, gait and station, range of motion, skin and subcutaneous tissue, mental status, cranial nerve, motor, tremor, abnormal movement examinations with decreased reflexes in the right upper extremity and right ankle compared with the left, negative Babinski and Hoffman signs, decreased sensation up to the level of the knee, the right lateral leg with loss of sensation, impaired balance, positive Romberg sign, and cautious and wide based gait for which she was using a wheeled walker. Magnesium was prescribed. She was referred for physical therapy.
An office note indicates routine follow-up for a trial of occipital nerve blocks and trigger point injections. Headache was noted to be bioccipital and behind the ears, shooting up from the neck. She underwent bilateral greater and lesser occipital nerve blocks and trigger point injections to the right trapezius on that date.
A later office note indicates that the patient had previously undergone an occipital nerve block, and was to undergo another block, though she was scheduled for telehealth visit. Topical creams helped with her symptoms. She had radiation of her pain behind her eye. She complained of 20/30 days of "zapping pain, sensitive to touch." She had a motor vehicle accident and had worsening headaches since the car accident. She complained of neck pain radiating to behind her eyes associated with photophobia and phonophobia. Examination was revealed normal mental status, cranial nerve and sensory examinations. Diagnoses were bilateral occipital neuralgia, cervicalgia and posttraumatic headache. It was noted "she has a history of Gilbert's therefore reluctant to take medications." Continued topical anesthesia and nerve blocks were recommended.
At issue is the medical necessity of the requested treatments.

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

No. This is a patient with a history of headaches. There is no evidence the peer reviewed medical literature that nerve blocks, including occipital nerve blocks and trigger point injections are more effective than pharmacologic therapies. There is no evidence that the patient has received or is receiving any pharmacological therapies. There is no contraindication to pharmacological therapies in the setting of Gilbert syndrome, and no rationale why the patient cannot be treated pharmacologically. There is no documentation of any other conservative therapy, such as physical therapy, for her symptoms. Therefore, in the absence of any contraindication to pharmacological therapies, and given the lack of any other conservative therapy including physical therapy, the occipital nerve blocks and trigger point injections were not medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Revision Right Total Knee Replacement Surgery
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay. The health plan's determination is upheld.

This case describes a female patient who underwent primary right total knee replacement which was complicated by post-operative adhesions. She underwent manipulation under anesthesia complicated by an extensor mechanism injury that required a surgical repair. A subsequent arthroscopic lysis of adhesions was also done. Due to persistent pain and motion loss in her right knee, the patient opted for revision right total knee replacement surgery. The surgery was successful with no documented complications. She was admitted to the hospital after surgery and progressed with supervised physical therapy. She was deemed stable for discharge. At issue in this case is the medical necessity of the inpatient hospital stay.

I uphold, in whole, the health plan's determination of medical necessity in this case. 

The inpatient hospital stay was not medically necessary for this patient. The provided medical records in this case document that this female underwent elective total knee revision surgery for persistent stiffness and pain. Her medical history was significant for only hypertension and hyperlipidemia and the revision surgery was not done for an infected prosthesis. Recent articles published by Gu and colleagues in the Journal of Knee Surgery and by Law and associates in the Journal of Arthroplasty concluded that short stay admission is safe and effective. Gu and his colleagues concluded that "rapid discharge following aseptic revision total knee arthroplasty (TKA) is not associated with increased risks for postoperative complications. Rapid discharge may have benefits for healthy patients undergoing single-component revisions. Careful selection of revision TKA patients for rapid discharge may help to lower the increasing costs of the procedure and improve patient outcomes." Law and his co-authors also concluded that "Outpatient revision knee arthroplasty was found to be safe in carefully selected patients and case scenarios. Presence of medical comorbidities was not associated with risk of complications."
The rationale for this determination is based upon the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature and the conclusions of the current, peer-reviewed literature as documented by Gu and colleagues in the Journal of Knee Surgery in 2019 and by Law and associates in the Journal of Arthroplasty in 2020. Recent articles published in peer-reviewed orthopedic journals have concluded that short stay and outpatient aseptic revision total knee replacement for select patients is safe and effective. Based on the records provided in this case, the patient had few underlying medical conditions, and her revision surgery was not done for an infection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: OncotypeDx Genetic Prostate Score

The insurer denied the OncotypeDx Genetic Prostate Score.  The denial is upheld. 

This male with prostate cancer had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in four of 14 cores. The prostate specific antigen (PSA) was less than (<) ten.

No, the proposed OncotypeDx Genetic Prostate Score was not medically necessary.

Per the American Urologic Association (AUA) Guidelines:
14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)

Guideline Statement 32:
Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion)

This patient has a very low-risk prostate cancer.

Although results are promising, further validation is necessary to understand fully the potential clinical utility of this test.  The National Comprehensive Cancer Network (NCCN) Guidelines note that "Their clinical utility awaits evaluation by prospective, randomized clinical trials, which are unlikely to be done."

The National Comprehensive Cancer Network (NCCN) Guidelines state that "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclear." "[A]ny of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures. 
Treatment: Inpatient admission. 

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

The patient is a female with a history of seizure disorder who presented to the emergency ward with the complaint of seizure and abdominal pain.  At presentation, her neurological evaluation was normal. Her computed tomography (CT) of the head showed no acute abnormality. She was started on Keppra and admitted for further evaluation. Her electroencephalography (EEG) and magnetic resonance image (MRI) were both interpreted as normal. The patient was diagnosed with intermittent porphyria and breakthrough seizures and discharged on Keppra. 

No, the proposed inpatient admission was not medically necessary. 

The patient had a history of seizure disorder and was not maintained on any anticonvulsant therapy.  Shortly after her presentation, she was at her baseline neurological status. Her diagnostic studies were all negative and she was stabilized on an anticonvulsant regimen within 24 hours without any recurrent spell after presentation.  The diagnostic studies, clinical evaluation, monitoring and treatment could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with history of leukemia, now in remission. She was admitted as inpatient to an epilepsy monitoring unit for evaluation of episodes of transient alterations of awareness for several years, described as "zoning out," as well as sleep disturbances, including vomiting in her sleep on one occasion and another occasion where she could not be aroused for an extended period of time. The "zoning out" episodes were observed by teachers at school, but the parents denied seeing staring spells at home. The parents also denied any convulsive seizure-like activity, head deviation, drooling, incontinence and tongue biting.  The patient was not on any anti-epileptic medications and video EEG (electroencephalogram) monitoring was recommended.

According to the History & Physical, long term EEG (electroencephalogram) monitoring was previously performed and was normal at that time.  It was also noted that route EEG (electroencephalogram) earlier in the year was also normal.  There is no past history of CNS (central nervous sytems) infection or febrile seizures.  During admission, continuous video EEG (electroencephalogram) monitoring was initiated.

According to the Discharge Report, no seizures or significant concerns were seen and the patient was not started on any antiepileptic medications. The study did show rare bouts of intermittent generalized slowing, suggestive of mild diffuse cerebral dysfunction. Discharge diagnoses were listed as transient alteration of awareness, sleep disturbance, and abnormal involuntary movements.

No, the Inpatient admission was not medically necessary.

The patient's neurological status was normal, without status epilepticus or recurrent seizures. There was no neurological or hemodynamic or respiratory instability. The patient is not on any antiepileptic medications, and there was no need in medication tapering. Therefore, the acute care admission was not medically necessary, and the patient's neurological needs could have been addressed at a lower level of care. Video EEG (electroencephalogram) can be performed without hospital admission, at a lower level of care.

The patient was neurologically stable, and the patient's needs could have been addressed at a lower level of care. Acute inpatient level of care was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Multiple sclerosis. 
Treatment: J1561: Injection, Immune Globulin, (gammunex-c/gammaked), Non-lyophilized (G. Liquid), 500 mg [milligrams]. 

The insurer denied coverage for the Pre-Service request for J1561: Injection, Immune Globulin, (gammunex-c/gammaked), Non-lyophilized (G. Liquid), 500 mg [milligrams]. 

The denial is upheld. 

This is a female patient with a past medical history of multiple sclerosis, migraines, and hypertension.  Per an office visit note, the patient has used Tecfidera in the past.  She had a relapse and new lesions on her magnetic resonance imaging (MRI) and a surveillance MRI showed radiologic progression.  She received her first cycle of Lemtrada.  She was reporting more difficulty with gait and spasticity.  Her gait showed very mild difficulty with tandem.  There was no limb dysmetria.  The strength in the right extremity was 5 -/5 and left strength was 5/5.  The Romberg was negative.  The provider recommended starting monthly intravenous immune globulin (IVIG). 

The patient was diagnosed with relapsing remitting multiple sclerosis that relapsed/progressed despite treatment with Tecfidera and Lemtrada and for which monthly IVIG was requested as a maintenance therapy for multiple sclerosis. However, there are no controlled studies supporting the safety, efficacy and long-term benefit of IVIG as a maintenance therapy for multiple sclerosis. Therefore this service is not likely to be more beneficial than any other standard treatments. 

The carrier's denial of the Pre-Service request for J1561: Injection, Immune Globulin, (gammunex-c/gammaked), Non-lyophilized (G. Liquid), 500 mg [milligrams] should be upheld.