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

Digestive System/Gastrointestinal
Surgical Services

The patient is a male with gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux with chronic cough, sore throat, and dyspnea, as well as asthma. Esophagogastroduodenoscopy showed esophagitis. pH study off proton pump inhibitor showed significant reflux which strongly correlated with cough and throat symptoms, and elevated DeMeester score of 18.8. Esophageal manometry showed normal motility and a Type 1 gastroesophageal junction; impedance showed 90% clearance. He has failed diet modification and omeprazole 40 milligrams (mg) twice daily, with persistent hoarseness, chest discomfort, and dyspnea. The question is whether the Stretta for the treatment of gastroesophageal reflux disease (GERD) is likely to be more beneficial for this patient than any standard treatment.

The health plan's determination is upheld.

A systematic review to evaluate all controlled trial evidence on the efficacy of Stretta for the management of gastroesophageal reflux did not show any benefit of Stretta over sham therapy [1]. Specifically, data on the mean percentage of time that pH was less than 4 (over 24 hours) showed no significant benefit of Stretta over sham therapy. Data on the change in mean lower esophageal sphincter pressure showed no statistically significant advantage of Stretta over sham. The pooled analysis showed no statistical advantage of Stretta over sham for stopping proton pump inhibitor therapy. Finally, the pooled analysis did not show a statistically significant benefit of Stretta over sham on improvement of quality of life scores from baseline. In addition to lack of efficacy, adverse events reported to the U.S. Food and Drug Administration include pneumonia, gastroparesis, esophageal perforation, cardiac arrest, and at least two deaths [1,2]. Subsequent studies have not been controlled. A 2019 review of evidence concluded that "high-quality randomized trials are warranted to address the controversy generated" by analysis of randomized trials of Stretta [3]. The most recent American College of Gastroenterology guidelines for the treatment of GERD do not recommend Stretta [4].
Appeal type: Experimental/Investigational
Decision: Upheld

Digestive System/Gastrointestinal
Surgical Services

Report # 1.
The patient is a male with a body mass index (BMI ) of 17.9 who presents with complaints of gastroesophageal reflux disease (GERD), with symptoms of chest pain and cough for 4 years. 24 hour pH study revealed an elevated DeMeester score consistent with GERD. Esophagogastroduodenoscopy (EGD) revealed esophagitis without hiatal hernia. Manometry was normal. The patient is symptomatic despite twice daily (bid) omeprazole. The subject under review is whether the proposed radiofrequency ablation Stretta procedure is likely to be more beneficial than any standard treatment or treatments for the patient's condition.

The health plan's determination is overturned.

Yes, the treatment is likely to be more beneficial for this patient than any standard treatment. This patient has GERD refractory to medication. Stretta is a standard endoluminal treatment for GERD. It is a Food and Drug Administration (FDA) approved treatment for GERD since 2000. It has been shown in published literature to be more effective than medication use for treatment of GERD, but less so than surgical fundoplication, however, it is much safer (morbidity, mortality, long term complications) than surgical anti-reflux procedures such as Nissen fundoplication or LINX. It is approved by numerous medical societies (Society for Surgery of the Alimentary Tract [SSAT], Society of American Gastrointestinal and Endoscopic Surgeons [SAGES]) with published guidelines to support its use based on safety, improved efficacy over medication and reasonable durability up to 10 years. It is considered a standard endoluminal treatment for GERD within the medical community.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Mild Maxillary Crowding; Mild Mandibular Crowding

Treatment:  Braces

The insurer denied braces.  The denial was reversed.   

This is a young male patient who consulted an orthodontist for orthodontic treatment.  Diagnostic tests were performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images revealing skeletal Class III canines, mandibular crowding, and anterior crossbite with gingival attachment loss.  He attained a score of 9 on the HLD index where 26 points is required. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies.  Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and ,therefore, medical/dental necessity for orthodontic care, a Handicapping Labio-Lingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

The healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient.

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

Diagnosis: Alcohol and Substance Use
 
Treatment: Inpatient substance abuse services

The insurer denied coverage for inpatient substance abuse services. The denial is reversed. 

This patient is a male admitted to this inpatient substance detoxification treatment for alcohol and substance detoxification treatment. He had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) score of 15 and had reports of withdrawal symptoms including sweats, tremors, nausea, diarrhea, abdominal pain, sleeping problems, irritable mood, anxiety, and teary eyes. He was drinking 1/5 of liquor per day and had over two decades history of alcohol use. He was inhaling 2 grams of cocaine per day. He was smoking 3.5 grams of cannabis daily with an over two decade's history. He had past inpatient substance detoxification treatment as well as inpatient substance rehabilitation treatment. He was unemployed and lacked a sober support system. He was put on a Librium protocol. He also took Mirtazapine and Olanzapine. He left against medical advice (AMA).

The insurer denied coverage for inpatient substance detoxification treatment. This reviewer disagrees with the decision to deny coverage for inpatient substance detoxification treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case, this patient had been using a large amount of alcohol daily and had significant alcohol withdrawal including a CIWA score of 15.

The patient lacked the coping skills to stop alcohol and substance use, lacked sober supports, and continued to use alcohol, cocaine, and cannabis in large amounts daily despite past inpatient substance detoxification treatment, as well as inpatient substance rehabilitation treatment. The discharge plan after this detoxification treatment was to attend inpatient substance/alcohol rehabilitation treatment, but he left AMA. The risk of complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use; therefore, he required the entire time in this inpatient detoxification treatment as he was at risk for more severe, complicated, and even life-threatening withdrawal such as delirium tremens.  

As a result, reverse the previous decision and approve coverage for inpatient substance detoxification treatment. The health care plan did not act reasonably, or with sound clinical judgment, or in the best interests of the patient.

The carrier's denial of coverage for the inpatient substance abuse services is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath (Breathing Problem) 
Treatment: Inpatient hospital 

This is the case of a female with a past medical history of asthma who presented to the emergency department with chief complaint of shortness of breath, productive cough, and sore throat. She was admitted to the hospital. 

The health plan's determination is overturned. The inpatient stay was medically necessary. This is a patient with asthma who presented with acute respiratory distress, accessory muscle use, wheezing, and a peak expiratory flow rate of 120 noted in the emergency department. Though she was not hypoxic, her work of breathing in addition to low peak expiratory flow of 120L was indicative of severe disease with high risk for treatment failure, potential impending respiratory failure and need for emergent aggressive treatment with IV steroids, NEBS, and frequent monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tachycardia 
 
Treatment: Inpatient Admission 

The insurer denied the Inpatient Admission. The denial was upheld. 

This patient is a male child with a medical history of seizures who presented to the Emergency Department with complaints of fever and headache. His presenting vital signs were blood pressure 147/88, heart rate 124, respiratory rate of 20 and temperature 101.8F. He received 2 liters of intravenous (IV) fluids; his tachycardia persisted with a heart rate of 127. After several days the patient's symptoms improved and he was discharged home with outpatient follow up instructions. 

In the justification for the inpatient level of care, the hospital states that the patient met criteria for sepsis.  However, he did not have any signs of decreased perfusion, palpitations or chest discomfort.  Moreover, because he continued to look well throughout, there was no evidence of a toxic appearance that would indicate a bacterial infection.  
 
The definition of sepsis in pediatrics is still controversial (see Reference) because children can exhibit non-specific tachycardia from fever, anxiety, and just from a viral illness.  In the patient's case, the tachycardia could be explained by fever and the viral illness.  As long as an arrhythmia or heart failure is ruled out by EKG and clinical examination, inpatient care would not be necessary, and adding antibiotics to the treatment regimen is not indicated.  

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.  

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

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Inpatient Hospital 

This is a patient with exertional angina who underwent a diagnostic catheterization at an outside hospital. He was transferred for elective intervention. He had a history of hypertension, hyperlipidemia, and diabetes. He underwent coronary intervention of a 75% left main stenosis with a drug eluting stent and 80% left anterior descending (LAD) with a drug eluting stent on 5/24/19. He was observed uneventfully overnight and discharged. At issue is the medical necessity of an inpatient stay. 

The health plan's determination is upheld. 

The patient had an elective, uncomplicated catheterization and coronary intervention. It was appropriate to monitor him post-procedure for several hours but that could have been performed at a lower level of care. It was expected that discharge would have been accomplished within 24 hours in this low risk patient. Therefore, an inpatient hospitalization was not necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with speech delay and autism that presented to the emergency department (ED) with multiple episodes of vomiting. He was seen three days prior for recurrent vomiting, was treated with a parenteral antiemetic, and was discharged home. He had no fevers, diarrhea, or abdominal pain. Multiple family members developed similar symptoms. Vital signs included temperature 37.1, heart rate 119, respiratory rate 22, and weight 9.7 kg. Examination was significant for no apparent distress, clear lungs, regular heart rate, normal peripheral pulses, and non-focal neurologic exam. Laboratory evaluation was significant for normal urinalysis, normal white blood cell (WBC) count, mildly elevated aspartate aminotransferase (AST) (46), normal carbon dioxide (CO2), and unremarkable metabolic panel. He was treated with a normal saline bolus, famotidine, and ondansetron, and admitted for further management. Admission diagnoses included vomiting and dehydration, and admission orders included fluid resuscitation and follow-up urine culture. Following admission, his diet was advanced and by dinner he was taking a regular diet. The hospitalist advised to monitor overnight but the mother refused, promising to follow-up with the pediatrician the next morning if necessary.

The health plan's determination is upheld.

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of 5 years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications.
This patient was taken to the ED for the second time in several days with recurrent vomiting. He was fluid resuscitated in the ED and had no further episodes of vomiting, but was admitted to document adequate intake without ongoing losses. While this was reasonable and appropriate, particularly because he had recurrence of vomiting, he was overall hemodynamically stable, physically active, without signs of lethargy or sepsis. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Subarachnoid Hemorrhage, Cerebral Vascular Accident
 
Treatment: Skilled Nursing Facility Admission

The insurer denied the Skilled Nursing Facility Admission. The denial was reversed.   

This is a male patient with a medical history of diabetes mellitus (DM), hypertension (HTN), congestive heart failure (CHF) and coronary artery disease (CAD). The patient had a subarachnoid hemorrhage (SAH) and a cerebral vascular accident (CVA) while traveling. The patient was airlifted to the hospital and underwent treatment for his CVA. While in the hospital he was treated for acute renal failure (ARF) and bacteremia. He had a tracheostomy and percutaneous endoscopic gastrostomy (PEG) tube placed for feeding. The patient had bowel and bladder incontinence. Since the SAH the patient has remained encephalopathic, responsive only to noxious stimuli, and has required full ventilator support for respiratory failure.  The patient was transferred to a skilled nursing home for ongoing skilled care. During his nursing home stay he was treated for fevers; sepsis, aspiration. He received antibiotics and management for his tracheostomy and ventilator. 

The patient was total care dependent.  Hospital course was complicated by sepsis/urinary tract infection (UTI).  The patient was bowel and bladder incontinent. Post hospitalization the patient was transferred to skilled nursing facility for ongoing care.  Nursing home stay was complicated by the development of fevers - secondary to sepsis.  UTI Aspiration vs central fevers.  The patient continued on antibiotics and other skilled care which included ventilator management and management of tracheostomy.  The patient was also on PEG feeding and needed management of PEG tube. This patient needed skilled nursing care given his multiple co-morbidities and status of vent dependency status post trach.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for admission to a skilled nursing facility is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pyelonephritis
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.  

This is a female patient with a medical history of hypertension, hyperlipidemia, viral liver disease and latent tuberculosis. She presented to the emergency department (ED) with complaints of back pain, abdominal pain, fever, nausea and vomiting for four days. She reported having a foul smell in her urine. She had been taking Tylenol yielding minimal relief of her symptoms. Laboratory work up was performed; revealing a white blood cell count of 10.5.  Intravenous (IV) fluid and medication were given. Urinalysis was performed that showed large blood and positive nitrites, moderate bacteria, and budding yeast. She was admitted to the hospital for treatment of pyelonephritis. Urology consulted on the patient. A computed tomography (CT) scan of the kidneys was performed that was negative for hydronephrosis. She was treated with IV fluids and IV Ceftriaxone.  The patient clinically improved and was discharged home with follow up instructions. 

According to current literature, a patient may be admitted when there is evidence of hemodynamic instability, vomiting, altered mental status, persistence or worsening of clinical findings such as fever, pain despite observation care treatment with there is a need of parenteral antibiotics needed beyond observation care treatment.  Additionally, if there is evidence of acute renal failure with the need for IV hydration, admission is also appropriate. The admission for pyelonephritis was medically appropriate.  The patient presented with a fever, tachycardia, and flank pain and was found to have leukocytosis and perinephric stranding on CT scan suggestive of pyelonephritis.  She required IV antibiotics and IV fluid administration, as well as a specialist consultation.  Therefore, the requested admission is appropriate in this setting.  The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Viral and Plantar Warts
 
Treatment: Cidofovir Compounded Cream

The insurer denied the Cidofovir Compounded Cream. The denial was reversed.

This is a young female with a history of viral and plantar warts that have been treated for two years with failed results.  It was reported that the patient had undergone topical treatments; salicylic acid in aquaphor, pulsed dye laser surgery, and hyperthermia treatment.  The patient most recently had pulsed dye laser treatment with Cidofovir cream ordered for treatment.

The patient has been treated for over two years for refractory warts.  She has tried and failed multiple commercially available first- and second-line treatments.  The patient has also tried and failed multiple sessions of cryotherapy with liquid nitrogen, topical therapy with salicylic acid wart peels, intralesional immunotherapy with Candida antigen, and paring down procedures.  The patient has refractory warts resistant to conservative therapies.  There is peer review literature to support the use of Cidofovir compounded cream for this patient.  Therefore, the request is approved.

Per Henrickson, S. E., & Treat, J. R. (2017), "Topical cidofovir has been successfully used with minimal risk in children with refractory warts (3).  Of note, there are reports of safe and efficacious use of cidofovir in solid organ transplant patients(4) and cidofovir has been shown in case reports to play a role in treating recalcitrant warts in immunocompromised patients, for example in HIV(5)."

Per Al Aboud, A.M. and Nigam, P.K. (2019), "Cidofovir has been used to treat cytomegalovirus [CMV] infections in HIV patients and case reports suggest it may be beneficial in patients with recalcitrant warts."

Per Padilla Espana L et al. (2014), "Topical cidofovir seems to be a useful alternative for the therapeutic management of recalcitrant plantar common warts that fail to respond to usual treatment."                                                         

The health care plan did not act reasonably or with sound medical judgment or in the best interest of the patient.      

The carrier's denial of coverage for the Cidofovir compounded cream is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Postpartum Endometritis 
Treatment: Inpatient Admission 

The insurer denied the inpatient admission. The denial was upheld. 
This is a female patient presented to the emergency department with abdominal pain, vaginal bleeding with clots and fever for one day. It was reported that she was several days status-post C-section delivery. She had a sonogram which revealed a 9x6cm intrauterine heterogeneous collection, possibly clots versus retained products. She underwent a dilation and curettage (D&C) for treatment of her presenting symptoms. She received intravenous fluids and antibiotics. She remained medically stable and was discharged home the following day. 

The diagnosis of postpartum Endometritis is clinical and largely based upon the presence of postpartum fever that cannot be attributed to another etiology after a thorough history and physical examination. 

The presence of one or more of the following clinical findings: tachycardia, midline lower abdominal pain, uterine tenderness, leukocytosis supports the diagnosis, but these findings are nonspecific.  In particular, variable degrees of midline abdominal pain, uterine tenderness, and leukocytosis are common after cesarean delivery in the absence of infection. This patient was afebrile and she had retained product of conception to explain her pain and bleeding. 

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

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.