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

Diagnosis: Advanced Osteoarthritis in Knees
 
Treatment: Synvisc-One injections

The insurer denied the Synvisc-One injections. The denial was upheld.    

This is a female patient with a history of bilateral knee osteoarthritis. She was evaluated in early 2019 and found to have effusions, tenderness to joint lines and decreased motion. A positive McMurray test was reported. Her x rays were reported to demonstrate advanced osteoarthritis to her knees. She had received Synvisc 1 in mid-2017 and early 2018 with good relief. Her physician recommended physical therapy and steroid injection. These treatment options were discussed. "The patient declined at this time and wants Synvisc to both knees."

The health plan acted reasonably with sound medical judgment in the best interest of the patient. Medical necessity is not substantiated. The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis if all other courses failed prior to surgery. The recommendations for use of Viscosupplementation have changed. 
A review of the Clinical Practice Guideline by American Association of Orthopedic Surgeons (AAOS) cites:

The 2013 OA knee treatment CPG contains one significant recommendation change from the 2008 CPG, and this is with regard to the issue of viscosupplementation. The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG.

The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, May 2013.)



Based on the above, the medical necessity for Synvisc-One injections is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of alcohol and cocaine abuse who was admitted to an inpatient detox facility and left against medical advice the following day.

On admission to the detox unit he is recorded to have complained of nausea, fatigue, insomnia, tremors, loss of appetite, anxiety, nervousness, restlessness, irritability, and sweats. The admission physical exam documents no abnormalities (e.g. dry skin, no finding of tremor). However, a Clinical Institute Withdrawal Assessment (CIWA) administered as part of the same evaluation documents a score of 12. The admission history and physical (H&P) does not document medical decision making around which complaints, if any, were better attributable to his recent cocaine use. His vital sign readings around the time of admission included a pulse of 58 and blood pressure of 127/80 at 1100 hrs and a pulse of 61 and blood pressure of 129/77 at 1220 hrs. The admission plan includes that he will be placed on a Librium taper. The medication administration record was not included for review. The nursing notes throughout the brief stay indicate he was calm and did not complain of withdrawal. His vitals the remainder of the stay ranged from 59-81 for pulse and 100-121/73-80 for blood pressure. On midday of the following day he requested to leave and was discharged with recommendations for follow up. He was not given any prescription for withdrawal prophylaxis.

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld. The patient did have a documented history of alcohol and cocaine use disorder. He did not have a history of seizures or delirium tremens. He was last in detox the month prior. The chart does not include a complete review of symptoms related to substance use disorder that would clarify severity. The chart did not include an admission LOCADTR. The nurses and doctors in the E.D. documented that there was no evidence of withdrawal but the plan was for inpatient level of care. No rationale is provided. The detox admission note documents a normal physical exam but a CIWA of 12 and that the patient had multiple complaints. The CIWA scale is a clinical tool that must be put into a full clinical context. Many of the variables on the CIWA scale can also be explained by recent cocaine use. The included chart does not include any medical decision making/reasoning around which symptoms were more or less likely to be attributable to alcohol withdrawal or recent cocaine use. The admitting providers did not document medical decision making around why inpatient level of care was needed. Why his initial urine was positive for benzodiazepines is not explored in the included chart. A LOCADTR assessment was completed using the relevant information documented in the chart and resulted in a recommendation for outpatient services with ancillary withdrawal services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion
Treatment: Inpatient admission
Inpatient level of care was not medically necessary.

An uncomplicated, elective cardiac catheterization was performed in this patient without chest pain, who had normal left ventricular (LV) function, an intermediate lesion RCA, and a minor finding on the anterior wall on nuclear study. No evidence of active ischemia was documented nor likely correlation of objective findings and symptoms. Thus this was a routine intervention that is usually performed at a lower level of care. 

The determination of the level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS). Exam and cardiac findings were normal including excellent LV function. Biomarkers and electrocardiogram (EKG) showed no evidence of acute ischemia ("abnormal nuclear stress test" was borderline). Chest x-ray (CXR) was normal. Echocardiogram showed no wall motion abnormality.  Nuclear scan was equivocal.  The Physicians' treatment did not reflect any serious emergent concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).   

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care provided was catheterization and telemetry, both frequently performed in a lower level of care. The patient was admitted for monitoring post procedure and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. 

The letter of appeal noted that the patient's age was over 85 years and that infusion of magnesium for a borderline low level required inpatient level of care. This is not consistent with admission criteria or community medical practice. While there may be an increased risk of an adverse event in the elderly population, one did not happen and no additional therapy was required.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present or conditions that did require an advanced level of care. All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was medically unnecessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:Palpitations 
Treatment: Inpatient admission 

Summary:
The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care.  There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia, with normal function.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added. All testing and therapy would have been appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, neck stiffness
Treatment: Inpatient admission
Inpatient level of care was not medically necessary.

This patient had atypical chest pain and a multitude of symptoms. While she had been previously scheduled for a cardiac catheterization as an outpatient, it was stated that was done reluctantly and planned to help her anxiety. Nuclear stress test and all objective testing had shown no evidence of ischemia. There was no suspicion of acute coronary syndrome (ACS) upon arrival at the emergency room (ER), no treatment for same and she was admitted for observation. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam (blood pressure [BP] normalized) and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Recent nuclear scan was negative for coronary artery disease (CAD). The Physicians' statements and treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).   

The letter of appeal was carefully considered but it offered no evidence to support necessity of inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD. All tests showed absence of ischemia.  While always a potential for an adverse event (and in this case a very low probability), one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present. The appeal note that stated that the admission was for cardiac catheterization is not consistent with history as the patient had that electively scheduled prior to this admission (reluctantly). Also cardiac catheterizations are routinely performed in a lower level of care.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diplopia

Treatment: Inpatient Admission

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

This is a male child who presented to the emergency department with complaints of a sudden onset of diplopia. According to his father the patient was unable to use his fork. He also reported that it happens when he takes his patch off. The patient does have a history of amblyopia with acute onset of painless horizontal binocular diplopia with neurological deficits. The documentation detailed that the patient's symptoms did resolve during transport to the emergency department. It was noted that the patient's neurological exam was normal. The dilated exam was normal with intermittent medial deviation of the left eye. Neurology evaluated the patient recommending a magnetic resonance imaging of the brain. The patient underwent the magnetic resonance imaging (MRI), resulting a normal MRI of the brain and orbits with and without contrast with scattered non-specific foci of T2 hyperintensity within the white matter bilaterally.  The patient's hospitalization was uneventful. He was discharged home with follow up instructions.

According to referenced literature the patient may be admitted for inpatient services when there is evidence of vasculitis, a cerebral aneurysm, a new onset severe neurologic finding that requires inpatient services or if there is evidence of encephalitis within the documentation none of the above was present. The patient was seen and directly admitted from an outside facility due to an acute onset of diplopia. The patient's neurologic examination was normal and it was recommended he undergo an MRI. The MRI did not reveal any significant acute abnormalities and it was recommended the patient follow-up with the pediatrician.

The insurer's denial of coverage for inpatient admission is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer#3

This is a female patient who is status post colonoscopy which revealed a small intestinal lymphoma located in the terminal ileum; duodenal type. A capsule endoscopy is under review. 
The primary indications for Wireless Capsule Endoscopy (WCE) or Video Capsule Endoscopy (VCE) are for diagnosis of obscure gastrointestinal bleeding location in adults (including iron deficiency anemia), suspected Crohn disease, and small bowel tumors. The procedure can be performed both in the ambulatory outpatient setting or inpatient for hospitalized patients.

Video capsule endoscopy (VCE) allows expanded range of endoscopic examination of the small bowel. The clinical application of VCE is mainly for Obscure Gastrointestinal Bleeding (OGIB). A small bowel tumor is one of the clinically significant diagnoses of VCE. Subsequent invasive interventions typically follow. 

Small bowel tumors are detected with a frequency of around 4% with VCE in indications of OGIB, iron deficiency anemia, unexplained abdominal pain, and others. "Familial adenomatous polyposis, Peutz-Jeghers syndrome, melanoma, lymphoma, and neuroendocrine tumor with hepatic metastasis are the high-risk groups for small bowel tumors, and surveillance programs for small bowel tumors are needed."(Young Cheung, D., et al. 2016). VCE and radiological imaging have value in screening.

According to the American Society for Gastrointestinal Endoscopy (ASGE) (2019), "Capsule endoscopy helps your doctor evaluate the small intestine. This part of the bowel cannot be reached by traditional upper endoscopy or by colonoscopy. The most common reason for doing capsule endoscopy is to search for a cause of bleeding from the small intestine. It may also be useful for detecting polyps, inflammatory bowel disease (Crohn's disease), ulcers, and tumors of the small intestine."                                                    

The carrier's denial of (91110)-capsule endoscopy should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer#2

This is a female patient who was diagnosed with follicular lymphoma, suggestive of duodenal grade 1-2. The patient was scheduled to have a series of diagnostic tests which included an upper esophagogastroduodenoscopy (EGD) with biopsies, a small bowel capsule endoscopy to study the rest of the small bowel, and a computerized tomography (CT) scan of the chest, abdomen, and pelvis.

Primary indications for capsule endoscopy are evaluation of suspected small bowel bleeding in adults, diagnosis of suspected Crohn's disease, and the diagnosis of small bowel tumors. The scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes.  The (91110) - capsule endoscopy does not need final approval from the appropriate regulatory bodies for this diagnosis. The lymphoma that was found incidentally was from an upper, small bowel origin, although found in the lower small bowel (terminal ileum). This indicates a diffuse process in the small bowel. The nature of the disease low grade lymphoma is widespread involvement and it is essential to determine the extent of involvement to plan treatment. A CT scan is not a good test for lesions in the small bowel, especially the type of lesions that were found in the terminal ileum. They can only be found on endoscopy. The standard of care next step of evaluation is an upper endoscopy, but this would only evaluate up to the duodenum. It is essential to evaluate the entire small bowel given the diffuse involvement noted by pathology already. The only way (short of surgical exploration, which is inappropriate) to evaluate the entire small bowel is a capsule endoscopy. The patient is a good candidate for (91110) - capsule endoscopy, as this is considered the standard of care. The (91110) capsule endoscopy is the best available treatment for this patient at this time.  

Therefore, as noted above, due to the need to evaluate the entire small bowel, short of inappropriate surgical intervention, the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of (91110)-capsule endoscopy should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Follicular Lymphoma
 
Treatment: (91110)-Capsule Endoscopy

The insurer denied the (91110)-Capsule Endoscopy. The denial was reversed. 

Reviewer #1:

This is a female patient who had under gone a colonoscopy screening for cancer.  A biopsy of the terminal ileum was performed that revealed low grade follicular lymphoma. It was advised that the patient have further testing done which included a video capsule endoscopy.  

The American Society for Gastrointestinal Endoscopy (ASGE) has reviewed wireless capsule endoscopy. The guideline has been published in Gastrointestinal Endoscopy 2013; 78: 805-815. Under the section on Indications, it states that a common application for capsule endoscopy is suspected small-intestine tumors.

Gastroenterology 2017; 152: 497-514 has published an article "Clinical Practice Guidelines for the Use of Video Capsule Endoscopy." The Article states that capsule endoscopy is suggested for surveillance in patients with small bowel cancer who require small bowel studies.

This patient had a lymphoma of the small intestine that was read as duodenal type. An investigation of the remainder of the small intestine was needed. Based on the guideline of the ASGE and the review article from Gastroenterology, it has been shown in the medical literature that when a small bowel tumor is present, capsule endoscopy is an appropriate test. Therefore, the test is supported by the literature and has ASGE approval for this indication. The patient needed small intestinal staging of the tumor; therefore, she was a good candidate for the test. Video capsule endoscopy is an effective test to examine for small intestinal tumors. Video capsule endoscopy is a safe, effective exam for examining the small intestine for tumors in a patient with small intestinal lymphoma. As such, this procedure is likely to be more beneficial for this patient than any standard treatment/procedure.

The carrier's denial of (91110)-capsule endoscopy should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pulmonary embolism
Treatment: Inpatient stay 
The inpatient admission was not medically necessary.

Summary:
This is a man with a history of HTN (hypertension), OSA (obstructive sleep apnea), anxiety and schizophrenia who presented complaining of three days of SOB (shortness of breath).  The patient was admitted with a diagnosis of PE (pulmonary embolism).

Evaluation showed the patient was hemodynamically stable with normal oxygenation on RA (room air).  The patient did not have history of cancer, heart failure or lung disease.  He did not have findings of tachycardia, tachypnea or hypertension.  Based on the patient's presentation, he was at low risk.  Individuals with low risk do not require treatment at an inpatient level of care.  The treatment provided did not require an inpatient level of care.  The inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a female patient with a history of one episode of generalized tonic-clonic (GTC) seizure  who presented to the emergency room (ER) with syncope for 10 seconds and new GTC seizure for 3 seconds followed by postictal phase for 2 minutes.  Blood glucose was checked and it was 77.  Neurology was consulted, and they recommended admission for video electroencephalogram (VEEG).  This was the second episode for this patient.  The last episode EKG was normal and 45 min-1 hour spot EEG was done and was negative.  Basic metabolic panel (BMP) was significant for elevated glucose at 228.  A complete blood count (CBC) was unremarkable.  Respiratory syncytial virus (RSV) and flu were negative.  An electrocardiogram (EKG) was performed and was normal.  She was admitted to the pediatric floor.  She did not have any seizures on the floor.  The video EEG was done for 48 hours and was unremarkable.  Cardiology was consulted and an echocardiogram (ECHO) performed, which was normal.  The health plan's determination is upheld.  

This patient presented with her second non-febrile seizure.  Upon arrival she had already returned to baseline.  She demonstrated no altered mental status.  17 months prior she had a normal EEG and normal EKG when she presented with her first seizure episode.  Her laboratory studies were unremarkable, and her vital signs were stable.  Inpatient level of care would not be required for a video EEG or echocardiogram.  Once deemed clinically stable in the ER she could have been treated at a lower level of care.  She did not require any highly skilled or technical care while in-house and remained seizure free throughout her stay.  Inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient right upper lip and right arm numbness and tingling, light headed sensation and dizziness 
Treatment: Inpatient stay 

Summary:
The patient presented with transient paresthesia, but she had a normal neurological examination and neuro-imaging. The distribution of symptoms would be atypical for TIA (transient ischemic attack). Risk stratification based on symptoms and history did not warrant acute admission. The neurological evaluation, monitoring, diagnostic studies and treatment could have been safely and effectively provided at a lower level of care.