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

Diagnosis: Pneumonia and sepsis

Treatment: Inpatient admission

The insurer has denied Inpatient admission. The denial was reversed.

This patient is a male who was admitted to the inpatient medical hospital as he had pneumonia and sepsis and was also getting methadone for heroin detoxification. He also had alcohol and cocaine use. He had requested heroin detoxification. Medical issues included worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia as well and was noncompliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in 3 months. He also received IV antibiotics but signed out AMA.

The insurer denied coverage for inpatient medical hospital treatment as not medically necessary treatment. They stated that he had no hemodynamic, pulmonary, neurological, or metabolic reason for hospitalization, and they recommended a less restrictive level of care. 

Chart notes provided enough specific evidence to support the patient required 24-hour hospital treatment during the period in question. The American Psychiatric Association Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicate those patients who exhibit failure to achieve abstinence or patients who relapse frequently, or fail to be cooperative with or benefit from outpatient detoxification; currently abuse 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 serious medical problems, including pneumonia and sepsis. He had methadone for heroin detoxification and had been drinking alcohol and using cocaine. He had worsened shortness of breath, cough, sputum production with yellow phlegm, and dyspnea on exertion. He had recent pneumonia, as well and was non-compliant with antibiotics. His CT revealed reticular infiltrates and he had a 20-lb. weight loss in three months. He also received intravenous (IV) antibiotics, so he could not safely and effectively be treated for heroin detoxification in an outpatient setting. He required 24-hour medical hospital treatment then. 

According to the LOCADTR, he did require 24-hour treatment as he could not safely and effectively be treated in outpatient detoxification settings, as he continued to use heroin, alcohol, and cocaine, despite multiple serious medical issues, and he required and needed methadone for heroin detoxification. He was at risk for worsened withdrawal symptoms if not in this 24-hour setting; including severe withdrawal symptoms. He had serious medical issues complicating treatment for heroin detoxification. Inpatient medical hospital treatment was medically necessary. The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell crisis
 
Treatment: Inpatient admission, medication, monitoring

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

This case involves a male who was brought to the hospital by ambulance with a complaint of pain in his low back, knees, hip, and chest. He complained of sickle cell crisis at presentation.  The patient had no cardiac history and was compliant with his medications. He was alert and oriented; he had no shortness of breath, no loss of consciousness, and lung sounds were clear and equal.  The abdomen was flat and soft.  The patient had no rigidity.  His pain was rated 10/10, blood pressure was 117/73, respiratory rate was 18, pulse rate was 90 and oxygen saturation was 100%.  Upon reevaluation, the patient's blood pressure was 93/55 and oxygen saturation on room air was 94%.  The patient was admitted for sickle cell crisis.  This was the patient's usual sickle cell crisis presentation. He had 2 rounds of pain medication and stated he still had his crisis pain. The patient underwent a chest x-ray which was normal.  The EKG showed normal sinus rhythm.  He refused intravenous fluids.  The patient was treated with pain medications. His pain improved and he was discharged.

MCG indicates that admission for sickle cell may be appropriate for patients who have acute pulmonary symptoms, hypoxemia or acidosis, and altered mental status, respiratory treatments needed that can only be performed in an acute inpatient setting, or pain insufficiently responsive to observation care that requires treatment in inpatient setting, such as parenteral opioids.  The patient did not have hypoxemia or an altered mental status. He responded to pain medications. The records failed to support the patient could not have been treated at a lower level of care, such as observation.  The patient was not noted to have failed observation care.    

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

Diagnosis: Septicemia

Treatment: Inpatient Admission

The insurer denied Inpatient Admission. The denial was reversed. 

This is a middle aged patient who was referred to the emergency department (ED) from a nursing home. He presented with complaints of fever, anemia, and left foot ulcer. The patient was started empirically on intravenous antibiotics (Vancomycin and Zosyn) for a chronic left foot infection/foot ulcer; a foul smelling discharge was noted from his left extremity. In addition, the patient required hemodialysis. An x-ray of the foot showed diffuse tissue swelling; an osteomyelitis could not be ruled out. A chest x-ray revealed moderate bilateral pleural effusions with underlying atelectasis or infiltrate.

According to the documentation, the patient was referred to the hospital from nursing home after developing fever (100.4 F) at hemodialysis and was noted to have severe anemia. The patient had numerous laboratory abnormalities including leukocytosis (WBC 16.4), anemia (Hgb 7.3), chest x-ray findings, as well as a chronic left foot infection. He required hemodialysis and had co-morbid risk factors.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure Disorder

Treatment: Inpatient Admission

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

This is a middle age male who presented to the Emergency Department in early 2019 by Emergency Medical Services for a syncopal episode.  Per the patient's wife, the patient was out of consciousness until Emergency Medical Services arrived for approximately 10 minutes later. The patient complained of a headache upon arrival, however, he denied chest pain, shortness of breath, and palpitations. It was noted that Cardiopulmonary resuscitation was performed by bystanders at the scene. His physical examination revealed the patient was awake and oriented x 3. The patient had no focal deficits and had a normal motor and sensory examination. He had an EKG which was normal and a computerized tomography scan of his head which was unremarkable; no intracerebral hemorrhage or contusion was identified. The patient was consulted by neurology for questionable seizure activity. The patient was discharged on Keppra after neurology confirmed the patient was stable. He was instructed to follow-up in one week.  

MCG indicate that admission may be appropriate for patients who have a new onset severe neurologic finding requiring inpatient care, a neurological trauma requiring inpatient treatment, or for a neurologic condition, symptoms, or finding for which emergency and observation have failed or are not considered appropriate. Additionally, admission for seizure would be appropriate for patients who had status epilepticus or repetitive seizures not controlled with emergent treatment, brain disorder, cardiac arrhythmia of immediate concern, altered mental status that is severe or persistent, a new focal neurologic deficit, or for a recurrent seizure. The records supported that the patient had a syncopal episode, rule out seizure. The patient was admitted with the diagnosis of seizure. At the time of admission, the patient did not have focal deficits and had not failed Emergency Department care. The records failed to support that the patient had hemodynamic instability, status epilepticus, repetitive seizures or recurrent seizures.  The records failed to support that the patient could not have been placed at a lower level of care, such as observation.

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

Diagnosis: Possible Sepsis/Pneumonia/Bronchitis

Treatment: Inpatient admission

The insurer denied inpatient admission. The denial was upheld.

This is a female who presented to the Emergency Department (ED) with complaints of fever, chills, muscle aches and pains, along with some blood streaked yellow sputum.  The patient has a past medical history of diabetes mellitus, hypertension, hernia repair, status post Cesarean section and myomectomy.

At presentation to the ED, vital signs included a temperature of 101F, a heart rate of 105, a respiratory rate of 20, and a blood pressure of 144/90 mm Hg.  Oxygen saturation on room air was 99%.  The patient was awake and alert.  Head, ears, eyes, nose, and throat (HEENT) exam was within normal limits.  Lungs were clear.  Cardiovascular system (CVS) S1 S2 was normal.  The abdomen was soft and non-tender.  The patient was alert and oriented x3. The white blood cell (WBC) count was 5.18K, the hemoglobin was 12.3 and electrolytes were within normal limits. The blood urea nitrogen (BUN)/Creatinine was 12/0.7 respectively. A respiratory syncytial virus (RSV) panel was negative, as was influenza.  The lactate was 1.4, the procalcitonin level was 0.15 and the urinalysis (UA) was negative. A chest x-ray had no acute infiltrate noted.

The patient was empirically started on broad spectrum antibiotics - Vancomycin/Cefepime for possible Sepsis/Pneumonia/Bronchitis.  The patient remained stable after presentation.  As per the history & physical, the patient was in no acute distress.  She was hemodynamically stable and not hypoxic.  Lungs were clear.  The WBC count was normal.  The chest x-ray was negative.  The patient's fever came down.  She remained afebrile and hemodynamically stable with oxygen saturations of 96-99% on room air.  The patient was subsequently switched to Rocephin and Azithromycin.

The patient remained stable after admission.  An additional WBC count was normal at 4.4K.  Blood and urine culture & sensitivity were negative.  There were no signs of sepsis.  The patient did not need acute hospitalization.  She could have been placed under observation status while diagnostic testing and treatment were initiated.  The patient was tolerating oral intake and could have been switched to oral antibiotics and discharged home with close follow-up in an outpatient setting.  The patient had bronchitis and no evidence of pneumonia radiologically.  The WBC count was normal.  The patient was not hypoxic.  The CURB 65 score was Zero.  

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

Based on the above, the medical necessity for the inpatient admission for acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer # 3:

This is a female patient who has successfully undergone 2 frozen embryo transfers. She is planning another attempt for in vitro fertilization pregnancy. She would like to have pre- implantation diagnosis for fetal aneuploidy using polar body biopsy.

The test is recommended for the member in expert guidelines and is the most appropriate test in these circumstances, and is shown to improve the rate of success for pregnancies in these circumstances and it also helps prevent pregnancies with aneuploidy. 
 
According to Vitez, S. F., et al. (2019), "Miscarriage is a frequent outcome seen in obstetrics with 1 in 5 pregnancies ending in an early pregnancy loss.  Aneuploidy is the most significant single factor affecting early pregnancy failure and miscarriage.  The risk of aneuploidy increases significantly with increasing maternal age.  There has been tremendous advancement in technology that has made preimplantation genetic testing for aneuploidy reliable and accessible.  For women in their mid-to-late 30s there is great utility in the use of PGT-A to facilitate single embryo transfer, reduce the risk of clinical miscarriage and ongoing aneuploidy gestations.  The current data supports use of preimplantation genetic testing for aneuploidy and single embryo transfer for this population of women."

The carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be reversed, as this procedure is likely to be more beneficial than any of the standard testing / procedures.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer # 2:
This is a female patient, gravida 3 para 1. She has twins who were previously conceived with in vitro fertilization of cryo preserved embryos from her original in vitro fertilization cycle with oocyte polar body pre-implantation genetic testing for aneuploidy.

According to Capalbo, A., et al. (2016) states, "Blastocyst biopsy is now widely used for both preimplantation genetic screening (PGS) for aneuploidies and preimplantation genetic diagnosis (PGD) of single gene defects.  In particular, trophectoderm biopsy coupled with comprehensive chromosome screening (CCS) now represents the most promising approach for PGS to detect aneuploidies coming from both male and female meiosis, as well as clinically relevant mitotic errors fixed during preimplantation embryo development."      

The patient is a good candidate for this procedure because she is at increased risk of conceiving embryos with fetal aneuploidy due to her history of infertility and advanced maternal age.     

The carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: IVF with preimplantation genetic screening. 
 
Treatment: 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.  

The insurer denied the 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos. The denial was reversed. 

Reviewer #1: 

This is a female patient G3P1 who previously received in vitro fertilization. She has a history of frozen embryo transfer twice without success. Her last attempt of frozen embryo transfer resulted in a biochemical pregnancy.  She would like to attempt another in vitro fertilization cycle with preimplantation genetic screening.
American Society of Reproductive Medicine (ASRM) also stated the following:" A study of women with recurrent miscarriages found no evidence of benefit of preimplantation genetic screening in women of any age."

At this time there are no data to support preimplantation genetic screening for recurrent unexplained miscarriage and recurrent implantation failures; its use for these indications should be restricted to research studies with appropriate informed consent. 

This patient is not a good candidate for the procedure, as the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos does not have final approval from the appropriate regulatory bodies for this diagnosis.
The requested service is not the best available treatment for this patient at this time, and is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
Issue under review: Intracept procedure

Determination:
The health plan should not cover the intracept procedure.

The health plan should not cover the proposed treatment based on general standard of care for vertebrogenic pain, and based on the patient not meeting the following recommended requirements by RELIEVANT, the Intracept Medical device manufacturer (source: https://www.relievant.com/wp-content/uploads/2019/05/MKT_0066-RevD_-_Reimbursement_Guide.pdf):

 Intracept is medically indicated in patients who have
- A history of low back pain of at least 6 months duration; and
- Failed to respond to at least 6 months of non-surgical management; and - MRI demonstrated Modic Type 1 or Type 2 changes* at one or more vertebrae from L3 to S1; and
- Activities of daily living that are limited by persistent low back pain; and 
- All other reasonable sources of pain have been ruled out.

The above-recommended requirements have not been met for the INTRACEPT procedure, because despite history of chronic low back pain of more than six months, the MRI findings did not point to any evidence of Modic type 1 or type 2  changes at any vertebra. There is also no documented evidence of limitation of ADLs (activities of daily living) by the patient, and that all other reasonable sources of the chronic low back pain have been ruled out.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
Issue under review: Intracept Procedure

Determination:
The health plan should cover the Intracept procedure.

Although intraosseus radiofrequency treatment of the basivertebral nerve (Intracept procedure) is a relatively new treatment for low back pain with Modic endplate changes, there is adequate evidence from randomized controlled trials, cited below, including a multi-center trial, to substantiate its effectiveness.  The patient's symptoms and the MRI evidence of Modic endplate changes confirm that the patient suffers from the type of back pain that has been shown to benefit from this treatment.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
Issue under review: Intracept procedure

Determination:
The health plan should cover the Intracept procedure.

The requested procedure is a new, albeit FDA-approved procedure with this patient's indication in mind. There are RCT (randomized controlled trials) that show its effectiveness at two years.  In fact, there is another follow-up study where it was recommended that patients cross over to the treatment arm due to effectiveness early on.  The indication is for back pain that is thought to be originating from endplate degeneration (modic changes), which is what is shown in this patient. The patient has failed conventional treatment, including PT (physical therapy), Medial branch blocks, and medications. 

Given that the alternative options (lumbar fusion), have not shown to have favorable responses for axial low back pain in the literature and is much more invasive, the requested Intracept procedure should be approved.
Appeal type: Medical necessity
Decision: Overturned

This patient has a past medical history of atrial fibrillation, multiple myeloma, deep venous thrombosis and recently had surgery for a leg fracture. The patients physician submitted a letter in support of increasing home care hours from 7 hours per day, 7 days per week to 10 hours per day, 7 days per week, and includes the following: Over the past year, the patient has had multiple hospitalizations and admissions for rehabilitation. 
 
The insurer denied coverage for personal care aide (PCA) services 10 hours per day, 7 days per week (total 70 hours per week). The denial was reversed.

This patient has extensive health problems and functional impairments.  She lives in a private home with her son and is dependent on assistance from others for all instrumental activities of daily living (IADLs) and needs extensive to maximal assistance for all activities of daily living (ADLs), except eating (limited assistance).  Based on her medical history, it appears the patients functional limitations are associated with various medical conditions, e.g. heart failure (may cause dyspnea, fatigue); arthritis (pain, decreased range of motion, unsteady gait); multiple myeloma (back pain, fatigue); obesity, body mass index (BMI 34.2; obesity is associated with risk for progression of osteoarthritis, and increased functional limitations and disability in the elderly). In addition, the patient needs assistance for locomotion/walking, transfers, toileting, incontinence care which occur at various and unscheduled times during the day and night.  The level of assistance needed by the patient for most ADLs requires substantial physical assistance from the caregiver (weight-bearing support).  Even when the patient is in bed, she needs extensive assistance for bed mobility.  This is an important aspect of her care, as immobility increases risk of pressure ulcers, so she needs help repositioning when in bed. The patient cannot prepare her meals; and she needs some assistance with eating.  Therefore, the patient would not be able to effectively manage having a meal, snack or fluids when she is alone. As per New York State regulations for personal care services, assistance from informal caregivers is voluntary.  The patients son is the only informal caregiver identified in the 2019 Uniform Assessment System. The patient needs a caregiver (paid or voluntary) present in her home to provide assistance with ADLs (including toileting, incontinence care, transfers, locomotion, bed mobility) during the day and night as a result of her functional impairments associated with multiple medical conditions. The son is requesting PCA services 10 hours per day (3 more hours per day than currently approved).  It is reasonable to conclude that he cannot provide care on a consistent basis for 10 hours per day. Therefore, it is medically necessary for PCA services to provide the assistance the patient requires during those 10 hours.
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the ER with a 3 day history of nausea, vomiting, and diarrhea and was subsequently admitted to inpatient.  The health plan has denied the inpatient stay as not medically necessary.  The health plan's determination is overturned.  This patient with nausea, vomiting, and diarrhea had moderate dehydration based on both clinical and laboratory evaluation and failed prior outpatient and ED management.  She required overnight hospitalization for continued IVF hydration to ensure safe discharge.