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

Diagnosis: Alcohol dependence
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was not medically necessary.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care for the time interval under review. The acute inpatient treatment of this patient's substance use disorder did not require the continued structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and the use of crack cocaine. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted continued inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment in the past with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. Thus, the request for continued inpatient level detoxification treatment and other medical services were not medically necessary in this case scenario, as the patient could have been safely and effectively managed with lower level services in a less restrictive treatment setting.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting for the DOS under review. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and stimulants/cocaine. Moreover as noted, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted continued inpatient level treatment. There were no severe symptoms of withdrawal or biomedical issues in this case, and the mild symptoms of withdrawal quickly resolved with normal vital signs and functioning with regard to daily activities, sleep and appetite. The request for continued detoxification treatment and 24-hour monitoring, and the other inpatient level services in this case were not medically necessary, as the health plan asserts. NY State OASAS LOCADTR 3.0 Criteria/Guidelines, as referenced below, are not met for the continued inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   
This is a middle aged male who presented to the Emergency Department (ED) in late 2018 with complaints of a headache, related to a syncopal episode from earlier that morning, causing an occipital hematoma. The patient reported that he had just finished a five day course of Lasix for lower extremity edema. His medical history includes; sarcoidosis with pulmonary involvement, inflammatory polyarthropathy, an anterolateral scar, ventricular ectopy including nonsustained ventricular tachycardia, nonischemic cardiomyopathy with a left ventricular ejection fraction (LVEF) of 23%.  An electrocardiogram revealed normal sinus rhythm with premature ventricular contractions (PVCs) and atrial premature complexes (APCs), first degree atrioventricular (AV) block (0.27) and small Rs in V1-5.  
He was evaluated by electrophysiology and the heart failure team, and underwent implantation of an implanted cardioverter defibrillator during hospital course. He was then discharged home.
Evaluation and treatment for syncope could have been completed at an observation level of care, based on his clinical presentation, prior diagnostic test results, and results of testing done shortly after presentation.  

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol and Heroin Detoxification
 
Treatment: Inpatient Admission

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

This is a male patient who was admitted to inpatient substance detoxification treatment in early 2019 for alcohol and heroin detoxification. He reportedly had withdrawal symptoms including tremors, sweats, nausea, anxiety, irritable mood, urges, yawning, difficulty sleeping, and fatigue with a Clinical Institute Withdrawal Assessment (CIWA) of 17. He has a significant history of daily alcohol drinking and heroin use. He continued substance use despite being in a current Methadone Maintenance Program. He was put on a Librium taper during this admission. He reportedly lacked coping skills and had difficulty identifying relapse triggers. He was discharged and referred back to the Methadone Maintenance Program.

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders states 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. This patient had a significant history of alcohol and heroin use. He was at high risk for severe withdrawal symptoms and even complicated and life threatening withdrawal. He required inpatient substance detoxification treatment. He was at risk for accidental overdose. 

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

The patient is a male with atopic dermatitis (AD). The patient has tried and failed topical steroids and Elidel. The provider requested Dupixent. This was denied as the health plan does not consider it to be medically necessary until all criteria are met. The subject under review is the medical necessity of Dupixent. 
The health plan's determination is upheld. 

Dupixent is not medically necessary as the patient does not have a documented contraindication, intolerance, or failure (CIF) to tacrolimus or phototherapy or systemic immunosuppressive medications.
While phototherapy may not be convenient to the patient's schedule, this is not a medical contraindication to preferred therapy. Dupixent is Food and Drug Administration (FDA) approved for the treatment of moderate to severe atopic dermatitis in patients over the age of 12. Standard treatment options for patients with atopic dermatitis include a regimen of topical steroids as well as topical calcineurin inhibitors. After topical agents fail, standard practice is to pursue systemic therapy such as phototherapy.

According to Wong et al., (2017) "Topical agents are the mainstay of treatment for mild-moderate AD and include topical corticosteroids (TCS) and topical calcineurin inhibitors (TCI). TCS are effective agents in addressing the pruritus and inflammation of AD and work by inducing inhibitory proteins that decrease inflammatory mediator activity.
For patients with moderate-to-severe disease refractory to topical therapy, consideration should be given to the use of phototherapy or systemic immunomodulatory agents. Narrow-band ultraviolet B (UVB) (wavelength = 311 nanometer [nm]) is the most commonly used type of phototherapy for AD and is typically administered 2 to 3 times per week. Narrow-band UVB is a safe option that can provide relief from the signs and symptoms of AD. Cyclosporine A is a calcineurin inhibitor that controls T-cell mediated inflammation by preventing the transcription of inflammatory cytokines. Cyclosporine A has been found to be effective in the management of severe and refractory AD in adults and children. Methotrexate, azathioprine and mycophenolate mofetil are antimetabolite medications that work as a folate antagonist, purine analog and purine synthesis inhibitor, respectively. These medications have been shown to be variably effective in treatment-resistant AD."

Systemic immunomodulators (e.g. cyclosporine, methotrexate, azathioprine, mycophenolate) are a prevalent treatment option for the management of chronic and/or severe atopic dermatitis. They are recommended in the care of those patients in whom optimized topical regimens and/or phototherapy do not adequately control the disease or when there is a substantial impact on the quality of life (QOL).

While the patient has tried and failed Elidel, the patient has not tried and failed tacrolimus which in comparison with Elidel has been found to have greater efficacy. The patient also has no history of skin cancer and is not immunosuppressed. The patient has no documented CIF to phototherapy or systemic immunosuppressive medications.
Appeal type: Medical necessity
Decision: Upheld

The patient was initially diagnosed with non-Hodgkin's lymphoma in 1991, at which time the patient received 6 cycles of chemotherapy and remained in remission for 19 years. Over the past one year the patient developed weakness, fatigue, left hip pain, and an unintentional 30-pound weight loss. An magnetic resonance imaging (MRI) was performed for evaluation of the hip pain and was read as showing a mass, and biopsy interpreted it as recurrent lymphoma. At issue is the inpatient stay.

The health plan's determination is upheld. The inpatient stay is not medically necessary. The patient was clinically stable at the time of admission, with normal vital signs and no complaints of any symptoms. The patient had no signs or symptoms suggestive of infection. The RICE chemotherapy regimen is not one that requires intensive support as indicated by carrying a high risk of prolonged marrow suppression (such as leukemia induction) or the need for aggressive hydration that cannot be managed in an infusion center. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypercalcemia, 
 
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This case involves a female patient with a history of kidney disease who presented to the Emergency Room. The patient reported being sent by her primary care physician after lab work had been obtained earlier in the week for work-up of hypercalcemia, and revealed a calcium level of 13.4. The patient also reported chronic left hip pain, as well as dyspnea with some palpitations. The patient had a past medical history of hypercalcemia, end-stage renal disease, and chronic hormonal imbalance. The patient reported that she had been dealing with this for the past year, and had been feeling lethargic and crampy when she walked too long. She had shortness of breath when taking stairs, in addition to urinary frequency. Upon examination, the physician noted that the patient was awake, alert and in no acute distress. The patient appeared tired looking. The assessment was otherwise negative. The patient had an EKG that revealed normal sinus rhythm at 61 beats per minute. Intravenous (IV) fluids were started and the patient was admitted for recurrent hypercalcemia.

There was no documentation of the calcium level being uncorrectable with emergency or observation level of care or no documentation of dehydration that was severe or persistent as evidenced by acute loss of weight from baseline, hemodynamic instability, acute renal failure, serum sodium greater than 150 mEq/L, significant symptoms or findings of altered mental status, cardiac abnormality, or malignant etiology requiring inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and Dyspnea.
 
Treatment: Inpatient Admission

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

The patient was a female patient with a past medical history notable for coronary artery disease, hypertension, diabetes mellitus, gastroesophageal reflux disease (GERD), and hyperlipidemia. She was brought by emergency medical services (EMS) to the ER with complaints of constant chest pain and dyspnea. The symptoms had been present for 1 day. She had a positive stress test at her cardiologist's office, and was advised to have an angiogram within 1 week. Physical examination was unremarkable. She was admitted to telemetry. She underwent coronary angiography, which showed 30% stenoses in the left anterior descending artery (LAD) and right coronary artery (RCA) with a patent stent in the circumflex artery. No revascularization was indicated. There were no complications. She was subsequently discharged home the next day.
Initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.
The cardiac catheterization did not require inpatient admission. There were no extenuating circumstances which establish medical necessity of inpatient level of care. 

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

Diagnosis:  Shoulder pain, cervical radiculopathy, chronic low back pain
 
Treatment:  Additional Physical Therapy Services

The insurer denied coverage for additional physical therapy services.  The denial was reversed.

This patient has a past medical history of diabetes mellitus type 2, degenerative joint disease (with previous bilateral total hip replacement), renal stones and asthma and who has been seen in physical therapy for right shoulder pain, cervical radiculopathy and chronic low back pain.  Per the physical therapy progress note, the right shoulder pain was a 10/10 and described as sharp, constant and aggravated by overhead movements and relieved by rest.  Low back pain was an 8-9/10 and described as throbbing, constant and aggravated by sitting and relieved by side-lying.  The patient did not have pain improvement with cyclobenzaprine and acetaminophen.  The patient was improving with physical therapy; however, the patient had to attend to family issues for two weeks.  The patient had an exacerbation of symptoms with increased stiffness and lack of motion.  Per physical therapy note three weeks later the patient was seen for right shoulder pain and low back pain.  Pain was a 6/10.  Since the last visit, the patient received an intra-articular corticosteroid injection into the right shoulder.  The patient reported the pain was improving and the patient was able to do more with physical therapy. 
  
The patient completed at least 25 physical therapy visits.  The patient's pain had decreased from a 10/10 to a 6/10.  While the patient did have some decreased range of motion to the right shoulder, the patient's recent cortisone injection to the right shoulder was providing significant pain relief, which allowed the patient to do more physical therapy exercises.  The patient previously had improvement in pain and range of motion in the lumbar spine with physical therapy.  Therefore, additional physical therapy visits would be appropriate.  As such, the additional physical therapy services are medically necessary, and the prior determination is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart block
 
Treatment: Inpatient admission, invasive procedure, monitoring

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

Patient was a man with a history of 2nd degree heart block, coronary artery disease, hypertension, hyperlipidemia, and diabetes mellitus. He presented to the Emergency Room (ER) with chest pain, lower extremity swelling, high blood pressure, and low heart rate. Heart rate on arrival was less than 40. EKG showed type II second degree heart block. He was admitted and evaluated by Electrophysiology. He was noted to have 2:1 heart block with a right bundle branch QRS, consistent with infra-nodal disease. He was treated with implantation of a permanent pacemaker. There were no procedural or post-operative complications. Echocardiogram showed normal cardiac function. He was discharged home. 

Inpatient admission status was medically necessary, per 22nd Edition MCG Guidelines for Cardiovascular Surgery or Procedure GRG: SG-CVS (ISC GRG). The member presented with symptomatic bradycardia with EKG evidence of high-grade atrioventricular block, requiring acute inpatient monitoring and definitive management with pacemaker implantation prior to discharge from the hospital.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Issue under review: Formulary exception for Emgality

Determination:
The health plan should not cover the Formulary exception for Emgality.

There is no documented reason as to why the patient cannot be treated with the preferred formulary alternative agents that he has not tried (divalproex sodium, timolol).  All of these agents are considered to be first-line treatment for his condition. There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Emgality relative to these medications.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Seizures
Issue under review:  Epidiolex

Determination:
The health plan should not cover the Epidiolex.

There is no evidence in the published medical literature or practice guidelines that for the patient's intractable localization-related epilepsy, Epidiolex is suspected to be more safe and/or more efficacious than available treatment approaches approved for localization-related epilepsy, such as Felbatol, Sabril, zonisamide or vagus nerve stimulator. 

As per Billakota, "Identification of CBD, 9-THC, and the endocannabinoid system in the mid-20th century has led to advancement of cannabis-based therapies for epilepsy.  Based on clinical trial data, Epidiolex is the first CBD medication approved by a national regulatory agency (US Food and Drug Administration for Dravet and Lennox Gastaut syndrome; European Medicines Agency for Lennox Gastaut syndrome).  Approval of CBD as a treatment for these rare and severe pediatric-onset epilepsy syndromes is an important milestone, but the complete spectrum of use of cannabis-derived products and the use of CBD for other epilepsy syndromes remains to be determined."

Therefore, there is no evidence that Epidiolex would be more beneficial than any of the standard treatments, and it should not be covered by the health plan.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:   Seizures
Issue under review: Epidiolex

Determination:
The health plan should not cover the Epidiolex.

The use of Epidiolex in this clinical context is not standard of care.  There are no clinical guidelines that support the use of Epidiolex for persons with seizures unless the underlying etiology is Dravet syndrome or Lennox-Gastaut syndrome.  There are no high-quality clinical trials supporting that Epidiolex improves outcomes in this clinical context or that it is equivalent or of superior efficacy to standard anticonvulsant regimens.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Seizures
Issue under review:  Epidiolex

Determination:
The health plan should cover the Epidiolex.

The request is for a cannabinoid (CBD) to improve seizure frequency in this patient with intractable epilepsy.  The best data is for certain epilepsy syndromes (Dravet's); however, some anecdotal reports and open label studies showed a 50% reduction in seizure frequency in pediatric and adult cases.  In this case, the patient has tried and failed multiple medications, in addition to two surgeries.  Therefore, a trial of CBD is warranted.
Appeal type: Medical necessity
Decision: Upheld

Peripheral Vascular Disease/PVD
Inpatient hospital

The patient is a female who presented to the emergency department (ED) with bilateral lower extremity (LE) edema. She is on chemotherapy for breast cancer. The patient suffered from generalized body aches. She was recently admitted to outside hospital for bilateral cellulitis, worsening LE swelling and redness. She was discharged one week prior after 4 days of intravenous (IV) antibiotics. She had subjective fever and chills. She was concerned about increased discharge from her leg wound. The patient also reported worsening dyspnea and orthopnea.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient has multiple chronic medical problems. Her DVT was treated previously. She did not have acute DVT during this admission. She did not have pulmonary emboli. She continued on anticoagulation, as prior to admission. There were no indications for inpatient admission from her DVT standpoint. The patient had an ulcer on her leg with drainage. However, it appears to be chronic and not infected. Only local care was recommended. There was no evidence of cellulitis. After one dose of IV Vancomycin, no more antibiotics were administered. There were no indications for inpatient admission from her venous ulcer standpoint. The patient came with worsening edema and dyspnea. However, her physical examination did not suggest acute distress due to heart failure. Her CXR did not reveal congestive heart failure (CHF). Her BNP and troponin was normal. 

She was treated with IV Lasix, and her improvement was measured by subjective criteria-less shortness of breath. The patient's condition and management does not meet criteria for inpatient admission. Her echocardiogram was unremarkable. There was mentioned "elevated left atrial pressure to 22". The accuracy his parameter is highly controversial. The inpatient admission was not medically necessary. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multifocal Bronchopneumonia 

Treatment: Inpatient Admission

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

This is a middle aged female who presented to the ED in early 2019 with complaints of shortness of breath for 3 days, dry cough, pleuritic chest pain, chest congestion, fatigue and headache. The patient reported a sick contact. Vital signs were:  Temperature 98.1 F, Heart Rate 123, Respiratory Rate 18, Blood Pressure 142/67, and Oxygen saturation was 97%. She was noted to have decreased breath sounds over right lower lobe.
Diagnostic testing revealed the patient had an elevated white blood cells (WBCs) to 13.8K, and uncontrolled blood sugar BG > 200.  A Chest x-ray was done which showed bilateral increased interstitial markings; mild pulmonary edema. A Computerized Tomography (CT) of the chest revealed multifocal bronchopneumonia and a pleural based mass over the left upper lobe 3.3 X4.6x2.6 cm; negative for a pulmonary embolism. Infectious Disease (ID) recommended treating the patient with intravenous (IV) Rocephin and Azithromycin. Her WBCs were monitored and she continued on IV antibiotics for treatment of bronchopneumonia, and was then discharged home. 

Given the patient's complicated presentation with multifocal bronchopneumonia and a pleural based mass whose etiology was not clear, it was appropriate for this patient to be admitted for treatment, observation and further diagnostic studies to arrive at a diagnosis. The patient was seen by Interventional Radiology who recommended a Tri phasic CT to rule out arterio-venous malformation before CT guided biopsy as the lesion had shown some features to suggest vascularity. The patient was scheduled for a CT guided biopsy, however she refused. 

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.