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

Diagnosis: Central Nervous System/Neuromuscular disorder.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Gamunex-C. 
The denial is upheld.

The patient is a female who was evaluated for complaints of dysarthria and dizziness. She had a prior history of an aneurysm repair. She was diagnosed with seronegative myasthenia gravis on the basis of response to steroids. Medications at that time were aspirin, atorvastatin, vitamin D, fluticasone, metoprolol, omeprazole, prednisone, pyridostigmine and sertraline. There is no documentation of a steroid-sparing immunosuppressant. She was considered for intravenous immunoglobulin (IVIG).

Review of a medication claims list indicates prescriptions for prednisone, methylprednisolone and pyridostigmine but none for any steroid-sparing immunosuppressant.

The reason for denial on prior review was that the patient had not had a trial and failure of a steroid sparing immunosuppressant such as azathioprine, mycophenolate mofetil, methotrexate, cyclosporine or tacrolimus.

An office note from her provider indicates that the patient had IVIG twice with improvement. She fell and fractured her ribs. Her Zoloft dose had been increased. Additional recommendations were made for further use of IVIG. The subject under review is the medical necessity for Gamunex-C.

The health plan's determination is upheld.

Gamunex-C is not specifically medically necessary for this patient. This is a patient with a history of seronegative myasthenia gravis. She had previously been treated with pyridostigmine and steroid. She was prescribed IVIG as maintenance therapy without a trial and failure of a steroid-sparing immunosuppressant. In myasthenia gravis, IVIG is evidence-based for one-time use in the setting of an exacerbation. It is also utilized in the setting of medically refractory disease (failure of maximum doses of steroid, steroid-sparing immunosuppressant and pyridostigmine), though the evidence of efficacy for this indication is less robust than that for its use in exacerbation. Other Food and Drug Administration (FDA) approved medications for myasthenia gravis such as complement inhibitors are not appropriate for this patient as there is no evidence of a of acetylcholine receptor antibody or muscle specific tyrosine kinase (MuSK) antibody positivity. The patient does not have an exacerbation. The patient does not have a failure of a steroid-sparing immunosuppressant and pyridostigmine. There is therefore no medical necessity for the use of Gamunex-C in the absence of a trial and failure of a steroid-sparing immunosuppressant, such as azathioprine, mycophenolate mofetil, methotrexate, cyclosporine or tacrolimus.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has multiple risk factors and known coronary artery disease with prior percutaneous coronary intervention (PCI) who had undergone recent catheterization and percutaneous coronary intervention (PCI) of the posterior descending artery (PDA). In the setting of continued angina, he presented for staged PCI of the obtuse marginal instant restenosis. He underwent successful laser atherectomy and percutaneous transluminal coronary angioplasty (PTCA) of the in stent restenosis, but the team was apparently unable to deliver a brachytherapy catheter. The procedure was considered successful, the patient was admitted overnight, and he was discharged the following day without significant event.
An inpatient admission was not medically necessary in this case. Although the patient had some medical problems that are associated with higher risk, the procedure was elective and performed without complications. The care of this patient was most appropriate at a lower level of care. There were no clinical, procedural, electrocardiographic, hemodynamic or post procedural issues that warranted a higher level of service for this patient. As noted above, this elective procedure was performed successfully without complications, and the care of this patient was appropriate at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient has a medical history of cardiomyopathy, persistent abdominal pain, vomiting, and leukocytosis. She presented to the emergency department with constant, nonradiating left lower quadrant abdominal pain for two days, nausea, vomiting, and loose bowel movements. She had been started on ciprofloxacin and metronidazole a day before at an urgent care center. She has been unable to tolerate oral antibiotics due to nausea. Her vital signs were notable for an elevated blood pressure of 174/93 millimeters of mercury (mmHg). The physical examination was notable for a soft, nontender abdomen. Lab results showed white blood cell count of 12.96 thousand per microliter (K/uL) with 85.4% neutrophils, and elevated lactate of 2.9 millimoles per liter (mmol/L). A computed tomography scan of the abdomen and pelvis showed acute left colonic diverticulitis, lack of bowel perforation, and nonobstructive kidney stones bilaterally. She was treated with intravenous fluids, metoclopramide, ciprofloxacin, metronidazole, and Zosyn. Lab results showed an elevated white blood cell count of 11.99 K/uL with 79.4% neutrophils, and a low potassium of 3.2 mmol/L. Lab results showed a normalized white blood cell count and potassium. She was discharged on ciprofloxacin and metronidazole to complete a 10-day course, with a plan for Primary Care, Gastroenterology, and Cardiology follow-up. At issue is the medical necessity of the inpatient level of care.
The inpatient level of care was not medically necessary. In patients with uncomplicated diverticulitis (without complications such as an abscess or perforation), outpatient management or observation is the standard of care [1]. The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated [2]. A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the emergency department and then discharged with oral antibiotics [3]. A systematic review of the literature underscored this [4]. A lower level of care can be appropriate when there are significant symptoms and leukocytosis, or when outpatient therapy has failed, as in this case [5]. There was no protracted fever or hypotension to suggest that antibiotics were ineffective. There had been no evidence of abscess on imaging [4-6]. The patient improved on intravenous antibiotics, and was appropriately discharged on oral antibiotics [7,8]. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, abscess, fistula, or other complication was documented. For these reasons, the inpatient level of care is not supported as medically necessary in this case, and the care could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 
The insurer denied radiation therapy for medical necessity. 
The denial was upheld. 

This patient is a male with a medical history of melanoma, colorectal cancer, and hormone refractory prostate cancer. He had previously been treated with a course of palliative photon-based radiotherapy to the lower thoracic spine. He required reirradiation to the same area for symptom relief and to prevent a pathologic fracture and neurologic decompensation. The patient received proton beam radiation therapy.
At issue is the medical necessity of radiation therapy (proton beam).
The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of radiation therapy (proton beam) was not medically necessary for this patient.

The standard of care radiation modality in the radiation oncology community for reirradiation, is photon-based intensity modulated radiation therapy (IMRT) or stereotactic body radiotherapy (SBRT). Photon-based reirradiation in the form of IMRT or SBRT is supported by the National Comprehensive Cancer Network (NCCN) Guidelines, American Society for Radiation Oncology (ASTRO) Guidelines, and in peer reviewed medical literature. There is currently insufficient high quality clinical outcomes published in peer reviewed medical literature to allow definitive conclusions regarding the relative safety and efficacy of proton beam radiotherapy for reirradiation of spinal metastases in a patient with stage IV prostate cancer with hormonal resistance, as compared to the standard of care of photon-based radiotherapy.

Therefore, the requested health treatment of radiation therapy (proton beam) was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision-Infection. 
Treatment: Inpatient hospital stay. 

The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination. 

This is the case of a patient with past medical history of hypertension who presented to the emergency department with 2 weeks of right eye swelling and redness now also affecting her left eye despite being on neomycin eye drops as an outpatient for the prior 2 days. 

On presentation, she was afebrile with blood pressure 149/97, heart rate 70, respiratory rate 18, and with oxygen saturation 99% on room air. Exam otherwise noted swelling and erythema around her bilateral eyes with bilateral conjunctival injection and purulent drainage, and no sinus pain, conjunctival injection, or pain with eye movement. Labs resulted with white blood cell count (WBC) 9.4, Hemoglobin (HGB) 13, platelets 264, sodium 142, potassium 4.0, blood urea nitrogen (BUN) 12, creatinine 0.7, liver function tests within normal limits, lactic acid 1.6. A computed tomography (CT) scan of the orbits showed no post-septal orbital inflammatory changes with no signs of orbital cellulitis. In the emergency department, she was given intravenous (IV) Vancomycin and ampicillin. She was brought into the hospital with concern for preseptal cellulitis and conjunctivitis and plans for Unasyn, Bactrim, Vigamox eye drops, and ophthalmology consult in the morning. 

She remained hemodynamically stable. Repeat labs were unremarkable. Ophthalmology saw the patient with assessment that she had viral conjunctivitis and with plans for timolol eye drops and ophthalmology clinic follow up. IV antibiotics were stopped. 

Inpatient level of care was not medically necessary. 

This is a patient who presented with bilateral eye swelling and redness that had not improved despite neomycin drops as an outpatient. Given worsening despite neomycin and concern for preseptal cellulitis, she was certainly appropriate to bring into the hospital for further monitoring, initial treatment with IV antibiotics, and ophthalmology consultation. It is unclear, however, why she could not have been safely cared for with lower level of care services in the absence of fever, imaging, or exam concern for frank orbital cellulitis, and in the absence of risk factors such as uncontrolled diabetes or other immunocompromise complicating her course or risk of adverse event and failure to respond to therapy. Furthermore, it is noted that ophthalmology assessment was that she likely had viral conjunctivitis with no antibiotics needed and with the patient safe to discharge on eye drops with follow up in the outpatient setting. Lower level of care services were appropriate for this patient without signs or symptoms or orbital cellulitis presenting with hemodynamic stability and with no underlying conditions predisposing the patient to high risk infection who additionally was able to be discharged very quickly from the hospital. Inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer.
Treatment: Zoledronic acid 4 mg.
The insurer denied Zoledronic acid 4 mg.
The determination is upheld.

The patient has a history of ductal carcinoma in situ of the left breast. The patient has undergone a mastectomy and received adjuvant tamoxifen. The patient has osteopenia. Zoledronic acid has been recommended and is under review for medical necessity.

The Zoledronic acid 4 mg is not medically necessary for this patient.

The authors of UpToDate unequivocally state "...There is no role for pharmacologic therapy as a means to maximize peak bone mass, except in very special circumstances...". These "very special circumstances" include "...physiologic hormone replacement for deficiency states in children, such as growth hormone deficiency or hypogonadotropic hypogonadism..."; this patient has no special circumstances. Prospective studies demonstrating a benefit to outcomes in this patient population have not been published. Lacking support in the peer-reviewed literature, in national guidelines, and by the authors of UpToDate, medical necessity cannot be established for this service/treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Infertility.
Treatment:  Current Procedural Terminology (CPT) code 81443 Genetic testing for severe inherited conditions (e.g., cystic fibrosis, Ashkenazi Jewish-associated disorders [e.g., Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachs disease], beta hemoglobinopathies, phenylketonuria, galactosemia, genomic sequence analysis panel, must include sequencing of at least 15 genes).

The insurer denied coverage for CPT code 81443.  The denial is upheld. 

This is a female patient with a diagnosis of infertility.  The provider ordered an extensive genetic carrier screening panel.  The patient has no personal or family history of any of these conditions and she does not belong to an ethnic group at high risk for these conditions.

The patient had genetic testing panel Current Procedural Terminology (CPT) code 81443 Genetic testing for severe inherited conditions (e.g., cystic fibrosis, Ashkenazi Jewish-associated disorders [e.g., Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachs disease], beta hemoglobinopathies, phenylketonuria, galactosemia, genomic sequence analysis panel, must include sequencing of at least 15 genes).

As per the American College of Obstetricians and Gynecologists (ACOG), "All patients who are considering pregnancy or are already pregnant, regardless of screening strategy and ethnicity, should be offered carrier screening for cystic fibrosis (81220) and spinal muscular atrophy SMA (81401).  All other genetic carrier screening in the absence of a positive family history or personal history and in the absence of an ethnic background at high risk for these conditions is considered not medically necessary."  ACOG based their recommendation on the fact that there is insufficient scientific evidence that the requested gene panel will have a significant impact on treatment planning or outcome.

So based on ACOG's recommendation and standard of care and the scientific evidence there is no benefit from panel testing.  

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome in this clinical scenario.  This patient is not a good candidate for CPT code 81443.  CPT code 81443 is not the best available treatment for this patient at this time.  The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for CPT code 81443 should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Congestive Heart Failure.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who presented to emergency department (ED) for dyspnea which was been increasing for 4 days. He also has a cough with sputum production. He has shortness of breath at night and inability to sleep. He also gained weight. The patient takes Torsemide every other day (he claimed that he cannot take it every day because he cannot go out after taking Torsemide), his cardiologist approved it. The patient drinks over one gallon of water per day.
The patient previously was seen with congestive heart failure (CHF) exacerbation, and has history of noncompliance with medications. He has known ejection fraction (EF) of 35%. The patient was admitted to the hospital with CHF exacerbation.

The Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented with worsening shortness of breath and was diagnosed with acute on chronic systolic heart failure exacerbation. The patient had an established diagnosis. The patient was well known to the cardiologist from previous inpatient and outpatient care. The overall impression was that the patient's CHF exacerbation most likely was due to poor compliance. The patient was treated with IV (intravenous) diuresis and improved. His vital signs were unremarkable. There were no additional diagnostic or therapeutic tests done. The patient had chronic renal disease, but it was not addressed with additional tests or procedures. Based on above, the patient's condition and management did not meet inpatient admission criteria. A lower level of care was more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman with a history of asthma who was admitted to the hospital. She presented with three days of diffuse worsening headache, photophobia and double vision. She was in her usual state of health until two weeks prior to presentation when a bicycle fell on the right side of her head. She did not lose consciousness. She delayed presenting to the emergency department due to concerns about COVID-19 exposure and childcare responsibilities. As her pain worsened, she was referred to the emergency department by her primary care doctor. The dizziness persisted for four days prior to admission and she reported feeling as though the room was spinning. She denied chest pain, shortness of breath and abdominal pain. In the emergency department, there was concern for meningitis versus carotid arterial dissection versus intracranial hemorrhage. She underwent lumbar puncture which demonstrated a low white blood cell count and the meningitis/encephalitis panel was negative, total protein was 29 and glucose 55. Head computed tomography (CT) was negative for acute findings. She was given intravenous (IV) antibiotics. Vital signs showed temperature 98.4 Fahrenheit heart rate 72 respiratory rate 18 blood pressure 124/87. On physical exam, heart was regular, breath sounds were normal, cranial nerves were intact, and there were two beats of nystagmus with right eye abduction. Visual fields were intact and strength was normal in all extremities. Labs showed white blood cell count (WBC) 4.0, hemoglobin 14.7, platelets 277, potassium 4.3, and creatinine 0.78. The patient was admitted for a headache with concern for post concussive syndrome in the setting of recent trauma. 

The hospital admission was not medically necessary. The patient underwent an extensive work up in the emergency department that ruled out several diagnoses and her lumbar puncture was negative for evidence of infection. Neurology also saw the patient and assisted with ruling out meningitis. The patient's symptoms resolved rapidly and there were no acutely concerning imaging or laboratory findings. Overall, she could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Seizures.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a man with history of seizures, alcohol abuse, hypertension, hyperlipidemia, prior subdural hematoma, and schizoaffective disorder who was admitted to the hospital. He was brought in by ambulance for seizures. According to his mother, he had two seizures at home and developed altered mental status. His fingerstick was 84 according to emergency medical services. In the emergency department, he had an episode of seizure that was witnessed by nurses and involved shaking of the entire body. Vital signs showed temperature 98.4 Fahrenheit, heart rate 92, respiratory rate 20, and blood pressure 179/95. On physical exam, heart was regular, breath sounds were normal, abdomen was soft, cranial nerves were intact, and there was no motor or sensory deficit. The patient appeared intoxicated. Labs showed white blood cell (WBC) 5.7, hemoglobin 12.2, platelets 117, sodium 139, potassium 4.1, calcium 8.5, creatinine 0.93, aspartate aminotransferase (AST) 95, alanine aminotransferase (ALT) 82, creatinine kinase 380, and Alcohol level 79. The patient was admitted with seizures and concern for alcohol withdrawal. The plan of care included Keppra, Neuro checks, monitor mental status, Ativan as needed for withdrawal, and intravenous (IV) fluids. Neurology saw the patient, and their assessment was that the patient had a breakthrough seizure due to non-adherence to medications and alcohol withdrawal. 

The Inpatient level of care is medically necessary for this patient with withdrawal and with evidence of alcohol withdrawal seizures. The episodes may be self-limited or may progress to additional seizures, loss of ability to protect the airway, and other complications. These types of patients require a higher level of care.
The patient presented with seizure in the setting of alcohol withdrawal and then had a subsequent seizure in the emergency department. Overall, there was concern that the patient's presentation was due to alcohol withdrawal seizures. He was seen by neurology and was at an increased risk of recurrent seizure due to his prior history of seizure and witnessed seizure episode in the ED. He was also hemodynamically unstable with hypertensive urgency. Patients with alcohol abuse who are experiencing withdrawal can rapidly deteriorate clinically, with delirium tremens, seizures requiring intensive care unit management and inability to protect the airway, and prolonged disability. Overall, the intensity of care required for patients with active withdrawal is increased and an inpatient level of care is appropriate.