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

Diagnosis: Intractable pain; cervical herniated disc; cervical radiculopathy,

Treatment: Inpatient admission

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

This patient is a female who presented to the emergency room after failed attempts at outpatient conservative treatment. She was admitted for intractable pain, cervical herniated disc, cervical radiculopathy, shoulder pain, arm pain-swelling, right arm pain and right hand weakness for 9 days. Her platelets were high at 634 and red cell distribution width (RDW) was high at 15.9. She had a history of thrombocytosis. She was admitted for pain control. She received Decadron intravenously (IV) every six hours, gabapentin 300 mg, heparin subcutaneously every eight hours. The Neurosurgery notes state that the patient did not want surgery. The neurologist recommended intervention if the patient underwent and failed outpatient trial of physical therapy and NSAIDs. His exam was right deltoid 4/5, biceps 5-/5, triceps 4+/5, wrist flexion/extension 5-/5, hand intrinsic 4/5. She experienced mild lower extremity hyperreflexia which may be physiologic. She was treated with Intravenous Decadron and pain management. The pain regimen was as needed (PRN) with morphine, Percocet and Tylenol. She was scheduled physical therapy and Occupational Therapy (PT/OT) consults and follow up MRI cervical spine. On a specified date the patient was seen by Pain Management with exam of 3/5 right grip strength and added gabapentin. She underwent anterior cervical discectomy (ACD) and arthroplasty and was discharged.

In this case, the patient was admitted for intractable pain. She did not want surgery and Neurosurgery felt it was not an urgent situation. She had good relief from pain medication, Percocet. There was no documentation of routine intravenous (IV) pain medications given.

The care could have been provided at an Observation level to control pain and discharged home with conservative treatment. Observation is used for a short period of time for assessment and reassessment before a decision can be made regarding whether a patient will be admitted inpatient or discharged from the hospital.

Therefore, the inpatient hospital stay is not medically necessary. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

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

This is a patient a history of hemoglobin SS disease (sickle cell disease) with hypersplenism and need for multiple admission related to his condition, who presented for care. His mother noted that he had a recent Emergency Department (ED) visit for fever and right foot itching for which he was treated with Benadryl. However, the swelling was not improving so his mother brought him back for further care. At the time of arrival he had tenderness over the 1st metatarsal bones on the dorsum of the right foot, heart rate of 123 beats per minute and respiratory rate of 22 breaths per minute. His lab results were remarkable for a hemoglobin of 7.0 and a white blood cell (WBC) count of 18.3. He was treated with intravenous (IV) fluids, Toradol for pain, Zantac, Tylenol, warm packs and his home medications. The health plan's determination is upheld. This patient has a past medical history of sickle cell anemia, and he presented with pain and swelling of the foot without fever or other concerning finding. He had no concerns of infection, his blood counts were stable, and while he had pain and swelling of the foot, there was no need for antibiotic coverage or treatment of infection. His lab results were at his baseline level and were stable throughout the stay. His care needs overall with Toradol and IV fluids could have been provided safely at a lower level of care.
This patient did not meet the criteria required for acute admission related to his sickle cell disease. There was no concern for acute chest syndrome, he had possibly a very mild vaso-occlusive episode, no clear aplastic or hemolytic crisis, no increasing splenomegaly, and no elevation in the serum bilirubin. He was afebrile, he was clinically stable and had no specific concerns that could not have been safely met at a lesser level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Chest Pain
Inpatient Hospital

The patient is a man with hypertension (HTN), diabetes and tobacco use who was admitted with chest and epigastric pain over 2 days prior to admission. Pulse was 53 beats per minute (bpm), blood pressure (BP) was 146/ 89 and respirations 20. An electrocardiogram (EKG) showed sinus bradycardia and no acute ST-T changes. He was admitted and ruled out for myocardial infarction with negative serial troponin levels. An echocardiogram (ECHO) showed an ejection fraction (EF) of 65%. He underwent a stress myocardial perfusion study which was abnormal.
A cardiac catheterization was performed showing a 70% mid left anterior descending stenosis. Angioplasty and stenting were performed to this vessel. There were no other significant coronary lesions. The evening following the procedure, he was noted to be borderline hypotensive, with MAP 63, and a bolus of 500cc of NS was given. He stabilized and was discharged, on aspirin, Brilinta, Imdur and rosuvastatin.
The inpatient stay is under review.

The health plan's determination is overturned in part. The patient presented with chest pain, and although he ruled out for myocardial infarction, he did have an abnormal stress test indicating myocardial ischemia. At this point, further investigation with coronary angiography is indicated. He underwent this procedure and was found to have a significant stenosis of the left anterior descending. Percutaneous coronary intervention was appropriately performed. Inpatient admission was indicated for evaluation of chest pain, with need for subsequent cardiac catheterization once stress MPI (Myocardial Perfusion Imaging) was abnormal.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Tetraplegia
Issue under review:  FES

Determination:
The FES is not medically necessary.

The patient is an adult male with history AIS (ASIA impairment scale) B C5-C6 tetraplegia secondary to a motorcycle accident, s/p (status post) C4-C7 fusion with loss of volitional motor function in bilateral upper and lower extremities and absent light touch sensation and proprioception bilaterally.

This is an exercise machine that is more likely for the convenience of the patient as an alternative to a more regular exercise program.  This is a request by the treating physician for a RT300 FES stated to be medically necessary to maintain his physical condition and to minimize concomitant medical conditions while using it as an ergometer.

The proposed FES is not medically necessary.  There is no clinical evidence that it, will in whole or in part, reasonably expected to be health beneficial for the patient, and/or withholding it, in whole or in part, is not reasonably expected to affect the patient's health adversely.  As stated above, this is an exercise machine, which is unlikely to be beneficial to the patient because of the level of spinal cord injury.  The request by his treating physician is for a machine to be used to maintain the patient's physical condition.

An ankle-foot orthosis is at least as likely to produce equivalent therapeutic results, as the health plan asserts.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crowded jaws
Issue under review: Comprehensive orthodontic treatment

Determination:
The Comprehensive orthodontic treatment is medically necessary.

The patient has very crowded and narrow jaws. Her four canines are blocked out, meaning they are not in their proper positions due to extreme crowding out by other teeth. It is very important to have all canines in their proper positions so that during the chewing cycle, the other teeth mesh properly. Without the canines to help guide the chewing, many other teeth will bang into each other and cause long term trauma, such as chipping or fracturing. TMJ (temporomandibular jaw) problems will most probably develop over time because of this as well. The only way to put the canines in position is with orthodontic treatment.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Missing teeth; tooth decay
Treatment: Root canal, tooth #10
Crowns, teeth #s 8-10
Retainer crown, teeth #s 17 & 20
Pontic, teeth #s 18 & 19

The proposed treatment for tooth #10 is medically necessary as well as the proposed treatment for teeth #17-20 is medically necessary.  However, the proposed treatment for teeth #8 and #9 is not medically necessary.  

Tooth #10 needs a root canal treatment and a crown; there is decay present. However, there is no indication for the need for crowns on teeth #8 and #9. There is no decay or fractures in these teeth; therefore they are not medically necessary. The patient is missing two teeth in the lower left. A bridge from teeth #17-#20 is medically necessary to give the patient a full complement of teeth to chew with in the lower jaw. The retainer crowns #17 and #20, as well as the pontics #18 and #19, are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

Patients with anemia can be placed in intensive care unit (ICU), inpatient bed or observation unit, depending on their clinical condition. In the presence of hemodynamic instability, respiratory abnormalities (tachypnea unresponsive to treatment, hypoxia, new onset cyanosis, and inability to protect airway), mental status changes, and/or other life-threatening events, inpatient admission and/or transfusion may be medically necessary. 

Although, the patient reported shortness of breath, there was no evidence of respiratory abnormalities on examination; her oxygen saturation was normal at the room air.  Physical examination did not support mental status change.  Further, although she was noted to have low blood pressure, hospital records did not state whether vital sign abnormality was not corrected by appropriate management (intravenous infusion of fluid) within 12-24 hours.  The patient did not show evidence of inadequate systemic perfusion for example, reduced urinary output and myocardial ischemia, etc. 

According to reference material, Hemodynamic instability indicated by one or more of the following):
Vital sign abnormality not readily corrected by appropriate treatment within 12 to 24 hours indicated by 1 or more of the following:
Tachycardia that persists despite appropriate treatment (eg, volume repletion, treatment of pain, treatment of underlying cause)
Hypotension that persists despite appropriate treatment (eg, volume repletion, treatment of underlying cause)
Orthostatic vital sign changes that persist despite appropriate treatment (eg, volume repletion). 
Vital sign abnormality that is severe indicated by one or more of the following:
Inadequate perfusion indicated by 1 or more of the following:
1) Lactic acidosis (greater than 2 mmol/L)
2)Other metabolic acidosis (arterial pH less than 7.35) not otherwise explained
3)New abnormal capillary refill (greater than 3 seconds)
4) Reduced urine output
5) Altered mental status
6)Myocardial Ischemia
Mean arterial pressure[A] less than 60 mm Hg
Mean arterial pressure[A] less than 70 mm Hg after 30 minutes of appropriate treatment (eg, fluid resuscitation)
IV inotropic or vasopressor medication required to maintain adequate blood pressure or perfusion
Sustained heart rate greater than 120 beats per minute in adult or child 6 years or older.

Although, the patient received one unit of PRBC, the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.  Hence, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Compressed discs and narrowed joint spaces

Treatment: Continued chiropractic care

The insurer denied coverage for continued chiropractic care. The denial was upheld.

This patient is a female who has a history of compressed discs and narrowed joint spaces. The patient was being treated with Chiropractic services. The patient was re-evaluated due to subjective complaints of neck and upper back pain. Continued therapy was planned.

The records reviewed did not include any outcome assessment forms to better understand the functional improvement and timeline of the provider's care.  The records reviewed did not include an active care or home exercise program that was adhered to by the patient or prescribed in the records.  There was no rationale during the multiple evaluations to revise the course of care or to obtain a second opinion.  Continued chiropractic care for the date of service specified is not considered medically necessary as well as prospective treatment related to the same clinical condition at this time, with consideration to the current records presented for review.  

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

The records submitted failed to support meaningful improvement in the clinical condition since the examination where the VAS [Visual Analogue Scale] fluctuated back and forth between 2 pain level points, for the most part and rarely went below a 4/10, staying around a 5-6/10 for each visit. Objective findings did not show meaningful improvement between a specified time with range of motion (ROM), orthopedic findings, neuro findings and diagnoses being the same or similar with minimal change during this time.  Denial of additional chiropractic services is acceptable. 

Medical necessity for chiropractic care (CMS section 240), "The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function."

The notes did not support additional meaningful improvement of the patient's subjective or objective findings with continued care.  The treatment appears to be maintenance or supportive care and therefore not medically necessary.

Based on the above, the medical necessity for the continued chiropractic care for date of service is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with short stature and slow growth velocity.  His height was 122.1 centimeters (cm) (height standard deviation score (SDS) -2.3, 1st percentile) and weight was 23.5 kilograms (kg) (4th percentile).  Growth velocity is reported to be 4.1 centimeters (cm)/year.  Bone age was 9 years at a chronological age of 9 1/12 years, predicting an adult height just below 63 inches based on his height measurement at that time.  Insulin like growth factor-1 (IGF-1) level was 232 nanograms per milliliter (ng/mL).  Provocative GH testing with arginine and clonidine revealed a peak growth hormone (GH) response of 28.2 ng/mL.  GH therapy is being requested for treatment of idiopathic short stature.  At issue is the medical necessity of Norditropin Flexpro.
The health plan's determination is overturned.
Based on current Food and Drug Administration (FDA) criteria, a trial of GH therapy is medically warranted in a patient whose height is more than 2 SDs below the mean for age and who is predicted to have a final adult height less than (<) 63 inches in a man.  This patient meets the FDA criteria for treatment, even though his provocative stimulation tests are normal and screening IGF-1 level are normal.
Appeal type: Medical necessity
Decision: Upheld

This is a  patient with chronic lymphocytic leukemia. The patient has previously undergone a matched unrelated donor transplant and has chronic graft versus host disease. The patient  has had a bone marrow examination to evaluate neutropenia; it is consistent with a potential autoimmune neutropenia. The patient  is receiving G-CSF. Intravenous immunoglobulin (IVIG) has been recommended by his physician and is the subject under review. The health plan's determination is upheld in whole. 
This patient is documented to have an absolute neutrophil count of 700. The authors of UpToDate note "...Autoimmune neutropenia is typically characterized by spontaneous remission with disappearance of autoantibodies. Specific treatment of neutropenia is usually not required.... Many patients remain free of infections and require no or minimal medical intervention. Observation with serial blood counts is the most common practice...."
This patient is asymptomatic and is receiving G-CSF. IVIG has been recommended if there is no response. Support for the use of IVIG in patients that are not ill or experiencing recurrent infections is sparse. There is a paucity of evidence that treatment with IVIG improves patient outcomes in this clinical scenario and specific recommendations to intervene are not present. For these reasons, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Appendicitis
Inpatient hospital

The patient is a male who is otherwise healthy and presented to the emergency department with right lower quadrant abdominal pain for the prior day. Ultrasound of the appendix demonstrated a 1 centimeter (cm) enlarged appendix. The patient was admitted and underwent antibiotic treatment prior to laparoscopic appendectomy. Subsequently, the patient was transferred to the recovery room and monitored overnight in the hospital before deemed ready for discharge on the following day.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient could have been safely and appropriately managed a lower level of care. Moreover, patients with acute non-perforated appendicitis like this child had can often be discharged home the same day from the hospital, without an overnight stay. An inpatient stay could be justified if there was some diagnostic dilemma (e.g., complicated appendicitis when computed tomography (CT) had been read as uncomplicated), an untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition.
Surgical treatment of otherwise healthy pediatric patients with acute nonperforated appendicitis is usually provided at a lower level of care. No evidence was presented in the primary medical records that would indicate that an acute inpatient level of care was medically necessary for this case.
Appeal type: Experimental/Investigational
Decision: Overturned

This case involves a male with a 20 year history of reflux that is not effectively managed with maximal medical therapy. He has changes consistent with Barrett's esophagus and was referred for a LINX device for treatment of his gastroesophageal reflux disease. His biopsy several years ago also demonstrated Barrett's as do current biopsies. His current pH testing is markedly abnormal demonstrating gastroesophageal reflux disease (GERD). His high resolution esophageal manometry demonstrates normal esophageal emptying and his upper G.I. shows normal anatomy with the exception of a small hiatal hernia. At issue is the use of LINX Laparoscopic Surgical Esophageal Sphincter Augmentation Procedure.

The health plan's determination is overturned. The Linx procedure is likely to be more beneficial than standard surgical therapy due to the equivalent effectiveness of these two approaches to GERD treatment and the documented lower risk of adverse events after Linx compared with standard surgical therapy (fundoplication). The plurality of the evidence demonstrates that the LINX is more beneficial than the alternative surgical option of fundoplication. Data shows that the procedure is similarly effective against reflux but with lower risks of surgical trauma, bleeding risk, risk of postoperative complications such as gas-bloat and inability to vomit. Currently, numerous published clinical studies have confirmed that the Linx device reinforces the lower esophageal sphincter, effectively reduces the percent time of esophageal acid exposure, and improves GERD health-related quality of life similar to that of fundoplication. In experienced hands, the operation time for Linx placement is shorter than that of Nissen fundoplication, primarily due to the fact that an extensive dissection of the fundus and re-creation of the angle of his and anti-reflux barrier is not necessary. Postoperative dysphagia has been reported, as with fundoplication, and for the majority of patients, these symptoms appear to be short-lived and resolve with observation or with dilation of the gastroesophageal junction.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient is a man (body mass index (BMI) 26 kg/m2) who sought surgical evaluation for the condition of gastroesophageal reflux disease (GERD). The surgical history and physical states that he is treated with Omeprazole for heartburn, but has breakthrough symptoms. He has been diagnosed with Barrett's esophagus despite ongoing treatment with PPIs (proton pump inhibitors). The patient was evaluated due to ongoing symptoms.
An upper gastrointestinal (UGI) showed normal esophageal motility and peristalsis. There was a minimal hiatal hernia and reflux noted during the study.
An esophagogastroduodenoscopy (EGD) showed no hiatal hernia. The pathology report documents the diagnosis of Barrett's metaplasia without dysplasia.
pH testing confirmed pathologic esophageal acid exposure with a DeMeester score of 65.2 (normal < 14.7).
Esophageal manometry identified adequately preserved esophageal motility. There was no manometric hiatal hernia. Distal esophageal amplitude was normal.
The treating surgeon has proposed the LINX procedure as treatment of GERD. The health plan has denied this treatment based on the contention that LINX is E/I.

The health plan's determination is upheld. The LINX is not likely to be more beneficial than standard treatment for this patient's condition of GERD in the setting of biopsy proven Barrett's metaplasia of the distal esophagus. While LINX magnetic sphincter augmentation has been shown by scientific evidence to be safe and effective for the condition of GERD with proven elevated esophageal acid exposure, in this case the records indicate a history of Barrett's metaplasia. The body of published literature regarding the LINX procedure has expanded with data supporting the efficacy and safety of magnetic sphincter augmentation for the diagnosis of GERD. However, in this case the records document the diagnosis of Barrett's metaplasia. LINX has not been adequately tested in such a clinical scenario.