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

Diagnosis: Constipation
Treatment: Linzess
The treatment with Linzess (linaclotide) is not medically necessary.

The patient is a female with bowel frequency of 1x/week. She has reportedly failed to benefit from milk of magnesia, magnesium oxide, Colace, Miralax. Claims data, however, only supports past use of Miralax and limited use of bisacodyl tablets as part of a colonoscopy preparation.

In treatment of the patient's condition, her health plan prefers she try psyllium as well as bisacodyl or senna. Her provider however opines that Linzess 145 mcg daily is the standard of care here. 

Evaluation as provided has been limited to colonoscopy which showed a small polyp. Neither a diagnosis of constipation-predominant Irritable Bowel Syndrome (IBS-C) nor Chronic Idiopathic Constipation (CIC) appear in available records. Rather, the provided ICD-10 code 59.00 for the patient denotes a diagnosis of unspecified constipation.

At issue is the medical necessity of Linzess as proposed.

Linzess is a guanylate cyclase-C agonist that is FDA-indicated in adults for treatment of IBS-C and chronic idiopathic constipation (CIC). (2)  

Linzess has demonstrable efficacy in patients with FDA-indicated use, with an NNT (number of patients needed to treat) of 5.1 (4)

The patient's records do not however convincingly demonstrate a diagnosis of CIC.  As such, off label use of Linzess is not medically necessary in preference to Plan recommended trials of Metamucil and/or bisacodyl or senna.

Available records do not support that the patient's constipation is acute, life threatening, nor refractory to as yet untried conventional medical treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Headache, sore throat, UTI
Treatment:  Inpatient admission
The inpatient admission was medically necessary.

The patient is a female whose inpatient admission is under review.  The patient has no significant past medical history (PMH) and presented with one day of fever, headache, right-sided eye pain, and sore throat.  She had frequency for two days, but denied dysuria, or hematuria.

In the ER:  
Temperature (T) - 102.8  
Pulse (P) - 120 
Respiratory rate (RR) - 20  
Blood pressure (BP) - 123/82 (decrease to 93/63)
General - mildly obese, no acute distress (NAD)
Head, ears, eyes, nose and throat (HEENT): positive (+) for erythema in throat, no exudate
Cardiovascular system (CVS) - tachycardia, otherwise normal
Chest - normal
Abdomen - left (L) costovertebral angle (CVA) tenderness
Skin - no rash

Labs revealed the following:
White blood cell (WBC) - 13.3 (high)
Hemoglobin (Hg) - 11.8 
Hematocrit (HCT) - 37.1
Platelets (PLT) - 349
Sodium (Na) - 135 (low)
Potassium (K) - 4.1, then 3.4 (low)
Chloride (Cl) - 100
Carbon dioxide (CO2) - 21
Blood urea nitrogen (BUN) - 8
Creatinine (Cr) - 0.9
Aspartate aminotransferase (AST) - 14
Alanine aminotransferase (ALT) - 33
Alkaline phosphatase (Alk phos) - 81
Lactate - 0.81

Throat was positive for strep A antigen.  Urine analysis (UA) was cloudy, with small blood, negative nitrite, moderate leucocyte esterase (LE), 25-50 WBC, eight to ten red blood cells (RBC), moderate bacteria, and moderate epithelial cells.

In the ER, the patient was thought to have sepsis secondary to pyelonephritis, along with a group A streptococcal infection.  In addition, she was found to be anemic, have hypokalemia, and hyponatremia.  Ultrasound showed mild hydronephrosis of the right kidney. Finally, the patient had an abnormal electrocardiogram (EKG) (T wave inversion V4-6).  The patient was hospitalized to stabilize the infection (treated with intravenous (IV) ceftriaxone), and treat other abnormalities noted above.  She improved quickly, and was discharged on 07/23/2019 on oral (PO) Keflex.


Outpatient treatment for pyelonephritis in women is given for uncomplicated cases (1). In this patient, the pyelonephritis was complicated for the following reasons (standard of care):  1)	Sepsis: high WBC count, tachycardia, tachypnea, hypotension, and 2)  Concomitant existence of another infection (group A strep pharyngitis).

Thus, this admission was warranted, supported by standard of care and IDSA guidelines. Failure to admit such as a patient can lead to loss of function, septic shock, or death.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Favorable Intermediate Risk Prostate Cancer, Elevated Prostate Specific Antigen (PSA)
 
Treatment: Oncotype DX Genomic Prostate Test

The insurer denied the Oncotype DX Genomic Prostate Test.  The denial was upheld.

This is a male patient with a diagnosis of favorable intermediate risk prostate cancer with an elevated prostate specific antigen (PSA) of 5. An Oncotype DX GPS test was performed to assist in identifying the appropriate treatment strategy. 

The Oncotype DX GPS is a biopsy based multigene test that has been clinically validated to provide an additional measure of risk stratification at the time of diagnosis to assist in decision-making for male patients trying to decide on treatment vs. active surveillance for localized prostate cancer.  This patient has PSA of 5, Gleason score 3+3 in 2/12 biopsies.  He is classified as having low risk prostate cancer.  

While National Comprehensive Cancer Network (NCCN) guidelines do state that molecular testing, including Oncotype DX GPS, be considered for men with (NCCN) low risk or favorable intermediate risk prostate cancer, and at least a 10 year life expectancy they note the absence of randomized prospective trials.  

American Urological Association (AUA) guidelines, on the contrary, state that for men with localized prostate cancer, "tissue based genomic biomarkers (such as Oncotype DX GPS) have not shown a clear role in active surveillance for localized prostate cancer, and are not necessary for follow-up."  The impact of tissue based gene expression tests, such as Oncotype DX PCA, on clinical practice and long term patient outcomes remains to be empirically demonstrated.  Prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking.

1)	The Oncotype DX GPS test for date of service specified does not show an improvement in health outcomes, as far as scientific evidence in peer reviewed literature supports.
2)	The Oncotype DX GPS test for date of service specified is approved by Medicare for reimbursement in certain cases of prostate cancer.
3)	This patient has low risk prostate cancer by biopsy/PSA/clinical exam results, and low risk prostate cancer does not automatically require additional confirmation of such by genomic biomarker testing.
4)	The genetic testing for date of service specified is not the best available treatment for the patient at this time.  Oncotype DX GPS is a laboratory based test, and not a treatment, per se.
5)	The requested service (Oncotype DX GPS test) for date of service specified is not likely to be more beneficial than any of the standard treatments/procedures for this patient.  Although it has bene studied at different institutions and clinically validated as an additional measure of risk stratification, it is not yet clear where this test fits into the algorithm of the diagnosis or management of prostate cancer.

The carrier's denial of coverage for genetic testing for prostate cancer should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney stones. 
Treatment: Inpatient admission. 

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

The patient is a male who was admitted with left renal colic. His vitals were: temperature 97.3, blood pressure 155/83, pulse 103 and respiratory rate 18. The WBC (white blood count) was 5600. The creatinine was 1.2. CT imaging demonstrated a 5 mm left distal ureteral calculus with mild hydronephrosis. The urinalysis had trace leukocyte esterase. IV (intravenous) pain medications, nausea medications and IVF (intravenous fluids) were administered. 

No, the proposed inpatient admission was not medically necessary. 

An acute inpatient level of care was not medically necessary. The patient's care could have been provided at a lower level of care. He was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis. Following admission, there were no unstable vital signs reported. He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, or persistent vomiting. Pain control and IVF followed by discharge in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems 
Dental/Orthodontic Procedure 

Diagnosis: Impacted teeth 
Treatment: Braces 

The insurer denied braces. The health plan's determination is overturned. 

The patient in question is a female with impacted teeth #6 and #11. She presents with a skeletal Class I malocclusion and significant crowding. She is treatment planned for 24-30 months of braces to address the crowding and impacted teeth, but treatment was denied due to lack of medical necessity. 

Orthodontic Treatment: Braces are medically necessary for this patient. The patient has impacted teeth #6 and #11. If left untreated the damage that can occur to the patient's teeth will be more time consuming and difficult to correct than the patient's existing orthodontic problem. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisors. For this reason, the braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Gastroenteritis. 
Treatment: Inpatient Admission. 

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

This is a patient with a history of Guillain-Barre, spinal stenosis, and Von Willebrand. She presented to emergency Department with complaints of nausea, vomiting, and diarrhea. She had a nerve block procedure two days earlier.  She reported having 40 episodes of vomiting and diarrhea. She had a fever of 101.2, but the vital signs were stable. Her abdominal exam was benign. There was no leukocytosis and her renal function was normal. The lactic acid was 4.4 with a repeat lactic acid result of 2.2. She was diagnosed with viral gastroenteritis. Intravenous (IV) hydration and anti-emetics were given. Her symptoms then improved. 

Clinical indications for admission for gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, severe vomiting, and severe dehydration. The patient did not have these conditions. After receiving intravenous hydration and anti-emetics, her symptoms resolved and the renal function was normal. 

This patient had gastroenteritis. She required intravenous hydration and anti-emetics. This could have been given with observation status. She did not meet MCG criteria for admission for gastroenteritis. The healthcare plan acted reasonably and with sound medical judgment and in the patient's best interest. An inpatient stay was not medically necessary. The denial is upheld. 

The carrier's denial of coverage for inpatient stay is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis
Treatment: 15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk 
The insurer denied the 15734 - Muscle, myocutaneous, or fasciocutaneous flap; trunk. 
The denial is overturned. 

Yes, the proposed treatment, 15734 - muscle, myocutaneous, or fasciocutaneous flap; trunk, was medically necessary.

The patient had a large defect in the gluteal region following resection of the hidradenitis. Options for management of the wound include closure by secondary intention, skin graft, fasciocutaneous flap or myocutaneous flap.  Fasciocutaneous flap is the preferred closure treatment.  Secondary intention is a very slow process, and skin grafts are prone to infection and breakdown. Myocutaneous flaps can affect ambulation.  Fasciocutaneous flaps (FC) have a robust blood supply and are more resistant to infection. 

Flap reconstruction was the most appropriate treatment for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Dental Disorder
Treatment: Braces, Monthly visit x4. The plan denied Braces, Monthly visit x4.
The determination is upheld.

The patient has severe maxillary and mild mandibular crowding. Tooth number (#) 11 has erupted labial within the arch due to lack of space. The patient has a class I occlusion with a 5 millimeter (mm) overjet and 30% overbite. The patient is treatment planned for orthodontics to align the teeth and correct the bite. At issue is the medical necessity of braces and monthly visit times (x) 4.
Tooth #11 is crowded but it has erupted successfully. There are no indications of gingival recession or pathology from the tooth position of #11. The tooth was not so crowded that it was prevented from erupting, which left untreated it could damage the roots of other permanent teeth (1) leading to more invasive procedures.
While the patient has crowded teeth, there is not an anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (2) The patient presented with none of those conditions. If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Fever and Rash.
Treatment:  Inpatient admission.
The insurer denied the inpatient admission.  The denial is overturned.

The Inpatient admission was medically necessary.

The patient is a male whose inpatient admission is under review.  The patient has a history of CAD (coronary artery disease), cardiomegaly, depression, DM (diabetes mellitus), hypothyroidism, pneumonia, and sleep apnea.  He presented with fever, headache, photophobia, and rash.  The patient reported that he had symptoms for two days.  His symptoms included joint pain, sore throat, diarrhea, dizziness, and pleuritic chest pain.  He had recent travel to [an island].

In the ER, the patient's vitals were as follows: T (temperature) - 99.1, P (pulse) - 98, BP (blood pressure) - 111/67, RR (respiration rate) - 19.  On general examination, the patient was found to be NAD (no acute distress).  The patient's CVS (cardiovascular examination) revealed tachycardia, regular rhythm, no M/R/G (murmurs, rubs, gallops).  The patient's pulmonary and abdominal examinations were normal.  Examination of the patient's skin revealed warm, dry, blanching, erythematous maculopapular rash on chest, back, neck, extremities, and scalp.

The patient's labs were as follows:  1)  WBC (white blood count): 4.4 (low), 2)  Hg (hemoglobin): 12.0 (low), 3)  Hct (hematocrit): 33.9, 4)  Plt (platelets): 78 (low), 5)  Na (sodium): 133 (low), 6)  K (potassium): 3.6, 7)  Cl (chloride): 95 (low), 8)  CO2 (carbon dioxide):  29, 9)  BUN (blood urea nitrogen): 20, 10)  Cr (creatinine): 0.8, 11)  ALT (alanine aminotransferase): 95 (high), 12)  AST (aspartate aminotransferase): 129 (high), and 13)  Alk phos (alkaline phosphatase): 116.

The patient was admitted with fever of unknown origin, considering meningoencephalitis, sepsis, Lyme disease, HIV, rocky mountain spotted fever, mononucleosis, babesiosis, leptospirosis, and PCN (penicillin)allergy.  The patient was started on IV vancomycin, aztreonam, and doxycycline.  While in the hospital, the patient was evaluated for depression (it was deemed he did not need inpatient psychiatric care), a lumbar puncture was attempted.  During the patient's work up, HIV test came back positive, further expanding the differential diagnosis.  The patient improved over the next few days, antibiotics were stopped, and he was discharged home on PO (oral) doxycycline.

The patient had fever, rash and severe thrombocytopenia.  Rocky Mountain Spotted Fever was suspected, a potentially fatal disease (1).  Meningoencephalitis was suspected, a potentially fatal disease.  HIV with opportunistic infection was suspected, one of many diseases with a potentially fatal outcome.  Standard of care would require admission, close follow-up and inpatient work-up.  Failure to admit such as a patient can lead to loss of function, permanent neurological damage, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain 

Treatment: Chiropractic Treatment Services CPT codes 98940 (Chiropractic manipulative treatment [CMT] spinal, 1-2 regions), 97035 (Application of a modality to 1 or more areas: ultrasound, each 15 minutes), and 97012 (Application of a modality to 1 or more areas:  traction, mechanical) 

The insurer denied the chiropractic treatment services CPT codes 98940 (Chiropractic manipulative treatment [CMT] spinal, 1-2 regions), 97035 (Application of a modality to 1 or more areas: ultrasound, each 15 minutes), and 97012 (Application of a modality to 1 or more areas:  traction, mechanical). The denial was upheld. 

This is a male patient who presented to a chiropractor with complaints of neck and upper back pain and decreased motion in his cervical spine. Manipulation, traction and ultrasound were performed; slight improvement was reported by the patient. 

According to the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), the "determination of the necessity for additional treatment should be based on the [clinical] response to the initial trial of care and the likelihood that additional gains can be achieved." 

However, the dates of services (DOS) in question did not show meaningful and measurable improvement with the current treatment protocols and suggested that the Maximum Therapeutic Benefit (MTB) was achieved prior to these DOS. The plan of care did not indicate any clinical rationale to investigate alternative treatment protocols that may enhance recovery for this patient's clinical condition. The treatment records appeared to support maintenance care and physician dependency, and were considered not medically necessary. 

The CCGPP guidelines indicate, "When the patient's condition reaches a plateau, or no longer shows ongoing improvement from the therapy, a decision must be made on whether the patient will need to continue treatment."  The patient's treatment records did not support that there would be additional meaningful and measurable improvement with the current clinical condition and expectation that further clinical improvement would be achieved with ongoing chiropractic treatment. The record suggest that ongoing chiropractic care would be considered maintenance care and not medically necessary. 

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

The carrier's denial of coverage for the chiropractic treatment services CPT codes 98940 (Chiropractic manipulative treatment [CMT] spinal, 1-2 regions), 97035 (Application of a modality to 1 or more areas: ultrasound, each 15 minutes), and 97012 (Application of a modality to 1 or more areas:  traction, mechanical) is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease 
 
Treatment: Inpatient Admission.  The insurer denied the Inpatient Admission.  The denial was reversed.   

This is a male patient with a history of chronic obstructive pulmonary disease (COPD).  It was reported that he had been to the Emergency Department (ED) one week prior to presentation with similar symptoms which included productive cough, shortness of breath (SOB), and wheezing.  He was discharged home on steroid therapy for one week.  He reported not feeling better after the completion of steroid therapy.  His presenting vital signs were: temperature (T) 98.5 C, heart rate (HR) 117, respiratory rate (RR) 28 and oxygen (O2) saturations 96%.  He had a white blood count (WBC) of 12.2K.  He was consulted by Pulmonology.  He had a chest x-ray that revealed left lower lobe (LLL) air space disease and questionable segmental atelectasis.  He received oxygen 2L via nasal cannula.  He received Intravenous (IV) antibiotics, steroids and bronchodilators. 

Based on this review of the medical record, the patient was noted to be significantly symptomatic despite a full course of outpatient treatment with steroids.  The patient was tachycardic and tachypneic and in distress, and had diffuse wheezing on exam despite ED treatment.  Moreover, the patient had an abnormal chest x-ray that showed left lower lobe (LLL) opacity that was likely due to atelectasis from mucus plugging or possible pneumonia.  As of the day before discharge the patient's heart rate was elevated at levels greater than 100 with a respiratory rate of 20.  Based on the review of the literature, this patient was treated appropriately with intravenous steroids, bronchodilator and antibiotics until the patient was medically stable for discharge.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the acute inpatient hospital admission from is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Primary diagnosis; Cardiac /Circulatory problems Congestive Heat Failure CHF
Primary treatment :Inpatient Hospital 

Summary:The patient with a past medical history significant for hypertension, heart failure with reduced ejection fraction, and diastolic dysfunction, who presented to the emergency department with a chief complaint of shortness of breath and bilateral leg swelling. The health plans determination of medical necessity is overturned. 

Yes, the requested health service/treatment of inpatient stay was medically necessary for this patient because of the severity of the patient's condition, primarily defined by acute decompensated systolic heart failure, acute respiratory failure that occurred as a result of decompensated CHF, comorbid conditions, and a need for administration of intravenous diuretics as well as close monitoring of the patient's cardiac and respiratory status.
As noted in the 2010 Heart Failure Society of America guidelines, hospital admission is recommended for patients with acute decompensated heart failure (ADHF) with the following clinical conditions:
Evidence of severely decompensated heart failure (HF) including hypotension, worsening renal function, or altered mentation.

Dyspnea at rest, which is typically reflected by resting tachypnea and less commonly reflected by oxygen saturation < 90 percent.
Hemodynamically significant arrhythmia including the new onset of atrial fibrillation with a rapid ventricular response.
Acute coronary syndromes.
Hospitalization should be considered for patients with acute decompensated HF with the following clinical conditions:
Worsened congestion, even if without dyspnea at rest.
Signs and symptoms of pulmonary or systemic congestion, even in the absence of weight gain.
Major electrolyte disturbance.
Associated comorbid conditions such as pneumonia, pulmonary embolus, diabetic ketoacidosis, or symptoms suggestive of transient ischemic attack or stroke.
Repeated implantable cardioverter-defibrillator firings.
Taking into consideration all these facts, the admission at the acute inpatient level of care was medically necessary and justified, because of the severity of the patient's decompensation in this case. The patient developed acute respiratory failure, which at least initially required noninvasive mechanical ventilation and subsequent treatment with supplemental oxygen. This patient required treatment with intravenous loop diuretics. Therefore, the inpatient stay was medically necessary.