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

Diagnosis:  Congestive Heart Failure, Pneumonia

Treatment:  Inpatient Admission

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

This is a female patient with a history of obesity, asthma, bronchitis, hypertension, atrial fibrillation, and congestive heart failure (CHF).  The patient presented to the Emergency Department (ED) with complaints of chest pain and increased lower extremity swelling, and shortness of breath for the past three days.  Cardiology consulted the patient.  A physical exam was performed that noted scattered wheeze on lung exam but no jugular vein distension (JVD) and positive lower extremity edema.  Laboratory work up was performed that revealed white blood cell (WBC) count of 8.8, BNP of 1425, D-dimer of 0.68, Troponin of 0.02, lactate of 2.3.  The patient's venous blood gas (VBG) showed pH of 7.31, pCO2 of 66.6, pO2 of 51 and HCO3 of 33.  A chest x-ray was done that showed bilateral airspace disease, pulmonary edema with possible underlying infiltration.  A computed tomography (CT) scan of the chest was performed that showed right middle lobe pneumonia; negative for a pulmonary embolism.  The patient was admitted to the hospital for treatment of congestive heart failure (CHF) and pneumonia.  The patient was treated with intravenous (IV) Lasix, and IV and oral antibiotics.  The patient's symptoms improved and the patient was discharged home. 

Based on the review of the medical record, the patient's diagnostic workup was pneumonia.  The patient's elevated BNP was not associated with her congestive heart failure.  The patient's inpatient stay was a brief treatment with intravenous antibiotic and Lasix that was switched to oral administration due to the patient's tolerance to oral intake.  The patient was noted to be afebrile and hemodynamically stable.  Based on the literature review, this patient's pneumonia was mild with CURB 65 score of 0 and did not require acute hospitalization.  By the following day, the patient was evaluated by the Cardiologist and was converted to oral medications and continued with maintenance cardiac medications. 

On admission if there was uncertainty in the patient's response to outpatient therapy due to the patient's conflicting clinical picture of pneumonia and congestive heart failure, the MCG guidelines for pneumonia recommends that this patient may meet for Observation Care level of care.  During this Observation Care status, the patient could have gotten her diagnostic workup and her Cardiologist consult evaluation.  The patient could have been observed overnight, and then discharge home on oral medications and follow-up as outpatient. 

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 inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mixed essential Parkinson's disease
 
Treatment: Neupro 2mg/24HR TD PT24

The insurer denied the Neupro 2mg/24HR TD PT24.  The denial was reversed.  

This is a female patient with a diagnosis of mixed essential Parkinson's disease. She currently takes carbidopa/levodopa three times a day with a 40% tremor control. She reported that she was experiencing side effects of the medication that included nausea and epigastric discomfort. Literature supports that adding Neupro 2mg/24HR TD PT24
Patch or transitioning from oral to monotherapy could potentially improve her remaining symptoms as she had a resting wrist tremor with mild rigidity in bilateral extremities. 

The patient has a clinical history of mixed essential tremor-Parkinson's disease with treatment related side effects with gastrointestinal (GI) upset with nausea with oral Sinemet therapy. The patient's treating physician wishes to start her on therapy with Neupro patch.

Available for more than a decade, rotigotine TP is a well-established, once-daily dopamine agonist (DA) formulation for use in the short- and longer-term treatment of Parkinson's disease (PD). It offers a convenient alternative when non-oral administration of medication is preferred and may be particularly useful in patients with gastrointestinal disturbances that reduce the suitability of oral medication. 

The patient is having GI predominant side effects with current oral carbidopa levodopa therapy. Neupro patch, alone or in concert with oral carbidopa levodopa therapy is used in cases with predominant GI side effects with inadequate efficacy. Therefore, in this case, the Neupro patch is medically necessary.

The insurer did not act reasonably, with sound medical judgment, and in the patient's best interest. 

Based on the above, the medical necessity for Neupro 2mg/24HR TD PT24 is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Parkinson's Disease
Home Health Care

The patient has a past medical history significant for coronary artery disease, hypertension, dementia, Parkinson's disease, osteoporosis, gastroesophageal reflux disease, osteoarthritis and urinary incontinence.
The patient requests personal care assistant service, 2 shifts 12 hours a day for a total of 168 hours a week. The patient was approved for a live-in aide, 24 hours a day 7 days a week and 6 hours per night 7 days a week respite aide starting on 12/31/2019. The health plan's determination of medical necessity is upheld in whole. This patient with multiple medical problems most notably Parkinson's disease, dementia and immobility requires care for most if not all Instrumental Activities of Daily Living (IADLs) and activities of daily living (ADLs). Patient is frequently confused and bedbound and needs care for feeding, bathing, and incontinence care. Patient needs care in order to reposition in bed every 2-3 hours and for incontinence care every 2-3 hours. The patient lives alone in a 2 bedroom apartment, there is a bedroom and/or living room where a live-in personal care aid can sleep. The patient has durable medical equipment including a hospital bed, Hoyer lift, wheelchair, roller walker, shower chair, grab bars and commode. Patient has incontinence supplies. Patient has support from the patient's son and family. According to the approved arrangement which includes 2 aides, one live-in and 1 for respite, the patient's needs can be met, and the aide will have enough time for proper rest with a second aide for respite care. There was no noted rationale why this service arrangement is not sufficient to take care of the patient's needs. The patient's needs will be covered 24 hours a day 7 days a week. The aide will have enough time for his or her own needs.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal - Knee Problem/Pain
Pharmacy/Prescription Drugs

The patient is a female with a complaint of bilateral knee pain and known degenerative arthritis in both knees. Cortisone injections were performed with minimal improvement in her knee pain. The provider has proposed Gel-One injections for both knees. At issue in this case is the medical necessity of the proposed Gel-One injections for this patient. 

The health plan's determination is upheld, in whole. 

The requested health service/treatment of Gel-One 30mg/3 ml Syringe is not medically necessary for this patient. The rationale for this determination is based on the provided medical records and the current, peer-reviewed orthopedic literature with respect to viscosupplementation injections for knee osteoarthritis. In their study published in the Journal of Bone and Joint Surgery in 2016, Tammachote and colleagues concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." Other studies reported by Jevsevar and colleagues also found limited efficacy of viscosupplementation injections such as Gel-One are not effective for the treatment of pain associated with knee osteoarthritis. Thus, the medical necessity of these injections is not established.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented to the emergency room complaining of shortness of breath after falling off of his bicycle and crashing into a tree. His significant injuries that were found while in the emergency room were a left sided pneumothorax, pneumomediastinum, possible lung hematoma, and fractures of his left 6, 7, 11, and 12 ribs. He also had a small amount of free fluid in the pelvis with thickening of the right colon, suggestive of a possible bowel injury. He was admitted to the trauma service and had a follow up chest x-ray showing resolution of the pneumothorax. He did well and was discharged to home the next day. At issue in this case is the medical necessity of an inpatient stay.
The health plan's determination is overturned. The inpatient hospital admission was medically necessary. This is a polytrauma patient with 4 rib fractures, pneumothorax, pneumomediastinum, possible bowel injury, and possible pulmonary hematoma. The presence of 3 or more rib fractures, at any age, significantly increases the morbidity of the rib fractures. Such patients are more likely to have pain that cannot be controlled with outpatient medications. They also benefit from continuous inhalation of 100% oxygen and require pulmonary expansion therapy to ensure that they do not develop further pulmonary sequelae. Given the number of rib fractures and the other injuries, this admission was medically necessary.
An UptoDate article on the subject of rib fractures addresses the disposition of patients:
"An increasing number of rib fractures is clearly associated with increased morbidity and mortality. As such, we recommend the following regarding disposition of the patient:
1) The presence of greater than or equal to 3 rib fractures suggests the need for hospitalization or transfer to a regional trauma facility." Thus, it is within the standards of practice to admit to an inpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Failure to thrive, and feeding difficulties.
 
Treatment: Feeding therapy visits (times 30)

The insurer denied coverage for feeding therapy visits (times 30). The denial is reversed. 

This patient is a female with a history of constipation, failure to thrive, and feeding difficulties.  She has food refusal behavior leading to poor weight gain.  This member has severe oral aversion leading to failure to thrive.  She required a prolonged hospital admission and nasogastric tube feeding.  The requested service is feeding therapy.

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Feeding therapy is the standard of care in the management of feeding difficulty due to oral aversion.  This treatment is considered safe and effective and relatively low cost when compared to enteral feeding via gastrostomy tube. 

According to Howe (2018), "For children who show the signs and symptoms of oral aversion, oral-motor therapy may be used as preventative or preparatory technique to build oral sensory tolerance, as well as to provide positive oral experiences.  Oral-motor therapy can also be used to treat oral-motor deficits as underlying reasons causing oral aversions." Per Sharp, W. G., et al. (2017), "Behavioral intervention which included positive reinforcement of appropriate mealtime behaviors, bite persistence (aka, contingency contacting, escape extinction), and/or stimulus fading represented the most common treatment approach." Lastly, according to Williams, K. E., et al. (2010), "Food refusal is a severe feeding problem in which children refuse to eat all or most foods presented and exhibit problems with growth".

Based upon the provided records, this member has severe oral aversion leading to failure to thrive. She required a prolonged hospital admission and nasogastric tube feeding.  The requested feeding therapy is the standard of care in the management of feeding difficulty due to oral aversion.  This treatment is considered safe and effective and relatively low cost when compared to enteral feeding via gastrostomy tube.  There is adequate peer-reviewed literature supporting the use of feeding therapy in this member`s condition.  The requested treatment is intended to treat the member`s disability and improve her condition.  The requested service is not intended for the convenience of the member or her treating provider.  Therefore, the requested feeding therapy is medically necessary.                                                         

The carrier's denial of coverage for the feeding therapy visits (times 30) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Schizophrenia
Mental Health: Inpatient

The patient is a woman with diagnoses of schizoaffective disorder (SCZAD) and Cannabis use disorder (CnUD). The patient presented to the emergency department (ED) with complaints of acute agitation, depressed mood, persecutory and paranoid delusions, beliefs in a conspiracy against her, fear of death threats. On evaluation in the ED, she also was noted to be hyperactive with pressured speech. She feared she would "lash out" at people. This fear indicated danger to others. She had clearly decompensated and required acute admission. 

The health plan's determination is overturned in part. Admission and dates of service (DOS) at the IMHT level of care were medically necessary for 10 days. After the 10 days, the patient could have been discharged. 

This patient's illness was severe and chronic. She faced severe psychosocial distress with homelessness and unemployment. She was non-compliant with her outpatient treatment. She was at risk for readmission if discharged before fully stabilized. This patient had to be treated for both her psychotic and mood symptoms. The treatment team for this patent recommended use of long acting intramuscular (IM) neuroleptics to prevent relapse. She had multiple past admissions. Future readmissions would most likely be less frequently required with long acting IM neuroleptics. Case notes document that she was still irritable and talkative, preoccupied, experiencing paranoid delusions, and refusing groups. She was less irritable and began to attend groups but not stabilized. She continued to refuse her long acting injectable of antipsychotic. She had a positive attitude for the first time, saying "It's going to be all right. I have a positive attitude." She had no suicidal or homicidal ideation. She was not delusional. Therefore, she could safely with good medical judgment be discharged after 10 days.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Spinal stenosis 
Treatment: 22869 - Insertion of lumbar interspinous process stabilization device without decompression or fusion 

The health plan should cover the 22869 - Insertion of lumbar interspinous process stabilization device without decompression or fusion, based on the medical records provided for review. 

The patient is a male. There is a letter of appeal indicating the patient has had at least six months of prior conservative treatment without significant pain relief.  He is reported to be not a good candidate for surgical decompression.  

The device procedure has received approval from the FDA.  The patient is reported to suffer from lumbar spinal stenosis with neurogenic claudication going on for two years.  He reportedly is experiencing decreased quality of life and effects on ADLs (activities of daily living).  His previous conservative treatment has included physical therapy and medication management with opioids and NSAIDs (nonsteroidal antiinflammatory drugs).  He has also undergone epidural steroid injection without significant benefit.  The available medical records report the patient has no spine instability.  

Office visit indicates the patient had bilateral low back pain radiating into the buttocks and bilateral posterior lower extremities, standing and walking, and reportedly has mildly painful bilateral rotation, full bilateral side flexion, straight leg raise is negative bilaterally.  He has deep tendon reflexes intact.  

MRI of lumbar spine is reported to show L4-5 severe central canal stenosis and degenerative disc herniation associated with ligamentum flavum and facet hypertrophy.  Reportedly the patient does not wish to have a full decompressive surgery with fusion, which would be much more invasive and was requested for consideration of an interspinous spacer, VertiFlex Superion.  

The 22869 - Insertion of lumbar interspinous process stabilization device without decompression or fusion is likely to be more than official from the standpoint that it may provide symptomatic improvement for the neurogenic claudication in relation to the spinal stenosis without the significant potential for adverse event to occur with a decompressive surgery as well as avoiding the significant post-surgical rehabilitation process.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Spinal stenosis  
Treatment: 22869 - Insertion of lumbar interspinous process stabilization device without decompression or fusion  

The health plan should cover the 22869 - Insertion of lumbar interspinous process stabilization device without decompression or fusion.  

The patient is a male with history of severe spinal stenosis who is not a good candidate for spinal surgery.  The patient has been offered decompression with instrumentation.  The patient is trying to avoid invasive surgery.  The patient has failed conservative treatments in the form of PT (physical therapy), medications, and epidural steroid injections.  

The 22869 - Insertion of lumbar interspinous process stabilization device without decompression or fusion is likely to be more beneficial.  

The patient is a male in whom a Vertiflex Superion (Insertion of lumbar interspinous process stabilization device without decompression or fusion) has been offered for the treatment of symptomatic moderate neurogenic claudication from lumbar spinal stenosis at L4-5.  The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, pain medications including opiate medications such as Percocet.  The patient was offered an alternative surgery in the form of a lumbar laminectomy/decompression with instrumentation.  Obviously, this is a considerably more invasive procedure which often reduces in restricts the patient's mobility after surgery and can limit their ability to return to gainful employment, especially if it involves manual labor.  Therefore, the options are limited.  The patient does have radiographic evidence of significant spinal stenosis limited primarily to 1 level, the L4-5 level.  The patient has had good responses to epidural steroid injections, however they have been short-lived.  Therefore, with the exception of more invasive surgical laminectomy, the interspinous process stabilization (Vertiflex Superion) is the only other option that the patient has not failed.  The patient has had epidural steroid injections physical therapy, and the other options that have been shown to be helpful in the literature.  

Vertiflex Superion (VS) has been shown to be effective in multiple peer-reviewed articles.  It has been shown to be as effective as lumbar laminectomy at five years.  Risks of the procedure are much less compared to conventional "open" surgery.  Postoperative recovery time is much shorter, and lumbar range of motion is preserved compare to instrumentation.  Given the above, the requested VS is medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tendinitis 

Treatment: Custom Shoe Orthotics

The insurer denied custom shoe orthotics. The denial was reversed.   

This is a male patient who consulted his endocrinologist for custom orthotics for treatment of his diabetes related tendinitis. It was reported that the patient had tried over the counter orthotics with no success. A request was made for custom shoe orthotics.     

Tendinitis is one of many complications that can occur to patients with diabetes. By providing a custom orthotic, this device could help against further inflammation of the tendon (i.e. worsening of the tendinitis), and decrease or prevent the patient from developing neuropathy symptoms and ulcers. Per Ravazi Ratki (2017) article, "The ultimate goal when formulating an orthotic prescription is to reduce tissue motion, accommodate osseous deformities and provide maximum shock absorption through a combination of clinical knowledge and a strong understanding of material science and product. It is important to remember that every patient is an individual: what is suitable for one person may not be indicated for another. Treatment therefore needs to be individualized to a patient's unique needs and expectations, thereby creating an opportune environment to reduce the risk of diabetes-related foot problems, aid healing and reduce the risk of re-ulceration/re-activation of an acute episode."  The benefits of custom shoe orthotics are also supported by Martinez-Santos et al (2019) article that states customized orthotics use the patient's foot shape and plantar pressure data to design an insole that can offload the forefoot in patients with diabetes. 

The patient has trialed and failed on over-the-counter shoe orthotics. This patient's cause of tendinitis is an associated complication of his diabetes. This patient is at high-risk for developing further worsening of tendinitis and foot ulcer that can result in amputation if left poorly treated. Since this patient has trialed and failed on standard, first-line of treatment, literature supports that custom shoe orthotics is medically necessary to treat this patient's diabetic tendinitis. 

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

The carrier denial of coverage for the custom shoe orthotics is reversed. The medical necessity is substantiated.