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

Chronic Kidney Failure/ESRD
Inpatient Hospital

The patient is a male with a history of end stage renal disease (ESRD) on hemodialysis, hypertension (HTN), seizures, cocaine use, and a brain aneurysm status/post (s/p) clipping who presented after missed episodes of dialysis. The patient has missed multiple dialysis sessions due to non-compliance. The patient complained of weakness and left hip pain on arrival. Vital signs of admission showed a blood pressure of 141/86, a pulse of 93, a respiratory rate of 20, a room air pulse oximetry of 98% and he was afebrile. On exam he was in no acute distress with clear lung fields, no documented pericardial run and no edema. He had no documented altered mental status. Labs on presentation showed a white blood cell (WBC) count of 7.2, a hemoglobin of 9.5, a potassium of 5.4, a bicarbonate of 24, a creatinine of 7.38 and a blood urea nitrogen (BUN) of 51. An electrocardiogram (EKG) was done which showed normal sinus rhythm. A chest x-ray did not show any acute cardiopulmonary process. He was admitted for management of azotemia in setting of missing dialysis. He was initially planned for dialysis in mid-2019 but the patient refused. He was discharged home one day later in stable condition with a plan for the patient to return for his dialysis treatments until an outpatient dialysis unit can be secured.

The health plan's determination is upheld.

No, an inpatient stay is not medically necessary. The patient presented after missing multiple episodes of hemodialysis. On presentation he was in not in any acute distress. He did not have documented uremic encephalopathy, uremic bleeding or uremic pericarditis. He did not have clinically significant respiratory distress with hypoxia and pulmonary edema. He did not have severe electrolyte abnormalities. While he did have an elevated potassium of 5.4 this was managed medically and there was no documentation of clinically significant arrhythmias. The patient did not have severe metabolic abnormalities such as metabolic acidemia. The patient did not have severe and persistent nausea and vomiting. The patient did not have another documented clinical reason for admission. In conclusion, based on the documentation provided, the inpatient stay was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Urinary Tract Infection/UTI
Inpatient Hospital

The patient is a female who presented to the emergency department (ED) via Emergency Medical Services (EMS) with a two-day history of fevers, sore throat, and headache. She was seen in the ED the day prior with fever of 102.8, and was diagnosed with a viral infection. She was discharged to the shelter where she lived with her mother. Rapid strep testing was negative at that time. She continued to have headache and sore throat, was sleeping more and eating/drinking less, so she was taken back to the ED for evaluation. Vital signs included temperature 38.7, heart rate 130, respiratory rate 20 with saturation 98% in room air, and blood pressure 95/60. Examination was significant for sleeping but being easily rousable, ill-appearing but no apparent distress, no neck stiffness, no meningeal signs, negative Kernig and Brudzinski, no photophobia, erythema of the left tonsil without exudate, clear lungs, benign abdomen, good perfusion, and non-focal neurologic exam. Laboratory evaluation was significant for normal white blood cell (WBC) count (7.9K) with left shift (72.4% neutrophils), unremarkable metabolic panel, normal lactate (0.6), urinalysis with small leukocyte esterase and 15-30 WBC/hpf. Chest x-ray revealed mild areas of hazy density in the left suprahilar and infrahilar regions suggesting mild bilateral infiltrates. She was diagnosed with febrile illness, pneumonia, dehydration, and possible upper pole urinary tract infection (UTI), treated with a normal saline bolus, ibuprofen, and ceftriaxone. She was admitted for further management. Admission orders included regular diet for age, intravenous (IV) fluids, anti-pyretics, and ceftriaxone. Azithromycin was added and cultures were followed. Repeat urinalysis was unremarkable (1-5 WBC/hpf). Her fever curve improved. She was deemed stable for discharge. Ultimately, blood, urine, and throat cultures were all negative. The inpatient stay is under review. 

The health plan's determination is upheld. The inpatient hospital admission was not medically necessary. This young school-aged female child presented to the ED for the second time with an acute febrile illness, sore throat, and headache. Her examination was unremarkable, and her laboratory findings were significant for pyuria and normal WBC count with left shift, concerning for urinary tract infection. She was determined to be dehydrated, treated with fluids in the ED. In addition to the urine findings, her chest x-ray was suspicious for infection as well, so she was admitted for parenteral antibiotics pending culture results and fever resolution. She remained stable throughout her hospital stay. Her fever curve normalized, and she had no symptoms of cardiorespiratory distress. While it was not unreasonable to monitor this child in the hospital for fevers and ability to tolerate fluids while awaiting pending culture results, she was overall hemodynamically stable with no decompensation. She did not require acute inpatient admission and could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Mental Health: Residential

The patient is a male who received inpatient rehabilitation level of care for a diagnosis of opioid use disorder. The patient had previously been at the inpatient detoxification level of care. The patient was reported to be treated for heroin abuse. He also had a history of cocaine use disorder and for prior inpatient detoxifications. He also had one prior rehabilitation level of care admission with subsequent relapse back to substance abuse. The patient had been on opioid maintenance therapy on methadone prior to admission. He was receiving 60 milligrams (mg) daily of methadone.

The health plan's determination is upheld. The Inpatient Rehabilitation is not medically necessary for this patient. Based on the records provided, the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Level of Care is:
Outpatient Treatment with Medication Assisted Treatment (MAT)
The patient did not have a life-threatening medical condition or severe psychiatric crisis requiring immediate hospitalization. Opioids were the substances with the most potential to cause harm. The patient clearly met criteria for opioid use disorder and multiple other substance use disorders. The patient was not in full remission from a substance use disorder. The patient was not using substances with risk of medical complications from withdrawal. The main substance of concern had been heroin in the patient had a history of being on maintenance therapy for this drug in the recent past the other drug of concern was cocaine. Neither of these drugs are associated with dangerous medical withdrawal symptoms. The patient did not have serious medical symptoms that needed to be managed in an inpatient rehabilitation setting for substance use disorder treatment to be effective. He did not have serious psychiatric symptoms that needed to be managed in an inpatient setting for treatment to be effective. The patient had been using in hazardous amounts or frequencies likely to imminently cause harm. Medication assisted treatment was clearly available in the community as the patient was already receiving it. He was apparently willing to utilize it. He likely could have stabilized in an outpatient program. He was not adequately performing responsibilities in work, social, and family roles. The record does not establish that he lacked strong self efficacy to pursue goals outside of a highly structured setting. He lacked a supportive network related to his recovery goals. He had demonstrated a therapeutic alliance with at least one professional help her in the past. He had stable access to food and shelter. The patient did not require residential care. He had completed detoxification and had a history of treatment in a medication assisted treatment program. There were no unstable medical or psychiatric problems requiring 24 hour care. He could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Stomach Pain
Inpatient hospital 

This is a case of a patient who has type 2 diabetes mellitus, deep vein thrombosis (DVT) treated with an inferior vena cava (IVC) filter, hepatitis C with cirrhosis, treated with Harvoni, hepatomegaly, splenomegaly, history of hemorrhoids, as well as pancytopenia.

The patient came into the emergency department with a four-day history of left upper quadrant abdominal pain. The pain occurred after the patient started lifting some heavy boxes, described as dull, 5 out of 10 on a pain scale, without radiation. It was improved with rest. In addition, in the 24 hours leading to the admission, the patient noted some fresh blood in the stool, after straining when passing a bowel movement. The patient denied melena or hematemesis. Uphold, in whole, the health plan's determination of medical necessity

No, Inpatient hospitalization was not medically necessary for this patient. The requested health service for inpatient stay is not medically necessary for this patient. A lower level of care was appropriate. The patient comes in with mild acute kidney injury, hyperglycemia due to poor compliance with insulin, as well as nonspecific left upper quadrant pain, with mild colitis on imaging.

In addition, the patient has chronic liver cirrhosis, and chronic splenomegaly, resulting in chronic pancytopenia. This was not an acute problem. All these problems could have been managed under a lower level of care in the hospital. The acute kidney injury was resolved within 24 hours, with IV fluids, suggestive of prerenal state. The patient's creatinine did not triple, and was not greater than 4, to satisfy any criteria for inpatient admission. There was no evidence of the electrolyte abnormalities associated with this, there is no evidence of uremia, mental status change, or an urgent need for renal replacement therapy.

In regard to the hyperglycemia related to diabetes, the patient has a chronic insulin supplementation regimen at home, with which the patient was reportedly very poorly compliant. There is no evidence of diabetic ketoacidosis (DKA), as evidenced by the admission labs, and there is no evidence of hyperosmolar state. There was no description of altered mental status or the need for continuous insulin infusion.
In terms of colitis, there was a clear description, that the patient's rectal bleeding, occurred after straining in the setting of chronic hemorrhoids. The patient had a normal colonoscopy with only one year prior to this presentation. The CT scan on admission, as well as the subsequent CT scans, failed to demonstrate significant findings of colitis, abscess, perforation. Recent clinical studies suggest treatment of mild colitis, to be done in the outpatient setting with oral antibiotics. Per these clinical trials, even micro-perforations with small abscesses can be treated this way and did not require inpatient hospitalization. Of note, the patient has none of these severe findings, therefore, there is no need, for inpatient hospitalization. In conclusion, all of the problems listed above can be managed under a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Prostate Cancer
Cancer Screening

This is a male patient with newly diagnosed prostate cancer. He was found to have low volume, low risk Gleason Grade Group 1 prostate cancer. Prior to initiation of therapy, the Oncotype DX testing was ordered and it is the subject under review.

The health plan's determination is upheld. 

Current guidelines of the National Comprehensive Cancer Network (NCCN) do not endorse the use of biomarkers for Gleason Grade Group 1 low risk disease. This is supported by current guidelines of the American Urological Association (AUA), which also do not endorse biomarkers for clinically localized prostate cancer as their clinical utility has not yet been determined.  These biomarkers have not been subjected to randomized controlled trials and have been marketed with significant industry support.
Appeal type: Experimental/Investigational
Decision: Upheld

Prostate Cancer
Cancer Screening

This is a male patient with prostate cancer had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in 3 of 14 cores. The clinical stage was T1c. The PSA was < 10.
The subject under review is whether the Oncotype DX Prostate Assay is likely to be more beneficial for the patient's condition than any standard treatments.

The health plan's determination is upheld. 

Per American Urological Association Guidelines, "Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance."2  Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up.2  In addition, the patient has a low-risk prostate cancer.
Appeal type: Experimental/Investigational
Decision: Upheld

Prostate Cancer
Cancer Screening

The patient is an older male who underwent a prostate biopsy for an elevated prostate-specific antigen (PSA). The biopsy showed Gleason 6 adenocarcinoma in 2 out of 12 cores. The clinical stage was T1c. An OncotypeDX test was ordered on the biopsy specimens. The subject under review is if the OncotypeDX test is likely to be more beneficial for this patient than any standard interventions. 

The health plan's determination is upheld. 

While Oncotype DX may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to currently support routine use. Hence, it is not considered a generally acceptable standard of care for management of patients with a diagnosis of prostate cancer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Admission

The proposed inpatient admission was not medically necessary; inpatient level of care was neither indicated nor provided.

The patient's symptoms had been present for months. This was an elective, uncomplicated catheterization. Radial catheterization was developed with one of its advantages being the safety in early ambulation and discharge. The overnight stay for observation and telemetry does not change that determination. While possible, bleeding post radial artery intervention is rarely seen, nor does it require extended monitoring. Many institutions protocols include a same day discharge.  Centers for Medicare and Medicaid (CMS), Recovery Audit Contractor (RAC) surveys, proposed two midnight rule and all guidelines specify this as an outpatient procedure even for an uncomplicated percutaneous coronary intervention (PCI). The overnight stay for observation and telemetry does not change that determination.

Per expert recommendations, aspirin (ASA) desensitization is not required before catheterization, and if it is done, it can occur as an outpatient. There was not any medical necessity for intensive care unit (ICU) or inpatient admission for that procedure to be done safely. Also, the probability of acute revascularization was small, and many protocols are available to proceed post revascularization without ASA.

The letter of appeal was carefully considered but it offered no evidence to support a higher level of care. The only care provided was telemetry, frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no "complex" care that required inpatient level of care in this patient's care post catheterization.  While there is always a potential for an adverse event, one did not happen and no actual treatment was needed. As noted, ASA desensitization does not require a higher level of care.

Milliman criteria requirements for ACS do not apply as patient does not meet criteria to support that diagnosis. It is incorrect to label the presentation of this case as unstable angina or myocardial infarction, as patient had symptoms for months and was now pain free. Electrocardiogram (EKG) showed no changes, and no acute medical treatment given for ACS. All testing and therapy would be appropriate, safe and guidelines consistent to be in an outpatient setting. Thus, inpatient level of care was not medically necessary.

The denial was consistent with guidelines and usual community care. Post cardiac care as described is routinely performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia

Treatment: Inpatient admission

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

This patient is a female with a past medical history significant for systemic lupus erythematous (SLE), breast cancer status post mastectomy, status post brain tumor resection, and status post right-sided pneumonectomy. The patient presented to the Emergency Department (ED) with complaints of fever, weakness, cough, shortness of breath, and hypotension. 

Vitals on presentation included a temperature of 101.3F, a blood pressure of 77/56, a heart rate of 81, a respiratory rate of 37, and an oxygen saturation of 97% on 3 Liters nasal cannula. Laboratory results were notable for a white blood cell count of 12.4, hemoglobin of 9.4, a hematocrit of 30.7, a creatinine of 0.5, and a glucose of 92.

This patient was admitted for pneumonia and was started on intravenous (IV) antibiotics (ceftriaxone and azithromycin), nebulizers, and IV fluids. Preliminary blood cultures grew gram negative rods. Infectious Diseases consulted and adjusted the antibiotic coverage.  A chest x-ray showed a left base opacity. A CT scan revealed patchy airspace opacity in the lingula. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue outpatient management, including a course of oral antibiotics (Cefdinir). 

According to medical records, the patient presented with fever, hypotension, tachypnea, and multiple laboratory abnormalities, including an elevated white blood cell count and anemia. Additionally, lung imaging studies both on a chest x-ray and CT scan were suspicious for pneumonia, as well as a pulmonary nodule of unclear etiology. Based on above findings in a high risk patient with significant comorbid conditions, including malignancy and SLE, the hospital admission was medically warranted. 

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

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Acne
Issue under review: Myorisan

Determination:
The Myorisan is medically necessary.

The patient is a male with acne.  He has failed doxycycline, minocycline, Differin and benzoyl peroxide.

Per the enclosed PA request, the patient has tried and failed doxycycline hyclate, minocycline, Differin and benzoyl peroxide.  His claims history also documents use of oral erythromycin with benzoyl peroxide.  Topical clindamycin or erythromycin is not an appropriate standalone therapy for severe acne.  Trimethoprim-sulfamethoxazole has a level B strength of recommendation compared to isotretinoin, which is level A.  Therefore, isotretinoin (Myorisan 40 mg) is medically appropriate and necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Positive patellofemoral (PF) maltracking 

Treatment: Current Procedural Terminology (CPT) 27412-Autologous chondrocyte implantation (ACI).

The insurer denied coverage Current Procedural Terminology (CPT) 27412-Autologous chondrocyte implantation (ACI). The denial was upheld.

This patient is a female with right knee pain.  She had undergone arthroscopic surgery three surgeries over several years; the last was early-2019(debrided cartilage lesion 2 x 2cm). Her pains never went away. She was 5 feet 1 inch in height and 175 pounds with a Body Mass Index [BMI] of 33.06. There was tenderness to joint lines. She had received an injection and was advised physical therapy (PT).  She was evaluated and diagnosed a positive patellofemoral (PF) maltracking.  The physician recommended a surgical reconstruction consisting of: ACI (autologous chondrocyte transplantation), Maquet procedure and extensor realignment. 

The physician has recommended several reconstruction procedures to treat the "isolated lesion" of the lateral plateau.  These included a Maquet procedure and realignment.  There was no consistency in the record to support a diagnosis of patellofemoral disease, i.e. consultations by the treating physician with no subjective complaint, objective finding on physical examination, imaging report or arthroscopic abnormality.  The recommendation for PF treatments is unclear.  Her physical findings were quite limited, i.e. no effusion, good range of motion without pain. 

Nevertheless, the type of surgery requested (ACI) is a last course of management if all other treatments have failed. 

There was no documentation of a full course of conservative measures.  Her treatment consisted solely of medication (none reported at this time) and a cortisone injection.  She had not received recent PT after her third operation.  She had not received a brace (lateral unloader) which could provide benefit.  She was not receiving medications and was not using an ambulatory aid. 

Indications for surgery have thus not been met at this time. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

Current Procedural Terminology (CPT) 27412-Autologous chondrocyte implantation, knee is not considered medically necessary for this patient.

The carrier's denial of coverage for Current Procedural Terminology (CPT) 27412-Autologous chondrocyte implantation (ACI), knee is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brachial plexitis
Treatment: Privigen (IVIG)

The requested IVIG is not medically necessary.

Summary:
The patient is a male with brachial plexitis. He has been treated with steroids and IVIG (intravenous immunoglobulin) with reported improvement. 

There are no high-quality clinical trials or standard-of-care guidelines supporting that IVIG improves outcomes for persons with brachial plexitis.  The current standard of care for this condition is conservative treatment. There is no role for immunomodulatory therapy or immunosuppressant treatment for this patient's condition, as it has never been shown to improve outcomes for persons with this diagnosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing tooth
Issue under review: 
D6010 - Implant placement
D6057 - Custom abutment
D6061 - Abutment supported porcelain fuse to metal crown (noble metal)

Determination:
The Implant placement, Custom abutment, and Abutment supported porcelain fuse to metal crown (noble metal) are medically necessary.

The patient is missing a tooth. There is a tooth on top of the tooth, so with a replacement tooth in this area, there will be chewing function restored. An implant is the most conservative way to replace this tooth. A bridge would require the drilling down of two teeth that do not need to be treated. There is no other tooth in the lower jaw that needs replacement. The implant, abutment and crown are medically necessary to restore this area.