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

This is a patient  with ischemic cardiomyopathy, heart failure, hyperlipidemia and an ejection fraction (EF) of 31%.  He was admitted  for an implantable cardioverter defibrillator (ICD) and the inpatient stay was denied. The health plan's determination is upheld.  This patient was admitted for an elective procedure.  ICD implantation requires placement of two or more new leads.  One is normally attached to the right ventricular wall with a screw at the tip of the lead.  The lead is rotated, which embeds the screw into the right ventricle (RV) wall.  Another lead is placed in the right atrium in a similar manner.  In order to enter the venous system, punctures are often made in the subclavian vein.  These punctures can cause pneumothorax and the onset of the pneumothorax can be delayed.  The placement of either lead can also cause cardiac perforation, with possible cardiac tamponade, which can also be delayed and not immediately apparent after implant.  These patients need to be monitored carefully in a telemetry setting after this procedure for one night.  However, although the patient could not have been discharged immediately after the procedure, he could have been managed at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The proposed treatment of inpatient treatment was not medically necessary. 

After either open or laparoscopic appendectomy for nonperforated appendicitis, patients may be started on a clear liquid diet and advanced as tolerated to a regular diet. Antibiotics are not required postoperatively. Most patients are discharged within 24. Same-day discharge is feasible, most commonly following a laparoscopic appendectomy

The patient presented with typical signs and symptoms of acute appendicitis. There was no evidence of sepsis either clinically or by objective data. The patient was hemodynamically stable with a normal heart rate and blood pressure, elevated white count and non-perforated appendix. In addition, there were no untoward intraoperative findings or complications and the patient recovered as expected.
Appeal type: Medical necessity
Decision: Upheld

The patient had chest pain on moderate exertion. He was referred for a cardiac catheterization. He was admitted overnight after the procedure. The health plan has denied the inpatient admission as not medically necessary. The health plan's determination is upheld. The inpatient admission was not medically necessary. It was reasonable to observe the patient for several hours after intervention to assure clinical stability and no adverse cardiac outcomes or bleeding. The risk of adverse events is at present low enough to have a high probability to discharge the patient within 24 hours and allow observation at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: IV fluids and iron supplementation

The insurer has denied inpatient admission. That denial was upheld.

The patient has a history of gastric bypass, perforated ulcer, and chronic anemia. The patient presented to the ER with a complaint of dizziness and lower extremity swelling. Her hemoglobin was 6.2. She would not accept blood products or transfusion based on religious beliefs. She was treated with IV fluids, and IV and oral iron supplementation. She signed out against medical advice.

The patient had a history of iron deficiency anemia. There was no history of active gastrointestinal (GI) bleeding. She denied chest pain or shortness of breath (SOB). She did not display symptoms which would have warranted admission under MCG guidelines, such as hemodynamic instability, active bleeding, altered mental status, syncope, cardiac arrhythmias, or acute renal failure. Though refused, transfusions could have been administered on an outpatient basis. The iron supplementation and IV fluids could have been provided under observations status. An inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient has a diagnosis of migraine headaches.  The headaches are reported as nearly daily and are associated with light sensitivity and nausea.  It is stated that treatment with Topiramate has been started and titrated up to 150 milligrams (mg) at night.  Topiramate extended release (ER), unclear brand, has been reported to not be as effective as Trokendi.

Trokendi XR is requested.  The health plan's determination of medical necessity is upheld in whole.  The patient has not failed a proper trial of Topiramate.  Topiramate, based on prescribing information, pharmacokinetics, and current migraine guidelines, should be prescribed as a twice daily medication.  Blurry vision is a commonly reported side-effect of topiramate that is independent of its formulation, i.e., it occurs with generic and brand name.  Several first line migraine prophylactic agents remain available.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic left-sided sacroiliac joint pain
Issue under review: Left neurolysis facet nerve

Determination:
The health plan should not cover the Left neurolysis facet nerve.

The available medical records do reflect that the patient underwent two successful SI joint diagnostic blocks with reported 100% pain relief following each procedure.  ISIS 2015 Interventional Pain Guidelines and ASRA 2015 Interventional Pain Guidelines support the use of SI joint radiofrequency for those patients who have undergone diagnostic blocks with at least 70% reduction for a duration of anesthetic.  The available literature does not reflect any superiority of the Simplicity device to conventional radiofrequency ablation of the SI joint and does not confer additional safety or reduction in side effect.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic left-sided sacroiliac joint pain
Issue under review: Left neurolysis facet nerve

Determination:
The health plan should cover the Left neurolysis facet nerve.

In patients who obtain short term benefit from the SIJ injections, RFA may be an alternative to provide relief. 

Based on the medical recent peer-reviewed literature, the studies below do show that radiofrequency denervation of the L4 and L5 primary dorsal rami and S1-3 lateral branches provide significant pain relief and functional improvement in patients with sacroiliac joint pain.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic left-sided sacroiliac joint pain
Issue under review: Left neurolysis facet nerve

Determination:
The health plan should cover the Left neurolysis facet nerve.

The patient has a history of chronic sacroiliac joint pain.  She has tried conservative treatment.  It is not uncommon to have sacroiliac joint pain after undergoing a spinal fusion at the L5-S1 level.  She underwent sacroiliac joint injections that were temporary.  She has had two diagnostic medial/lateral branch blocks with significant relief.  Radiofrequency ablation of the sacroiliac joint nerves (medial branch blocks at L5 and the sacral area, lateral branch blocks/peripheral nerve blocks of the S1, S2 and at times the S3 levels) has been shown in the literature to be effective.  This procedure is not experimental or investigational.  This procedure has been studied in for well over a decade.  Numerous articles dating back to 2018 have shown its effectiveness over placebo.  

Multiple newer techniques have been recently been found for improved results.  Given that the alternatives are treatment with chronic opiates, or surgical treatment for the sacroiliac joint, which has not been shown to have favorable results, the requested ablation of the medial/lateral branches are medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with Crohn's Disease. He has had fistulizing disease since 2011. The patient was on anti-TNF therapy which he eventually failed along with a demonstrated skin allergy. In 2018 the patient was started on Stelara without a loading dose.  The patient's provider has requested approval for Stelara every 4 weeks.  The health plan's determination of medical necessity is overturned. This patient is in a very difficult situation - he has already failed the best drug class for fistulizing Crohn's disease which are the anti-TNF agents. If he fails Stelara there may not be a good alternative and he could end up on total parenteral nutrition (TPN) or require surgery. Therefore, Stelara Q4 weeks is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Treatment: Esophageal sphincter augmentation device
The health plan should cover the esophageal sphincter augmentation device.
The esophageal sphincter augmentation device is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.
This patient suffers from GERD.   Even with PPI and H2 blocker, there is refluxing gastric contents.   Surgical therapies exist that resolve this very well.  Without LINX procedure, a laparoscopic Nissen fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  Linx is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been show to dramatically improve patient satisfaction long term.  It is approved by the FDA.  There is published data on patients who have had the device for six years, showing a very low complication rate and a high resolution of GERD.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Treatment: Esophageal sphincter augmentation device
The health plan should cover the esophageal sphincter augmentation device.
The requested esophageal sphincter augmentation device is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease. 
LINX is a standard treatment for medically refractory/symptomatic GERD in patients who do not have significant morbid obesity, Barrett's esophagus, prior gastric surgery or age less than (<) 18 years. The treatment is supported as a standard anti-reflux treatment which is more effective than medications and as effective as laparoscopic Nissen fundoplication for short- and mid-term outcomes with less morbidity and mortality. It is supported by high level published literature and is supported by updated guidelines from the Society of American Gastrointestinal and Endoscopic Surgery (SAGES) published in 2017 and the Society for Surgery of the Alimentary Tract (SSAT). The device is approved by the Food and Drug Administration (FDA) for treatment of GERD. This patient has GERD with no exclusion criteria to LINX and has failed medical management. The requested procedure is medically necessary and appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma exacerbation

Treatment: Inpatient admission, diagnostic evaluation, and medication management.

The insurer denied inpatient admission. That denial was reversed.

The patient has a history of asthma and has had multiple previous asthma admissions to the hospital.  The patient has required two steroid treatments in the previous three weeks.  The patient also has a history of anxiety and depression which was being treated with Zoloft.  The patient was seen in an UrgiCare center 11 days prior to this admission and was diagnosed with sinusitis and she was prescribed azithromycin and prednisone.  The patient then developed difficulty breathing, coughing and wheezing and was treated with her asthma relief medication in the home with no improvement.  When the child did not improve she was brought to the hospital by her mother for an evaluation.

In the Emergency Room (ER) the child was noted to be in moderate respiratory distress with retractions and increased work of breathing.  The child was treated with 3 doses of DuoNeb, steroids, magnesium, and intravenous (IV) fluids with some improvement noted.  When the evidence of increased respiratory effort, wheezing and prolonged expiratory phase persisted despite treatment the decision was made to admit the child to the hospital with a diagnosis of status asthmaticus.  The plan was to continue treatment with oxygen, IV fluids and albuterol every 3 hours.

The patient was treated appropriately in the ER for status asthmaticus.  The decision to admit the patine to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 3 hours and steroids was consistent with the standard of care for a child with a history of multiple previous asthma admissions and persistent respiratory distress.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opiate Dependence
 
Treatment: Inpatient Substance Detoxification treatment 

The insurer denied the coverage for inpatient detoxification. The decision was reversed.

The adult patient was admitted to inpatient substance detoxification treatment in the hospital for detoxification from opiates. The patient's had withdrawal symptoms including tremors, yawning, sleeping problems, joint pain, irritable mood, anxiety, nausea, sweats, and diarrhea. The patient was using 80 mg OxyContin 3 tablets per day and had legal issues, for which the patient was on federal probation and mandated for treatment for substance use. The patient had past reported treatment in late 2018 for inpatient detoxification and rehabilitation, and was put on a methadone taper and discharged to a substance inpatient rehabilitation treatment. 

The insurer denied coverage for continued inpatient substance detoxification treatment in the hospital as not medically necessary. They stated that there was no acute instability or toxicity from substances requiring inpatient treatment and no acute psychiatric or medical issues or life-threatening withdrawal. They recommended a less restrictive level of care.

This reviewer disagrees with the decision to deny coverage for continued inpatient substance detoxification treatment in the hospital, as the chart notes provided do support the need for inpatient medical hospital detoxification treatment. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he did require continued 24-hour treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. It was not likely that the patient could attend an outpatient substance detoxification treatment due to continued use despite past inpatient substance treatment; therefore, the patient required only inpatient substance detoxification treatment. The patient also was at risk for accidental overdose. The patient also needed inpatient substance detoxification.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Treatment: LINX Reflux Management System
The health plan should cover the LINX Reflux Management System.

The LINX Reflux Management System is likely to be more beneficial.

The patient is a woman with hoarseness and tightness in her throat with acid brash. She was found to have a hiatal hernia on upper endoscopy, elevated esophageal acid exposure on esophageal pH monitor, and normal motility on barium esophagram.  She was recommended to undergo laparoscopic hiatal hernia repair with LINX.  She has tried omeprazole without benefit. 

This patient suffers from GERD (gastroesophageal reflux disease), causing profound symptoms.    Even with PPI (proton pump inhibitors), there is refluxing gastric contents.   Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  Linx is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA.  There is published data on patients who have had the device for six years, showing a very low complication rate and a high resolution of GERD.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Treatment: LINX Reflux Management System

The health plan should cover the LINX Reflux Management System.

This patient is a female with BMI 26.73 kg/m2 with history of long standing GERD (gastroesophageal reflux disease). The patient has been treated with PPI (proton pump inhibitors) without improvement. 24 hour pH study revealed an elevated DeMeester score consistent with GERD. UGI (upper gastrointestinal series) revealed normal motility. EGD (esophagogastroduodenoscopy) revealed a hiatal hernia. 

This patient has GERD that is refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is and FDA approved treatment for GERD, comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. 

The LINX Reflux Management System is likely to be more beneficial.

LINX is FDA-approved treatment for GERD. The only current exclusion is age <18, BMI >35 and history of prior gastric/bariatric surgery which this patient has not had.  This patient is an adult without morbid obesity or history of prior bariatric/gastric surgery who has failed medical management for GERD. The patient has no exclusion for LINX, an FDA approved treatment of GERD which has been shown in published literature to be comparable for mid-long-term control of GERD to laparoscopic Nissen fundoplication with less mortality and less dysphagia complications.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Postpartum Preeclampsia 
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was modified.   

This is a female patient with a medical history of gestational diabetes, hypertension, and hypothyroidism. She presented to the clinic status postpartum day 10 from a repeat cesarean section with complaints of an elevated blood pressure. Blood pressure on admission was 151/77. The plan was to obtain preeclampsia labs, administer Magnesium Sulfate, and control blood pressure. Protein in urine was positive and the patient's Lactate dehydrogenase (LDH) was elevated. Her blood pressure was monitored and controlled. She was treated with Magnesium Sulfate and discharged home in stable condition with outpatient instructions. 

This patient presented 10 days after delivery with elevated blood pressure, protein in urine and elevated LDH. Delayed postpartum preeclampsia can be defined as signs and symptoms of the disease leading to readmission more than two days but less than six weeks after delivery, although various other definitions have been used. The signs and symptoms can be atypical; for example, the patient may have thunderclap headaches alternating with mild headaches or intermittent hypertension. The risk factors for delayed postpartum preeclampsia appear to be similar to those for preeclampsia during pregnancy, but some patients have no risk factors.

The diagnosis of preeclampsia is based on the new onset of hypertension and either proteinuria or end-organ dysfunction after 20 weeks of gestation in a previously normotensive woman:
Systolic blood pressure >=140 mmHg or diastolic blood pressure >=90 mmHg, and (1 of the following)
1) Proteinuria >=0.3 grams in a 24-hour urine specimen or protein: creatinine ratio >=0.3, or

2) Signs of end-organ dysfunction (platelet count <100,000/microliter, serum creatinine >1/1 mg/dL or doubling of the serum creatinine, elevated serum transaminases to twice normal concentration).

This patient had elevated blood pressure, protein in the urine, as well as elevated LDH level. This patient did have a diagnosis of pre-eclampsia. Admission was medically necessary to control blood pressure and administer magnesium sulfate to prevent a possible seizure. However as of a specified date, the patient's blood pressure was controlled and her LDH was coming down. She has received 24 hours of magnesium sulfate and could have been discharged home on home blood pressure monitoring to return if any worsening of her blood pressure. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient on a partial basis for specified dates. The inpatient hospital admission for the first specified date range is considered medically necessary for this patient. However continuous admission thereafter was not appropriate.

Based on the above, the medical necessity for the inpatient admission for the first set of date range is substantiated and continuous admission for the subsequent dates is not substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of coronary artery disease, cardiomyopathy, coronary artery bypass surgery, hypertension, and dyslipidemia with dyspnea on exertion for 3-6 months. He underwent an elective cardiac catheterization  as well as a successful percutaneous intervention of a diagonal artery as part of a staged procedure. There were no complications. 
The health plan's determination of medical necessity is upheld. 
This patient underwent successful elective and non emergent percutaneous intervention without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high risk medications requiring prolonged in-hospital monitoring.