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

Diagnosis: Atopic dermatitis
Treatment: Dupixent

The treatment with Dupixent is not medically necessary.

The patient is a young female with atopic dermatitis, treated with topical steroids, Eucrisa, Protopic and phototherapy.  Her provider is requesting treatment with Dupixent.  The patient has a history of eosinophilic esophagitis, failure to thrive and zinc deficiency.  Documentation states that the patient may be undergoing work up for immunodeficiency.

Medical necessity is generally defined as:
1) In accordance with Generally Accepted Standards of Medical Practice; 2) Clinically appropriate, in terms of type, frequency, extent, site of Service, duration, and considered effective for your illness, injury, disease, or symptoms; 3) Not primarily for the patient's convenience, the patient's family's convenience, the patient's caregivers, convenience of that of the Physician or other health care Provider; and 4) Not more burdensome than the same or similar Service provided by a different Provider, by way of a different method of administration, an alternative location (e.g., office vs. inpatient), and/or an alternative Service or sequence of Services at least as likely to produce equivalent therapeutic or diagnostic results.

Dupixent is not approved in children under 12 and has not been extensively studied in children younger than six.  This patient is a complicated case and there is no literature to support use of Dupixent at this age, and in a patient with possible immune deficiency.  This likely needs to be further clarified. In some cases, IVIG (intravenous immunoglobulin) has been used for similar patients.  While the provider's position is recognized, Dupixent is not FDA approved for children less than 12 and there is little research in patients less than six.  Since this patient is younger than six, the request must be denied as there is no support for this medication at this patient's age. Therefore, due to lack of support in current literature, the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Radiology Services (including Ultrasound)
The patient is a male. A letter of medical necessity indicates complaints of a subacute change in mental status, with complaints of dizziness, difficulty concentrating and memory loss. He was hospitalized for three days. Testing had included an electroencephalogram (EEG), magnetic resonance imaging (MRI), magnetic resonance (MR) angiography and a computed tomography (CT) scan. He was placed on Effexor that increases blood pressure. He subsequently required a hospitalization for paranoia that was treated with risperidone, Vistaril and Xanax. He also complained of trouble sleeping, weight loss of 30 pounds, and short-term memory loss. The provider did not believe that there was a thought disorder and noted that MRI, MR angiography and EEG were normal. The provider was concerned about behavioral variant of frontotemporal dementia and was noted to have a marked movement disorder that included myoclonus and akathisia. The differential diagnosis was a paraneoplastic/autoimmune limbic encephalitis that could precede a finding of cancer and could present with acute or subacute mood and behavioral changes, as well as short-term memory problems, complex partial seizures or cognitive dysfunction. A PET scan was recommended. 

The health plan's determination is upheld. The PET scan is not medically necessary for this patient. This is a patient who is being seen for a change in mental status. The provider did not perform a full mental status examination. There was no documentation of a standardized mental status examination, such as a Montreal cognitive assessment or a mini mental state examination. There was no documentation of a of any referral for neuropsychological testing. PET scans are Food and Drug Administration (FDA) -cleared to differentiate Alzheimer's disease from frontotemporal dementia when a neurological evaluation, including neuropsychological testing cannot make this differentiation. This is a patient who presented with neuropsychological symptoms. The standard of care for this patient would be performance of neuropsychological testing to differentiate a psychiatric from etiology from dementia and to assist in determining the specific type of dementia the patient has.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis to the knees
Issue under review: Hyaluronan injections

Determination:
The Hyaluronan injections were not medically necessary.

This is an adult male with a diagnosis of osteoarthritis to his knees. He had received injections of Synvisc One to both knees. His physician recommended an additional series of injections. 

The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis (OA) if all other courses fail prior to surgery.   However, the recommendations for use of viscosupplementation have changed. 

A review of the Clinical Practice Guideline by AAOS  cites:

The 2013 OA knee treatment CPG contains one significant recommendation change from the 2008 CPG, and this is with regard to the issue of viscosupplementation. The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG.

The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from three high-quality and 11 moderate-quality research studies that met the inclusion criteria.

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, 05/2013.)

The Orthopedic group reports "strongly do not recommend use".

The denial would thus be appropriate and consistent with current practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-small cell lung cancer
Treatment: Transfer to another facility for end of life inpatient admission
The proposed transfer to the other facility is not medically necessary.

The patient is a female with metastatic non-small cell lung cancer (NSCLC).  She is experiencing multiple comorbidities including a bowel obstruction and neoplasm related pain with a Palliative Performance Scale (PPS) of 50-60% necessitating ongoing hospitalization.  At the family's request, the patient was transferred from one inpatient acute care hospital to another acute care hospital for continued care.

There is no documentation of the reason for transfer to a different facility providing the same level of care.  The two hospitals are able to care for the patient in an identical fashion.  The care needs of the patient's condition in this case do not warrant transfer to the new facility.
Appeal type: Medical necessity
Decision: Overturned

Peripheral Vascular Disease
Surgical Services (All)

The patient is a female who initially presented for Raynaud's syndrome. She is noted to have bilateral lower extremity pain and swelling. There is no documentation that the patient has worn compression stockings or attempted any other conservative modalities (i.e. leg elevation, avoidance of prolonged standing, etc.). She is noted to have reflux in her bilateral great saphenous veins based on venous insufficiency ultrasound. Her provider is recommending endovenous ablation of her left great saphenous vein.

The health plan's determination is overturned.

The requested endovenous ablation procedure for the left great saphenous vein is Medically Necessary based on the peer reviewed literature and the current standard of care in the Vascular Surgery community.

There is documentation (Letter of Medical Necessity) which provides additional details regarding the patient's symptoms.

Based on the letter of medical necessity, the patient does present with lifestyle limiting symptoms associated with her left sided venous insufficiency and reflux.  She works in sales and her pain and throbbing interfere with her work as clearly documented by the provider.  She has worn graded compression stockings without symptomatic relief.  Her duplex ultrasound demonstrates reflux in her left great saphenous vein.
Endovenous thermal (laser or radiofrequency) ablation is the standard of care for this particular problem.

Hamann and colleagues demonstrated excellent results with radiofrequency ablation (RFA) of the great saphenous vein in a recent randomized trial. The authors wrote that the current treatment strategy for many patients with varicose veins is endovenous thermal ablation. The most common forms of this are endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). However, at present there is no clear consensus on which of these treatments is superior. The objective of this study was to compare EVLA with two forms of RFA: direct RFA (dRFA; radiofrequency-induced thermotherapy) and indirect RFA (iRFA; VNUS ClosureFast TM). Patients with symptomatic great saphenous vein (GSV) incompetence were randomized to receive EVLA, dRFA or iRFA. Patients were followed up at 2 weeks, 6 and 12 months. The primary outcome was GSV occlusion rate. Secondary outcomes included Venous Clinical Severity Score (VCSS), Aberdeen Varicose Vein Questionnaire (AVVQ) score and adverse events.  Some 450 patients received the allocated treatment (EVLA, 148; dRFA, 152; iRFA, 150). The intention-to-treat analysis showed occlusion rates of 750 (95 per cent c.i. 680 to 820), 599 (521 to 677) and 813 (751 to 876) per cent respectively after 1 year (P=0007 for EVLA versus dRFA.

Endovenous thermal (laser or radiofrequency) ablation is the standard of care for this particular problem. The most recent consensus guidelines from the Society for Vascular Surgery and the American Venous Forum support the use of thermal ablation based on this patient's indications. The peer reviewed literature strongly supports the use of endovenous radiofrequency ablation for this patient.
Appeal type: Medical necessity
Decision: Upheld

This is female who presented due to poor weight gain and vomiting. The patient went to the primary care doctor for a weight check and was sent to emergency room (ER) for a concern of vomiting. The mother described it as projectile and with multiple spit ups. She reported the baby to be hungry after these episodes. Mother denied any vomitting on the day of presentation. Mother states the vomiting episodes have been happening for the past month and can happen one to three times per day right after feeding. She states the baby spits up after every feed. Mother is feeding the baby Enfamil 5 ounces every three hours but she is preparing the formula with two scoops to 5 ounces of water. Last feed of the day is at 9 pm and the baby does not feed again until 6 AM. Mother has been doing this for one month.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient presented with vomiting and weight loss. Baby was sent to the emergency room (ER) to rule out pyloric stenosis which was ruled out. Gastroesophageal reflux disease (GERD) was noted on ultrasound. Careful history taking elicited that the child was fasting for 9 hours at night and also was receiving inadequate calories due to incorrect formula preparation. She also had mildly elevated LFTs (liver function tests). Once the surgical emergency was ruled out, the mother could have received education on reflux precautions, proper feeding techniques, appropriate feeding intervals as well as correct way to mix the formula with close follow up as an outpatient. There was no significant physical findings on exam to suggest dehydration. Child was with good appetite. While hospitalized, the only interventions were measuring intake and output, daily weights, scheduled feeds and parent education. These interventions did not need to be done as an inpatient. This patient could have been managed at a lower level of care with subsequent discharge and follow up as an outpatient. This patient did not require any highly skilled or technical care to manage her safely. The inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient with a seizure disorder, on treatment with Keppra, as well as a variety of other medical problems including chronic obstructive pulmonary disease (COPD), bi-level positive airway pressure (BiPAP) dependent obstructive sleep apnea syndrome, and history of stroke without residual deficits, presented to the emergency department with generalized weakness, 1 week after the patient suffered a seizure at home. The patient reported some difficulty holding a cup, and a feeling as if being intoxicated. Denied any chest pain, headaches, or vision changes. No memory problems. The patient is reportedly compliant with aspirin and statin therapy. There was no loss of consciousness. The reported seizure occurred while sleeping approximately 1 week prior to presentation. The emergency department admitted the patient for evaluation of transient ischemic attack (TIA) versus presyncope. An echocardiogram and carotid duplex were ordered. A neurology consultation was requested. Keppra and carbamazepine were continued on admission. The patient was seen by neurology and felt that the patient had no neurologic deficits per their expert exam. They recommended obtaining an echocardiogram and carotid duplex, as well as a psychiatric evaluation due to the patient's prior history of psychiatric disorders.
The patient was evaluated by psychiatry, who determined that the patient's condition was consistent with major depressive disorder, and started the patient on Seroquel. They recommended an outpatient psychiatric follow-up. The carotid duplex came back with negative findings. The echocardiogram showed a normal cardiac function. The health plan's determination of medical necessity is upheld in whole. The patient presented with vague symptoms of generalized weakness and gait ataxia, without focal neurologic deficits. Head CT was negative for intracranial pathology. The patient was evaluated for near syncope versus TIA and had completely normal results and a neurology specialist evaluated the patient within 24 hours and noted no focal neurologic deficits. The work-up for TIA was completed, and the patient was safely discharged home. There is no evidence that the patient was at risk of suffering a major stroke, based on the ABCD2 score. There is no conclusive evidence of syncope. The seizure was unwitnessed and occurred 1 week prior to presentation. The patient had no recurrent seizures while in the hospital. The patient did not fail a lower level of care prior to being admitted to an inpatient medical stay.
Appeal type: Medical necessity
Decision: Upheld

The is a patient with a left adnexal cyst, thickened endometrial stripe and possible cervical lesion by ultrasound. She had an attempted hysteroscopy at an outpatient surgical center. At issue is the medical necessity of performing the procedure at the hospital outpatient center.

The patient had abnormal endometrial thickening in the postmenopausal state, however, there is no reason this procedure needed to be performed at the hospital. This procedure could have been performed in an ambulatory surgical center or office. The patient had no significant past medical history documented. She was not overweight nor were any anesthesia complications anticipated. She had no cardiovascular disease and the surgery was anticipated to be short and ambulatory. No inpatient hospital admission was anticipated. She had no significant complications or blood loss. She had no abnormal laboratory tests nor ultrasounds. She could have had her hysteroscopy performed in an ambulatory center or office setting and there is no medical necessity for a hospital procedure.
Appeal type: Medical necessity
Decision: Overturned

Immunologic Disorder
Pharmacy/Prescription Drug.

This is a patient with lupus, treated with oral Plaquenil, methotrexate, quinacrine, and topical tacrolimus. Her provider is requesting continuation of high-dose Tacrolimus 0.3% compounded cream. 
The health plan's determination is overturned. The tacrolimus compound is medically necessary for this patient. According to the current medical literature, this high-dose Tacrolimus compound is effective for refractory cutaneous lupus. A cohort study  involved 13 patients with treatment-resistant cutaneous lupus erythematosus (CLE), all of which demonstrated improvement. The study concluded that TCPO may be more effective than either 0.1% tacrolimus or clobetasol propionate 0.05% ointment monotherapy in the treatment of recalcitrant CLE. A case report in 2015 involved three patients with treatment-refractory, biopsy-proven discoid lupus erythematosus (DLE). These patients were prescribed a novel, off-label preparation of tacrolimus lotion, 0.3%, in an alcohol base as an adjunct to oral antimalarial therapy. All 3 patients demonstrated improvement in lesion severity and hair regrowth with the use of this regimen after 3 months and continued improvement thereafter.
According to the provider's appeal letter, the patient has severe extensive cutaneous lesions. She has failed oral plaquenil and oral therapy with methotrexate.
Given this patient's refractory disease and response to this topical, as well as support in the literature, the request is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical radiculopathy; thoracic segmental dysfunction
Issue under review: Continued chiropractic services

Determination:
No, the Continued chiropractic services were not medically necessary.

The patient is a teenage male. It was noted that the patient continued with the chiropractic treatments for diagnoses consisting of cervical radiculopathy as well as thoracic segmental dysfunction.

The clinical rationale to continue with the chiropractic care/treatment to this adolescent patient has not been supported through the records submitted concerning this case. According to the records, it is noted that the patient underwent approximately 17 visits with the attending practitioner. A sufficient course of in-office conservative chiropractic care/treatment had been provided to this patient to the point in question. The patient is no longer showing gain with the care provided. Standard of care would support home-based activities in lieu of in-office treatments at this time.  

The documentation fails to support the necessity of continued ongoing care/treatment that was being provided to the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Lyme disease
Issue under review:  Ceftriaxone Infusion

The Ceftriaxone Infusion is not medically necessary.

The patient does not have specific, somatic complaints that are consistent with chronic Lyme disease.  Her serology is negative for chronic Lyme disease, as the IgG ELISA and Western blot are negative.  Her CSF (cerebrospinal fluid) studies are negative for CNS (central nervous system)-Lyme disease.  She has received appropriate antibiotic treatment with oral antibiotics for acute Lyme disease.  Therefore, continued treatment with parenteral antibiotics is not appropriate or consistent with standard of care guidelines or data derived from clinical trials published in the peer-reviewed literature.
Appeal type: Medical necessity
Decision: Upheld

Thyroid Problems
Inpatient Hospital

The patient is a woman with multinodular goiter and hyperparathyroidism. She underwent an uncomplicated thyroidectomy, parathyroid exploration with superior parathyroid reimplantation. There were no operative or peri-operative complications. She was admitted as an inpatient. She was admitted for airway distress and signs of hypocalcemia. Vital signs were stable. Calcium levels were stable. The inpatient is under review.

The health plan's determination is upheld. The inpatient hospital stay was not medically necessary. The patient no pre-operative concerning medical issues. Her calcium level was normal. She did not have invasive thyroid or parathyroid cancer. The patient had a thyroidectomy for multinodular goiter causing compressive symptoms and parathyroidectomy for elevated parathyroid hormone (PTH) yet had a normal calcium. There were no operative complications. There were no peri-operative complications. There was no sign of airway distress, hematoma formation, or low calcium levels. The patient could have been managed at a lower level of care which allows for a period of overnight observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol withdrawal with diarrhea, fevers, chills as well as nausea
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient had a history of alcoholism as well as congestive heart failure, hypertension, diabetes, elevated cholesterol, and prior Clostridium difficile colitis. The patient presented with alcohol withdrawal with diarrhea, fevers, chills as well as nausea. The patient had frequent watery diarrhea with abdominal cramping. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. The patient did not develop a severe hypoxia or an exacerbation of congestive heart failure. As such, the care could have been rendered at a lesser level.