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

Diagnosis:  Congestive Heart Failure exacerbation
Treatment:  Inpatient stay

The inpatient admission was not "medically necessary".

The patient is a female admitted to the hospital with a past medical history significant for HTN (hypertension), asthma, CAD (coronary artery disease), status post CABG (coronary artery bypass graft) in 2015, diabetes mellitus, obesity and CHF (congestive heart failure), who presented to the ER for complaints of dyspnea on exertion and leg edema for one and a half weeks duration.  The patient was hemodynamically stable.  ECG did not reveal acute ischemic changes. Cardiac enzymes were negative.  The patient was admitted for management of CHF exacerbation.  The patient was treated with IV Lasix and was subsequently switched to oral diuretic.  Her symptoms improved with treatment, and the patient was discharged from the hospital with a plan for outpatient follow-up.

The patient presented for management of CHF exacerbation. The patient was hemodynamically stable, with adequate oxygen saturation.  The diagnosis of an acute MI was ruled out by cardiac enzymes, which were negative.  There was no evidence of acute myocardial infarction, ACS, malignant arrhythmia or hemodynamic instability.  The patient improved with diuretics, and her symptoms responded to treatment.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who presented to the emergency department requesting detoxification treatment and was medically screened and admitted  to inpatient level services for detoxification of heroin, Xanax and alcohol use; he had been using up to 30 bags of heroin with intranasal administration together with 4 milligrams (mg) of Xanax and two pints of vodka daily. His substance use disorder had its onset in adolescence with progression of the disease over a 37 year time frame with severe opioid, sedative-hypnotic-anxiolytic and alcohol class substance use disorders. He was also using cocaine intermittently. The patient had no history of withdrawal seizures or delirium tremens. His referral was prompted by his desire to receive substance abuse treatment, and the desire to stop using heroin and other substances of abuse in the context of psychosocial stressors and withdrawal symptoms. He presented with mild symptoms of withdrawal with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 2 and Clinical Opiate Withdrawal Scale (COWS) scale score of 0 reflecting minimal withdrawal symptoms and complaints of loose stool, nausea, anxiety and irritability.

The patient was admitted and placed on a detoxification regimen with Methadone and Ativan, comfort medications, as well as vitamin replacement therapy. The detoxification was uncomplicated with regard to withdrawal management. The patient received counseling and education from the staff. His clinical course was uncomplicated with normal vital signs and the patient was discharged with referral for clinically appropriate aftercare with his primary care physician.

The health plan's determination is upheld.

The requested benefit of inpatient detoxification treatment and withdrawal management for the dates of service in question could have been safely and effectively provided at a lower level of care status. The patient in this case was using heroin, alcohol, Xanax on a continuous daily basis. There were no co-morbid general medical problems or co-occurring psychiatric disorders that complicated this case. Moreover, the withdrawal symptoms were not reported to be significant, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol. The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in the community. Thus, medical necessity is not met in this case for the requested inpatient services in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria and scientific literature. Additionally, NY State Office of Alcoholism and Substance Abuse Services (OASAS) LOCADTR 3.0 Criteria/Guidelines, referenced below, are not met for this case as the patient could have safely been treated at a lower level of care status for substance use disorder treatment for the dates of service in question.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3: 

This patient is a young male with diagnoses that include encephalomyelitis, catatonia, and dissociative stupor, autistic disorder, past history of Epstein Barr virus infection, Strep throat, Rickettsia and disorders involving the immune system (including immunodeficiency).  

All the submitted copies of the published articles, medical news items, family testimonials and NIH scientist's letter submitted used to support the request for IVIG therapy for the patient have been reviewed. However, these papers do not provide adequate evidence that IVIG therapy has a therapeutic role in treatment of the patient's conditions.  Of note, the letter from Doctor Swedo defends the use of the PANS/PANDAS treatment guidelines (2014) meeting held at the National Institutes of Health (NIH).  It does not state that those guidelines in any way address IVIG for treatment of autism disorders, inflammatory conditions or, immunologic conditions not associated with PANDAS or other behavioral or neuropsychiatric disorders.  The Cunningham panel is not a standard accepted lab panel for diagnosis of neurologic post inflammatory syndromes.  The antibody titer for anti-dopamine receptor D1 is not elevated, but is border-line, and the other four antibodies on that panel are normal.  Even if the patient was considered to have a Pandas syndrome, the papers quoted do not support any efficacy of IVIG.  Additionally, the paper from Journal of Child and Adolescent Psychopharmacology 2015 addressing 12 cases of IVIG for treatment includes conjectural case reports without any definitive proof that the improvement of the patient symptoms was due to IVIG therapy.  

The carrier's denial of coverage for Privigen (IVIG) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer # 2:

This case involves a young male who has a history of autism and was previously function independently. However, in mid- 2015 the patient began a slow steady downward decline. He started wetting the bed and was diagnosed with a streptococcal infection.  He was treated with oral antibiotics and initially improved. However, his condition worsened again.  Despite several courses of oral antibiotics he had a regression in his overall behavior requiring assistance in all aspects of his life. He was treated with various drugs with no signs of improvement. It was recommended the patient undergo treatment with intravenous immunoglobulin for post infectious autoimmune encephalopathy.

Literature details the proper treatment of autoimmune encephalitis begins with the appropriate work-up and diagnosis.  Diagnosis must be made first and typically includes meeting criteria as evidenced by the subacute onset of working memory deficits, altered mental status, or psychiatric symptoms with at least one of the following: New focal central nervous system (CNS) finding, seizures not explained by previously known seizure disorder, CSF pleocytosis, or MRI features suggestive of encephalitis.  There must also be a reasonable exclusion of alternative causes.  Treatment with IVIG may be recommended in refractory cases of disease.  

While it is noted the patient was previously functioning, it is unclear from the record if the patient has undergone treatment, such as a tonsillectomy.  Typically, surgical intervention is recommended prior to treatment with IVIG.  Furthermore, the patient has undergone a Cunningham panel which did not reveal results consistent with Pandas.  Therefore, the record has insufficient evidence to support use of the requested medication.

The carrier's denial of coverage for Privigen (IVIG) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: PANS/PANDAS Pediatric Autoimmune Neuropsychiatric Disorder Associated with group A Streptococci.

Treatment: Privigen (IVIG) Injections

The insurer denied Privigen (IVIG) injections. The denial was upheld.

Reviewer # 1:

The patient is a young male with a past medical history of Epstein-Barr virus, autistic disorder, dissociative stupor, and immunodeficient.
The patient is also noted to have PANS/PANDAS pediatric autoimmune neuropsychiatric disorder associated with group A streptococci.

Privigen (IVIG injections) for treatment of Pediatric Acute Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Syndrome Associated with Streptococcal Infection (PANDAS) is likely to be more beneficial than any of the standard treatments for this patient.  Clinical presentation can vary from mild to debilitation, with sudden onset of symptoms including intense anxiety, mood lability, Obsessive compulsive-like issues and/or tics in association with a streptococcal-A (GABHS) infection prior to the symptoms can occur.  This association between PANDAS and streptococcal infection has been somewhat controversial and research is ongoing.

Currently, there are limited options for management of PANS/PANDAS.  Such Intervention includes immunomodulatory therapy such as IVIG, along with prophylactic antibiotics, psychiatric care, and cognitive-behavior therapy for moderate to severe PANS/PANDAS.
The carrier's denial of coverage for Privigen (IVIG) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatitis B
Issue under review: Vemlidy

Determination:
The Vemlidy is not medically necessary.
The patient has chronic hepatitis B and is doing well on tenofovir disoproxil fumarate, with undetectable virus. He has normal renal function. Tenofovir disoproxil fumarate is the formulary preferred agent. As the patient does not have any contraindications to continuing tenofovir disoproxil fumarate, there is no medical reason to change to Vemlidy. With regard to the appeal letter, it fails to note that the patient has undetectable virus on tenofovir disoproxil fumarate. 
The provider notes that the virus is detectable. However, the guidelines for treatment in patients with chronic hepatitis B who have a positive hepatitis B e-antigen such as this patient, recommend treating patients when the HBV DNA is greater than 20,000. This patient has an HBV DNA less than 20, which is essentially negative. Therefore, the patient is having a good response to current treatment.
While patients with lupus can develop renal issues, that varies depending on the severity of the disease, and the patient currently has normal renal function. As continuing tenofovir disoproxil fumarate is clinically appropriate and accepted standard of medical care, the proposed Vemlidy is not medically necessary, and the health plan acted reasonably, with sound medical judgement and in the best interest of the patient.
Appeal type: Step Therapy
Decision: Upheld

The patient has seronegative rheumatoid arthritis (RA).  Other past medical history (PMH) is degenerative joint disease (DJD), depression, hypothyroidism and asthma.  The patient is feeling 'okay' on Humira (getting samples) per her provider's note.  Prior treatment:  Plaquenil (not tolerated due to vomiting), arava (migraine's) and Enbrel.  The patient has allergies to nonsteroidal anti-inflammatory drugs (NSAIDs) and sulfa drugs.
The issue in this case is that the use of Humira is being denied by the health plan, as the patient has not tried either MTX (methotrexate), leflunomide, sulfasalazine, or hydroxychloroquine. 

The health plan's determination is upheld.  Humira is not medically necessary for this patient.  It's reasonable for the patient to try MTX with close monitoring of LFT's.  MTX is not contraindicated given the patient has normal LFT's when checked recently.  MTX is not expected to be ineffective based on the known clinical history and conditions of the patient and the patient's prescription drug regimen.
Appeal type: Medical necessity
Decision: Upheld

The patient  with a history of stimulant (cocaine) use disorder and opiate use disorder who was admitted to an inpatient detoxification unit .The patient presented seeking detoxification from cocaine and heroin. the health plans determination is upheld in whole. Inpatient detoxification services were not medically necessary. The patient had a relatively low initial COWS score and reported using a relatively small amount of heroin daily. On the days in question  he had no documented symptoms of opiate withdrawal while completing this taper and his vital signs were normal. He was not evaluated daily by a physician to determine whether this level of care was needed. There was no updated evaluation of why this level of care was indicated. COWS scoring was not updated daily.
 LOCADTR assessment was completed based on the information available in the chart and resulted in a recommendation that inpatient detoxification was no longer indicated.
Appeal type: Medical necessity
Decision: Upheld

The patient has a past medical history significant for deep venous thrombosis (DVT). This review is for the medical necessity of Pradaxa 150 milligrams (mg) capsule twice a day.

The health plan's determination is upheld.  Pradaxa is not medically necessary.  The plan's formulary alternatives include Coumadin, Xarelto and Eliquis.  In the records provided, there is no notation of failure of either of the plan's formulary medicines.  There was a notation that the patient had problems with Coumadin secondary to self-medication issues.  There is no noted intolerance to either of the plan's formulary medications.  There has not been any specific noted superiority in regards to Xarelto/Eliquis versus Pradaxa for the treatment of chronic DVT.  Based upon review of the records provided and that there is no noted failure or intolerance to the plan's formulary medications, the Pradaxa is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

The patient has morbid obesity, hypothyroidism and hypertension. The patient presented with symptoms of exertional dyspnea and fatigue with mild to moderate exertion for 6 months. Patient had palpitations and dizziness. An electrocardiogram (EKG) showed sinus rhythm with a rate of 84 beats per minute and poor R wave progression anteriorly. There were nonspecific ST and T changes.

A stress (persantine) nuclear study was performed, showing a perfusion defect in the anterior and apical segments with stress, equivocally improved at rest. Images were suboptimal due to artifact related to the patient's size, with a body mass index (BMI) of 30. Post stress test ejection fraction (EF) was 68% by gated Single-photon emission computed tomography (SPECT). A positron emission tomography (PET) scan was ordered by the patient's provider.  it is medically necessary to rule out myocardial ischemia in this patient with symptoms which may represent myocardial ischemia who has had an equivocal stress nuclear study. The reason for the equivocal stress nuclear study is likely the patient's large size, which results in degradation of the image. This is less likely to happen with a PET scan.

Cardiac PET myocardial perfusion imaging has higher diagnostic accuracy and lower radiation dose exposure during a shorter examination time compared with stress nuclear imaging, and is an established, highly accurate test for the detection of coronary artery disease. In the study by Danad et al (reference 3 below) cardiac PET stress imaging had a better diagnostic accuracy than either SPECT (stress nuclear) or CT coronary angiography.

In further support, Per Milliman Guidelines, one indication for cardiac PET is for patients needing an assessment of myocardial viability in whom SPECT myocardial perfusion scan or stress echocardiogram findings are inconclusive. That is the clinical situation for this patient.

The health plan's determination of medical necessity is overturned in whole
Appeal type: Medical necessity
Decision: Overturned

The patient presented to the emergency department with a three-day history of watery diarrhea and poor oral intake. The past medical history is significant for preterm birth at 36 weeks' gestation and was diagnosed with a viral upper respiratory tract infection two weeks to presentation. The current illness was characterized by vomiting, diarrhea, markedly decreased oral intake and decreased number of wet diapers. In the emergency department, he received volume resuscitation. The patient had significant laboratory abnormalities, including and elevated potassium and a low absolute neutrophil count. The patient underwent an abdominal ultrasound to rule out volvulus or intussusception. Despite attempts at oral rehydration, he had ongoing vomiting and diarrhea, prompting admission to the hospital. 

The health plan's determination is overturned. The inpatient admission was medically necessary. The patient required admission for intravenous hydration. Gastroenteritis and resultant dehydration is a leading cause of infant mortality in developing nations. Prompt volume resuscitation and ability to tolerate oral intake is essential to prevent the development of hypovolemic shock and end-organ failure. While many children can tolerate outpatient management of diarrhea and dehydration, this infant failed an oral challenge in the emergency department. Indications for admission include:
1) Lack of improvement with rehydration
2) Continued copious diarrhea that is likely to lead to recurrent dehydration if intravenous
3) replacement of ongoing losses does not occur
4) Inability to drink

This patient demonstrated these clinical features. These findings, accompanied by hyperkalemia and a low absolute neutrophil count, would prompt an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned in Part

The patient is a male with a history of hypertension, diabetes, atrial fibrillaton/flutter, chronic obstructive pulmonary disease (COPD), congestive heart failure, mild left ventricular systolic dysfunction, and chronic kidney disease. He was transferred from a nursing home to the hospital for scheduled cardiac catheterization for complaints of exertional chest pain. Upon arrival, he was hemodynamically stable with a normal cardiac exam. He had a left foot ulcer and a left thigh skin abscess that was being treated with Bactrim. Laboratory evaluation showed acute kidney injury (AKI) with a serum creatinine level of 1.94 milligrams per deciliter (mg/dl) (baseline 1.2 mg/dl). His serum potassium was 6.0 millimoles per liter (mmol/L). There were no acute electrocardiographic changes. The catheterization was postponed. He was treated for hyperkalemia with calcium, dextrose, insulin and albuterol and admitted to the hospital. The AKI and hyperkalemia were attributed to enalapril and spironolactone, which were held. The creatinine was 1.88 mg/dl and his potassium was 6.5 mmol/L. He was treated again for hyperkalemia. The next day his creatinine was 1.66 mg/dl and his potassium level was 5.0 mmol/L. The progress note indicates that the patient was stable and would be discharged the next day. The note indicates that the patient was scheduled for discharge with catheterization to be performed as an outpatient but that there were no nursing home beds available. He then remained hospitalized due to a lack of nursing home availability. Days later his creatinine was 1.38 mg/dl. Cardiac catheterization showed slow flow but no obstructive lesions. The procedure was uncomplicated. Daily notes until discharge indicate that the patient was stable for discharge but remained in the hospital due to lack of nursing home availability. He was discharged.

The health plan's determination is overturned, in part. 

An inpatient level of care was medically necessary in part. 
The reason for the patient's initial admission was acute kidney injury and hyperkalemia. Hyperkalemia to the degree seen in this patient can result in cardiac arrest and requires emergent treatment and careful monitoring. Thus, an inpatient level of care with continuous monitoring was medically necessary initially. However, this patient's renal function and electrolyte abnormalities improved quickly with treatment and discontinuation of the offending medications. His potassium was within normal limits without any specific treatment. The progress note indicates that the patient was stable and would be discharged the following day. There was not a medical reason for continued hospitalization. The patient did undergo cardiac catheterization. No obstructive disease was documented, and the procedure was uncomplicated. This did not justify an inpatient level of care.
Therefore, the inpatient stay was medically necessary in part.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Bipolar disorder
 
Treatment: Inpatient mental health treatment, medication, monitoring

The insurer denied the continued inpatient mental health treatment. The denial was modified.

This male was admitted for inpatient mental health treatment due to suicidal thoughts, depression, and psychotic symptoms including paranoid and delusional thinking, disorganized thinking, internal preoccupation, poor impulse control, flight of ideas, irritable and depressed mood, anxiety, pressured and hyperverbal speech, poor activities of daily living (ADL's), and non-compliance. He reportedly had been using crack/cocaine, K2 (synthetic marijuana) and alcohol. He had past reported psychiatric hospitalizations and a past reported suicide attempt. He had a diagnosis of bipolar disorder. 

The APA Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports the least restrictive level of care for safe and effective treatment is appropriate; patients with manic episodes, psychotic symptoms, or psychomotor agitation, aggressive or self-injurious behavior, suicidal or homicidal intent or plan are candidates for inpatient treatment. In this case, this patient had both manic and psychotic symptoms in addition to suicidal thoughts with a past reported suicide attempt, and alcohol and multiple substances of use, so he was considered a candidate for psychiatric hospitalization. 

As of day #5, the patient denied depression, hallucinations, paranoia, suicidal or homicidal ideation, plan, or intent. There were no reports of delusional or disorganized thinking or feelings of hopelessness. There were no specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting, and there were no reports of manic episodes, acute medical instability, or specific evidence that he was an imminent danger to self or others. 

Based on the above, inpatient hospital admission is modified to approve the first 4 days,  as medical necessity is substantiated, but deny remaining dates, as medical necessity is not substantiated.