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

Diagnosis: Tetraplegia 
Treatment: Skilled nursing facility 

The insurer is denied coverage for skilled nursing facility. The denial is upheld. 

The patient is a male who underwent C5-C7 anterior cervical discectomy and fusion (ACDF), C3-7 posterior laminectomy and posterior decompression with resultant tetraplegia. He was admitted to acute inpatient rehabilitation unit and subsequently transferred to SNF for subacute rehabilitation. Currently under review is the medical necessity for care in a skilled nursing facility (SNF). 

The patient was admitted to the acute rehabilitation facility secondary to incomplete tetraplegia. After several weeks of acute rehabilitation, the patient was admitted to the SNF. However, after several weeks of sub-acute rehabilitation therapy there was a plateau in functional progress. According to the physical therapy notes as of a specified date, the patient remained totally dependent for bed mobility, transfer activities and non-ambulatory. Several months later his functional status was much the same. He again was totally dependent for bed mobility, transfer activities and non-ambulatory. There was also no significant functional improvement documented in the occupational therapy notes. In addition, there were no complex nursing or medical issues that warranted continued SNF length of stay. 

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, skilled nursing facility (SNF) care was not medically necessary. 

The carrier's denial of coverage for skilled nursing facility is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer 
Treatment: Oncotype DX testing 

The insurer is denied coverage for Oncotype DX testing. The denial is upheld. 

This is a male patient with T1c and 2 cores of Gleason 6 and PSA of 5.3. This patient who is a candidate for active surveillance would benefit from magnetic resonance imaging (MRI) prostate to make sure there are no other suspicious or aggressive prostate cancer in difficult biopsy areas such as anterior apex. The Oncotype Dx is used to test prostate biopsy specimens, however, if patient has a large prostate or cancer in a difficult to biopsy area, the results would not be accurate. Literature shows in very low or low risk prostate cancer patients, genomic testing such as Oncotype DX is unlikely to change clinical management. Therefore, Oncotype DX testing is not considered medically necessary for this patient. 

"The Genomic Prostate Score has limited clinical usefulness in patients at very low risk since the NCCN risk group did not change. While it may be more useful for men at low and intermediate risk, for 32 (31%) of whose risk group was reclassified, clinical management decisions did not always appear to reflect these changes." (Gaffney, C. et al. 2019) 

"The genomic test used in this case, Oncotype DX, provides a GPS based on expression of genes from multiple prostate cancer pathways. This test estimates the likelihood of favorable versus adverse pathology if the patient were to have immediate prostatectomy. Prior studies have shown that Oncotype DX results can influence clinical decision making about AS versus radical treatment. For example, in a clinical utility study, the GPS disagreed with the clinical risk category in 39% of cases, and 18% of recommendations for treatment versus AS changed based on the results." (Loeb, S. (2018)

"Multifocal, low-grade and high-grade prostate cancer foci exhibit distinct prognostic
expression signatures. These findings demonstrate that prognostic RNA expression assays performed on low-grade prostate cancer biopsy tissue may not provide meaningful information on the presence of coexisting unsampled aggressive disease." (Salami, S. S. et al. 2018) 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for Oncotype DX testing should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hyperemesis gravidarum.
Treatment:  Inpatient stay.

The insurer denied the Inpatient stay.  The health plan's denial is upheld in whole. 

The inpatient admission was not medically necessary.

This patient presented to the hospital through the emergency department with a history of migraines and anemia with reported vomiting over the past month.  The patient was currently 16 weeks pregnant per the ER H&P.

The inpatient admission was not medically necessary at the acute inpatient level of care status for this patient, given the normal physical exam and lack of unstable presentation requiring inpatient stay in the setting of hyperemesis gravidarum.  In this case, there was no acute intervention for the patient and the exam was unremarkable with no acute distress.  The patient was noted to improve with the initial few hours of evaluation in the ER.  There was no acute blood loss noted.  There was an IV placed in this case.  There was no coagulopathy suspected.  The patient did not meet the Milliman Care Guidelines (MCG) 22nd edition entitled "Hyperemesis Gravidarum."

Based upon a review of each MCG Guideline criterion, the patient is noted to have no serious gastrointestinal pathology by lab assessment or physical exam.  A lower level of care would have been sufficient, based upon improvement noted in the first 24 hours of the admission.  The patient had no tachycardia and was able to have intake.  There was also no hemodynamic instability, as the patient had normal vital signs.  There was no vomiting that was severe or persistent documented.  There were no severe electrolyte abnormalities noted, and potassium was not severely deranged, suggesting no excessive vomiting.  There was no acute renal failure and no altered mental status in this case.  There was no fetal compromise at this gestational age.  There was no suspicion of hydatidiform mole present, given a normal ultrasound performed.  The patient did not require treatment or monitoring that required inpatient admission.  Patient had no need for excessive IV fluids (> 3 liters per day).  There was no need for parenteral nutrition in this case, as the patient was on an oral diet and intake.  Thus, there was no criterion that was met for inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Deformity of the foot.
Treatment:  AFO and accessories (ankle foot orthoses).

The insurer denied the AFO and accessories (ankle foot orthoses).  The denial is overturned. 

The patient is a male with mild autism disorder, who presented with deformity of the foot with deformed gait.  He was noted to have a total walker gait.  He has been able to function normally by using ankle foot orthoses (AFOs), which were prescribed to him by his physiatrist.  As he has outgrown them, he was evaluated for a new pair of bilateral custom foot orthoses with the addition of an articulated ankle to allow for greater mobility.

Yes, the proposed AFO and accessories are medically necessary.

The patient suffers from lower extremity deformity that is typically treated conservatively with an ankle-foot orthosis.  The patient has a congenital deformity that prevents standard prefabricated orthoses from adequately treating the condition.  Prefabricated ortheses are typically utilized for more standard conditions, such as pes planus (flat feet) and arch pain.  The unique congenital deformity requires a custom approach to address it adequately.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Palpitations, chest pain.
Treatment:  Inpatient admission.

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

No, the proposed treatment was not medically necessary.

The patient is a male with no significant past medical history, presented to the ER for complaints of palpitations and chest pain, intermittent for one to two weeks duration. 

The patient was hemodynamically stable.  Electrocardiogram (ECG) revealed sinus tachycardia with non-specific ST changes.  Cardiac troponins were negative.  The patient underwent a computed tomography angiogram (CTA) of the chest, which was negative for pulmonary embolus (PE).  A stress echo was obtained, which revealed inferior-lateral hypokinesis, suspicious for ischemia and he was transferred for cardiac catheterization.  The cardiac catheterization revealed no significant coronary artery disease, and the patient was discharged home with a plan for outpatient follow-up.

This patient presented for evaluation of chest pain.  The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a stress test, which was abnormal, suggestive of ischemia.  The patient underwent a coronary angiogram, which revealed no coronary artery disease (CAD), so the stress test was false positive.  There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability.  Pulmonary embolism was ruled out by a CT scan.  There were no peri-procedural complications.  The standard of care for patients presenting for catheterization is ambulatory care with post-procedure observation.  Thus, the medical record does not support medical necessity for acute inpatient care, and the services could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Arm and Back Pain.
Treatment:  Inpatient Hospital Stay.

The insurer denied the inpatient hospital stay.  The determination is upheld.

The patient has a past medical history of a seizure disorder and complex regional pain syndrome who presented to the hospital on 11/13/19 with left arm and left upper back pain that she had been dealing with for a year but that significantly worsened.

On presentation, she was afebrile with a blood pressure (BP) of 147/79, heart rate 69, respiratory rate 18, and oxygen saturation of 100% on room air.  The exam otherwise noted limited range of motion of her left upper arm secondary to pain and tenderness.  Lab results were grossly unremarkable.  An x-ray of the cervical spine showed normal alignment without evidence of an acute fracture or subluxation.  A chest x-ray also showed no acute process.  An electrocardiogram (EKG) did not show obvious acute ischemia.  The patient was brought into the hospital for neurostimulator implantation.  She subsequently was noted to have a low grade fever and was noted to have a swab that resulted positive for influenza B.  The patient was started on Tamiflu, the procedure was rescheduled, and she was subsequently discharged.

At issue is whether an inpatient stay was medically necessary.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.  This patient presented with acute worsening of her chronic pain and initial plans for neurostimulator placement.  The procedure subsequently was delayed after she had a low grade fever to 100 degrees Fahrenheit and was diagnosed with influenza B, and she was discharged the next day.  In the absence of intractable pain failing observation and requiring inpatient treatment, a new neurologic deficit requiring inpatient care, or other acute decompensated medical issues aside from the flu with which she had no hypoxia and was stable for outpatient treatment, it is unclear why this patient could not have been safely treated at a lower level of care.  Inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Digestive system/Gastrointestinal /Abdominal/Stomach pain.
Treatment:  Inpatient hospital.
  
The insurer denied the inpatient hospital stay.  The denial is upheld in whole.

This case involves a patient with a history of human immunodeficiency virus (HIV), with last CD4 count 261, treated with highly active antiretroviral therapy, who developed anal squamous cell carcinoma and recently started on chemoradiation.  The patient has developed diarrhea for two days.

No, the health service/treatment of inpatient stay is not medically necessary for this patient.  The above presentation can be managed under a lower level of care.  The patient presents with multiple bouts of diarrhea in the setting of receiving chemotherapy and concurrent radiation.  There was no evidence of hemodynamic instability or severe dehydration.  The electrolytes were normal, and so was the renal function.  Resistant colon infections were rapidly ruled out.  Per the documentation, there are no peritoneal signs or severe abdominal pain.  There is no radiographic evidence of toxic megacolon and no vomiting.  There is no evidence of colon abscess, gastrointestinal (GI) bleeding, that could not be monitored in a lower level of care.  The patient was diarrhea free within 24 hours of admission.

In summary, the hospitalization of this patient can be accomplished under a lower level of care.  Therefore, the inpatient hospital stay is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bronchitis.
Treatment:  Inpatient admission.

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

This is a young female patient who presented to the Emergency Department (ED) after being seen by her primary care provider for fever, cough and difficulty breathing.  The patient was treated with nebulized albuterol and Tylenol at home.  It was reported that the patient had had a similar episode a few months ago where she was treated with albuterol.  In the ED, the patient was noted to appear tired with significant increase in her work of breathing.  On exam it was noted that the patient had rales, wheezing and was experiencing subcostal retractions, tachycardia, and tachypnea; her respiratory rate was 48 breaths per minute.  The patient was given oxygen, an intravenous (IV) fluid bolus and Orapred.  Laboratory work up was done that revealed a white blood cell (WBC) count of 18,200.  The patient's respiratory distress did not improve with the treatment in the ER; she was admitted for observation.  The patient's breathing rate remained elevated; 50 breaths per minute.  It was determined that she had bronchitis.  She was admitted to the hospital for further medical treatment.  She was treated with albuterol every 2 hours.  After several days of treatment she was medically stable and discharged home.

Based on the review of the medical record and literature, inpatient admission was medically necessary for this patient.  The patient was treated appropriately in the Emergency Room (ER) for respiratory distress with rales and wheezing.  The patient's tachypnea, retractions with increased work of breathing did not respond to treatment in the ER.  The decision to admit to the hospital for ongoing treatment with IV fluids, albuterol and oxygen was appropriate and consistent with the standard of care.  The patient had also trailed observation level of care but due to her need for more frequent albuterol treatment and close monitoring, the patient was admitted to inpatient level of care.

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

The carrier's denial of coverage for the inpatient stays should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain and back pain.
Treatment:  Inpatient admission.

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

No, the proposed treatment, admission at an acute inpatient level of care, was not medically necessary. 

The patient is a female.  Her medical history included gallstones.  Her surgical history included Cesarean section. 

The patient presented to an emergency room with an 11-day history of abdominal and back pain.  Her vitals were temperature 98.1, pulse 114, blood pressure 144/91, respirations 19, and oxygenation 98%.  Physical examination demonstrated tenderness to palpation of the right upper quadrant of the abdomen.  Serum laboratories demonstrated a normal white-blood-cell count of 6.58; her liver-function-tests were unremarkable.  Abdominal ultrasound demonstrated cholelithiasis without evidence of cholecystitis, though the common bile duct was dilated to eight millimeters (mm). 

The patient was admitted at an acute inpatient level of care with a diagnosis of cholelithiasis, possible choledocholithiasis.  She was made nil per os [NPO] and provided with intravenous fluids, antibiotics, analgesics, and anti-emetics.  Magnetic resonance cholangiopancreatography (MRCP) demonstrated choledocholithiasis. 

The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and stone extraction; the procedure and recovery were uncomplicated. 

The patient underwent laparoscopic cholecystectomy; the surgery and recovery were uncomplicated.  Having returned to her baseline health and function, the patient was discharged home in good and stable condition with outpatient surgical follow-up. 

There were two diagnoses and two procedures but neither required admission at an acute inpatient level of care.  The patient underwent ERCP for choledocholithiasis.  According to the literature, "a selective policy, an ERCP on an outpatient basis seems as safe as when performed on an inpatient basis" [Jeurnink, et al.]. 

The patient underwent laparoscopic cholecystectomy for cholelithiasis.  According to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES): "patients undergoing uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis may be discharged home on the day of surgery" [SAGES]. 

Indeed, insofar as the patient did not demonstrate significant co-morbidities or physiologic derangements, and insofar as the procedure, the surgery, and their recoveries were uncomplicated, the patent could have been treated at a lower level of care, precluding the need for admission.

Based on the provided medical documentation and in accordance with peer-reviewed literature and national guidelines, for this patient, admission at an acute inpatient level of care was not necessary.  The patient could have been and should have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Migraines
Issue under review:  Botox

Determination:
The Botox is medically necessary.

The patient is a young female with history chronic daily migraines, intractable and severe.  According to the records, the neurologist began treating the patient, at which time the patient had had headaches every day for three years.  Prior to that, she had headaches for several years but to a lesser degree, and the headaches worsened approximately two to three years prior to seeing the neurologist.  According to the neurologist, the patient had failed trials of cyproheptadine, amitriptyline, and Topamax. After multiple office visits and medication adjustments, the patient was noted to be slightly improved, at which point she was taking amitriptyline and Trokendi, and was also using Naproxen as a rescue medication.  She had received authorization to undergo Botox injections.  

The patient continued to have 16 to 20 headaches per month and underwent her first series of Botox injections.  As of a follow-up with the neurologist, the patient was doing slightly better . She was having three to four headaches per week with her pain rated as 3-4/10.  She tolerated the Botox injections well with no side effects, and they were to be repeated in 12 weeks. 

As of five months later, the patient had not had to use her rescue medication.  She had stopped taking Trokendi and had no worsening of her headache.  Another series of Botox injections was performed, and the use of Emgality was discussed.  

Three months later, another round of Botox injections was administered, and it was noted the patient had undergone three Aimovig injections and was tolerating it well and did not need to use Naproxen.  The neurologist noted the patient's headache frequency was finally on target with both Botox and Aimovig.  

As of a recent follow-up, the patient had interim worsening, and she estimated having seven severe headaches during December along with some mild ones.  She used Naproxen three to four times.  The neurologist recommended increasing the patient's Aimovig dosage and that her Botox therapy be continued.  

The medicine requested, Botox, was denied since the policy doesn't approve it in combination with Aimovig.  This is the subject of this appeal.

The patient has intractable chronic migraine, which is only controllable in the patient's case with a combination of Aimovig and Botox.  The patient has failed multiple preventative medications previously.  Without Botox, the headache control will deteriorate.  Therefore, the proposed treatment is medically necessary. 

There are no FDA or practice guideline warnings to indicate that the combination of Aimovig and Botox is unsafe or contraindicated.  The patient's headaches are only controlled with the combination of these two medications.  Therefore, the best interest of this patient is to continue Botox and Aimovig.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mixed connective tissue disease and collagen vascular disease associated immunosuppression 

Issue under review: Gamunex-C

Determination: The Gamunex-C is not medically necessary. 

The patient is an adult male for whom Gamunex C is requested. He has mixed connective tissue disease and collagen vascular disease associated immunosuppression.  He was improved on methotrexate, plaquenil and prednisone, but ran out of medication while abroad and is now flaring. 

Mixed connective tissue disease (MCTD) is thought to be incurable, and no randomized trials have been performed to guide therapy. The management is largely guided by the known effectiveness of specific therapies for similar problems seen in systemic lupus erythematosus, scleroderma, or polymyositis. Many of the clinical manifestations of MCTD associated with significant morbidity, such as aseptic meningitis, myositis, pleurisy, pericarditis, and myocarditis, tend to be intermittent and responsive to glucocorticoids. Glucocorticoids may occasionally be effective in MCTD for esophageal involvement. 

Immune globulin derived from the plasma of paid and volunteer donors is used in the treatment of an array of disorders, including primary and secondary immune deficiency states and a variety of autoimmune and inflammatory disorders. However, it is not indicated for use in collagen vascular diseases and is not an accepted off-label use of immune globulin, according to current available literature. 

Gamunex-C is an immune globulin injection (human), 10% liquid indicated for treatment of: 1.1 Primary Humoral Immunodeficiency (PI) GAMUNEX-C is indicated for treatment of primary humoral immunodeficiency in patients 2 years of age and older. This includes, but is not limited to, congenital agamma globulinemia, common variable immunodeficiency, X-linked agammaglobulinemia, Wiskott-Aldrich syndrome, and severe combined immunodeficiencies. 1.2 Idiopathic Thrombocytopenic Purpura (ITP)
GAMUNEX-C is indicated for the treatment of adults and children with Idiopathic Thrombocytopenic Purpura to raise platelet counts to prevent bleeding or to allow a patient with ITP to undergo surgery. 1.3 Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) GAMUNEX-C is indicated for the treatment of CIDP in adults to improve neuromuscular disability and impairment and for maintenance therapy to prevent relapse. 

The patient has a diagnosis of collagen-vascular disease associated secondary immunosuppression. Gamunex-C is not medically necessary, because it is not a Food and Drug Administration (FDA)-approved treatment of collagen-vascular disease associated secondary immunosuppression. 

Therefore, Gamunex-C, is not medically necessary as supported by the current medical literature or standard of care.