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

This is a patient with a history of reactive airways disease who presented to the emergency department with wheezing and respiratory distress.
He was well until 2 days prior to admission when he began having cold symptoms including a runny nose and cough. He was started on his albuterol nebulizer treatments at home. Despite these treatments, he continued to have respiratory distress with belly breathing, so he was brought to the emergency department for further evaluation. He also vomited 3 times at home.
Upon admission, he was initially treated with albuterol every 4 hours with an additional treatment every 2 hours as needed, as well as prednisolone and supplemental oxygen as needed. He was found to have rhino/enterovirus infection. He improved during the hospitalization, tolerated every 4 hour treatments, and by the following day was felt to be stable for discharge with follow-up as an outpatient.
The health plan's determination is overturned.

This is a very young boy who presented with wheezing and respiratory distress due to a viral infection. He continued to have symptoms despite receiving appropriate treatment at home as well as intensive treatment in the emergency department setting. Following his initial treatments in the emergency department, he became hypoxemic and continued to have respiratory distress. At that time, he was requiring frequent bronchodilator therapy as well as supplemental oxygen. Inpatient admission was required for continued bronchodilator therapy, supplemental oxygen as needed, and close monitoring with escalation of treatment as indicated. While he improved quickly after hospital admission, this could not have been predicted ahead of time. The decision making at the time of admission for this patient was consistent with his young age, the persistence of symptoms despite appropriate and aggressive treatment, and the initial need for frequent bronchodilator therapy and supplemental oxygen along with close monitoring for potential deterioration of clinical status.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2:		

This is a female patient with Crohn's Ileocolitis diagnosed originally over a decade ago. She also has a component of irritable bowel syndrome (IBS), and a Low Fermentable, Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAP) diet has been suggested. Due to an overlap of symptoms between Crohn's disease and IBS, the treating physician would like to utilize fecal calprotectin as a biomarker. The scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes. Fecal Calprotectin is specific to intestinal inflammation.

Per Kennedy, NA., et al. (2019), "In a retrospective analysis of patients with CD [Crohn's disease], we found that measurements of fecal calprotectin made during routine monitoring can identify patients at risk for disease progression, independent of symptoms or disease location. It is therefore important to screen asymptomatic patients for mucosal inflammation and pursue complete resolution of inflammation."

According to Li, R. et al. (2019), "BACKGROUND: Fecal calprotectin (FC) is widely used to discriminate between patients with inflammatory diseases such as inflammatory bowel disease (IBD) and functional diseases such as irritable bowel syndrome (IBS). ELISA is a time-consuming method for the measurement of FC, whereas a fluorescent immunochromatography test can obtain results in around 30 minutes and thus enables a rapid response to clinical decision...

CONCLUSIONS: FC Proglead may be used as a suitable alternative to FC BUHLMANN for the disease activity assessment for patients with IBD, considering its convenience and shorter turnaround time."      

Guidelines from Gastroenterology Associations include the use of Fecal Calprotectin for diagnosis and surveillance of IBD.  The patient is a good candidate for the fecal calprotectin provided. She has a history of IBD/Crohn's Disease. 

According to Rex, DK., (2014), "Calprotectin is a protein shed in the stool of patients with an inflamed bowel. Fecal calprotectin levels have been shown to correlate with healing in inflammatory bowel disease (IBD), to predict relapse, and to differentiate patients with low and high risk for IBD before diagnosis."     

The requested test (fecal calprotectin) is a non-invasive method of diagnosing irritable bowel disease (IBD). Thus, it is more beneficial than Colonoscopy in some cases by avoiding a biopsy.

 This testing is likely to be more beneficial than any other standard testing.
                                            
The carrier's denial of coverage for Current Procedural Terminology (CPT) code 83993 Calprotectin, fecal provided for diagnosis code E 53.8 should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease
 
Treatment: Current Procedural Terminology (CPT) code 83993 Calprotectin, fecal

The insurer denied coverage for Current Procedural Terminology (CPT) code 83993 Calprotectin, fecal. The denial was reversed.

Reviewer #1:

This patient is a female with a long history of Crohn's disease of the small and large intestine.  She remains with rectal urgency and attacks of diarrhea.  Her symptoms have been increasing over the past three years.  Her physician is attempting to determine if her ongoing symptoms of diarrhea are related to Crohn's disease.

Clinical and Experimental Gastroenterology has an article titled "Fecal Calprotectin in Inflammatory Bowel Disease."  The conclusions were that fecal calprotectin has adequate sensitivity and specificity in identifying patients who have IBD rather than functional disease.  It has been determined to be useful to assess the disease activity and response to treatment.  Rises in calprotectin were felt to indicate disease relapses.

Inflammatory Bowel Diseases has an article titled "Meta-analysis: Fecal Calprotectin for Assessment of Inflammatory Bowel Disease Activity."  There were 13 studies examined in the final analysis.  The conclusion was that fecal calprotectin is a reliable marker for assessing IBD activity.

The scientific evidence in the peer-reviewed literature has shown that fecal calprotectin results in an improvement in health outcomes.  The FDA has cleared calprotectin as a marker intended for differentiating Irritable Bowel Syndrome from IBD.  The patient is a good candidate because of the need to consider multiple causes for her ongoing symptoms.  It is the best treatment since it is non-invasive.  Obtaining stool calprotectin is a beneficial, proven method of assessing IBD activity.  The denial is reversed.

This testing is likely to be more beneficial than any other standard testing.

The carrier's denial of coverage for Current Procedural Terminology (CPT) code 83993 Calprotectin, fecal provided for diagnosis code E 53.8 should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
 
Treatment: NovoLog FlexPen 100 unit per milliliters subcutaneous Solution Pen-Injector

The insurer denied coverage for NovoLog FlexPen 100 unit per milliliters subcutaneous Solution Pen-Injector. The denial was upheld.

This is a male patient with diabetes using Novolog insulin was switched by the insurer to Admelog insulin. The patient used the new insulin and indicated that he is unable to maintain adequate blood sugar control with the Admelog insulin. He wishes to switch back to the Novolog. His insurer has denied this as not medically necessary. Lab reports from mid-2018 indicated HgbA1c= 8.8, in early 2019 HgbA1c=7.9, and in mid-2019 HgbA1c= 7.7. Fill data from the pharmacy indicates Admelog was dispensed in late 2018, early 2019, and mid-2019. External appeal application indicates HgbA1c of mid-2018 was prior to Admelog and the subsequent two were on Admelog. Hand written notes on the lab value of mid 2018 state that this was obtained prior to Admelog and while on Novolog consistent with the pharmacy dispense data. The subsequent lab values have handwritten notes stating while on Admelog. The data therefore presents the lowest HgbA1c while the patient is on Admelog. 

The target HgbA1c for non-pregnant adults is <7%. (1) The data presented suggests that the patient most likely approximates this in mid-2019 while on Admelog. Comparative data on use of the two analogs shows little difference in overall control between the products. (2) Given the patient's individual response and the general data available that Admelog provides adequate control compared to Novolog, there is no data to indicate the patient should switch back to Novolog.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for NovoLog FlexPen 100 unit per milliliters subcutaneous Solution Pen-Injector is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of Crohn`s disease diagnosed in 2018. The patient failed conventional therapy but improved on Remicade 10 milligrams (mg) per kg (kilogram) every 8 weeks. The Remicade level on this dose was undetectable. Despite the clinical improvement, the patient has evidence of active disease. The inflammatory markers are elevated (erythrocyte sedimentation rate (ESR) 19) and the patient has anemia.
The requested service is increasing Remicade from 10 mg per kg every 8 weeks to every 4 weeks in order to improve the drug level.

The health plan's determination is upheld. The requested 384 units of injection infliximab (Remicade), 10 mg is not medically necessary. This patient has a low level of Remicade and evidence of active disease. The use of higher doses and/or more frequent infusions is indicated and appropriate in this patient in order to improve the drug level and improve the chances of remission. The requested dose of 10 mg per kg every 4 weeks is an acceptable dose when escalation of treatment is indicated.
Per the clinical practice guidelines (Ruemmele FM) "In clinical practice pediatric gastroenterologists will adjust dosing (from 5 mg/kg to 10 mg/kg for infliximab IFX) and/or intervals from every 8 to every 4 weeks in IFX-treated patients with the goal of sustaining continuous clinical remission". Dose escalation is acceptable to a maximum of 10 mg per kg every 4 weeks, which is the requested dose. The requested dose of 10 mg per kg every 4 weeks is indicated and supported by adequate peer reviewed literature for this patient. However, the patient can receive Inflectra at the dose of 10 mg per kg every 4 weeks. Inflectra is the generic (biosimilar) of Remicade. Both medications are considered bio-equivalent and can be used interchangeably. There are no clear guidelines on switching from one product to another. The standard of care is to continue the effective treatment and adjust the dose in order to achieve adequate drug levels. There is recent evidence showing that both biosimilars and the brand Remicade are equally effective. In this case there is no documentation of that this patient has tried and failed Inflectra. The brand name Remicade is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Chest Pain
Inpatient Hospital

The patient is a female with hypertension, hyperlipidemia, and hypothyroidism. She presented to the hospital with intermittent mild left (L) chest pain for 2 weeks prior to admission. Blood pressure (BP) was 160/84 and pulse 73. Respirations were 18 and pulse oximetry was 98% on room air. Troponins were negative, and electrocardiogram (EKG) showed a left bundle branch block (LBBB). She was treated with aspirin, Plavix and intravenous heparin. She later complained of L arm and shoulder pain while hospitalized. Echocardiogram (ECHO) showed an ejection fraction (EF) of 55-60% with diastolic dysfunction, trace mitral regurgitation and mild aortic stenosis. She was transferred to another facility for coronary angiography. The procedure was performed and showed a 60% right coronary stenosis. Medical therapy was advised. Metoprolol was added to her medications which included aspirin and a statin, as well as losartan for hypertension (HTN). She was discharged.

The health plan's determination is upheld, in whole. 

No, inpatient hospitalization is not medically necessary. The patient presented with chest pain and L arm pain, suspicious for angina, but was hemodynamically stable. Her EKG was abnormal, but not diagnostic for ischemia. She ruled out for myocardial infarction, with negative serial troponin levels. She did not have objective findings to indicate an alternative serious cardiac or pulmonary diagnosis, such as aortic dissection or pulmonary embolus. She could have been treated at a lower level of care status, but full inpatient hospitalization was not medically necessary, based on her presentation and course.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/ Neuromuscular Disorder
Inpatient hospital

The patient is a female with a history hypertension, diabetes, and low back pain.  She presented to the emergency room with a brief history of dizziness with moving her head, along with some nausea and vomiting. The vital signs were normal. Physical exam was notable only for slight horizontal nystagmus to the left. Labs were non-contributory. The computed tomography (CT) scan of the head was unremarkable. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with oral medications. A magnetic resonance imaging (MRI) showed some non-specific white matter lesions. The neurologist evaluated the patient and did not make a specific assessment. The hospital course was clinically uneventful, and the patient was discharged the following day.
The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

No, the requested health service/treatment of inpatient stay was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, or imaging of an imminently life-threatening cause of the patient's complaints. Therefore, there were no objective findings substantiating the need for acute inpatient level of care. In addition, the services provided - oral medications, neurology consultation, and MRI - were not at the acute inpatient level of intensity. The patient's care could have been safely and efficiently provided at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

High Risk Suicide
Inpatient Hospital

The patient has a history of Parkinson's disease who presented to the emergency department after being found in water following a suicide attempt. She had recently been expressing statements that she did not want to live, according to her daughter. In the emergency department, she was cleared by trauma surgery and held for a psychiatric consultation. She also developed atrial fib with rapid ventricular response, which converted back to sinus, and borderline low blood pressure. Vital signs showed temperature initially 92 Fahrenheit and later 97.8 Fahrenheit after rewarming, heart rate 116, respiratory rate 24, oxygen saturation 99%, and blood pressure approximately 90/60. On physical examination, neck was supple, heart was regular with no murmurs, breath sounds were clear, and there were no neurologic deficits. Labs showed aspartate aminotransferase (AST) 28, white blood cell (WBC) 18.36, hemoglobin 11.7, platelets 283, troponin 0.01, glucose 243, creatinine 0.8, sodium 148, and Lactate > 10. Chest x-ray was negative for pneumonia. Hip x-ray was negative for fracture. The patient was admitted with new onset atrial fib with rapid ventricular response and suicide attempt. The plan of care included telemetry, monitor electrolytes, psychiatry consult, blood culture, urine culture, echocardiogram, cardiology consult, and close observation to prevent a future suicide attempt. She was started on Remeron by psychiatry. Echocardiogram showed normal left ventricular function and no other acute abnormalities. She remained in sinus rhythm and was discharged to a psychiatry service. The inpatient stay is under review.

The health plan's determination is overturned. The inpatient stay was medically necessary for this patient. Because of the patient's initial hypothermia, elevated lactate levels, and increased risk of a recurrent suicide attempt, an inpatient level of care was indicated. There was also an increased risk of recurrent atrial fib with rapid ventricular response given her recent metabolic derangements and hypothermia with re-warming. Patients with this constellation of characteristics are not typically managed at a lower level of care. The patient had depression and a suicide attempt, and the primary medical reason for admission was medical stabilization in the setting of recent atrial fib with rapid ventricular response, hypothermia, and lactic acidosis. She returned to normal sinus rhythm in the emergency department and was Hemodynamically stable, primarily receiving rate control, anti-depressive therapy, echocardiogram, and cardiology evaluation. However, she was significantly hypothermic, was at increased risk of recurrent suicide attempt, and was at increased risk of lactic acidosis or sepsis in the setting of elevated lactate levels.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male who presented with shortness of breath. He was well until approximately a week prior to admission when he developed a headache and a productive cough. He then developed shortness of breath. At school on the day of admission, he felt unable to catch his breath, so he went to the school nurse. The school nurse called his father, who subsequently brought him to urgent care. At the urgent care center, he received 2 albuterol nebulized treatments as well as corticosteroids. His symptoms initially resolved but his oxygen saturation dropped down to 88%. Emergency Medical Services (EMS) was called and he was brought to the emergency department for further care.

In the emergency department he was found to have tachypnea with diminished breath sounds on the right side, and he received albuterol/Atrovent nebulized treatments. Laboratory values were obtained, and a chest x-ray showed right lower lobe and right middle lobe atelectasis/infiltrate. His respiratory status had improved, but his oxygen saturation dropped down to 92% on room air. He was started on ceftriaxone and azithromycin for community-acquired pneumonia and was admitted for further care for persistent hypoxemia.
Following admission, his oxygen saturations ranged from 89-93%. He was started on supplemental oxygen by nasal cannula, which was weaned off as tolerated. He was also given intravenous ceftriaxone as well as oral azithromycin, and albuterol every 3 hours as needed. By the following day he had improved and was stable on room air. He was discharged to home on amoxicillin and azithromycin to complete a full course of therapy, with follow-up as an outpatient.

The health plan's determination is overturned.

This is a patient who presented with respiratory distress due to pneumonia and underlying reactive airways disease. He continued to have symptoms despite appropriate treatment at both the urgent care center and in the emergency department. He became hypoxemic prior to his transport to the emergency department and continued to have low oxygen saturation levels after treatment in the emergency department. He required inpatient admission for administration of supplemental oxygen, intravenous antibiotics for pneumonia, and close monitoring with additional treatments as needed.
The decision making at the time of admission for this patient was consistent with his age, the persistence of symptoms including hypoxia despite appropriate treatments, and the need for ongoing treatments including supplemental oxygen and intravenous antibiotics in an inpatient setting with close monitoring for potential deterioration of clinical status.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Spastic cerebral palsy
Issue under review: Screening for genetic disorders

Determination:
The health plan should cover the Screening for genetic disorders.

Whole exome sequencing should be covered as a diagnostic test for this patient. As noted by her pediatric neurologist, Dr. Paciorkowski, at a tertiary children's hospital (University of Rochester Medical Center), this child has symptoms that strongly suggest a genetic explanation for her spastic cerebral palsy (dysmorphic facial features, including low set and posteriorly rotated ears, down slanting palpebral fissures, asymmetric orbits, asymmetric mid facial structures, dysmorphic corpus callosum with ventricular dilatation and cortical visual impairment). Although born prematurely at 34-35 weeks gestation, her post-natal course did not include symptoms of neonatal encephalopathy and her brain MRI did not identify lesions consistent with hypoxic-ischemic encephalopathy or periventricular leukomalacia. She has had CMA (chromosomal microarray analysis) testing that resulted in findings thought to be "very likely benign" and therefore not a sufficient explanation for her clinical condition. 

Recent published studies have found genetic etiologies in up to one-third of patients with unexplained cerebral palsy (Millan, et al. 2019). Whole exome sequencing has been found to have a significant diagnostic yield (up to 30% of cases) in patients with strong clinical suspicion of genetic etiology. This patient fulfills the "Indications for Diagnostic Testing (Whole Exome Sequencing)" mentioned in the American College of Medical Genetics and Genomics Policy Statement - "1. WGS/WES should be considered in the clinical diagnostic assessment of a phenotypically affected individual when: (c) A patient presents with a likely genetic disorder but specific genetic tests available for that phenotype have failed to arrive at a diagnosis." 

When it identifies an etiology, it has been shown to have a positive impact on clinical management and a reduction in additional diagnostic testing.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Spastic cerebral palsy
Issue under review: Screening for genetic disorders

Determination:
The health plan should cover the Screening for genetic disorders.

The patient has brain malformation associated with white matter dysplasia. The medical literature, reference 4, indicates about 40% yield of whole-exome sequencing in previously undiagnosed white matter disorders, and reference 5 indicate similar yield and about 10% likelihood of substantial change in the management based in the testing results. Overall, the medical literature indicates that in the cases with positive findings for mutations, change in management is often needed, such as surveillance for complications, assessment of the involvement of other body systems, and sometimes even pathology specific treatment, such as vitamin supplementation, cofactor or medicine. Considering that the testing requested has the potential to alter management, such testing is medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Intoxication (alcohol withdrawal)
Treatment:  Inpatient admission
The Inpatient admission was not medically necessary.

This patient with a history of alcohol abuse and withdrawal presented with alcohol intoxication.  Evaluation showed the patient to be hemodynamically stable.  There were no findings of tachycardia, vomiting, tremor, or DTs (delirium tremens).  Labs were consistent with chronic alcohol use.  The patient did not have findings of alcohol withdrawal that could not be managed at a lower level of care.  On day 2 of admission, IVF were discontinued.  CIWA was not elevated during admission.  The patient remained clinically stable throughout hospital stay without findings of alcohol withdrawal.  The requested inpatient admission was not medically necessary.