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

Primary diagnosis: Obesity
Primary Treatment: Surgical Services (All)

The patient is a male with a body mass index (BMI) of 41 and obstructive sleep apnea is requesting authorization for a laparoscopic sleeve gastrectomy which has been previously denied based on lack of medical necessity. The subject under review is the medical necessity of the proposed procedure and inpatient stay.

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

Yes, the requested service of laparoscopy sleeve gastrectomy and inpatient stay is medically necessary for this patient.
The patient is a male with a BMI of 41 and obstructive sleep apnea, and thus he meets the National Institute of Health (NIH) guidelines for bariatric surgery.  He has been cleared by a mental health provider, and by cardiology for surgery.  He also has a hiatal hernia that would require surgical correction.  Even in the absence of a hiatal hernia, the patient meets criteria for bariatric surgery based on the 2018 American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines for adolescent bariatric surgery. The new ASMBS guidelines published in 2018 no longer recommend using age as a criteria for authorization for weight loss surgery. Any patient with a BMI over 40, with obstructive sleep apnea merits surgery if that is what the patient, family, and providers all agree is the best management strategy. 
Thus, there is no medical rationale to deny authorization for bariatric surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: West syndrome, intractable seizures
Treatment: S9123 & S9124 - Private duty nursing, ten hours/day, seven days/week

The private duty nursing, ten hours/day, seven days/week, is medically necessary.

According to the American Academy of Pediatrics Guidelines for Home Care of Infants, Children, and Adolescents with Chronic Disease, "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." (1) Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." (1)

This female child has a number of medical needs as a result of and in addition to her diagnosis of West syndrome with intractable epilepsy. She requires constant supervision to allow for rapid intervention for seizure activity. She cannot eat by mouth, and is dependent upon gastrostomy tube feedings. She requires airway clearance with non-invasive ventilatory support during sleep. She is fully dependent upon caregivers to manage all of her needs, and most importantly to recognize seizures and provide the necessary emergency care. She has two levels of emergency care, midazolam nasal spray and rectal Diastat. Both of these medications are effective at seizure control, but both are also sedatives and if used in combination place the child at risk for hypoventilation and even respiratory failure. Judicious use of these medications in combination with close monitoring and intervention as needed can keep this child safe and even prevent unnecessary hospital visits. However, this is not appropriate for layperson caregivers. This type of management is akin to that received in the hospital setting, specifically the intensive care unit (ICU), and belongs in the hands of skilled nursing staff. 

Based on this child's very complex history and current needs, the requested ten hours/day, seven days/week of private duty nursing services are not custodial in nature and are medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thyroid cancer
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

She had completion thyroidectomy. The patient's care could have been delivered at a lower level of intensity than acute inpatient care. This patient had no preoperative complications requiring acute care interventions as an inpatient.

The medical literature and standards of care support outpatient or observation for patients with total thyroidectomy (or completion thyroidectomy).  This patient had no preoperative complications to warrant any acute inpatient care interventions.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: PTSD
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was not medically necessary.

This patient reportedly had a long history of malingering, dishonesty, and non-compliance with treatment. He admitted to fabricating symptoms in order to obtain drugs or hospital admissions. His symptoms were highly suggestive of a personality disorder which could not respond to acute inpatient treatment. During the dates under review, the patient did not present any acute behavioral problems or mood problems which would require acute inpatient care. There was no evidence whatsoever that this patient could benefit from such care. Nothing in the documentation reviewed indicates that this patient could not have been treated equally safely and effectively in a less intensive setting during the dates of service under review.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glaucoma
Issue under review: Cosopt PF

Determination: 
The Cosopt PF is medically necessary.

According to the American Academy of Ophthalmology's Preferred Practice Patterns, medical therapy for the treatment of glaucoma is presently the most common initial intervention to lower IOP (intraocular pressure). There are many drugs available for initial therapy, and medication choice may be influenced by many factors, including side effects, dosing schedules, and the degree of pressure lowering needed. The patient and ophthalmologist together decide on a practical and feasible regimen to follow in terms of dosing and adherence in the context of the patient's age, preferences, and degree of ocular damage.

In this case, the patient with severe glaucoma is being treated with Cosopt PF and Zioptan, both of which are preservative-free.  As the patient cannot tolerate glaucoma drops with preservatives, the formulary alternatives of dorzolamide/timolol, latanoprost, travoprost, and Travatan Z are contraindicated, as they contain preservatives.  Continued coverage of the requested medication is therefore medically necessary per standard of care.
Appeal type: Medical necessity
Decision: Upheld

Prostate Cancer
Genetic Testing

The patient is a male who underwent a prostate biopsy for an elevated prostate-specific antigen (PSA). The biopsy showed Gleason 6 adenocarcinoma in 3 out of 12 cores. The clinical stage was T2a. An OncotypeDx test was ordered on the biopsy specimens. The Medical necessity of the test is under review.

The health plan's determination is upheld. The Oncotype DX prostate score is not medically necessary for this patient. While Oncotype dx may eventually have a role in making treatment decision about patients with prostate cancer, there is limited data on clinical outcomes to currently support routine use. Hence, it is not considered medically necessary and standard of care for management of patients with a diagnosis of prostate cancer. The American Urological Association (AUA) Guidelines on Clinically Localized Prostate Cancer, 2017 states, "Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up."
Appeal type: Medical necessity
Decision: Upheld

Primary Treatment:  Inpatient Hospital 
Primary Diagnosis:  Central Nervous System / Neuromuscular Disorder

The patient with a past medical history significant for multiple Cerebrovascular accident (CVAs), paroxysmal atrial fibrillation, hypertension, hyperlipidemia, and insulin-dependent diabetes mellitus, who presented to the emergency department with sudden onset of weakness and slurred speech that started on the day of admission while at church.
At the time of the initial evaluation, the patient denied any loss of consciousness but complained of blurry vision and some shortness of breath.  The patient stated that those symptoms were similar to those experienced at the time of the previous strokes.  Apparently, by the time that the patient was seen by admitting physician, these symptoms significantly improved.  The health plan's determination of medical necessity is upheld in whole.
The patient's symptoms resolved quickly, and the imaging studies performed in the hospital did not reveal any evidence of acute stroke or head bleed.  During this admission, this patient did not require administration of parenteral anticoagulants or antiplatelet agents and did not require invasive blood pressure monitoring or any other procedures necessitating admission at the acute inpatient level of care.  The patient  also did not require the administration of intravenous blood pressure medications.  Taking into consideration these facts, admission at a lower level of care was the most appropriate in order to establish the diagnosis and monitor closely for possible deterioration of neurological symptoms.  Neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive urgency

Treatment: inpatient hospital services

The insurer denied coverage inpatient hospital services. The denial was upheld.

This patient is a man with a past medical history notable for hypertension, hyperlipidemia, diabetes mellitus, deep venous thrombosis, heart failure with reduced ejection fraction, and obesity. He presented to the ER with complaints of abdominal pain radiating upward toward chest area. The chest pain was associated with shortness of breath. The vital signs noted: blood pressure of 163/120. He was admitted with hypertensive urgency, but left against medical advice (AMA).

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

The patient presented with abdominal and chest pain, as well as shortness of breath, consistent with congestive heart failure. The initial evaluation in the ER was unremarkable, including a non-diagnostic electrocardiogram (EKG). The Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the Observational setting, allowing for additional cardiac testing and control of his blood pressure.

Further evaluation was warranted, however inpatient admission criteria according to InterQual Guideline for Acute Coronary Syndrome was not met. There was no evidence of other medical conditions warranting inpatient level of admission. 

Based on the above information, the medical necessity for the inpatient hospital services is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer
Treatment: Magnetic resonance image (MRI)

The MRI of the chest was medically necessary.

The patient is a female with advanced breast cancer who was referred for evaluation and treatment.  She had a magnetic resonance image (MRI) in late 2018. This showed an extensive tumor invading the pectoralis muscle.  After being seen, she underwent neoadjuvant treatment with Taxol.  A repeat magnetic resonance image (MRI) was performed hospital in early 2019 to assess response and degree of involvement of pectoral invasion.  This showed some increase in the size of the tumor and muscle invasion.  This information was necessary to plan further treatment for this patient.  

The health plan turned down the payment for the second MRI stating it had already been performed in late 2018.

The physicians needed the second MRI to assess response to the therapy given in the interval since the last MRI. The second MRI showed some increase in the size of the tumor and muscle invasion.  This information was necessary to plan further treatment for this patient.  

This is a very complicated, large tumor.  It is necessary to assess response before proceeding with further therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Eczema and yellow jacket bite of the hand
Treatment:  Fluocinonide 0.05% cream
The Fluocinonide is not medically necessary.

This is a female with eczema and a yellow jacket bite of the hand that was very itchy.  Fluocinonide 0.05% cream was requested.  The patient was also prescribed prednisone. She had used fluocinonide cream 0.05% in the past (2002, 2008, 2016, and 2019).

The plan offers multiple alternate topical steroids that have the same effect and efficacy as the requested medication.  Some alternatives include betamethasone, betamethasone dipropionate, triamcinolone and desoximetasone.
Appeal type: Medical necessity
Decision: Upheld

Gastroesophageal Reflux Disease/GERD
Pharmacy/Prescription Drugs

The patient is a male under evaluation and management for gastroesophageal reflux disease (GERD) for 15 years. The patient does abuse alcohol. The patient has esophagitis along with diabetic gastroparesis. There is no significant hiatal hernia. The patient has previously tried lansoprazole briefly and then pantoprazole for about one year as well as Nexium over-the-counter (OTC) (20 milligrams [mg]). The provider states that the patient also tried and failed several other proton pump inhibitor (PPI) medications, including omeprazole, esomeprazole, and Zegerid.
The patient's provider has prescribed Dexilant. This request was denied by the plan, which does not consider it to be medically necessary as there are several formulary alternatives covered by the plan.

The health plan's determination is upheld. 

No, the requested treatment with Dexilant is not medically necessary for this patient. The patient could be treated on the plan preferred drug lansoprazole 30 mg twice daily (BID), which is the equivalent to Dexilant 60 mg. The plan preferred drug omeprazole 40 mg BID would also be roughly the equivalent with respect to acid suppression. Pantoprazole, which the patient is currently on, is considerably less potent.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes type 2
Issue under review: CGMS

Determination:
The CGMS is medically necessary.

The patient is a female with type 2 diabetes on Levemir and Novolog trying to become pregnant, complicated by hypoglycemia.

In a study of 101 patients with type 2 diabetes on two or more injections per day, use of the continuous glucose monitoring system significantly improved A1C levels. The changes in HbA1c were -0.82% vs. -0.33% in the intervention group using the continuous glucose monitoring system and control group, respectively (P = 0.005), and 68.6% of the patients in the intervention group using the continuous glucose monitoring system had their HbA1c reduced by 0.5% compared with 30.2% in the control group (P < 0.001), and 39.2% had their HbA1c reduced by 1.0% vs. 18.6% in the control group without an increased frequency of hypoglycemia [1]. 

In a second randomized controlled trial, continuous glucose monitoring was shown to lower A1C in patients with uncontrolled type 2 diabetes on multiple daily insulin injections (adjusted difference in mean change of A1C with use of continuous glucose monitoring, -0.3% [95% CI, -0.5% to 0.0%]; P = 0.022) [2]. 

This patient, who is trying to conceive, has type 2 diabetes and she is on multiple daily insulin injections and her A1C is above the goal of <6% in pregnancy. In addition, she is experiencing hypoglycemia, which can be mitigated with use of continuous glucose monitoring. Without continuous glucose monitoring, this patient is at risk for a complicated pregnancy (as hyperglycemia can cause congenital defects) and hypoglycemia (which can cause seizures and be life-threatening). Therefore, yes, the proposed continuous glucose monitoring is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse
Treatment:  Inpatient admission

The Inpatient admission was medically necessary for this patient.

The requested benefit of the Inpatient admission and associated services could not have been safely or effectively provided at a lower level of care in this case scenario.  The patient in this case was using large quantities of opioid and cannabis on a daily continuous basis that did warrant the admission and inpatient level detoxification and withdrawal management and monitoring.  Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient struggled with withdrawal symptoms in the context of associated clinical features that included limited insight, impaired judgment and poor control of impulses, and psychosocial stressors with limited sober supports.

Thus, the adult inpatient stay and detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level setting with 24-hour monitoring and withdrawal management.  The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors that included the social environment and occupational and legal domains, and functional impairments do reflect the seriousness of the substance use disorder.  The patient did require a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure or general medical complications if detoxification and withdrawal management were to have been attempted at a lower level of care.  Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity review, including the appropriate application of NY OASAS LOCADTR 3.0 Criteria-referenced below.

The requested benefit of Inpatient admission is clinically appropriate, medically necessary and warranted, and should therefore be covered in this scenario. The inpatient level detoxification treatment could not have been effectively provided with lower level services, as noted above. Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to substance use disorder services, including ASAM Patient Placement Criteria and NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

The patient has chronic migraine headaches and gets approximately three migraine headaches per week. As prophylaxis against the migraine headaches, the patient has tried amitriptyline, but this caused side effects. In addition, the patient has tried topiramate and Trokendi XR, but these were ineffective and caused side effects. In an attempt to reduce the frequency of the patient's migraine headaches, the provider has prescribed Aimovig injection. The health plan has denied coverage of the Aimovig on the basis that it is not medically necessary because Aimovig has been shown to be safe and effective only for patients 18 years of age and older. This determination is under review.

The health plan's determination is upheld. Aimovig Injection 140 mg/mL is not medically necessary for this patient. Aimovig is an anti-calcitonin gene-related peptide (CGRP) monoclonal antibody. CGRP is expressed in small nerve fibers that carry pain signals and are thought to be involved in migraine headaches. Controlled clinical trials have revealed that anti-CGRP monoclonal antibodies are safe and can reduce the frequency of migraine headaches in adult patients (18 years of age and older). However, this medication has not been studied in children and is not known to be safe and effective in people less than 18 years old. Therefore, Aimovig cannot be considered medically necessary for this patient at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizure
Issue under review:  Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The patient is a child.  The patient had one seizure, this being the third time in his life, but there was no reporting of status epilepticus or recurrent seizures.  The patient's neurological examination was described as normal.  There was no change in the patient's mental status.  There were no focal deficits.  During his hospital course, he had no further seizure-like activity and tolerated lamotrigine.  The patient was discharged the following day after no recurrent events during the night.  The patient was instructed to follow-up with neurology for a video EEG.  Therefore, the patient's seizure could have been managed at a lower level of care with oral or intravenous anti-epileptic medicine, and seizure precautions.  Medical literature and practice guidelines do not support inpatient admission for discrete seizures without status epilepticus.  Since the patient's care and safety could have been provided at a lower level of care, there was no medical necessity for the inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Postpartum preeclampsia
Treatment: Inpatient admission

The inpatient admission was medically necessary.

The patient is a G1 P1 female.  She presented five days postpartum with high blood pressure.  She stated that her blood pressures at home were 150-170/80-100 and was receiving Procardia XL 30 mg/day.  She had a history of chronic hypertension and A1 diabetes.  Of note, during her antepartum course, she did not have any elevated blood pressures and did not require blood pressure medications or magnesium during her delivery hospitalization.  

In the emergency room, the patient's blood pressures were 170's/90's.  She was diagnosed with postpartum preeclampsia with severe features.  She was admitted and treated with magnesium sulfate for 24 hours and labetalol.  During the hospitalization, she did complain of a headache, which resolved.  Her blood pressures remained elevated, requiring upward titration of the labetalol dose.  

The health plan contends that the hospitalization was not medically necessary due to the absence of severe problems such as chest pain or seizures and cites MCG guideline Hypertensive Disorders of Pregnancy (OR: M-285).  The facility contends that the hospitalization was medically necessary for the diagnosis of preeclampsia with severe features and that the medical record clearly indicates the need for acute medical management.

This patient at high risk for preeclampsia due to AMA (advanced maternal age), primigravida, and history of chronic hypertension, with no evidence of hypertension in her antepartum course, presented with severe range blood pressures in her early postpartum course consistent with the diagnosis of postpartum preeclampsia with severe features.  This is a potentially life-threatening condition, which mandates hospitalization for seizure prophylaxis with intravenous magnesium sulfate, titration of antihypertensives for treatment of severe hypertension, and close observation for development of multi-organ-system complications.  Therefore, the hospitalization was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cavities
Treatment: General anesthesia

Summary:
The general anesthesia for dental procedure (41899) is medically necessary. 

Patient is a young female with multiple cavities needing nine dental restorations. Patient is uncooperative. Has a negative history with nitrous oxide. Recommendation is for general anesthesia to be used to allow all treatment to be done at once. Planned used of general anesthesia is medically necessary to treat this patient.