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

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 

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

The patient is a female. Her medical history included obesity and postpartum state. She presented to an emergency room with a one-day history of vomiting and right-upper-quadrant abdominal pain. 

The patient's vital signs were as follows: temperature 36.5, pulse 78, blood pressure 120/85, respirations 18, and oxygenation 95%. Physical examination demonstrated "mild epigastric [tenderness to palpation]." Serum laboratories demonstrated a normal white-blood-cell count of 8.7 and elevated hepatic enzymes. Abdominal ultrasound demonstrated gallstones. 

The patient was admitted at an inpatient level of care with a diagnosis of "symptomatic cholelithiasis." She was made nil per os [NPO], and provided with intravenous fluids. 

The patient underwent laparoscopic cholecystectomy. Surgery and recovery were uncomplicated. For her transaminitis, the patient underwent gastroenterology consultation and serum laboratories. 

Having returned to her baseline health and function, the patient was discharged home with outpatient surgical and gastrointestinal follow-up. 

No, the Inpatient admission was not medically necessary. 

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

The patient's transaminitis, which only required gastroenterology consultation and serum laboratories, also could have been evaluated and treated at a lower level of care. 

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

Diagnosis: Abdominal pain.  

Treatment: Inpatient admission.  

The insurer denied coverage for the inpatient admission.  

The denial is upheld.  

This is a female patient who presented to the hospital with abdominal pain and chest pain.  She was afebrile and her vital signs were stable.  The abdominal exam was benign.  A computerized axial tomography (CAT) scan revealed a dilated common bile duct (CBD).  The plan was for a magnetic resonance cholangiopancreatography (MRCP).  The MRCP was negative for choledocholithiasis.  It was felt that she passed a stone.  

According to Milliman Care Guidelines (MCG), the clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone include having acute cholangitis or acute cholecystitis.  For both of these conditions there need to be systemic signs of inflammation.  In this case, she did not have acute cholecystitis or acute cholangitis.  She also did not have hemodynamic instability, severe vomiting, severe dehydration, severe pain or bacteremia.  

This patient had abdominal pain and likely passed a gallstone.  She did not have acute cholangitis or systemic signs of inflammation.  The MRCP could have been done as an outpatient.  She did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Stone.  

The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary.  

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyruvate kinase deficiency
Treatment: Deferasirox
The insurer denied the Deferasirox.
The denial is upheld. 

The patient is a male who has pyruvate kinase deficiency. He was noted to have evidence of increased iron deposition in his liver based on magnetic resonance image (MRI) done with T2 weighting.  Records indicate that serial magnetic resonance image (MRI) testing has revealed increasing levels of iron deposition.  The most recent magnetic resonance image (MRI) identified 88 micromoles per gram of liver iron, 4.9 milligrams (mg) iron per gram dry weight.  This is consistent with mild iron overload based on the magnetic resonance image (MRI) report. Records indicate that the patient has been periodically managed with iron chelation in the past, most recently with deferasirox.  No serum ferritin measurement is provided.

No, the proposed treatment is not medically necessary.

This patient has pyruvate kinase deficiency. Secondary iron overload is a known complication of this condition.  It arises due to ineffective erythropoiesis along with chronic transfusions.  Management of iron overload in this condition follows that of iron overload associated with other hematologic conditions. This patient has mild iron overload as noted above, and typically iron chelation is not employed in patients with only mild iron overload.

A recent review indicated that a cutoff of ferritin over 1000 or liver iron content (LIC) of 7 milligrams per gram (mg/g) dry weight is used to decide on initiation of chelation in patients with thalassemia.  While this patient does not have thalassemia, there is no evidence that initiation of iron chelation at a lower liver iron content (LIC), such as requested in this case, can improve health outcomes. 

A recent publication regarding iron chelation in patients with pyruvate kinase deficiency indicated that using a serum ferritin of 1000 to diagnose iron overload likely missed some patients and was too conservative.  However, this publication did not address a recommended target for initiation of iron chelation, nor did it show that using a lower target liver iron content (LIC) or serum ferritin to initiate chelation improve health outcomes.  Therefore, the proposed treatment with iron chelation in this patient with mild hepatic iron overload is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tracheobronchitis/Pneumonia; and Asthma. 

Treatment: Dupixent Syringe 300 milligrams/2 milliliters.

The insurer denied coverage for Dupixent Syringe 300 milligrams/2 milliliters.

The denial is upheld. 

This is a male patient who was seen by a pulmonologist for suspected asthma.  The patient has a history of Lower Respiratory Tract Infections (LRTI) Pneumonia.  He was treated with oral antibiotics.  Imaging studies reportedly showed some atelectatic changes in the left lower lobe (LLL).  Computed Tomography (CT) was essentially unremarkable with some suggestion of band like atelectasis in LLL.  During the Pulmonology visit which was a video visit, the patient was complaining of some cough and following up for his Pneumonia.  The patient was on low dose Symbicort with some relief.  The patient was recommended to continue on Symbicort.

During a subsequent follow up visit the patient was still complaining of shortness of breath (SOB) and some cough.  The patient had taken multiple courses of antibiotics along with tapering steroids for Pneumonia.  However, the imaging studies were not consistent with Pneumonia.  The patient's lungs were clear on exam.  A follow-up CT Chest also revealed only some atelectasis and scarring in LLL and some ground-glass opacity (GGO) consistent with air trapping.  The plan was to continue on Symbicort.

On a subsequent visit, the medical doctor noted recurrent episodes of steroid responsive airway disease with wheezing, cough and chest tightness.  The physician also noted multiple courses of steroids with efficacy.  The patient was afebrile and hemodynamically stable.  Physical exam was unremarkable with clear lungs.  Oxygen (O2) saturations were 94%.  The patient had a normal white blood cell (WBC) count.  Eosinophils (Eos) were 0.7% with Absolute Eosinophil Count (AEC) of 42.  The patient was on high dose Symbicort and the plan was to add Pulmicort to Symbicort and also give the patient Dupixent.

This patient was being treated for Tracheobronchitis/Pneumonia.  A formal diagnosis of Asthma was made.

As per review of Pharmacy records the patient had only filled prescriptions for Inhaled Corticosteroid/Long Acting Beta Agonist (ICS/LABA) only 3 times: Budesonide/Formoterol once and then subsequently Symbicort twice.  No prescriptions for oral steroids had been filled.

This patient did not meet the criteria for treatment with Dupixent, i.e.: Eosinophilic Asthma (the patient had a WBC count of 6,000 with 0.7% Eos with AEC of 42).  In addition, he did not fail medical therapy as evidenced by the lack of any record of an emergency room visit and also the pharmacy records do not support failure to respond to high dose Inhaled Steroids plus additional controller medication (the patient had only 3 prescriptions filled for ICS/LABA).

Treatment with Dupixent is not indicated at this time.  The prior denial is upheld.

The carrier's denial of coverage for Dupixent Syringe 300 milligrams/2 milliliters is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision 
Treatment: Emergency Care/Emergency Room 

The patient is a male with no past medical history who presents to a local emergency room (ER) stating he has had pressure behind his eyes, headache, intermittent shakiness, lightheadedness and generalized feeling "off" for the past few days. He is concerned that his blood pressure is high. He has no history of high blood pressure. He denies chest pain, abdominal pain, dysuria, hematuria, vomiting, diarrhea, constipation, black tarry stool or any other constitutional symptoms. He gave a history of a recent sinus infection. Vital signs: blood pressure (BP) 157/87, heart rate (HR) 79, respiratory rate (RR) 18, temperature 97.6oF, 100% room air (RA) Pox (pulse oximetry). The ER visit is under review. 

The health plan's determination is upheld. The ER visit was not medically necessary for this patient. 

The patient's symptoms that were present for several days would not be expected to cause a prudent layperson to seek emergent medical attention. The symptoms would not cause the patient to fear that his health was in jeopardy or that he would suffer an organ dysfunction or disability without emergency care; especially since the symptoms existed for several days. A more reasonable scenario would be evaluation by the patient's private medical doctor or an urgent care center. The prudent layperson standard for the ER visit is not met.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary/Kidney Disorder - Kidney Stones
Inpatient Hospital

The patient is a male who presented to the hospital with a sudden onset of left flank pain. The patient was afebrile with a blood pressure of 123/65 millimeters of mercury (mmHg) and a pulse of 65 beats per minute (bpm). The urinalysis was negative. Labs were notable for a white blood cell count of 16,340, a potassium of 4.4, and a creatinine of 1.6. A computed tomography of the abdomen/pelvis demonstrated stable mild to moderate left hydronephrosis with a 2-millimeter (mm) obstructing calculus at the left ureterovesical junction. Intravenous fluids and Flomax were provided along with as needed analgesics. Urology performed a cystoscopy with ureteroscopy and left ureteral stent placement. The patient's pain resolved. The white blood cell count dropped to 12,250 and the creatinine dropped to 1.1. At tissue is the medical necessity of the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient.
The patient had unilateral hydronephrosis due to a ureterovesical stone. The patient did not have a solitary kidney or a renal transplant. There was no evidence of bilateral obstruction. He had only a mild degree of acute kidney injury, with prompt improvement in renal function with hydration. There was no evidence of pyelonephritis or urinary tract infection. The patient did not have persistent vomiting or severe pain requiring frequent or continuous administration of parenteral analgesics. There was no fever or hemodynamic instability. The procedure performed was an ambulatory procedure, and it was performed without complication. In summary, the inpatient admission was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia
Issue under review: Peroral Endoscopic Myotomy

Determination:
The health plan should cover the Peroral Endoscopic Myotomy.

The patient is an adult male who was evaluated for dysphagia since 2018 with worsening symptoms of intolerance to both solid and liquids and weight loss over 20 lbs. He underwent barium swallow and high resolution manometry. He was diagnosed with type II achalasia. The AP is requesting Per-oral endoscopic myotomy (POEM) for the management of achalasia.

Multiple retrospective and prospective studies have evaluated the safety and efficacy of POEM. Data from these studies show that serious adverse events are extremely rare. For the management of type I (minimal esophageal contractility) and type II (panesophageal pressurization) achalasia, POEM is associated with an efficacy of approximately 85% to 95%.

The two primary treatment options for achalasia are POEM and laparoscopic Heller myotomy. The main benefit of POEM is that it is a scarless and less invasive treatment modality. POEM also provides a quicker relief of dysphagia compared to laparoscopic Heller myotomy, which is routinely performed concomitantly with a partial fundoplication, resulting in up to six months of recovery from dysphagia. Lastly, POEM is typically performed in an outpatient setting and is associated with less postprocedural pain vs surgery. The main shortcoming of POEM is the potential increased risk of reflux as compared to surgery. Nonetheless, reflux can typically be easily managed with a once-daily proton pump inhibitor. Alternatively, endoscopic fundoplication (eg, transoral incisionless fundoplication [TIF]) is now possible and can be used to manage patients who continue to experience reflux symptoms despite medical therapy. TIF is also an option for patients who are interested in coming off all acid-suppressant therapies.

POEM represents a first-line treatment option for achalasia, and it has equivalent or superior efficacy to Heller myotomy. The POEM approach has matured as a treatment for achalasia, with outstanding 2- to 5-year outcomes. The best results are seen in patients with type II achalasia, which is this patient's diagnosis.

Alternative treatments for achalasia include botulinum toxin injection, pneumatic dilation. No head-to-head comparison has been made of POEM and botulinum toxin; however, with a short-term efficacy of 6 to 12 months maximum after injection, botulinum toxin should be reserved for patients who are not candidates for any other alternative treatment option. Furthermore, repeated injections of botulinum toxin can result in significant submucosal fibrosis that may render subsequent myotomy more challenging (and occasionally impossible). Pneumatic dilatation once again is temporary modality, the patients need repeated dilations, and it has only success rate of 50-60%.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia
Issue under review: Peroral Endoscopic Myotomy

Determination:
The health plan should cover the Peroral Endoscopic Myotomy.

The patient is an adult male with achalasia. His MD is requesting treatment with POEM (peroral endoscopic myotomy).

Medical literature supports that POEM is safe and effective treatment for achalasia, and has a positive effect on health outcomes. 

Per Inoue, H., et al. (2015), "Per-oral endoscopic myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used. Adverse events were rare (3.2%), and there were no mortalities. 

Significant improvements in Eckardt scores and LES pressures were seen at 2 months, 1 year, and 3 years post-POEM. Based on our large series, POEM is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy." 

Per Patel, K., et al. (2016), "In conclusion, POEM is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia-related symptoms. Randomized comparative studies of Heller myotomy and POEM are required to determine the most effective treatment modality, with additional investigation of more novel metrics such as EndoFLIP and objective measures of reflux (e.g. impedance studies) pre- and post-treatment." 

Lastly, per Zaninotto, G., et al. (2018), "Recommendations: we conditionally recommend POEM as an effective therapy (control of symptoms) for achalasia both in short- and medium-term follow-up with results comparable to Heller myotomy for symptom improvement." 

POEM, therefore, is more beneficial than Heller myotomy for the treatment of achalasia. As POEM is safe and effective treatment for achalasia, and is less invasive than Heller myotomy, and as it has a positive effect on health outcomes, it is medically appropriate for this patient and should be covered by the health plan.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia
Issue under review: Peroral Endoscopic Myotomy

Determination:
The health plan should cover the Peroral Endoscopic Myotomy.

The patient is an adult male with type II achalasia, as determined by high resolution esophageal motility testing and esophagram. 

Of note, the patient also has GERD (gastroesophageal reflux disease)/gastritis as determined endoscopically, and gastroparesis to liquids but not solids, as determined by gastric emptying study.

Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and a defective relaxation of the lower esophageal sphincter (LES) resulting in an impaired bolus transport and stasis of food in the esophagus. [Boeckxstaens, 2005] Because its exact etiology still is unknown, current treatment options of achalasia are directed only at relieving the functional obstruction at the level of the LES. Three manometric subtypes are identified based on the residual esophageal wave pattern: type I in which the esophageal body shows minimal contractility; type II, in which there is no peristalsis but intermittent periods of compartmentalized esophageal pressurization; and type III, in which there are spastic contractions in the distal esophagus. (1)

Recommendations for treatment from the American College of Gastroenterology (ACG) for achalasia include the following: 
1) Initial treatment: either graded pneumatic dilation or laparoscopic surgical myotomy with a partial fundoplication. 2) PD and LHM should be performed in high-volume centers of excellence. 3) Choice of initial therapy should be guided by patients' age, gender, preference, and local institutional expertise. 4) Botulimun toxin therapy is recommended in patients who are not good candidates for, or are unwilling or cannot undergo, more definitive therapy with PD or surgical myotomy. 5) Esophagectomy should be reserved for patients who have failed PD and/or myotomy and who are good candidates for surgery.

Similar conclusions relative to efficacy of POEM versus the gold-standard LHM, show similar post-operative GERD, but favor the shorter length of stay and reduced post-operative narcotic requirements of POEM for the patient's indication. (7,8)  Most recently, best practice advice from the American Gastroenterological Association concluded: "if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes." (9)

As such, POEM is not investigational for the patient's indication, and is medically appropriate (with greater likelihood of benefit than available standard approaches) for treatment of the patient's condition within standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated LFTs (Liver Function Tests).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He has a history of alcohol abuse. He presented to the ED (emergency department) from inpatient detoxification for elevated LFTs (liver function tests).

The patient had no complaints. The patient's VS (vital signs) were as follows: Temperature 98.4, pulse 75, respiration rate 20, blood pressure 146/89, pulse oximetry 96%. His exam was unremarkable. His labs were as follows: WBC (white blood count) 3.5, H/H (hemoglobin/hematocrit) 119/35.8, Plt (platelets) 122. BMP (basic metabolic panel) was within normal limits. AST (aspartate aminotransferase) was 1199, and ALT (alanine aminotransferase) was 854. Alk Phos (alkaline phosphatase) was 162. Total bilirubin was 1.6. RUQ (right upper quadrant) US (ultrasound) revealed hepatic steatosis, contracted; gallbladder. The patient was admitted.

The patient's vital signs were stable on day 2 of admission. AST was 710 and ALT was 665. GI (gastroenterology) consult noted acute alcoholic hepatitis and recommended outpatient follow up. The plan was to monitor for withdrawal.

The patient's vital signs were stable on day 3 of admission. No withdrawal was noted. LFTs were trending down. AST was 568 and ALT was 611. The plan was to discharge.

The patient's vital signs were stable on day 4 of admission. LFTs were trending down. The patient was cleared for transfer back.

No, the Inpatient admission was not medically necessary.

Medically necessary services are those which are the following:

1) Safe 2) Effective 3) Generally accepted national standard of medical practice 4) Not provided primarily for convenience of the patient or the practitioner5) The least intensive and/or most appropriate alternatives among diagnostic and treatment options.

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

This patient with a history of alcohol abuse was admitted after having presented with incidental finding of elevated LFTs while in detoxification. The patient was asymptomatic. The patient was hemodynamically stable and had normal oxygenation. He did not have liver failure. There were no signs of infection. Electrolytes and renal function were normal. He did not have symptoms to alcohol withdrawal. GI consult recommended outpatient work up. The patient was monitored during hospital stay. The patient remained clinically stable, without withdrawal, and LFTs trended down. The patient was clinically stable and did not receive intervention that required an inpatient level of care.