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

Diagnosis:  Duchenne muscular dystrophy. 
Treatment:  Deflazacort (Emflaza).
The insurer denied coverage for Deflazacort (Emflaza).  The denial is reversed.

This patient is a male child who has been diagnosed with Duchenne muscular dystrophy.  The documentation indicated the patient has been utilizing the requested medication for several years.  The patient was noted to have never trialed prednisone.  The physician indicated the requested medication has been shown to cause fewer side effects, including better preservation of bone mass, as well as less weight gain and less glucose intolerance.  The recommendation has been made for the patient to continue utilizing the requested medication.  A chart note indicated the patient was nonambulatory.  The patient's mother reported he was getting weaker and was utilizing the wheelchair full-time.  The treatment detailed the patient cannot raise his arms above his head only by flexing elbows or using accessory muscles.  The recommendation was made for prolonged stretching.  The request has been submitted for Emflaza.

The medical literature notes that Emflaza is a corticosteroid indicated for the treatment of Duchenne muscular dystrophy (DMD) in patients 2 years of age and older.  According to current peer-reviewed literature, prednisone and deflazacort have similar efficacy with regard to improved muscle strength.  Deflazacort, however, is associated with less weight gain than prednisone.  The documentation indicated that the patient did have a diagnosis of Duchenne muscular dystrophy and has been on treatment with Emflaza without concerning side effects.  This patient is post-pubertal with highest risk of weight gain occurring in this age group.  Increase in weight will only worsen his bone health and ability to reduce the risk of contractures and fractures.  The expected weight gain with Prednisolone would be greater, so this would not be ideal in a patient who is post pubertal and has lost ambulation and is hence unable to exercise.  Discontinuation of the medication would not be medically prudent, as it had been providing benefit.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the medication Deflazacort (Emflaza) for the treatment of Duchenne muscular dystrophy is substantiated.  The insurer's denial is reversed
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe low back pain 
Treatment: Inpatient Stay 
The insurer denied Inpatient Stay 
The denial is Overturned

The patient is a male with Hodgkin's Lymphoma who was admitted through the ER for severe low back pain with possible new compression fracture, requiring IV medications.  The patient complained of Urinary incontinence.  

This is a male who was admitted through the Emergency Department for severe low back pain, urinary incontinence that had become worse over the previous weeks.  He has been seen as an outpatient for the same issues at an urgent care center and was treated with PO medications, including opiates.  The pain started after moving some furniture and then made worse with a flight.  He does have a history of spine issues, as well as a history of Hodgkin's Lymphoma.  In the ER, his pain was uncontrollable, requiring high dose IV medications.  He complained of urinary incontinence.  He had x-ray results that showed an age appropriate compression fracture.  It was unclear if there was cauda equina syndrome, or the fracture would require surgical intervention.  MRI was performed, but he still required IV medications.  The patient was started on IV steroids in the event of spinal cord injury. Given the above, the MCG care guidelines for admission are met. The patient required admission for work up of possible severe spinal injury versus fracture, versus extension of cancer/metastatic disease.  On retrospective review, the patient did not require surgery, but medical decisions regarding admission cannot be made retrospectively, only in real time.  In addition, the patient did have metastatic disease that did require biopsy.  The patient did refuse the biopsy initially due to pain, and likely was overwhelmed with the possibility of metastatic disease. The patient's pain did improve, and was able to work with Physical therapy, as they awaited the results of the biopsy.  Depending on the results, chemotherapy, and/or radiation may be required and may be required quickly.  Therefore, given the above, the requested inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pericarditis

Treatment: Hospital admission

The insurer denied coverage for hospital admission. The denial is upheld.

This patient is a female with a past medical history of hyperlipidemia who presented to the Emergency Department (ED) with complaints of chest pain. The patient's vital signs were stable.  The patient's chest x-ray indicated linear atelectasis at the left lung base.  The patient's electrocardiogram (EKG) was suspicious for an ST-elevation myocardial infarction (STEMI) requiring serial EKGs and troponin monitoring. The patient was admitted to the Cardiac Telemetry Unit for telemetry monitoring. The patient's troponin levels were negative. The patient had a transthoracic echocardiogram which indicated an ejection fraction of 66% to 70% with normal left ventricular systolic function and mild aortic regurgitation. The patient's subsequent EKGs indicated diffuse ST elevations in the inferior and lateral leads with no reciprocal changes noted. The clinical impression of the patient's chest pain and electrocardiogram changes were thought to be due to pericarditis. The treatment plan included Colchicine, Ibuprofen and Pantoprazole medications and to monitor for worsening chest pain and signs of hemodynamic instability. The patient was reassessed and cleared for discharge to home with outpatient instructions for a follow up appointment with Cardiology and to continue taking Colchicine, Ibuprofen and Pantoprazole.  

Based on the review of the medical record, this was female who presented with a history of shortness of breath and chest pain. Despite these symptoms, the patient's vitals in the ER were stable and her pain was manageable with oral medication, ibuprofen. The patient's clinical workup in the ER and diagnostic studies indicated that this patient's symptoms were consistent with pericarditis. This patient's initial abnormal EKG that was suspicious for acute myocardial infarction warranted further diagnostic testing and monitoring with serial EKGs and troponin. However, considering that this patient's initial troponin was negative and was hemodynamically stable, this patient's further diagnostic testing and monitoring could have been safely provided in the observation level of care. The patient had no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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

Based on the above, the medical necessity for the hospital admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis 
Issue under review: Inpatient Admission 

Determination: The inpatient admission was not medically necessary. 

The patient is an adult female. She had swelling and pain for two weeks before seeing a dentist, who placed her on antibiotics. She saw an oral surgeon who removed tooth #31 a few days prior to admission. The patient did not improve and went to the ER. 

The patient's vital signs were stable and she was afebrile. The white blood cell count was normal. The pharynx was clear, there was no lingual swelling, the floor of mouth was soft and not elevated. There was mild swelling in the buccal vestibule. There is no documentation of a CT. 

The patient was admitted. The patient was taken to the dental clinic, where she underwent an intraoral incision and drainage with IV sedation. Post operatively, the O2 (oxygen) saturation was 98% on room air, there was no nausea or vomiting, she was communicative and ambulating and considered stable enough to discharge. She spent the night and was sent home. 

The patient underwent an incision and drainage in the clinic with sedation, and was stable enough for discharge after the procedure. There are no medical reasons for an admission.

According to the literature, the admission criteria for an infection were threat to airways or other vital structures, need for general anesthesia, septic fever, marked swelling, need for inpatient control of a concomitant systemic disease, and need for intravenous antimicrobial treatment. The patient did not require an admission for any of the above.
Appeal type: Medical necessity
Decision: Upheld

Infusion therapy

An office note from the patient's provider indicated a diagnosis of Guillain-Barre syndrome, the patient had one round of intravenous immunoglobulin (IVIG) and was walking and feeling better. Examination revealed diffuse weakness at 4+ +/5 in the upper extremities and 4+/5 in the lower extremities, areflexia, a stocking-glove decreased sensation to pinprick from the knees down, unsteady severe sensory ataxia utilizing a walker and normal constitutional, head, eye, neck, cardiovascular, pulmonary/chest, musculoskeletal, mental status, cranial nerve, skin and psychiatric examinations. Radiology reports from a hospitalization were also provided. Diagnosis was Guillain-Barre syndrome/Acute inflammatory demyelinating polyneuropathy (GBS/AIDP). A second round of IVIG was recommended. 
The health plan determination is upheld in whole. The requested service of Gamunex-C (IVIG) is not medically necessary. IVIG is indicated for the treatment of Guillain-Barre syndrome (acute inflammatory demyelinating polyneuropathy). On occasion, patients may need a second five-day treatment if there is no improvement or if there is a continued deterioration. There is no evidence in the medical literature that providing patients with additional IVIG after an initial successful course of treatment resulting in improvement further improves outcomes. In this case, the patient was prescribed the second course of IVIG despite having improvement. As there is no evidence that this will improve  recovery, the second course of IVIG is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease
Issue under review: Infliximab

Determination:
The Infliximab is not medically necessary.

The patient is a teen-aged female. She was recently diagnosed with moderate to severe Crohn's disease (CD) of small and large intestines. Her physician requested to start Remicade (infliximab) as the initial therapy.

The health plan's preferences require that the patient have a trial and failure of standard treatments, including mesalamine, immunomodulators and corticosteroids. There is no documentation that the patient has tried any other medications. Thus, the requested infliximab does not meet criteria.
The treatment guidelines for Crohn's disease in children recommended biological agents for following conditions (Ruemmele et al 2014):
1) Anti-TNF (tumor necrosis factor) therapy is recommended for inducing and maintaining remission in children with chronically active luminal CD despite prior optimized immuno-modulator therapy. 2) Anti-TNF therapy is recommended for inducing remission in children with active steroid-refractory disease; 3) Anti-TNF therapy is recommended as primary induction and maintenance therapy for children with active perianal fistulizing disease in combination with appropriate surgical intervention.

As documented in clinical information, this patient has moderate to severe Crohn's disease, and her physician requested to try biological agent infliximab (Remicade) as the initial therapy. The recent practice survey found that, "Eighty-four percentage of centres reported to fulfil the revised Porto criteria in the majority of patients. In luminal Crohn disease (CD), exclusive enteral nutrition is used as a first-line induction therapy and immunomodulators (IMM) are used since diagnosis in the majority of patients" (Bronsky et al 2019). This patient does not have active perianal fistulizing disease, active steroid-refractory disease or chronically active luminal Crohn's disease despite prior optimized immuno-modulator therapy. Thus, the proposed treatment with initial infliximab therapy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic short stature
Issue under review: Omnitrope 

Determination:
The Omnitrope is medically necessary.

The patient is an adolescent female diagnosed with ISS (idiopathic short statute). This request is for Somatropin. As reported, she is on GH (growth hormone) therapy. Her pretreatment height was 136.9 cm (-2.53 SDS). Her pretreatment height velocity is reported to be 4.1 cm/year. Her bone age was delayed 11 to 12 for age by her provider reading at a CA (chronological age) 12 years three months. Her height on therapy was 148.7 cm (-1.7 SDS). Her height velocity on therapy is reported to be 9.52 cm/year. 

Growth hormone stimulation testing peaked at 13.55. SHOX testing was negative. IGF1 (insulin-like growth factor 1) was normal at 338. 

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines (4-9). FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient has a pretreatment height less than or equal to -2.25 SD. The pretreatment height velocity would not allow the patient to reach a normal adult height. The patient is a continuing therapy patient and has benefited from growth hormone. The patient has open growth plates. Continuation of growth hormone is medically necessary until growth plate fusion. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Arrhythmia

Treatment: Inpatient Admission

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

This is a male patient with a history of obstructive sleep apnea (OSA) on CPAP, Polycythemia Vera, glaucoma, coronary artery disease (CAD), and status post right inguinal hernia repair. He presented to the hospital for a scheduled electrophysiolgic (EP) study and ablation. The patient underwent an EP study with an ablation without complications. It was reported that the patient had an episode of atrial arrhythmia post ablation and reverted back to sinus rhythm. The patient was medically stable and discharged home. 

In this case, there were no clinical reasons for the hospital admission and the patient could have safely been managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity (Biviano AB et al, 2017). Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day (Bartoletti S et al, 2019). The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care, such as observation care status. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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

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

Diagnosis: Cholecystitis

Treatment: Inpatient Admission

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

This is a female patient with a history of hypertension, diabetes and morbid obesity. The patient presented to the Emergency Department (ED) with complaints of abdominal pain radiating to her right upper back with associated fever, chills, vomiting and diarrhea for five days. A physical exam was performed that revealed right upper quadrant abdominal tenderness with a positive Murphy sign. Laboratory work up was done that revealed a white blood cell count of 10. An ultrasound of the abdomen was performed that showed a distended gallbladder with calculus in neck, and mild wall thickening in some regions. The patient underwent a laparoscopic cholecystectomy without complications. The patient was able tolerate a diet. The surgical incisional sites were clean and dry. The patient was medically stable and was discharged home.

The Milliman Care Guidelines indicate that admission to inpatient care is appropriate for patients with hemodynamic instability, severe pain requiring acute inpatient management, when peritoneal signs are present, such as severe abdominal tenderness, rebound tenderness, a rigid abdomen, or involuntary guarding, or for a procedure that cannot be performed on an ambulatory basis. The patient had right upper quadrant tenderness with a positive Murphy sign. The patient's laboratory studies were unremarkable. The patient's lipase was 34 and her total bilirubin was 0.5. The patient underwent an ultrasound of the abdomen that revealed distended gallbladder with calculus in neck, and a mild wall thickening in some regions. The records failed to support an inpatient admission. Furthermore, it was unclear why the laparoscopic cholecystectomy was delayed and not performed sooner. The patient could have been discharged from the emergency room until the date of the surgery. The records failed to support complications after surgical intervention. There were no exceptional factors noted that warranted inpatient level of care.  

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

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

Diagnosis: Glioblastoma multiforme 
Treatment: Skilled Nursing Facility 
Decision: Upheld 

Summary: 
This is a male with a history of glioblastoma multiforme with overall poor prognosis. He is total assist with all activities of daily living (ADLs) due to generalized weakness and somnolence. Continued daily skilled services are not indicated at this time, and ongoing care can and should be provided at a lower level. Skilled services are no longer needed on a daily basis to maintain or prevent decline. There are no medical issues to support the need for daily skilled nursing care. This review suggests that you are appropriate for an alternative level of care, such as home health care therapies, hospice/palliative care and family assistance as needed. For these reasons, the proposed treatment of Long term Care Facility is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rib and Facial Fractures
Treatment: Inpatient Hospital Stay
The insurer denied an Inpatient Hospital Stay.
The determination is upheld.

This patient presented to the hospital as the victim of an assault. She has a past medical history of coronary heart disease, hypertension, chronic obstructive pulmonary disease (COPD), seizure disorder, and stroke. At the time of presentation, the Glasgow Coma Score was 15. Her heart rate was 68 and oxygen saturation was 98%. There was facial ecchymosis and broken/missing teeth. The hematocrit was 42.7. Photos document severe facial swelling and ecchymosis surrounding the left eye. Imaging showed nondisplaced left 3rd and 5th ribs and a left orbital wall fracture.
The patient was admitted to the hospital. A plastic surgery consultation was obtained with recommendations for non-surgical treatment of facial laceration and orbital fracture. She was treated with intravenous (IV) fluid and analgesia. She requested to be discharged. She was tolerating a soft mechanical diet. She was discharged from the hospital with instructions for short term follow up.

At issue is the medical necessity of an inpatient stay.

The submitted medical records do not support the medical necessity of inpatient admission.

This patient presented to the ED following an assault. Her evaluation and clinical work up identified nondisplaced left 3rd and 5th ribs, a left orbital wall fracture, and facial abrasion and laceration. The patient was hemodynamically stable at the time of presentation with normal vital signs. She did not require surgical intervention for the facial fracture or laceration. In this case, the care and treatment provided could have safely been rendered with a lower level of care which would have allowed for the provision of IV fluid, pain medication, surgical evaluation, and overnight monitoring. The records support that this patient had an uncomplicated period of observation. She remained hemodynamically stable without aberration of vital signs. There was no hemodynamic instability and the patient was able to tolerate a mechanical soft diet. There is no documentation of severe pain requiring continuous or frequent (every 2-4 hours) parenteral analgesics. The evaluation and care could have been appropriately provided at a lower level of care than inpatient.