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

Diagnosis: Chest pain
 
Treatment: Inpatient admission, diagnostic testing, monitoring

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

The patient has a history of coronary artery disease, hypertension, hyperlipidemia, and diabetes mellitus. She presented to the emergency room (ER) with chest pain and fatigue. She was sent to the ER by her cardiologist. She had taken nitroglycerin x 2 with relief of her symptoms. EKG showed normal sinus rhythm. Troponin was normal. Chest radiography and physical examination were unremarkable. Vital signs were stable. She was admitted to rule out acute coronary syndrome. Cardiac biomarkers remained negative. She was evaluated by cardiology, and was referred for coronary angiography. This showed non-obstructive coronary artery disease and normal left ventricular systolic function. She was discharged home. 
The patient presented with chest pain, however the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic short stature
Issue under review: Genotropin

Determination:
The Genotropin is medically necessary.

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 height velocity is poor and would not allow the patient to reach a normal adult height. The patient therefore does meet idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with chronic obstructive pulmonary disease (COPD) who has been residing in a rehabilitation/nursing home. Personal care services for 12 hours a day, seven days a week is requested. The health plan has approved personal care services for six hours a day, seven days a week. The plan cites a physical therapy note that shows that the patient's overall functional level has improved. The plan also recommends using a commode or urinal or adult protective underwear to assist with toileting. The nursing home discharge paperwork states that the patient is independent for eating and oral hygiene, needs assistance with toilet hygiene for set up and clean up, independent for dressing, independent for washing, and needs assistance with set up and clean up for footwear and showering and bathing. In addition, the HELPS Assessment Report is used and estimates an average of six hours of need for assistance per day. The issue under review is the medical necessity of personal care services, 12 hours a day, 7 days a week.  The health plan's determination of medical necessity is overturned. It is reasonable to approve 12 hours of personal care assistance due to the fact that toileting needs may be unpredictable in timing and the patient has documented "extensive assistance" needs for toileting and transfers for toileting. The patient's family would provide personal assistance for the remaining 12 hours overnight.
Appeal type: Formulary Exception
Decision: Upheld

This is a patient with human immunodeficiency virus (HIV) infection. She was initially treated with Genvoya but this was felt to contribute to her development of peripheral neuropathy, specifically, the nucleoside reverse transcriptor inhibitor (NRTI) drugs within Genvoya were felt to be contributory to the development of peripheral neuropathy. Based on this, her physician is requesting Juluca therapy.  The health plan's determination of medical necessity is upheld. There is no existing data which would suggest Juluca (combined dolutegravir and rilpivirine in a combination pill) is a more efficacious anti-HIV regimen than Tivicay (dolutegravir) plus Edurant (rilpivirine). This patient's physician raises the concern of adherence given Juluca is one pill per day regimen compared to Tivicay + Edurant as a 2 pill per day regimen. There was no additional information provided which would suggest that this patient has had difficulty with medication adherence. Based on the available information, it can be concluded the available formulary medications (Tivicay and Edurant) should be equally safe and effective when compared to the requested Juluca therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional impairment
Treatment: Request for 10 hours per day x 7 days per week of home care 

The insurer denied the request for 10 hours per day x 7 days per week of home care 
The denial was reversed.

This is a female with history of hypertension, diastolic heart failure, chronic obstructive pulmonary disease (COPD), vertigo, vascular edema, and legally blind in one eye.  The patient requires 10 hours of home care daily. A reduction in the hours may be dangerous and lead to poor outcome. The patient is a female; lives alone in basement apartment; son lives upstairs. The following includes differences in the patient's functional status compared to the UAS from early in the year: 1) IADLs: no change. 2) ADLs: Dressing lower body: extensive assistance (maximal assistance. Walking: activity did not occur during entire period (extensive assistance). Locomotion: maximal assistance (extensive assistance). Other ADLs: no change. Primary mode of locomotion: wheelchair, wheeled by others. Noted that all care currently provided by nursing home.

Based on UAS reports and a letter from the patient's physician, the patient has cardiac and pulmonary disease, including heart failure and chronic obstructive pulmonary disease (COPD). She is taking multiple medications for these conditions.  She has a diagnosis of dementia. There is no full description of the extent of her cognitive impairment in the available records, but based on the UAS, she has poor/unsafe decision making capacity and memory impairment. She cannot use the phone unassisted, and is unable to use a PERS. 

The carrier's denial of coverage for consumer directed personal assistance services (CDPAS) 10 hours per day, 7 days per week is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Detoxification
 
Treatment: Inpatient Substance Detoxification Treatment. 

The insurer denied the Inpatient Substance Detoxification Treatment.  The denial was reversed. 


This is a female patient admitted to inpatient substance detoxification treatment in early 2019 for substance detoxification. She reportedly had withdrawal symptoms including nausea, sweats, joint pain, and anxiety, and had high blood pressure of 148/84 and increased heart rate of 96. She had been using multiple opiates including 10 bags of heroin per day, 5 bags of fentanyl per day, 12 mg of non-prescription Suboxone, and 10 mg of Methadone per day, as well as $50 of crack per day. Medically, she had a history of hypertension and diabetes. She was reportedly homeless, unemployed, and lacked a sober support system, had poor coping skills, and difficulty identifying relapse triggers. She had multiple past inpatient substance detoxification treatment and past inpatient substance rehabilitation treatment. She was put on a 5 day Methadone protocol and received Methadone during this admission and then was discharged with a referral to another facility for Methadone maintenance treatment program.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This was the case with this patient.

According to the LOCADTR she did require 24 hour treatment from as she needed detoxification medication to modify withdrawal and prevent moderate to severe withdrawal which she was at risk for due to her large amount of opiate use and she had reports of current opioid withdrawal on admission.  She had comorbid medical conditions including hypertension and diabetes and a comorbid psychiatric diagnosis of bipolar disorder so she was considered a more at risk patient in need of 24 hour inpatient substance detoxification treatment then. Also, this patient had multiple past substance detoxification treatments and past inpatient substance rehabilitation treatment and still was using large amounts of opiates. 

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care at Cornerstone of Medical Arts Center is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Angioplasty and Stent Placement
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.    

This is a male patient who presented to the hospital in early 2019 for an elective outpatient cardiac catheterization with possible coronary angioplasty. He has a past medical history hypertension, hyperlipidemia, and irritable bowel syndrome. He underwent coronary angioplasty and stent placement. He was treated with intravenous fluids and completed the procedure without complications. He was noted to have bleeding at the groin access site requiring no intervention. He had a fever and diarrhea which was positive for Clostridium Difficile (C. diff) ; he was started on oral Vancomycin. He remained clinically and hemodynamically stable and was discharged home. 
Inpatient admission status is not medically necessary for this patient. Per Milliman Care Guidelines (MCG) Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this is an elective outpatient procedure which allows for up to 23 hours of observational level monitoring in the hospital. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating clinical circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and stenting. The patient was hemodynamically stable and his (C. diff) diarrhea could have been managed in the outpatient clinical setting.

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

Diagnosis: Left Upper Extremity Deep Vein Thrombosis 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was modified. 

This is a middle aged female patient who presented to the Emergency Room in late 2018 for a chief complaint of chest and arm pain for the week prior to presentation.  The patient reported that she had mild swelling in the right underarm and heart palpitations.  The patient had a past medical history significant for an immune disorder, end-stage renal disease following a transplant, hypertension, hyperlipidemia, hyperparathyroidism, asthma, bilateral deep vein thrombosis and arterial thrombosis.  Upon assessment the patient had a blood pressure of 191/114 and she was alert and in no apparent distress.  An electrocardiogram (EKG) revealed a heart rate of 70 beats per minute (bpm) with no acute infarction.  Her creatinine was 2.17, hemoglobin was 16.5 and troponin level was negative.  An upper extremity Doppler revealed a deep vein thrombosis in the left subclavian and axillary vein.  A heparin drip was initiated.  

The MCG general admission guidelines state that an inpatient admission is recommended when intravenous (IV) anticoagulation, vasoactive medication or antiarrhythmic medication is to be administered.  

MCG heparin guidelines state that inpatient admission is recommended for a patient who requires post hospital oral anticoagulation therapy and who is not anticoagulated and is of high risk of short-term venous or arterial thromboembolism that is newly diagnosed.  

There was documentation that the patient had a history of bilateral lower extremity deep vein thrombosis (DVT) and was diagnosed with a left upper extremity deep vein thrombosis in the Emergency Department.  The patient was not taking an oral anticoagulant at the time of assessment, was started on intravenous (IV) heparin and subsequently admitted to the hospital as an inpatient.  There was documentation that the patient continued IV Heparin and then started on an oral dose of Eliquis thereafter.  

The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care from is modified.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation 
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This patient presented with symptomatic atrial fibrillation and was effectively treated with AV nodal blocking agents.  Following evaluation and additional testing, the patient reverted to normal sinus rhythm and was released from the hospital.  

Bellew et al studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department.  In this study of almost 600 patients, there was no difference in outcome.  American Heart Association (AHA) guidelines note that admission to the hospital for management of atrial fibrillation in patients that achieve rate control do not require hospital admission. (Reference 2) This patient reverted to normal sinus rhythm several hours after presentation.  In conclusion, this patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission.
The denial was upheld. 

This is a female patient who presenting to the Emergency Department (ED) with complaints of shortness of breath, orthopnea, and increasing bilateral leg swelling for the previous two weeks. Her shortness of breath worsened when she walked and when she lay down. She had a medical history of insulin-dependent diabetes mellitus, hypertension, CAD, status post triple bypass, hypothyroidism and morbid obesity. Her Initial exams in the ED showed blood pressure of 147/97, pulse rate of 100, weight of 136.7 kg, distended abdomen, mild generalized tenderness to palpation, positive jugular vein distention, bilateral lower extremity 2+ pitting edema, abdominal pain. She was admitted for treatment of shortness of breath. Her hospital course of treatment included intravenous Lasix, lab work up and diagnostic testing. She was evaluated by Cardiology, Vascular, Electrophysiology (EPS), and Physical Therapy. The patient was medically stable and cleared for discharged and instructed to follow-up with primary care doctor and Electrophysiology physician.

A study by Diercks, et al. attempted to identify factors that could find a low risk group of patients with acute decompensated heart failure who were suitable for management in a 23-hour observation unit. They prospectively studied a sample 530 in-patients presenting to the ED with a diagnosis of CHF. 499 patients met the criteria for this observation unit and had no adverse events during the time in the emergency department or during a 30-day follow-up. The major predictors were systolic blood pressure greater than 160 and a normal troponin level. They concluded that initial blood pressure and troponin can identify patients with congestive heart failure with lower risk for adverse events and could be managed in the hospital for less than 24 hours. Emergency-department (ED)-based observation-unit treatment has been shown to reduce inpatient admissions, hospital bed-hours, and costs without adversely affecting outcomes for several conditions. A sequential group design study compared risk-matched, acute decompensated heart failure patients admitted directly to the inpatient setting with those admitted to an ED observation unit for up to 23 hours before ED disposition. Outcomes were 30-day readmissions or repeat ED visits for heart failure or 30-day mortality. Estimates of bed-hours and charges between the groups were compared. Sixty-four patients were enrolled with 36 inpatient admissions and 28 observation unit patients. No patients died within 30 days. Observation unit patients had no significant difference in outcomes, a decrease in time from ED triage to discharge, a saving in mean bed-hours, and less total charges. This pilot trial provides preliminary data that suggest admitted, low-risk heart failure patients may be safely and cost-effectively managed in an ED-based observation unit.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Multiple sclerosis

Treatment: Mavenclad

The insurer denied Mavenclad for formulary exception.  That denial was reversed.

This patient has a history of multiple sclerosis.  The patient was initially started on Avonex following the diagnosis of MS in 2016 and continued to have symptoms on the medication. She was then switched to Tecfidera and had recurrence of the symptoms when she was off of it in the early postpartum period.  In early 2017 the patient had breakthrough MS MRI activity on Copaxone and was switched to Tecfidera.  In late 2017 the patient had no new or worsening neurological symptoms to suggest breakthrough MS activity, and the patient was on Tecfidera.  In late 2018 it was noted that the MRI from 2017 was unchanged, and the plan was to continue on Tecfidera and to repeat MRI the following year.  In early 2019 there was an Magnetic Resonance Imaging (MRI) of the brain which showed periventricular bilateral hemispheric hyperintensities.  It also showed interval appearance of enhancing lesion in the left cerebellum and left posterior frontal periventricular white matter.  In mid-2019 the patient was seen by the Physician's Assistant (PA) for follow up regarding multiple sclerosis.  He noted that the patient's MRI showed two new enhancing lesions.  He noted that the patient denied any new neurological exam.  He noted that the patient was comfortable transitioning to Mavenclad.  In the impression he noted the options for treatment either Tysabri or Mavenclad. 
The patient had failed 3 disease modifying therapies including Avonex, Copaxone, and Tecfidera.  At this point, it is obvious that the patient will need one of the more potent disease modifying therapies like Tysabri, Mavenclad, or Lemtrada.  Gilenya, the only medication on the formulary that the patient has not tried, is not as potent as the other options, and the patient should be approved for Mavenclad. 

Mavenclad is considered among the potent MS therapies and would be more effective than Gilenya.  The more recent MRI is showing new lesions, which indicates that current treatment is not effective for this patient.  Changing to Mavenclad, which has a higher potency, gives the patient the chance for a more effective therapy.  Gilenya would not provide this for this patient.  
                                    
The insurer's denial for Formulary Exception for Mavenclad 10mg tablet is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Menorrhagia
 
Treatment: Surgical procedure- hysteroscopy, D&C and ablation

The insurer denied the requested surgical procedure. The denial was upheld.

The patient is a woman with chief complaint of menorrhagia who underwent an endometrial biopsy that showed proliferative endometrium, benign. The provider recommended a hysteroscopy, D&C and endometrial ablation. Her hematocrit was 38.3. This patient had reported heavy bleeding. The next step is to manage the bleeding.
Progestins and oral contraceptive pills are considered first line treatment for abnormal, irregular or heavy bleeding. The levonorgestrel releasing intrauterine system has been shown to significantly reduce bleeding and cramping, and may be used for women with heavy abnormal bleeding. Tranexamic acid is an antifibrinolytic taken during menstruation; it has been shown to be an effective treatment to decrease abnormal heavy uterine bleeding and improve quality of life. There is no documentation that the patient has tried and failed any of the first line treatments. If all of the above fail then a surgical procedure, including an endometrial ablation, could be considered. As of now, there is no indication for a hysteroscopy, D&C and ablation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Disseminated germinoma
Treatment: Proton Beam Radiation Therapy
The proposed proton beam radiation therapy is not medically necessary.
In this case, the patient has a diagnosis of disseminated germinoma with disease involving the CSF s/p systemic therapy.  Craniospinal radiation therapy was recommended, and proton beam radiation therapy to 21.6Gy followed by a boost was requested.  However, based upon and in conclusion of this review, the proposed treatment is not considered medically necessary for this patient under these unique circumstances.
Proton beam radiation therapy is a type of very precise external radiation treatment in which protons are used to treat cancer and other conditions.  Compared to photon, a proton beam that is delivered with sufficient energy has a low "entrance dose". A proton beam also has a high-dose "Bragg peak" region, which is designed to cover the entire tumor and there is no "exit dose" beyond the tumor involved in proton radiation therapy.  Because of this unique property, proton beam therapy is highly successful in minimizing damage to normal tissue and surrounding organs, resulting in fewer side effects.  Proton beam radiation therapy is a Food and Drug Administration (FDA) approved procedure and is not subject to institutional review board (IRB) review.
Although proton beam radiation therapy has been shown to be safe and effective for the treatment of intracranial lesions, there is insufficient clinical data in the medical literature to show that proton is equivalent or superior to other treatment options such as photon intensity modulated radiation therapy (IMRT) for germinoma or for craniospinal radiation.  There are ongoing trials evaluating the role of proton therapy for adult primary brain tumors and or craniospinal radiation.  In addition, in this case, there was no proton/IMRT comparison plan provided showing that the IMRT plan was inadequate in sparing the surrounding critical structures.   Proton beam radiation therapy, therefore, is not considered medically necessary due to insufficient peer-reviewed data in well-conducted randomized trial supporting its use.