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

Laceration
Inpatient Hospital

The patient is a male who fell over a bike and suffered a complex right groin laceration. He came in as a trauma activation, hemodynamically stable but with a deep and complex wound right groin. He had appropriate imaging and consults. He did not have vascular compromise; this was an isolated injury. He was appropriately taken to the operating room and the wound was interrogated and no major vascular injury was identified, his wound was washed out and complex wound repair was done. The patient did well and went home following day.

The health plan's determination is upheld.

As stated above, the patient was taken to the operating room and complex wound repair was done. The patient did well and went home following day. There was no intra-abdominal or retroperitoneal injury. There was no major blood loss, no limb threat, and no major vascular injury. This case did appropriately require resources, but ultimately did not require an inpatient stay. Given the isolated nature of this injury and low injury severity score, this complex wound does not meet inpatient criteria, based on Milliman Care Guidelines (MCG) for inpatient stay.
Given that no major vasculature was injured, and that the patient was always stable, this case does not meet inpatient criteria. The standard of care was to work up patient and as done in this case go to operating room to repair the wound laceration. This could have been accomplished at a lower level of care status, an inpatient status would not be medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Autism, schizophrenia, urinary incontinence, intellectual disability
Treatment:  Increase in consumer directed personal care assistance hours to 60 hours per week 

The proposed treatment of an increase in consumer directed personal care assistance hours to 60 hours per week is deemed medically necessary. 

This is a male with a history of autism, schizophrenia, urinary incontinence and intellectual disability.  Due to these medical issues, he requires assistance with the majority of his activities of daily living (ADLs).  On the most recent UAS-NY assessment, the patient was found to require assistance with toileting, changing his pull-ups and cleansing himself post elimination.  Furthermore, he requires extensive assistance with bathing, personal hygiene and dressing his upper and lower body.  For these reasons, the currently approved plan of 23 hours per week of consumer directed personal care assistance is not sufficient to meet the patient's current needs.  Hence, the proposed treatment of an increase in consumer directed personal care assistance hours to 60 hours per week for improved assistance with completion of the patient's ADLs is deemed medically necessary to offer increased assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Coronary artery disease 
Treatment:  Inpatient admission

Inpatient level of care was not medically necessary.

This male presents with atypical symptoms and scheduled for an elective angiogram. Computed tomography angiogram (CTA) and echocardiogram were consistent with likely coronary artery disease (CAD).  The patient has a history of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and hypertension.  The patient was pre-hydrated for procedure as his creatinine was borderline high at 1.3 and blood urea nitrogen (BUN) 25.  He underwent successful, uncomplicated PCI to saphenous vein graft (SVG) of obtuse marginal (OM). Continued hydration with intravenous fluids (IVF) was ordered post catheterization.  Due to presence of grafts, increase contrast dye was used.  The patient was admitted to telemetry where he was monitored, the femoral site was observed, routine lab tests were ordered and optimal medical therapy begun.  His stay was uneventful without chest pain or groin discomfort.  Renal function was not adversely effected.  The patient was discharged the next morning.

This was a scheduled elective catheterization and intervention.  The patient was never unstable and continued to be pain free and hemodynamically stable.  As renal function was on the high end of normal, he was hydrated before and after the catheterization/PCI.  This involved 75 cc per hour of normal saline (NS).  The patient did not have any adverse events, and he maintained his baseline renal status. 

The determination of level of care is primarily dependent on the actual care a patient receives and whether a higher level of acuity is needed to give this care.  This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care.  In this case, the patient underwent an elective case without any complications or adverse events.  It was appropriate to hydrate patient, but that did not require acute level of care.

The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care.  The only cardiac care provided post uncomplicated PCI was telemetry, frequently performed in a lower level of care.  The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care.  There was no care given that required inpatient care.  All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care.  Thus, inpatient level of care was not medically necessary.  While there "was a concern" for renal problems, none occurred and no additional therapy was required.

Milliman criteria requirements were not fulfilled for unstable angina, as there was never any evidence of acute coronary syndrome (ACS) present.

The standard of care for uncomplicated interventions has become observation and commonly same day discharge. 

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Urinary Tract Infection/UTI
Inpatient hospital

This is the case of a female with past medical history of bulimia nervosa, uncontrolled diabetes mellitus (DM) with last HGBA1c (hemoglobin A1C. 9.7 in 8/19, hypothyroidism, and chronic kidney disease (CKD) with last Creatinine (Cr) 2.05. She presented to the emergency department (ED) with dysuria, hematuria, flank pain, and nausea x 1 week. She denied fevers or chills. She had presented to an outside ED previously with the same symptoms and been prescribed Macrobid, but did not pick up the prescription.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This is a patient who presented with dehydration, mild acute kidney injury (AKI), and UTI with uncontrolled DM. She had had prior UTIs but there was no mention of her having had UTIs with antibiotic-resistant organisms. She presented without fever or other hemodynamic instability, without leukocytosis, and with mild AKI. There was no concern for DKA. Given the AKI and history of poorly controlled DM with mild AKI, she was certainly appropriate to bring into the hospital for observation, but it is unclear why she would not be expected to improve quickly as she did and in this setting why inpatient care was medically necessary. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder and jaw pain
Issue under review: Inpatient admission

Determination: 
The inpatient admission was not medically necessary.

The patient is an adult female. She presented to the ED complaining of headache and left shoulder pain radiating to the jaw for two days.

This patient presented with atypical chest pain but reported a history of previous myocardial infarction that was not evident on 12 lead electrocardiogram or echocardiography.  Her pretest probability of coronary artery disease is low to moderate (Reference 1).  Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score she was considered low risk (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG, or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been treated at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Glaucome
Treatment: CPT 0449T LT - procedure of the eye (Xen)
The health plan should cover the proposed treatment. 

The treatment performed is consistent with the standard of care.

The requested health service or procedure is likely to be at least as beneficial as any standard treatment(s) for the patient's condition or disease.

There is abundant literature that describes evidence that the Xen gel implant is a safe and effective minimally invasive glaucoma surgery for the treatment of advanced glaucoma refractory to medications. The Xen gel implant is at least equivalent to other forms of minimally invasive glaucoma surgery. 

In this case, the patient already underwent the standard treatments for glaucoma including all available eye drops, as well as argon laser trabeculoplasty x 180 degrees in the left eye. Not only that, the patient also underwent minimally invasive glaucoma surgery with two iStent implants in the left eye at the time of cataract surgery. All of these treatments failed. The Xen gel implant has particularly been shown to be effective in cases such as this, where drops and previous filtration surgery have failed. 

The pivotal trial (Grover, 2017) is a Phase III, prospective, multi-center, single-arm, open-label study that enrolled 65 individuals with refractory glaucoma who had previously failed filtering procedures, cilioablative procedures or maximally tolerated medical therapy. At 12 month follow-up, intraocular pressure was reduced by 25.1 ( 3.7) mmHg to 15.9 ( 5.2) mmHg.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Taltz
The treatment with Taltz 80 mg/ml autoinjector is medically necessary.

The patient is a woman with psoriasis for whom Taltz 80 mg/ml autoinjector is requested. The letter of medical necessity states that the patient has been on Taltz for one year, and cleared. She has a new lesion on the wrist (granuloma annulare). This request is for continuation of therapy.

The patient has been on Taltz for one year and is clear with no adverse effects and with complete clearance. She is stable after one year of treatment with Taltz, and it is medically appropriate and necessary to continue this treatment. Requesting for the patient to try a different treatment at this time is not medically appropriate, because she is being successfully treated with Taltz for a long period of time and is doing well and is stable. It would risk the patient's psoriasis flaring and the disease becoming less manageable. Taltz is medically necessary as continuation of therapy.
Appeal type: Medical necessity
Decision: Overturned

Gender Dysphoria - Gender Dysphoria
Pharmacy/Prescription Drugs

This patient with gender dysphoria was seen by the endocrinologist for failure to thrive, short stature and gender dysphoria. The patient's height and weight have improved over time, but the patient continues to have gender dysphoria. At the time of the evaluation by the physician, it was noted that the child had Tanner 2 breast tissue. The recommendation was made to suppress puberty due to gender dysphoria with Lupron 30 milligrams (mg) IM every (q) 3 months. The first injection was given with another dose scheduled but this was denied by CVS Caremark.
The subject under review is the medical necessity of the Lupron.

The health plan's determination is overturned.

Yes, this is medically necessary for this patient for gender dysphoria.
Based on the Endocrine society Guidelines - this treatment is an accepted practice guideline for patients with gender dysphoria. This treatment is given when patients achieve Tanner 2 puberty, which this patient has based on treating endocrinologist's clinical notes.
In addition, under "Criteria for Initial Approval" Under B "Gender Dysphoria"- CVS Caremark guidelines state that Authorization of 12 months may be granted for pubertal suppression in preparation for gender reassignment in an adolescent member when all the following criteria are met:
1)The member has a diagnosis of gender dysphoria ( this patient has met this criteria)
2) The member has reached Tanner stage 2 of puberty - This patient has met this criteria.

In summary, the request for Lupron is supported by the Endocrine Society Guidelines and the clinical criteria as medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mycobacterium avium-intracellular lung infection (MAI)

Treatment: Amikacin Liposome inhalation suspension (Arikayce)

The insurer denied coverage for Amikacin Liposome inhalation suspension (Arikayce). The denial upheld.

This patient is a male who was diagnosed to have MAI infection in the setting of Bronchiectasis. He was noted to have MAI in Sputum several years ago, which was when treated was first started. He was started on a conventional regimen with Azithromycin, Ethambutol and Rifampin. He was on treatment for about 22 months. The patient had to stop Rifampin due to developing some side effects. Subsequently all antibiotics were stopped as he improved symptomatically. Sputum for MAI was done while on treatment. Negative results were noted in early and mid-2017 and early 2018, and positive in late 2018.

He had an episode of hemoptyis in mid-2019 for 1 day. He started getting upper respiratory infection like symptoms and chest congestion again in late-2019. The patient denied fever, weight loss, and shortness of breath. This time the patient was placed on Liposomal Amikacin Inhalation (Arikayce). It appears that this patient had a relapse of MAI after initial response. He had negative sputum between mid-2017 and late-2018. It appears that he had responded to the initial regimen and has now relapsed. As the decision was made to re treat the patient the appropriate regimen would still be 3 drugs - Azithromycin, Rifampin and Ethambutol. Just because he was not able to tolerate Rifampin in the past, it does not necessarily mean that he will not be able to tolerate it ever again.

Moreover this patient has not failed to show a response after at least 6 months, continuously, to at least two drugs of this 3 drug regimen. Moreover there is no sputum testing to show that this MAC complex isolate was susceptible to Amikacin and had a MIC of less than 64 micrograms/ml. All relapses are to be treated in the same manner as the initial infection, i.e. with at least 2 of the 3 first line drugs - (Macrolide Abs -  Azithro or Calrithrmycin , Rifamycin Abx - Rifampin or Rifabutin , and  Ethambutol ) for at least 6 months before additional  second line drugs are to be considered for treatment failure.

Liposomal Amikacin Inhalation suspension (Arikayce) is not medically necessary. The health plan has acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Amikacin Liposome inhalation suspension (Arikayce) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:GU/Kidney Disorder
Secondary: UTI
Treatment: Inpatient hospital stay
This is the case of a patient with a past medical history of hypothyroidism and recent diagnosis of  (UTI) who presented to the emergency department (ED) with a chief complaint of fever x3 days, shaking, nausea and vomiting with the inability to take (PO). Notably, patient had taken Bactrim for one day after which the patient presented to the primary care physician (or provider) (PCP) with ongoing fevers and chills at which point  antibiotics were switched to cipro after a urine culture (UCx) revealed E. Coli sensitive to ceftriaxone (CTX) and cipro. Patient had ongoing fevers and chills after 2 days of cipro and presented to the emergency room (ER) in this setting. On presentation, patient was febrile to 39.5 with heart rate (HR) 153, blood pressure (BP) 97/68, respiratory rate (RR) 20, saturating 97% on room air (RA). The urinalysis (UA) showed +WBCs, + red blood cells (RBCs), small leukocyte esterase (LE). Patient was treated for sepsis in the ER with intravenous fluids (IVF), intravenous (IV) antibiotics and cultures and was subsequently brought into the hospital.
Patient was seen by urology with assessment that patient had sepsis without obstructing stone or need for acute urologic intervention. Patient was continued on IVF and IV abx. The next day the  WBC trended down to 6.5 and patient was noted to be hemodynamically stable. Patient  was subsequently discharged to complete a course of outpatient cipro. The health plan's determination is overturned in whole. This is a patient who presented with sepsis as manifested by fever, leukocytosis, tachycardia to 150s, and known UTI despite being on outpatient treatment with Bactrim x24 hours and then cipro x48 hours prior to admission. Patient furthermore had nausea and vomiting with inability to take PO. In the setting of known UTI and sepsis, this patient required aggressive treatment with copious IV fluids and antibiotics in addition to close monitoring to ensure that sepsis did not progress to septic shock and the patient  did not develop other associated organ failure. Given this, treating  at the inpatient level of care was medically necessary. Though this patient improved quickly and was able to be discharged the next day, it is felt that it was equally likely given the sepsis on presentation that the patient would not have recovered as quickly and required longer hospitalization for sepsis treatment. Care at the inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain
Treatment: Inpatient stay

Summary:
The patient is a female who presented to the emergency ward with the complaint of neck pain.  She did not have any new neurological deficits on examination at presentation. 

The inpatient admission was not medically necessary. The patient presented with neck pain. She had a normal neurological evaluation and there was no evidence of acute cervical spinal cord pathology requiring acute inpatient admission. She could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular Disorder - Ataxia
Inpatient Health

The patient is a female with a history of hypertension, asthma, and osteoporosis. She presented to the emergency room with dizziness and unsteady gait. Vital signs revealed a blood pressure of 163/87 with a pulse of 52. The oxygen saturation was 94%, and she was afebrile. The physical exam was unremarkable. Lab testing was non-contributory. The chest x-ray and head computed tomography (CT) scan were unremarkable. The electrocardiogram (EKG) was negative for ischemia. The patient was admitted for further treatment and evaluation. The hospital course was clinically uneventful, and she was discharged the following day.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. Based on the standard of care and peer reviewed literature, the inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Back Pain
Radiology Services (including Ultrasound)

The patient is a male who presents with bilateral lower extremity pain. The patient was evaluated by his vascular surgeon for leg pain and based on the documentation, the specialist believes the pain may be from a primary neurologic source. The provider is recommending an magnetic resonance imaging (MRI) of the cervical, thoracic and lumbar spine to rule out a neurologic source of leg pain.

The health plan's determination is overturned in part. The MRI of the cervical and thoracic spine are not medically necessary and are not standard of care diagnostic tests used to assess leg pain.
The MRI of the lumbar spine is medically necessary to evaluate the patient's leg pain and to rule out abnormal conditions of the lumbar spine potentially causing pain to the lower extremities.
The patient was evaluated by his vascular surgeon for leg pain and based on the documentation, the specialist believes the pain may be from a primary neurologic source. The MRI of the lumbar spine is an appropriate diagnostic test to evaluate spinal stenosis, a condition that often mimics vascular disease in the lower legs. In this case, the patient presents with lower extremity pain and thus an MRI of the lumbar spine is medically necessary based on the peer reviewed literature and the current standard of care in the United States.
The MRI of the cervical and thoracic spine are not useful in the evaluation of lower extremity pain or neuropathy and are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ears/Nose/Throat
Treatment: Inpatient hospital stay
The patient is a child with a history of recurrent respiratory papillomatosis. The medical history is significant for previous papilloma removal.
It was noted that there was an anterior glottic web, but no significant regrowth of papilloma. The child had significant dysphonia; thus it was decided to treat the glottic web. The child was brought to the operating room on an elective basis. There was no reported pre-operative stridor or difficulty breathing. The patient underwent a suspension laryngoscopy/bronchoscopy, excision of glottic web, and steroid injection into the anterior glottis. There were no complications. The child was admitted under an inpatient status. There were no peri-operative complications. The patient was discharged the next day. The health plan's determination of medical necessity is upheld in whole. The child had an elective vocal fold surgery to help with a hoarse voice. This type of surgery is usually performed in an outpatient status or ambulatory basis which may require a period of overnight observation in the hospital at a lower level of care. There is no documentation that the child had any breathing concerns or unstable vital signs prior to the surgery. There were no operative complications noted. There were no peri-operative breathing concerns noted. There was no documentation that this child had any breathing concerns or unstable vital signs immediately after surgery. It is not considered standard of care for an inpatient admission status as there is very little risk to airway concerns with a surgery on the anterior portion of the vocal folds.