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

Diagnosis: Influenza A with right lower lobe pneumonia
Treatment: Air Ambulance Transport

Summary:
The patient is a male child that developed respiratory symptoms. He was seen in Urgent Care for evaluation and referred to the ED. He was subsequently admitted to Hospital A's pediatric ward for management of influenza A with right lower lobe pneumonia. He was noted by the Nurse practitioner to be in moderate respiratory distress with tachypnea and retractions. Albuterol was ineffective. Because of need for PICU (pediatric intensive care unit) services, he was transferred to Hospital B for further care. Air ambulance transport was utilized to decrease the out-of hospital time.  

In the case of this young male child, he presented to the ED with signs and symptoms of acute respiratory distress secondary to influenza A infection and right lower lobe pneumonia. Despite treatment following admission to the pediatric ward, he remained symptomatic with suprasternal/intercostal retractions, tachypnea, and tachycardia. The treating professional determined that he required transfer to a PICU for higher level of care, necessitating transfer to another facility. 

Hospital A is approximately 23-24 miles from Hospital B, per Google Maps a 40+ minute ride by ground. When managing moderate to severe respiratory distress, particularly if there is concern for impending respiratory failure, travel time upwards of 30-40 minutes is excessive and places the patient at risk for significant morbidity. As in this case, with persistent retractions, tachypnea, and tachycardia, expedited transfer was necessary to minimize out-of-hospital time and risk to the child. Based on the documentation, current standard of care, and plan language, air transport was medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, hyperlipidemia, alcohol use
disorder with seizures and delirium tremens
Treatment: Inpatient admission
The insurer denied the inpatient admission.

The denial is upheld. 

This male has a history of hypertension (HTN), hyperlipidemia (HLD) and alcohol use disorder with seizures and delirium tremens (DTs). He presented to the emergency department (ED) for alcohol withdrawal. He complained of one week of headache, nausea, and diarrhea.

In the emergency department, the patient had diaphoresis, headache, tremors, and tongue fasciculations. He had a history of multiple admissions for alcohol withdrawal. Vital signs were as follows: temperature 97.8, pulse 106, respirations 18, blood pressure 142/87 and oxygen saturation 99%. Exam was remarkable for right facial drooping consistent with Bell's palsy. Labs revealed the following: white blood cell (WBC) 6, hemoglobin/hematocrit (H/H) 15/42, platelets 213, alcohol (EtOH) less than ten, sodium (Na) 134, potassium (K) 3.9, carbon dioxide (CO2) 22, blood urea nitrogen (BUN) / creatinine (Cr) 12/.72, and potential of hydrogen (pH) 7.43. The patient's electrocardiogram (EKG) showed sinus tachycardia. Symptoms improved after two doses of Librium. The patient was admitted with alcohol withdrawal. Plan of care included Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. Psychiatry consult revealed a diagnosis of severe substance use disorder. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 4. He was not in active withdrawal. Recommend medication assisted treatment (MAT) with Naltrexone and Gabapentin. On the last day, the patient was cleared for discharge.

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice.

This patient with a history of alcohol abuse and withdrawal was admitted after presenting with alcohol withdrawal. He was not acutely intoxicated. The patient was hemodynamically stable and afebrile. He had mild tachycardia but no arrhythmia. He had findings of alcohol withdrawal that responded to treatment in the emergency department. Admission history and physical was unremarkable for findings of alcohol withdrawal. He did not have comorbid conditions. The patient was admitted with plan for Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol.

During the hospital stay, the patient did not have findings of acute alcohol withdrawal. He was being managed with oral medication assisted treatment. The patient was clinically stable and did not have findings of severe alcohol withdrawal. He did not have symptoms that required an acute inpatient level of care and had not failed a lesser level of care. The acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebellar stroke

Treatment: Inpatient hospital stay

The insurer denied coverage for the inpatient hospital stay. 

The denial is overturned. 

This is a male patient who presented to the Emergency Department (ED) with complaints of persistent tenderness as well as weakness to the right lower extremity and numbness. The patient reported utilizing marijuana regularly. On physical exam, the patient was in no acute distress. He had a temperature of 97.6 degrees with a pulse of 65. The physician indicated the patient should undergo laboratory studies and receive intravenous (IV) fluids. It was noted that the patient likely had cannabis induced vomiting. A reassessment indicated the patient tolerated oral fluids, however he was unable to walk steadily. It was recommended he undergo a Computed Tomography (CT) scan. The patient was also recommended to undergo a Neurology consultation. 

The patient had an old infarct to the right cerebellum per CT scan. The Neurology note indicates there was diminished sensation and temperature to the distal right lower extremity. The laboratory studies did not reveal any significant abnormalities. The Neurologist indicated the patient should undergo magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), as well as a transthoracic echocardiogram (TTE) and carotid duplex. It was also recommended the patient continue with medications and participate in rehabilitation. The patient was admitted and continued treatment. He began utilizing medications that included aspirin and atorvastatin. The patient underwent additional diagnostic studies to include MRI and MRA. Imaging showed suggestion of high-grade stenosis to the posterior flow. A carotid duplex was also performed, detailing suggestion of a distal obstruction in the right vertebral artery. The patient was transferred for a higher level of care.

The patient had a stroke confirmed on the CT study, which revealed a cerebellar stroke. This situation would require and aggressive work-up. The inpatient admission was medically necessary.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital stay is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal mass.
Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is overturned. 

This patient is a male child with a history of asthma who presented to the hospital with abdominal/back pain. The evaluation revealed a large abdominal mass, lung lesions and mediastinal lymph adenopathy. His labs were normal, and he was otherwise stable. He was admitted to the hospital to obtain a biopsy of transitional cell carcinoma (TCC) and a port-a-cath. He was then discharged. 

"Neuroblastoma (NB) is the most frequently-occurring extracranial childhood tumor. It is classified as an embryonal neuroendocrine tumor, originating from neural crest progenitor cells. Hence, it can occur anywhere along the sympathetic nervous system, including the superior cervical, paraspinal, and celiac ganglia; the majority arises in the adrenal glands. Due to the high variability in its presentation, clinical signs and symptoms at presentation can range from benign palpable mass with distension to major illness from substantial tumor spread. This activity reviews the cause, pathophysiology, and presentation of neuroblastoma and highlights the role of the interprofessional team in its management" (Mahapatra, S. et al. 2020).

Up to Date, in their discussion of abdominal masses in children, state "Wilms tumor and neuroblastoma are the most common intra-abdominal tumors; others include leukemia, lymphoma, hepatic tumors, ovarian tumors, and soft tissue sarcomas. The age of the child helps in the differential diagnosis. Wilms tumor and neuroblastoma occur more commonly in infants, whereas leukemic or lymphomatous involvement of the liver, spleen, or retroperitoneal lymph nodes occurs more commonly in older children."                                                     

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The inpatient hospital admission is considered medically necessary for this patient. The hospital admission for evaluation of a 10 centimeter mass in this patient's age group, is appropriate. This was almost assuredly malignancy and while many of this testing can be done on an outpatient basis, that would take weeks. The differential for this process would include high grade lymphoma, leukemia, neuroblastoma, Wilms tumor, and sarcoma, some of which are aggressive cancers. Prompt evaluation and initiation of chemotherapy is of utmost importance in childhood aggressive tumors. Therefore, hospitalization was the appropriate course of action to obtain tissue biopsy and prepare for chemotherapy in this individual.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent major depressive disorder
Treatment: Trintellix, Pre-service
The insurer denied the Trintellix, Pre-service
The denial is overturned. 

The case involves an adult female diagnosed with recurrent major depressive disorder successfully treated with Trintellix which was then stopped due to the lack of insurance coverage. She had failed to respond to several antidepressant medications with and without augmentation including the more recent treatment with Zoloft and Abilify and Buspar. Other recent trials have included augmentation with Rexulti and ziprasidone and Topamax as well as use of olanzapine and as needed (PRN) dosing of Vistaril.

The patient resumed treatment with Trintellix titrated to ten milligrams (mg) daily with relative tolerability despite nausea address with as needed dosing of Zofran. The patient responded to Trintellix with euthymic mood and diminished anxiety. Comorbid conditions include unspecified anxiety disorder, post-traumatic stress disorder (PTSD) and attention deficit hyperactivity disorder (ADHD) with the latter treated with Adderall. There are no reported symptoms of mania, thought disorder, psychosis, or severe cognitive impairment. Trintellix is supplemented with anxiolytic medications, as noted. There is no substance use disorder in this case.

Yes, the proposed treatment with Trintellix is medically necessary for this patient.

The continued treatment with Trintellix is reasonable and in the best interest of the patient, and is being prescribed with sound medical judgment for the treatment of major depressive disorder. In this case, to switch to another antidepressant medication that poses risk for side effects or adverse effects and that has only a 50 to 70 percent probability of a response and only a 50 percent or less probability of a remission is not reasonable or in the best interest of the patient, as the patient has sustained a clinical response to the currently prescribed Trintellix in keeping with prevailing standards of medical practice.

Thus, the request for Trintellix to treat recurrent major depressive disorder is considered medically necessary and clinically appropriate in keeping with the NY State instruction for this medically necessity review.

As noted above, the continued treatment with Trintellix is reasonable and in the best interest of the patient, and is being prescribed with sound medical judgment for the treatment of major depressive disorder. Clinical guidelines for the management of major depressive disorder recommend that a patient be continued with medications or medication that are that known to be effective and that have produced a clinical response and/or remission, as in this case.

This answer is consistent with published practice guideline recommendations and the scientific literature, referenced below, and consistent with instructions for this review.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer.
Treatment: Radiation Therapy For Metastases (Pre-service).

The insurer denied the Radiation Therapy For Metastases (Pre-service).  The denial is overturned. 

The patient is a male with a diagnosis of hepatocellular carcinoma with bilateral adrenal metastasis status post prior systemic therapy, TACE (Transarterial chemoembolization) and Y90 (radioactive isotope yttrium90) radioembolization.  Palliative radiation to the adrenal lesions was recommended and hypofractionated intensity modulated radiation therapy (IMRT)(similar to stereotactic body radiation therapy [SBRT]) was requested.

Yes, the proposed Radiation Therapy For Metastases is medically necessary.

A study from University of Michigan evaluated 58 patients with adrenal carcinoma treated with surgery alone versus surgery and adjuvant radiation therapy.  The authors found that the lack of radiation was associated with a 4.7 times the risk of local failure compared with patients that underwent adjuvant radiation therapy.  In this case, the target volume is in very close proximity of the kidneys, and the tolerance dose of the kidney is only about 18 Gray (Gy), which is well below the intended palliative dose.  In this case, the patient is quite symptomatic, and intensity modulated radiation therapy (IMRT) is the best radiation technique that can provide symptomatic relieve while sparing the surrounding critical structures such as the kidneys.

In this case, a three-dimensional (3D) / intensity modulated radiation therapy (IMRT) comparison plan was done.  The three-dimensional plan would result in doses to the spinal cord and kidneys exceeding tolerance.  The intensity modulated radiation therapy (IMRT) plan was able to reduce the dose to those structures to a safe level.  IMRT, therefore, should not have been denied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Porcelain fused to metal crown for tooth #18 (2751)
The insurer denied the Porcelain fused to metal crown for tooth #18 (2751).
The determination is upheld.

The patient presented  for evaluation and treatment of tooth number (#) 18. Provided for review are previous letters of appeal and denial, a narrative from the patient, a single American Dental Association (ADA) claim form, and a partial full mouth radiographic series. This was denied on the basis that there was not a complete view of the tooth in question radiographically, no clinical rationale offered by the provider, and not sufficient documentation to justify the medical necessity of the treatment.
At issue is the medical necessity of the planned treatment of porcelain fused to metal crown for tooth #18 (2751).

The documentation provided does not support the medical necessity of the procedure of white glass with metal crown for tooth #18. There are not any clinical notes, any diagnosis, any indication regarding the prognosis of the tooth, nor rationale for why the treatment is considered necessary by the provider. The radiographic documentation provided does not show the tooth completely and the image by itself does not support any particular therapy. Additional information was requested and an unsigned statement from East Village Dental stating that there was a large composite on tooth #18. The additional information still does not support the treatment and there is still not any clinical documentation to support the unsigned statement or the treatment rendered.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Durable Medical Equipment. 

The insurer denied functional electrical stimulation (FES) cycle. The denial is Overturn. 

The patient is a female who was involved in a pedestrian vs. motor vehicle accident (MVA) sustaining multi trauma. Her injuries included cervical (C)1-C2 fracture dislocation with Type II odontoid fracture status/post (s/p) Occipital through C5 posterior fusion resulting in a C1 Asia Impairment Scale (AIS) A spinal cord injury (SCI). She also sustained a traumatic brain injury, multiple rib fracture and lumbar (L)2 compression fracture. She was rendered quadriplegic and ventilator dependent. She sustained both upper motor and lower motor neuron injury. She has neurogenic bladder and bowel and is dependent for all care. Her family opted to take her home and they underwent extensive training to be able to safely care for her at home. She was discharged home. The subject under review is whether the requested functional electrical stimulation (FES)  therapy system is likely to be more beneficial for this patient's diagnosis than any standard treatment. 

The health plan's determination is overturned. 

The patient has C1AIS A SCI, complete. She is ventilator dependent and dependent for all tasks. She has both upper and lower motor neuron injury, but peripheral nerves are intact. The patient would likely benefit from the proposed treatment of functional electrical stimulation above standard therapy. The patient is just over one year post injury and is still within a window of possibly making some functional gains. Studies have shown, although small, benefit of FES in early acute complete SCI patients with some improvement in function, decreased muscle atrophy, improved respiratory and cardiac status. Since the patient is ventilator dependent at this time, she would benefit from FES in the home to prevent atrophy of respiratory musculature. She is young and would benefit from minimizing muscle atrophy as well as risk of osteoporosis, pressure injuries and improved cardiac output for best chance of preserving and perhaps improving function as she is not yet at maximal medical improvement (MMI) from her sustained SCI.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Durable Medical Equipment. 

The insurer denied functional electrical stimulation (FES) cycle. The denial is upheld. 

The patient is a female with medical history significant for cervical (C)1 Asia Impairment Scale (AIS) A tetraplegia resulting from a traumatic accident. The patient was denied coverage of a RT300 functional electrical stimulation (FES) therapy system. The subject under review is whether the requested service is likely to be more beneficial for this patient than any standard treatment. 

The health plan's determination is upheld. 

The proposed health service or treatment of RT300 FES Therapy System is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient is a female who has a C1 AIS A spinal cord injury with no motor or sensory preservation. Documentation provided does not support that this therapy system would be more beneficial than any standard treatment. First off, documentation noted that the patient had "accumulated 12 sessions and was able to tolerate 30 minutes of treatment without fatigue limitations...patient propelled the FES Ergometer for 3 miles at 30 revolutions." Documentation did not provide the data for the 12 sessions. It did not show the patient's energy expenditure. To support such a therapy device it would be important to see the energy expenditure increase, as an upward trend of energy expenditure values demonstrates the patient is able to decrease the risk for muscle atrophy and suggests improvements in muscle conditioning. Data showing that the patient has developed improved distance and endurance over multiple sessions is also important to consider. Secondary to the severity of the patient's spinal cord injury (C1 AIS A spinal cord injury with no motor or sensory preservation), the RT300 FES therapy system is not likely to be more beneficial than any standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Durable Medical Equipment. 

The insurer denied functional electrical stimulation (FES) cycle. The denial is upheld. 

This is a female patient diagnosed with traumatic spinal cord injury with cervical (C)1 Asia Impairment Scale (AIS) A tetraplegia. Records indicate the patient was prescribed an RT300 functional electrical stimulation (FES) Cycle therapy system for home use. It was noted the patient has been using the FES system in the rehabilitation hospital and had an excellent response. The provider notes that there is significant benefits shown through research using FES and it was felt necessary that the patient be provided with a device for the home setting. It was stated that FES is the only therapy modality that allows the patient to achieve strong coordinated muscle activation below the level of her injury. It was noted that her peripheral nerve supplies intact allowing her to respond to electrical stimulation. Reconsideration of approval is requested. 

The subject under review is whether the FES is likely to be more beneficial for this patient than any standard treatment. 

The health plan's determination is upheld. 

There is no evidence that the proposed health service or treatment is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This is a female patient diagnosed with traumatic spinal cord injury with C1 AIS A tetraplegia as a result of a traumatic accident that occurred. The provider notes that she has now lost volitional motor function below C1 in the bilateral upper and lower extremities and sensation in proprioception is absent below C1 spinal level bilaterally. It was noted the patient has been using the FES system in the rehabilitation hospital and had an excellent response. It was recommended that she be provided with an RT300 FES cycle ergometer system for home use. However, there is a lack of evidence found in the peer-reviewed medical literature regarding use of these devices in the home setting rather than in a skilled rehabilitation facility.