Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Chronic Lyme disease and neurologic/CNS (central nervous system) involvement
Treatment:  Intravenous antibiotic (Rocephin 2 grams IV)

The patient is a male, who was diagnosed with Lyme disease with a tick bite and illness. 

The patient developed severe vision changes with headaches.  He had been evaluated by numerous doctors, including an optician, ophthalmologist, retinal specialist, and a neuro-ophthalmologist.  His tests included a brain MRI and MRA.  He made multiple trips to the ER for severe headaches, and vision issues.  The patient also has c/o (complaints of) optical migraines for many years.

During his course of treatment, the patient has been prescribed oral antibiotics to include doxycycline, Ceftin, and Zithromax, Malarone.  According to the letter by his physician, the patient continues to suffer from severe symptoms, including the following:  fatigue, fevers, chills, loss of concentration, memory loss, irritability, crying, eye pain, headaches, jaw pain, ear ringing, sore throat, swollen glands, dizziness, lightheadedness, stiff neck, back pain, chest pain, palpitations, loss of appetite, tremor, stiff joints, sore muscles, and heat / cold intolerance.

The Intravenous antibiotic treatment is not likely to be more beneficial than any standard treatment or treatments for the patient's condition or disease.

Patient does not have a positive Western Blot test for Lyme.  This indicates that based on the above lab results, it is clear that a definitive diagnosis of Lyme disease is not established.  In spite of this, the patient has received several courses of antibiotic treatment, including doxycycline, Ceftin, and Zithromax, and Malarone.

The diagnosis of Lyme disease is only established based on positive serology and specific symptoms, signs and objective data to establish disease.  Mere presence of serological evidence of exposure is insufficient to establish the diagnosis.  In this case, the diagnosis of Lyme disease is not established. 

The patient's symptoms are nonspecific and do not include any objective data to establish the diagnosis of end organ disease with Borrelia burgdorferi (Lyme disease).  Further, the diagnoses of neuroborreliosis, myocarditis, synovitis and arthritis are not established based on any objective evidence in this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Chronic Lyme disease and neurologic/CNS (central nervous system) involvement
Treatment:  Intravenous antibiotic (Rocephin 2 grams IV)

The patient has a history of Lyme disease, and a more recent history of tick exposures, and a multitude of symptoms, and some signs including peripheral cranial nerve VII palsy.

The requested Intravenous antibiotic treatment will provide no known medical benefit.  As such, the complications, including side-effects from the medication and other complications like line infection, endocarditis, sepsis, and death are greater. 

The patient has a positive Lyme IgG but a negative Lyme Western Blot.  This translates to a negative test (1).  A symptomatic patient with Lyme carditis or encephalitis would have a positive result, and antibiotics that were given were after the Western Blot were sent, which would take some time (many months) to fade anyway. 

Of note, the patient had only one band positive of Western Blot.  Western Blots take various proteins of the Lyme bacteria, thus a Western Blot can be viewed as 10 opportunities to test against Lyme.  The patient only had one positive, which is not uncommon and not associated with disease. 

While ceftriaxone is beneficial in Lyme encephalitis (2), in this and other studies, the patients were Western Blot positive.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Chronic Lyme disease and neurologic/CNS (central nervous system) involvement
Treatment:  Intravenous antibiotic (Rocephin 2 grams IV)

The patient is a male with a history of chronic Lyme disease and neurologic/CNS (central nervous system) involvement. 

Despite receiving multiple rounds of oral antibiotics for treatment of his Lyme disease, the patient continues to have neurologic symptoms and objective abnormalities on laboratory testing, including evidence of B12 deficiency, magnesium deficiency and leukopenia (low white blood cell count).  All of these findings are consistent with chronic Lyme disease.  Furthermore, review of the below referenced articles reveals successful treatment of Lyme encephalopathy and chronic neurologic manifestations of Lyme disease with IV Rocephin compared to standard treatments, which are less efficacious.  For these reasons, the requested health service Rocephin 2 grams IV 1x/daily is deemed more beneficial than standard therapy and should be covered.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 Diabetes and pregnancy
 
Treatment: Dexcom G6 Continuous Glucose Monitoring System

The insurer denied the Dexcom G6 Continuous Glucose Monitoring System. The denial was reversed.

This patient was a female who had Type 1 diabetes and was 8 weeks pregnant. She consistently monitored her blood glucose 6-7 times per day. Without continuous glucose monitoring for type 1 diabetes, potential fetal complications from varying glucoses can happen and be avoided by having firsthand information of glucoses with the equipment. The requested Dexcom G6 continuous glucose monitoring system transmitters, receivers and sensors are medically necessary.

The Dexcom G6 Continuous Glucose Monitoring System (Dexcom G6 System) is a real time, continuous glucose monitoring device indicated for the management of diabetes in very well person's age 2 years and older. It is intended to replace fingerstick blood glucose testing for diabetes treatment decisions. In their 2016 guidelines, the American Association of Clinical Endocrinologists (AACE) /American Diabetes Association (ADA) state the following: "CGM is likely to provide significant benefits to the following patient populations, although additional studies are needed: Patients older than 65 years with comorbidities and/or at risk for severe hypoglycemia; women with diabetes who are or are planning to become pregnant as well as women with gestational diabetes; patients with kidney disease; and, patients with diagnosed hypoglycemia unawareness." 

Based on the above, the medical necessity for Dexcom G6 continuous glucose monitoring system transmitters, receivers and sensors, using the following codes: A9276, A9277, A9278, K0553 and K0554, is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Polyarticular RF negative juvenile idiopathic arthritis (JIA)

Treatment: Infliximab 

The insurer denied coverage for Infliximab. The denial was reversed.

This patient is a male child diagnosed with polyarticular RF negative juvenile idiopathic arthritis (JIA) several years ago. He was treated in the past with NSAIDs, methotrexate, Enbrel, Orencia and tocilizumab. There was good control with the latter and he was off treatment from late 2017 to mid-2018. He then flared and was restarted on tocilizumab with poor results. He continues to flare, in at least the knees, ankles and feet. He is on methotrexate and meloxicam. His Rheumatologist has requested coverage for infliximab, noting that he needs control of his disease and due to psychiatric problems he has great anxiety about self-injection (vis-a-vis Humira). 

The insurer has denied coverage, as infliximab is not indicated for JIA. 

It should be noted that the patient does have JIA, which by definition has age of onset of less than 16 years. But what is more important is that he now has active arthritis behaving like and being treated like adult RA (Rheumatoid Arthritis). There is no clear definition of what age separates JIA from adult RA. In the labelling for Xeljanz (not indicated for JIA) the definition of pediatric age is not noted. In the labelling for Rituxan (also not indicated for JIA) there is the suggestion of 17. Polyarticular JIA usually evolves into adult RA if it remains active, and is then treated as RA no matter what the age of onset.

This being the case, it is not clear that the labelling restriction for infliximab applies. Even if it does, there is documentation of use of infliximab in JIA just like other anti-TNF medications, despite lack of labelling. The two papers submitted with the appeal include infliximab, as do the references cited below.

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

As noted above, it is reasonable to consider this a case of adult RA, at which point there is no issue with FDA labelling. He has active disease and has failed multiple types of therapy. Even if one considers this patient to still be a juvenile, there is documentation noted above that indicates that infliximab is used to treat JIA just like its related anti-TNF relatives.  

Based on the above, the medical necessity for Infliximab is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient presented with a one day h/o abdominal pain and back pain after eating spicy food. The pain was not associated with any nausea, vomiting, diarrhea, chest pain, or shortness of breath. In the ED, she was hemodynamically stable and afebrile. Her abdominal examination was benign except for some abdominal tenderness but no signs of peritonitis. Her labs were remarkable for mild to moderate elevation of liver function tests. The US of the abdomen revealed some gall bladder edema and thickening ad no gall stones. The MRCP did not reveal any evidence of biliary obstruction. HIDA scan revealed nonvisualization of the gall bladder at four hours, and low ejection fraction. The surgical consult was done and did not recommend any surgical intervention during this hospitalization. The GI and ID recommended IV antibiotics, which were continued until the date of discharge. The patient was able to tolerate the diet the day after admission. Given this clinical scenario, the patient could have been safely and appropriately managed at the lower level of care.

During her hospitalization, the patient remained hemodynamically stable and afebrile and tolerated diet well without any nausea and vomiting. She was managed conservatively with IV antibiotics for possible cholecystitis and General surgery recommended no intervention and advised the patient to follow up as an outpatient for further management of cholecystitis.
Appeal type: Medical necessity
Decision: Overturned

Developmental Delays/Cognitive
Mental Health: Outpatient

The patient is a female who is in treatment with twice weekly multimodal psychotherapy for management of a pervasive developmental disorder (autism spectrum and intellectual disability); schizoaffective disorder, bipolar type; communication disorder; generalized anxiety disorder; and, Tourette's syndrome. The extended psychotherapy targets social skills, disruptive and inappropriate behaviors, self-care, and symptoms and behaviors related to the comorbid conditions. The patient has reportedly made progress with regard to functioning but continues to display problems with executive functions (organizing, sequencing, problem solving and decision making), communication-especially with regard to social cues and norms, inappropriate social behaviors including abnormal vocalizations and intrusions, rigidity with regard to behavior and conversation, and obsessive-compulsive related symptoms including those associated with the Tourette's syndrome. The patient has relationship problems and other functional impairments that limit her ability to function socially and within the family constellation.

The health plan's determination is overturned. The Extended Outpatient Psychotherapy Sessions in question are medically necessary for this patient. The Extended Outpatient Psychotherapy Sessions under review is consistent with prevailing medical standards or clinical guidelines pertaining to patients with the conditions diagnosed in this case, as well as the scientific literature involving evidence-based treatments, known to benefit patients with the conditions diagnosed in this case. The patient has moderately severe symptoms of mood and anxiety and obsessive compulsive related disorders and ongoing stressors related to the developmental and communication disorders together with severe symptoms of dissociation; she has not reached a plateau with respect to symptoms or functioning, and the treatment plan focuses on maintaining progress with symptoms relief and coping skills, as well as continued attention to emotional and social functioning, and interpersonal and daily functions. The goals of treatment are reasonable and in the best interest of the patient and are consistent with prevailing standards of medical practice with regard to the intensity and frequency and duration of treatment with psychotherapy in order to address the conditions under treatment in this case. The case is complicated by the multiple conditions that impact communication, social functioning and ability to maintain self care, and the patient has continued to benefit from the ongoing treatment as noted in the clinical summaries.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for a subarachnoid cyst who presented to the emergency department with complaints of a headache that had been going on for 1 week and an episode of loss of consciousness.
The patient reported headaches in the past. This was evaluated by her primary care physician and she had a magnetic resonance imaging (MRI) scan of the brain performed before this admission, which demonstrated a left parietal region measuring 1.2 x 1.5 centimeter (cm), thought to be an arachnoid cyst versus encephalomalacia. It was reported that the patient had episodes of loss of consciousness in the past.
The patient was oriented to person, place, and time. She appeared to be lethargic. Based on the report from the emergency department, the initial strength in the upper and lower extremities on the left side was 1/5, but within a short period improved to 3/5. It was indicated that the patient's muscle strength on the left side was improving.  She was admitted to the hospital with a diagnosis of syncope versus cerebrovascular accident (CVA). The health plan's determination is upheld.
This patient presented to the hospital after she had a syncopal episode, which was associated with a headache and significant weakness in the left upper and lower extremities. Considering the circumstances, the patient was appropriately admitted to the hospital and had a workup for CVA/TIA. At the same time, the weakness in the left upper and lower extremities resolved very fast, and the patient essentially had no other neurological symptoms. On the next day after the day of admission, it was documented that the patient's neurological exam was unremarkable.
It was mentioned that the patient had low blood pressure at times, but she had no symptoms related to the low blood pressure while in the hospital.
Care could have been provided at a lower level, to ensure complete resolution of the patient's neurological symptoms such as left-sided weakness (which was resolving very fast) to perform appropriate workup and ensure clinical stability. This was performed during the hospitalization and did not require admission at an inpatient level of care.
Even though this patient had new-onset severe neurologic symptoms such as weakness at the time of the initial evaluation, this resolved quickly. At the time the patient was seen by admitting physician, the left upper and lower extremity weakness was mild and estimated as 4/5.
Taking into consideration this information, care could have been provided at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic transverse myelitis
Treatment: Continued skilled nursingg facility level II

The proposed treatment is not medically necessary.

The patient has a history of coronary artery disease with myocardial infarct, hypertension, diabetes, lumbar spine stenosis and chronic neuropathic pain.  The patient was acutely hospitalized with acute onset bilateral upper limb paresthesias and neck pain.  Imaging demonstrated no cord compression.  There was elevated T2 signal and contrast enhancement from C3-4 to C4-5, which was felt to be consistent with a demyelinating, autoimmune or paraneoplastic process.  

In the current case, the patient has had severe to profound impairments that have persisted for a prolonged period of time.  On the right side, there has been severely weak proximal limb strength and fair to good strength distally.  On the left side, there has been no functional motor activity.  Her neurogenic bladder has persisted and she continues to require intermittent bladder catheterizations.  Her impairments have not significantly changed since she first presented to acute inpatient rehabilitation, even before she transferred to the skilled nursing facility.  She has remained essentially totally dependent for all self-care and mobility.  There has been no evidence of otherwise meaningful functional progress towards community reintegration such as progress with power wheelchair mobility/control, learning to direct care, or practical family/caregiver training.  The patient's care had become custodial as of the dates in question.  This is underscored by the findings in neurology clinic which continued to show a lack of functionally significant neurological improvement.  Her medical and nursing care needs could have been met in the community with custodial level assist or a custodial level facility, with home services and outpatient medical follow up.  Her rehabilitative needs could have been reassessed if she demonstrated meaningful neurological recovery or for implementation of a realistic and active plan to reintegrate the patient to the community despite her profound impairments within a reasonable time frame.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Food poisoning

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male child who presented to the emergency department with multiple episodes of dizziness. While in the ED, he was treated with intravenous fluids x2, Zofran 4 mg IV and famotidine and was re-evaluated every 1 to 2 hours. The patient had an oral challenge, but he still had nausea. Lab work was within normal limits, and electrolytes showed no abnormalities. The patient still endorsed nausea and inability to tolerate oral intake. Pediatrics was consulted, and an admission was recommended for inability to tolerate oral intake. Pepcid 17 mg IV and additional Zofran 4 mg IV were ordered. The patient received IVF and was weaned as he began to tolerate advanced oral intake. He was discharged to home. 

According to 2014 guidelines for the management of acute gastroenteritis in children, indications of hospitalization for acute gastroenteritis in this population include: shock, severe dehydration, neurological abnormalities (lethargy, seizures, etc), intractable or bilious vomiting, failure of oral rehydration, and/or suspected surgical condition.(1) While oral rehydration is preferred, in children who fail oral rehydration, administration of rehydration fluids intravenously is effective and should be recommended.(2) 

In this particular case, the patient did not fulfill any of the above criteria for admission. The patient had tolerated an oral fluid challenge, after which he felt nauseated (though no vomiting was noted per ED documentation provided - only nausea and gagging). The symptoms were presumed to be related to a benign and self-limited condition (food poisoning) and resolved by the time the child awoke. Given his age (nearly adult), and the fact that he was well hydrated with a normal examination, even with persistent nausea he could have been safely discharged home with anticipatory guidance to return should vomiting recur. 

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

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

Diagnosis:  Conversion disorder
Issue under review:  Transfer to specialty hospital

Determination:
The Transfer to specialty hospital is medically necessary.

The patient is a female with complex medical history.  She has history of being wheelchair bound and non-ambulatory since receiving multiple vaccines.  She later developed shaking, poor feeding, and lack of speech.  She has been hospitalized several times and has undergone comprehensive and extensive evaluations by Neurology and Child Psychiatry and now bears the diagnosis of functional neurological system disorder, also known as conversion disorder.

This young teenage female patient is extremely complicated with a complex combination of symptoms and manifestations despite negative extensive work-up.  She has failed all care options that have been provided, including multiple outpatient services and her current inpatient interventions.  She is almost completely non-functional but is cognitively intact as a result of severe and profound functional neurological system disorder.  The specialty physicians (pediatrics, child psychiatry, adolescent medicine, physical medicine & rehabilitation) that have been providing her care all agree that she requires higher level of care at a specialized facility in order to regain function.  While less severe disorders may respond to psychological interventions and physical therapy, severe disorders, such as in this patient, require a unified treatment approach.  The requested receiving facility can provide the complex care that this patient requires and at this point may be her only chance for recovery.  The requested transfer is medically necessary and appropriate.