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

Diagnosis: Left knee patella fracture

Treatment: Physical Therapy Services (97140) 

The insurer denied coverage for Physical Therapy Services (97140). The denial was upheld.

This patient is a male who was diagnosed with a left knee patella fracture after a fall in late-2018.  The patient was initially non-weight bearing for approximately 4 weeks and was then advanced to weight bearing activity.  The patient began physical therapy treatment in early-2019. The documentation detailed on a specified date, which is the date in question, that the patient was seen for the 15th visit of therapy. The patient reported ongoing improvement.  The patient consulted a physical therapist for treatment for his injury. A 12 week treatment plan was implemented that included therapeutic exercises, therapeutic activities, gait training, neuromuscular rehabilitation, manual therapy, massage, patient education, electrical stimulation, ultrasound, phonophoresis, cryotherapy, and hot packs. The patient was treated with manual therapy as well as neuromuscular re-education and therapeutic exercise. The patient continued with treatment. The physical therapy progress note indicated that as of a specified date in early-2019, the patient was independent with home exercise plan (HEP). Continued improvement in pain and function was reported. However, this appears to be maintenance care as the pain is waxing and waning. 

The documentation does not support the requested manual therapy on a specified date was medically necessary for this patient. There are no objective findings demonstrating improved range of motion (ROM) with the manual therapy. Uphold denial.

Based on the above, the medical necessity for the Physical Therapy Services (97140) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coughing; wheezing
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is a male child. He was taken to the ED because of coughing and difficulty breathing.

This young child presented with signs and symptoms of respiratory distress consistent with viral respiratory infection and reactive airway disease. He had received dexamethasone in the outpatient setting as well as amoxicillin for otitis media prior to presentation, but developed worsening symptoms nonetheless. He received prednisolone and albuterol/Atrovent in the ED, and because he remained symptomatic, was admitted for further care. While it was reasonable to manage this child in the hospital with frequent albuterol treatments every two hours, as well as enteral steroids, he was overall hemodynamically stable, with no evidence of sepsis or impending respiratory failure, no significant dehydration, and no oxygen requirement. He did not require acute inpatient management and could have been safely managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

Cellulitis 
Inpatient hospital

The patient is a male with diabetes, and hypertension who was sent to the hospital by his podiatrist for pain to lower extremity with swelling and redness. The patient had symptoms for four to five days prior to admission and was sent by the podiatrist to the hospital for evaluation and antibiotic therapy of cellulitis of left foot second digit. Intravenous clindamycin was started along with pain control. An x-ray of the foot did not show any acute pathology. Wound cultures were sent and oral doxycycline was started and continued with discharge to complete an outpatient course. The inpatient admission is under review.

The health plan's determination is upheld. The Inpatient Hospital Admission was not medically necessary at an inpatient level of care. Based on available data the patient had no fevers, inability to take oral intake, or altered mental status that is severe or persistent. An x-ray of the foot did not show any acute pathology. In addition, the patient had no hemodynamic instability, cardiac arrhythmias of immediate concern, or significant respiratory findings that are severe or persistent. There was no significant electrolyte or metabolic abnormalities that required inpatient level of care. The patient could have safely and effectively been managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Overturned

Abdominal/Stomach Pain
Inpatient Hospital

The patient is a female who presented to medical attention after experiencing multiple (>10) episodes of emesis after having eaten food from a local bagel shop. Upon arrival to the emergency department, she was tachycardic, not febrile. She received intravenous fluids and an anti-emetic. Despite initial attempts at hydration, she was unable to tolerate oral intake, so was admitted for intravenous hydration. When she was able to tolerate oral intake, and she was discharged home. The issue at hand is the inpatient admission.

The health plan's determination is overturned. The Inpatient Hospital Admission is medically necessary for this patient. She failed an oral rehydration challenge, and despite a reasonable period of observation in the emergency department that included intravenous antiemetics to promote her ability to take fluids by mouth, this was unsuccessful. At that point, admission is indicated. An inpatient admission allowed for replacement of ongoing losses related to vomiting and diarrhea and would prevent further derangements in her volume and electrolyte balance.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  GERD
Issue under review:  LINX procedure

Determination:
The health plan should cover the LINX procedure.

The health plan denied the request for Linx procedure calling the procedure experimental or investigational.  It has not been experimental for many years.  

This patient suffers from chronic GERD (gastroesophageal reflux disease).  Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none of the others have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  Linx is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been shown to dramatically improve patient satisfaction long term.  It is approved by the FDA.  There is published data on patients who have had the device for six years, showing a very low complication rate and a high resolution of GERD.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Issue under review: LINX procedure

Determination:
The health plan should cover the LINX procedure.

This patient has GERD that is refractory to medical management.  Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management.  LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication, with less risk of mortality and major morbidity.  The treatment is considered standard in the medical community and been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons and SSAT (society of surgeons of the alimentary tract).  The treatment is not for the convenience of the patient or provider. 

The only current exclusions for this procedure are adolescents, morbid obesity and history of prior gastric/bariatric surgery, which this patient has not had. 

The procedure is not investigational.  This patient is an adult without morbid obesity or history of prior bariatric/gastric surgery who has failed medical management for GERD.  The patient has no exclusion for LINX, an FDA-approved treatment of GERD, which has been shown in published literature to be comparable for mid-long-term control of GERD to laparoscopic Nissen fundoplication with less mortality and less dysphagia complications.
Appeal type: Medical necessity
Decision: Upheld

This is a pregnant patient who had been initially seen with severe right lower quadrant pain, hematuria, urinary urgency and vaginal itching. The patient denied fever or chills and had reported some nausea and decreased appetite. The patient was suspected have a kidney stone and a renal ultrasound was performed and noted a 6 millimeters (mm) kidney stone in the right distal ureter with pelviectasis on the right side. There were also multiple kidney stones in the right kidney and multiple kidney stones in the left kidney. The patient had felt better on the following day, was seen by urology, and was discharged home after pain resolved. The patient then called back with pain on the left side. 
She denied any contractions, leakage of fluid, or vaginal bleeding and reported active fetal movement. The patient underwent a repeat ultrasound which noted bilateral pelviectasis with the right being greater than the left. Ureteral jets were not seen and she was readmitted with renal colic. Urology performed a consultation and recommended a stone protocol computed tomography (CT) scan. The CT scan showed a distal bilateral renal calculi of 6 mm on the left and 4 mm on the right. The patient was then consented for bilateral double-J stents with cystoscopy, which was completed without complications in the operating room. Following this procedure, the patient felt some preterm contractions and underwent hydration and oral indomethacin. Active fetal movement was noted. The patient was eating and drinking well. Her urine culture had returned for group B strep positive status which was also noted earlier in pregnancy due to colonization. The patient was tolerating oral medications and diet. She began to feel well on postoperative day #1 and was discharged home. The health plan's determination is upheld. In this case, the MCG Guideline entitled Renal Colic and Kidney Stones was reviewed with the medical records. In this case, the patient was admitted to the hospital and underwent placement of stents for renal stones. This was completed in an uncomplicated fashion. She was treated with IV pain medications but transitioned to oral medications for control of pain. She had oral intake and hydration. There were no complications of the pregnancy and the patient was given hydration and indocin following the procedure for mild cramping. There was no cervical dilation noted and the fetus remained reassuring. 
In this case, the patient did not require acute inpatient care as she had stable vital signs without evidence of acute renal failure. There was no evidence of obstruction. The patient was noted to have 2 renal stones and underwent a procedure to place a stent. Following the placement of the stent, there was no need for inpatient level of tear. There was no vomiting or severe pain that cannot be managed with oral medications. There is no evidence of urinary tract infection. For this reason, the patient did not meet any indication for acute inpatient hospitalization based on these guidelines. Care could have been provided at a lower level than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Malocclusion
Issue under review:  Braces, monthly visits

Determination:
The Braces and monthly visits are not medically necessary.

The patient's occlusion is reasonably normal.  She has a Salzmann index of 21 (needs 26).  There are no dental reasons that this patient needs orthodontic treatment; she should be able to function normally without any trouble.  Therefore, the braces and monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Primary hyperparathyroidism; status post parathyroidectomy

Treatment: Tymlos 80 mcg dose pen injector

The insurer denied coverage for Tymlos 80 mcg dose pen injector. The denial was reversed.

This patient is a female with a history of primary hyperparathyroidism, status post parathyroidectomy and bariatric surgery in mid-2018. The patient had prolonged hospitalization post bariatric surgery, and a weight loss of 100 pounds.  She sustained right medial condyle fracture. Her bone mineral density (BMD) in late-2019 indicated 31% reduction in hip BMD, and 11% in spine BMD.  The lab revealed elevated level of C-Telopeptide at value of 1282 pg/ml, indicating rapid bone loss.  Tymlos was prescribed to the patient.  Her insurance company denied Tymlos 80 mcg dose pen injector.

In view of the history of this patient, including treatment of osteoporosis, history of fragility fracture, evidence of elevated bone turnover (h.g C-telopeptide), anabolic treatment like Forteo or Tymlos is indicated. (1,2)   On the basis of current American Association of Clinical Endocrinologists (AACE) Guidelines(3)  it is preferable to start anabolic therapy like Tymlos for two years then switch to bisphosphonate or Denosumab.   The high level of C-Telopeptide in this patient suggests high bone turnover. (4)

This patient is postmenopausal, with osteoporosis fragility fracture and elevated bone turnover, will benefit from Tymlos that is rapid acting anabolic medication, that results of increased BMD can be seen in three months,(1)  to get benefit form bisphosphonate may take time even over a year, and she may sustain another fragility fracture.  

Tymlos for this patient is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for Tymlos 80 mcg dose pen injector is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who sustained an acute twisting injury to his left ankle which resulted in a displaced bimalleolar ankle fracture. The patient was admitted to the hospital despite the fact that the injury occurred two days earlier in Canada. The patient was brought to the operating room for an open reduction and internal fixation of this left ankle fracture. The patient remained admitted to the hospital. The health plan's determination is upheld.

Based upon the provided medical records, this patient sustained a closed ankle fracture two days prior to seeking treatment in the emergency department. The records document that the patient was not at high risk and had no significant medical history. The rationale for admission provided in the history and physical document states that the patient failed outpatient therapy and that he was unable to ambulate. However, the patient had been ambulating for two days prior to seeking evaluation. In addition, the current, peer-reviewed orthopedic literature supports the performance of outpatient ankle fracture care. In their article published in the Journal of Bone and Joint Surgery in 2016, Qin and colleagues concluded that "In patients with closed fractures and minimal comorbidities, outpatient open reduction internal fixation (ORIF) was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, re-operations, and readmissions relative to inpatient." Two recent articles published by Qin and colleagues in Orthopedic Clinics of North America in 2018 and in the Journal of Bone and Joint Surgery in 2016 have documented the efficacy and safety of outpatient care for closed ankle fractures that require open reduction and internal fixation surgery. Thus, the inpatient hospital admission is not supported by the current, peer-reviewed orthopedic literature and was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Nail onychomycosis
Issue under review: Formulary exception for Jublia topical solution

Determination:
The health plan should not cover the Formulary exception for Jublia topical solution.

The medication is a topical medication utilized for treatment of onychomycosis.  Mycosis is a benign condition of the toenails which leads to discoloration and dystrophy.  This can be treated with topical medications.  Standard therapy includes either over-the-counter medications or prescription ciclopirox 8%.  There has been no documentation that this has been attempted, there has been an allergy to any of these medications, or that use of these medications was not efficacious.  Since this is the case, this medication should not be covered at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type I Diabetes 

Treatment: Continuous Glucose Monitoring System device with the Dexcom G6

The insurer denied coverage for Continuous Glucose Monitoring System device with the Dexcom G6. The denial was reversed.

This patient is a male with diagnosis of Type I Diabetes, since childhood. The patient is using insulin pump, and it appears that he is not under good glycemic control. Based on A1c-8.3 from late 2019, his physician requested to put the patient on CGM device Dexcom G6, which has the required feature of alerting the patient when blood sugars are falling down (hypoglycemia). The insurer denied this sensor.
The Juvenile Diabetes Research Foundation recommends CGM and describes the sustained benefit of it on glycemic control and hypoglycemia.(1)  The American Diabetes Association in Diabetes Care, 2018 Jan 41(2) emphasizes the above claim. Also the American Association of Clinical Endocrinologists (AACE) Guidelines for use of CGM recommend factory-progressed trigger for a hypoglycemia alert <7mg/dL for optional programmable alert at lower values <55 and <45 mg/dL.(3)  The CGM DexCom G6 has these required qualities.(4)

Since this patient has Type I Diabetes, uncontrolled, with nocturnal hypoglycemias on CGM the Dexcom G6 is medically necessary for this patient. The health plan did not act reasonably.

The carrier's denial of coverage for the replacement for a Continuous Glucose Monitoring System device with the Dexcom G6 is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Other
Ambulance  

The patient was initially involved in a motor vehicle accident. The police noted that the patient had altered mental status and emergency medical services were called for evaluation. Due to aphasia, a stroke was suspected, and the patient was taken to the emergency room. The patient was evaluated by the tele neurology physician and determined to have an acute ischemic stroke. the patient  was treated with tissue plasminogen activator (tPA) and determined to have a large vessel occlusion that was appropriate for a mechanical thrombectomy. The patient was transferred however, to the closest appropriate facility, which is a comprehensive stroke center and able to perform thrombectomy. Uphold in whole the health plans determination.

The requested service was not medically necessary for the patient. In this situation, the closest appropriate facility was accessible by ground in less than 60 minutes. The patient was flown by air ambulance to another facility, one that was accessible by ground transportation in approximately 90 minutes. 

As acute stroke requires time sensitive intervention, even if the patient required air ambulance transportation, the most appropriate facility would be the closest facility able to treat the patient's condition. The closest facility by any means of transportation.. This facility is noted to be a comprehensive stroke center and therefore has interventional stroke procedures available, including mechanical thrombectomy.
Appeal type: Medical necessity
Decision: Upheld

This is a previously healthy female who presented to the emergency department (ED) with 4 days of a fever, cough, and congestion. Maximum (max) fever 102 degrees Fahrenheit (F), additional symptoms included several episodes of emesis, loose stools, decreased oral intake, and decreased urine output. She had an older sister with Influenza A and B, though this child tested negative before being started on Tamiflu prophylaxis 2 days prior to admission. Immunizations were up to date (except for influenza vaccine), and there was no recent travel history or daycare attendance. The physical exam is described as no distress, age-appropriate, moist mucus membranes, and non-labored breathing. Respiratory syncytial virus (RSV) and influenza swabs were negative. A chest x-ray showed minimal infiltrates in the left upper lobe and right lower lobe. The patient was started on intravenous fluids (IVF) and ceftriaxone; Tamiflu was also continued. She was admitted to the hospital for ongoing care. The health plan's determination is upheld. This is an otherwise healthy child with known influenza exposure who presented to the ED with 4 days of fevers and respiratory symptoms. Her blood work was indicative of a viral process, and the chest x-ray diagnosed pneumonia. There was no vital sign abnormality except for a fever upon arrival to the ED; there was no persistent tachycardia or hypoxia. The patient was described as well-hydrated with normal lung examination and nothing to indicate an inability to tolerate oral medications. She was admitted to monitor her status in the context of a low ANC but was otherwise well-appearing. Thus, this child could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

CHF
Inpatient hospital stay

The patient has a past medical history significant for hypertension, hyperlipidemia, diabetes mellitus type 2, atrial fibrillation, and coronary artery disease  presented to the Hospital with complaints of shortness of breath. The patient was discharged from another hospital just one day before the day of admission after being hospitalized for 29 days. During this hospitalization, the patient underwent 3 coronary angiograms and got 11 stents placed. Upon presentation of the current admission, the patient was awake, alert, not in acute distress. Respirations were nonlabored, but the patient had bibasilar crackles. The rest of the physical exam, including the cardiovascular exam, was unremarkable. A chest x-ray performed at the time of admission demonstrated an enlarged cardiac silhouette, prominent bilateral hila, and diffuse interstitial markings most consistent with pulmonary vascular congestion and underlying advanced interstitial edema. The patient was admitted to the hospital with shortness of breath, which was attributed to congestive heart failure in the setting of ischemic cardiomyopathy, coronary artery disease. The patient was admitted to the telemetry unit and received treatment with intravenous diuretics. The patient continued treatment with Aspirin, Plavix, Coreg. Treatment with Amiodarone and Eliquis was continued considering the previous history of atrial fibrillation. The health plan's determination of medical necessity is upheld in whole. This patient was admitted to the hospital with acute diastolic CHF in the setting of known coronary artery disease and ischemic cardiomyopathy.
At the time of admission, the patient was afebrile and hemodynamically stable, had normal oxygen saturation, and no need for invasive or non-invasive mechanical ventilation. The patient had no signs of respiratory distress.
This patient responded to treatment with intravenous diuretics fairly quickly. At the time of admission and during the hospitalization, there was no evidence that the patient had acute coronary syndrome. the patient had mild acute CHF that did not require treatment at the inpatient level of care and could have been handled at the lower level of care. Neither the severity of the patient's condition nor the complexity of the services provided justified admission at the inpatient level of care.