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

The patient has a a past medical history significant for asthma, bipolar disorder, and human immunodeficiency virus (HIV) infection who presented to the emergency department with complaints of left lower back pain with radiation to the left buttock and left groin. The pain was associated with left leg weakness for 1 month. Review of systems was obtained on admission. It was negative for a recent trauma, uncontrolled urination or bowel movements, headache, dizziness, blurred vision, light sensitivity, difficulties to swallow, cough, shortness of breath, chest pain, nausea, vomiting, fever, chills, abdominal pain, dysuria, abnormal vaginal spotting with discharge, or hematuria. On the physical exam, the patient was afebrile, blood pressure was 116/72, heart rate 79, respiratory rate 16, and oxygen saturation 97% on room air. The patient was in no acute distress and was well-developed. The patient was admitted to the hospital. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. Considering the fact that the patient was immunocompromised due to HIV infection with a recently reported relatively high viral load, this patient definitely had a significant risk of a serious medical problem associated with the back pain. Therefore, a thorough evaluation was absolutely warranted.
The patient was appropriately ordered MRI of the lumbar spine, which did not demonstrate evidence of abscess, fracture, or demyelination, or any other serious complications that could be associated with active HIV infection. At the same time, the MRI of the lumbar spine showed that the patient had a mild disc herniation, which was most likely responsible for the patient's symptoms. This degree of disc herniation did not require any surgical intervention.
It was also important to mention that the patient was afebrile and hemodynamically stable all the time. The patient had an essentially normal physical exam, including a neurological exam. The patient had a normal white blood cell count. There were no significant abnormalities in the laboratory results that would justify admission at the acute inpatient level of care. The patient had no other acute medical conditions that would necessitate evaluation and care at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dysuria, lower abdominal and back pain
Treatment: Inpatient admission

The proposed treatment, inpatient admission, was medically necessary.

The patient does not meet the criteria for simple cystitis or pyelonephritis that could be treated as an outpatient as given by the Infectious Diseases Society of America (IDSA) (1). The patient has a history of multiple UTIs, with a recent admission for a UTI secondary to ESBL E. coli. Given her history, continuing symptoms, and abnormal examination, hospitalization and IV treatment with close observation and workup was standard of care and the necessary. Given the constellation of the signs and symptoms, one outcome could have been prolonged IV antibiotics and arrangement for home infusions. Although, she ended up not having a UTI, this further consolidates the correct decision in admitting her, as she needed an inpatient workup to determine this. Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

This case describes a female patient with a complaint of bilateral knee pain and osteoarthritis in her right and left knees. Her orthopedic provider administered a cortisone injection and recommended proceeding with a course of four orthovisc injections for each knee. 
At issue in this case is the medical necessity of the recommended viscosupplementation injections.

The health plan's determination is upheld.

The rationale for this determination is based upon the current, peer-reviewed orthopedic literature on the topic of viscosupplementation injections for osteoarthritis of the knee. Recent studies have found that the efficacy of viscosupplementation injections is, in fact, minimal. Thus, the medical necessity of the proposed orthovisc injections in this case is not established. 
A recent article published by Tammachote and colleagues in the Journal of Bone and Joint Surgery in 2016 concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." A second articled published by Jevsevar and associates in the Journal of Bone and Joint Surgery in 2015 concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid (HA) treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials." Thus, the current literature does not endorse viscosupplements as an effective means to treat osteoarthritis of the knee and the medical necessity of the Orthovisc injections in this case is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Growth hormone deficiency
Issue under review: Humatrope

Determination:
The Humatrope is not medically necessary.

The peer-reviewed literature, including consensus clinical guidelines and randomized controlled trials are summarized below:

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society (1), the Lawson Wilkins Pediatric Endocrinology Society (2, 3), and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists (4). The above-referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on auxological, biochemical and sometimes radiological findings. 

The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are below:

1)Severe short stature, defined as a height of more than 3 SD below the mean 2) Height of more than 1.5 SD below the mid-parental height 3) Height of more than 2 SD below the mean, and a height velocity over one year of more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over one year in children over two years of age 4) In the absence of short stature, a height velocity of more than 2 SD below the mean over one year, or more than 1.5 SD sustained over two years. 

The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing, with a peak GH of less than 10ng/ml. 

The patient's GH stimulation testing peaked at less than 10ng/ml. The patient had a normal IGF1. The patient did not meet auxological criteria, as pretreatment height and height velocity are normal.

The pediatric endocrine society recommends against making a diagnosis of growth hormone deficiency based solely on failed growth hormone stimulation testing.

Idiopathic Short stature
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines (4-9). FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient does not have a pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria. 

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pressure
Treatment: Inpatient admission
The proposed treatment, inpatient admission, was not medically necessary. 

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

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

Home Health Care 

The patient requested personal-care assistant service hours, and has past medical history significant for dementia, urinary incontinence, chronic obstructive pulmonary disease (COPD), diastolic heart failure, respiratory disease, frequent falls, urinary tract infections and macular degeneration.
Patient requested personal-care consumer directed personal assistant services  Patient is currently approved for live-in consumer directed aide. The health plans determination is upheld in whole.  A Uniform Assessment System (UAS) State of New York was reviewed. Primary Care documentation  was reviewed and the sleep observation study was reviewed.
The patient's personal care needs can be met including Activities of Daily Living ADLs and Instrumental Activities of Daily Living (IADL)s along with safety supervision with a live-in aide. Additional services with 126 hours a week/18 hours per day of consumer directed personal-care services would not be medically necessary. In fact, the patient has more scheduled service hours with a live-in aide versus an hourly aide, 18 hours per day 7 days a week. Based upon the observational study the patient does have needs at night however those needs can be managed and also the personal care aide does have enough time to get adequate sleep which, according to law, means 5 hours of uninterrupted sleep. According to the observational studies this can be achieved as noted. The patient is ambulatory not bed bound. There is no noted medical need necessitating frequent repositioning in the middle of the night. There is no noted paraplegia or hemiplegia which would require this frequent repositioning. The patient has no noted open sores either.
Therefore, the patient's personal care service hours are adequate to meet her needs. Additional service hours are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease
Issue under review: Stelara

Determination:
The Stelara is not medically necessary.

The patient has Crohn's, and has failed treatment with anti-TNFs (tumor necrosis factor). While Stelara is FDA-approved for Crohn's, and is a reasonable alternative treatment for Crohn's, there is no medical literature to support that Stelara is more effective than the plan-preferred Entyvio for the treatment of Crohn's. Therefore the requested Stelara is not medically necessary over the plan-preferred Entyvio. The health plan did act reasonably, with sound medical judgment and in the best interest of the patient in denying Stelara, provided that the patient is treated with Entyvio.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe global developmental delay; Quadriparesis; Seizure disorder
Issue under review: Private duty nursing with a registered nurse

Determination:
The Private duty nursing with a registered nurse is medically necessary.

The American Academy of Pediatrics has published guidelines for home care of infants, children, and adolescents with chronic disease: "comprehensive planning should minimize physical and emotional risk to the patient, adverse effects on family members, or unforeseen financial burdens." Further, "the goal of a home health care program for infants, children, or adolescents with chronic conditions is the provision of comprehensive, cost-effective health care within a nurturing home environment that maximizes the capabilities of the individual and minimizes the effects of the disabilities." (1) 

This young male child has a number of evolving clinical challenges as a result of his spastic quadriparesis, global developmental delay and seizure disorder. He aspirates all forms of nutrition and is no longer able to take foods and fluids by mouth. He recently had a nasogastric tube in place for formula to meet his nutritional needs. He receives his feedings via a feeding pump multiple times throughout the day and night. In addition, he is at risk for aspiration from his own secretions and must be monitored for signs and symptoms of respiratory distress. He suffers from seizures, and must be monitored at all times for seizure activity, with emergency treatment when necessary. While his mother is the primary caregiver and is fully trained in his care, she works six hours daily, attends school three hours daily, manages the household while the father works full time six days weekly, and cares for the needs of the other two children. It is neither safe nor possible for her to provide the care necessary to maintain this child's health and well-being for more than short periods of time daily. The family currently receives some personal care assistant hours weekly, but this is neither sufficient nor medically appropriate to manage his medical challenges. The requested private duty nursing are therefore medically necessary and appropriate (in addition to the personal care assistant hours).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcoholic Hepatitis with Ascites.

Treatment: Inpatient Hospital Admission

The insurer denied the Inpatient Hospital Admission. The denial was reversed.


This is a male patient who presented to the emergency department (ED) with complaints of shortness of breath, abdominal pain and bloating for three days. It was reported by family that the patient had been drinking excessively. The patient had a series of diagnostic testing done while in the ED which included laboratory work up which revealed a white blood cell count of 14.67, a lactate of 7.5 and liver enzymes which were elevated. The patient was treated with intravenous (IV) fluids with electrolyte replacement. An electrocardiogram (EKG) was performed which showed sinus tachycardia, left ventricular hypertrophy, a normal axis, and no ST-Elevation Myocardial Infarction. The patient was admitted to the Medical intensive Care Unit (MICU) for treatment. Gastroenterology was called to consult on the patient. He had a hemoglobin of 7.8 and noted to have melena; he received one unit of packed red blood cells; his repeat hemoglobin was 8.8. The patient was started on IV Protinix and an Octreotide IV drip. A computed tomography (CT) scan of the abdomen revealed colonic wall thickening from the cecum through the splenic flexure and abdominal and pelvic ascites. The liver was cirrhotic and ascites was present. The patient underwent a paracentesis; three liters of fluid were removed and sent for a fluid protein level for Serum Ascites Albumin Gradient score. The patient was discharged after a period of medically stability. 

Clinical indications for admission for Liver Disease Complications (M-570) including having cirrhosis with an acute exacerbation. The acute exacerbation requires all of the following components: total bilirubin over 5, INR greater than 1.5, and the acute onset of ascites. The patient had all 3 of these conditions. The bilirubin was 5.8, the INR was 1.57, and there was acute onset of ascites.

This patient had acute alcoholic hepatitis and cirrhosis. He was tachycardic and had a very high lactate level. He developed a hemoperitoneum due to a paracentesis with a coagulopathy. He met MCG criteria for admission for Liver disease complication with the high bilirubin, high INR, and acute onset of ascites. 

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

Diagnosis: Severe Persistent Asthma Exacerbation
 
Treatment: Inpatient Hospital Admission

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

This is a young male patient who presented to the emergency department (ED) with complaints of shortness of breath. The patient had a past history of asthma, and multiple intubations. It was documented that the patient had presented to the ED earlier that morning with similar symptoms; he was treated for asthma and released. The patient reported that he was an emergency medical technician (EMT) and after he was released that morning he continued to treat himself for his condition. He received Nebulizers, Solu-Medrol and bronchodilators. The patient was placed on Bilevel Positive Airway Pressure (BIPAP) at 35%. He had a chest x-ray that was negative. The patient continued to have bilateral wheezing. His urine toxicology was positive for Tetrahydrocannabinol (THC). The patient was discharged the next day medically stable on oral steroids and bronchodilators. 

The patient was tolerating fluids and food orally and was treated with oral steroids after admission. The patient was stable for discharge on oral steroids and bronchodilators after a period of observation. The observation status could be extended up to 48 hrs. Based on the above information the prior denial was appropriate. This patient did not meet criteria for this acute admission. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  

The carrier's denial of coverage for the inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Circadian Rhythm Sleep Disorder 

Treatment: Hetlioz

The insurer denied the Hetlioz. The denial was reversed.  

This is a young male patient with a diagnosis of Circadian Rhythm Sleep Disorder. 

He has a history of attention deficit disorder (ADD), anxiety, mood disorder, asthma, chronic sinusitis, gynecomastia, and obstructive sleep apnea. It was noted that the patient had an attempted suicide by a Xanax overdose in early 2019, and had spent two weeks in a psychiatric facility for treatment. Light therapy was recommended for his sleep disorder diagnosis. The patient underwent a sleep study which revealed mild sleep apnea, periodic limb movements associated with restless leg syndrome, and mildly abnormal sleep architecture. He was evaluated by an Ear, Nose and Throat specialist. Continues Positive Airway Pressure (CPAP) treatment was recommended, however, it was not tolerated by the patient. It was reported that the patient was drinking a lot of caffeine energy drinks in attempt to stay awake and focus on school work; he was a senior in high school. The patient was started on Hetlioz. The patient reported major improvement in his sleep since he was started on the medication six months earlier.  

Per UpToDate (2018), "Individuals with non-24-hour sleep-wake rhythm disorder (N24SWD) are unable to maintain appropriate alignment with the 24-hour environment, so each day their sleep-wake patterns shift (typically later) with respect to external time.  N24SWD has previously been referred to as free-running disorder, non-entrained disorder, or hypernychthemeral syndrome In sighted individuals with N24SWD, we suggest use of nightly melatonin as well as morning light therapy." 

According to the current peer-reviewed medical literature, N24SWD occurs mostly in blind individuals, but may occur in patients with sight.  Hetlioz is a melatonin receptor agonist indicated for the treatment of N24SWD.  At this time, Hetlioz is the only drug to be approved by the US Food and Drug Administration (FDA) for the treatment of N24SWD.  The patient is not blind.  He has a diagnosis of Circadian Rhythm Sleep Disorder.  The patient had other psychiatric diagnoses which may affect this disorder.  The documentation indicated that the patient has utilized Ambien, light therapy and melatonin with no relief.

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

The patient with diabetes and hyperlipidemia who presented to the hospital with complaints of nausea and vomiting. This was followed by a sensation of chest discomfort. She had lightheadedness after vomiting. Four days prior to the  presentation, the patient had undergone a stress test, but did not know the results. The patient was admitted. The patient was seen in cardiology consultation. Per the consult note, the patient reported that that the recent stress test was abnormal. The chest pain was felt to be atypical for angina. However, in view of the  elevated troponin, cardiac catheterization was recommended. This was performed and showed mild diffuse stenosis of the left anterior descending coronary artery. The health plan's determination of medical necessity is upheld in whole. The inpatient hospitalization is not medically necessary. The patient was hemodynamically stable, had chest pain, which was not typical for angina, had an EKG without diagnostic changes of acute myocardial infarction, and had borderline troponin levels. With the World Health Organization (WHO)WHO criteria cutoff for Troponin T for acute myocardial infarction (0.1). Her EKG did not show definite evidence for acute myocardial infarction. A lower level of care status was appropriate.
Appeal type: Medical necessity
Decision: Overturned

This patient is under consideration for bariatric surgery. The patient was 64 inches tall and weighed 288 lbs. This corresponds to a body mass index (BMI) of 49.4 kg/m2. The patient has comorbid health issues of diabetes, and joint pain. The patient has attempted weight loss with dietary efforts using programs such as Weight Watchers, Satkin Diet and high protein diets. Unfortunately, the patient has not been successful with significant sustained weight loss. The patient sought evaluation for bariatric surgical consultation. A Laparoscopic Sleeve Gastrectomy is under review.

The health plan's determination is overturned. Given this patient's diagnosis, current health condition and my medial judgment, the proposed sleeve gastrectomy procedure is medically necessary for this patient and is consistent with generally accepted guidelines established by The National Institutes of Health and The American Society for Metabolic and Bariatric Surgery. This patient has a current BMI in excess of 40 kg/m2 with weight related comorbid health conditions that include diabetes and joint pain. The patient has successfully completed a multidisciplinary bariatric evaluation. Sleeve gastrectomy is in accordance with generally accepted standards of medical practice, is clinically appropriate and considered effective for the member's disease, is not cosmetic or experimental, is proven to be more medically effective than any standard nonsurgical care and treatment, and is not for the convenience of the member or physician. The proposed sleeve gastrectomy is medically necessary for this patient and is consistent with the standard of care.