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

Diagnosis: ADHD; Autism Spectrum Disorder (ASD)

Treatment: Vyvanse capsule (lisdexamfetamine)  

The insurer denied coverage for Vyvanse capsule (lisdexamfetamine). The denial is upheld.

This patient was a male child with attention deficit hyperactivity disorder (ADHD) symptoms including inattention, distractibility, difficulty listening and paying attention, hyperactivity, and impulsivity.  The patient also had developmental delay in social communication and interaction, language, and motor skills.  The patient was also diagnosed with Autism Spectrum Disorder (ASD). The patient took Ritalin and Metadate CD as well as Adderall XR for treatment of his ADHD. However, there were reports of lack of efficacy and side effects including affective lability and decreased appetite. The patient also had difficulty tolerating taking the medication because of the patient's intolerance to the bead-like texture of the medication. The pediatric neurologist recommended Vyvanse to target this patient's ADHD stating that this medication can be dissolved in liquid. 

The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder reports that pharmacotherapy with psychostimulants are considered first line treatment for attention deficit hyperactivity disorder (ADHD).  Also, the American Academy of Pediatrics reports that psychostimulants are considered standard treatment for ADHD.  In preschoolers, dextroamphetamine is FDA approved for ADHD for ages under 6 years old whereas Vyvanse is not.  Since Vyvanse is FDA approved for children 6 years and older, it is not considered medically necessary for this patient. The patient also had not tried and fail on FDA approved psychostimulant for children 3 years old and older, which is an appropriate medication for this patient's age.  

Vyvanse which is considered an FDA approved medication for ADHD for ages 6 and older, is a brand name medication for Lisdexamfetamine dimesylate (generic). This medication is still not FDA approved for use for children younger than 6 years old whereas dextroamphetamine is. Thus, Vyvanse is not considered medically necessary to treat this patient's medical condition.

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

The carrier's denial of coverage for Vyvanse capsule (lisdexamfetamine) should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee Injury
Issue under review: Arthroscopy procedure

Determination:
The health plan denied the Arthroscopy procedure. The health plan's denial is upheld.

The patient is an adult female. She injured her left knee. She underwent arthroscopic surgery, which included examination under anesthesia, primary repair of ACL (anterior cruciate ligament), and trephination of medial meniscal tear measuring 15mm (stable without surface tear).

The medical record demonstrates presence of an undersurface medial meniscal tear. A trephination was completed. The procedure consists of placing holes in the meniscus with a needle to promote healing and blood flow. 

A search was conducted using PubMed (National Library of Medicine). The key word was trephination/knee. 

There were limited references found with first description of the procedure in 1993. No applicable studies were reported until 2016. A meta-analysis was completed, which demonstrated no support for performing trephination in ACL surgery. 

There were no other references found. 

National Guidelines for surgical management of meniscal pathology do not currently include trephination. It has not been shown to be effective nor standard of care.

The Plan has thus acted reasonably and with sound medical judgment.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hyperlipidemia 
Treatment: Formulary Exception for brand name Lipitor (atorvastatin) 

The insurer is denied is coverage for Formulary Exception for brand name Lipitor (atorvastatin). The denial is upheld. 

This is a male patient with a history of hyperlipidemia and hypertension with a significant family history of heart disease. It was noted that he had no exertional symptomatology or change in exercise tolerance. It was noted in an encounter that the patient's personal list of medication included Lipitor 80 milligram tablets. Note indicates LDL was 80 mg on 80 mg of Lipitor. Neither clinical note indicates any side effects from generic medications nor do they mention their use. The appeal dated notes that the patient had experienced severe side effects from generic atorvastatin and Rosuvastatin and was only able to tolerate Lipitor. The insurer has denied coverage for Lipitor (atorvastatin). The insurer would cover the drug when the patient tried and had an inadequate treatment response or intolerance to the required number of formulary alternatives, or the patient had a documented clinical reason such as expected adverse reaction or contraindication that prevented the patient from trying the formulary alternatives. The formulary alternatives were atorvastatin, ezetimibe-simvastatin (generic Vytorin), fluvastatin, lovastatin, pravastatin, Rosuvastatin (generic Crestor), simvastatin. 

The patient was prescribed Lipitor 80 mg. There is no documentation that the patient has tried and failed formulary alternatives to brand-name Lipitor. The patient does not have clinical atherosclerotic cardiovascular disease, but rather is being prescribed a statin for primary prevention purposes. Studies to date have not shown a difference between brand or generic atorvastatin. 

In addition, as per Up to Date, "In primary prevention, when the decision is made to treat, we suggest treatment with a moderate dose of a statin such as atorvastatin 20 mg or 5 to 10 mg of rosuvastatin, rather than starting at a higher dose." They also note that "In primary prevention patients who do not achieve a particular LDL-C level on statin therapy, we suggest not adding a non-statin lipid-lowering medication (Grade 2C). That is, the patient should be maintained on statin therapy as their only lipid-lowering medication. 

"There is no absolute recommendation that favors any one particular statin. Qian, et al. in a meta-analysis found no difference on coronary plaque regression between rosuvastatin vs atorvastatin. Therefore, there is no clinical justification for Formulary Exception. Lipitor is preferable over atorvastatin or other formulary alternatives. As previously stated the clinical notes do not indicate any side effects from the generic (formulary) medications nor do they mention their use. Therefore the requested formulary exception for use of brand-name Lipitor is not supported. 

The insurer's denial of Formulary Exception for brand name Lipitor (atorvastatin) is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems.
Treatment: Inpatient Hospital.
The insurer denied: an inpatient stay.
The denial is: Upheld in whole.

The patient is a female with a history of diabetes, hypertension, and coronary artery disease. She presented to the emergency department complaining of more than 12 hours of left chest, arm, and shoulder pain with radiation to the jaw. Her blood pressure was 112/69 millimeters of mercury (mmHg) with a heart rate of 75 beats/minute. Her cardiac exam was unremarkable. There was tenderness to touch in the left arm and moving the arm exacerbated the pain. Her serum troponin level was normal. Her electrocardiogram showed sinus rhythm without acute ischemic changes. Chest x-ray was unremarkable. She was admitted to the hospital to rule out acute coronary syndrome. A repeat troponin level was normal. Venous Duplex of the left arm showed no evidence of deep vein thrombosis. An echocardiogram showed normal left ventricular systolic function. There was mild mitral regurgitation and moderate tricuspid regurgitation. The patient was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

An inpatient stay was not medically necessary. This patient, with known coronary artery disease, presented with atypical symptoms that were thought possibly represent acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. On the other hand, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. Her HEART score was 3, representing a low risk for major adverse cardiac events. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive Neurologic Syndrome 
Treatment: Magnetic Resonance Imaging (MRI)
The insurer is denied coverage for Magnetic Resonance Imaging (MRI).
The denial is overturned.

This is a patient with a diagnosis of progressive neurologic syndrome characterized by autonomic dysfunction, poor balance, dysarthria, REM Behavioral Disorder and Parkinsonism. This clinical presentation was considered for possible multiple system atrophy (MSA). A standard part of the neurologic work-up for MSA (or any neurologic disease) is magnetic resonance imaging (MRI). In this case, the MRI was virtually diagnostic of MSA because it showed prominent putaminal iron deposition. The MRI was essential for correct diagnosis and treatment of this rare disorder.1 MRI is an essential part of the diagnostic workup for MSA. Thus, MRI was medically necessary for this patient.1-3

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

Based on the above, the medical necessity for the Magnetic Resonance Imaging (MRI)
[Procedure code 70551], performed is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite, Overjet, and Anterior Crowding 
Treatment: Comprehensive and Periodic Orthodontic Treatment 
The insurer denied the comprehensive and periodic orthodontic treatment.
 The denial was overturned. 

This is a patient who consulted an orthodontist for an evacuation for orthodontic care. Diagnostic testing was performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment plan from the orthodontist. The orthodontist identified overbite, overjet and anterior crowding and has recommended orthodontics. Dr. Gush has completed the Handicapping Labio-Lingual Deviation (HLD) index report attaining 26 total points. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify for orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 26 points on the HLD index (5 overjet, 8 overbite, 10 anterior crowding, 3 labiolingual spread) which is at the threshold of 26 points to support orthodontic care. Thus, comprehensive and periodic orthodontic treatment is considered medically necessary for this patient. 

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

The carrier's denial of coverage for comprehensive and periodic orthodontic treatment should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bariatric surgery.
Treatment: Psychological testing.
The insurer denied the psychological testing. 
The denial is upheld. 

No, the Psychological testing services provided not medically necessary.

This morbidly obese female underwent psychological testing in preparation for bariatric surgery. The patient weighs 335 pounds for a height of 5'5" tall. She is interested in gastric bypass surgery. The patient is employed as an attorney and presents no documented signs of psychosis, suicidality, substance abuse, cognitive difficulties, or any other mental health issue, which would contraindicate such surgery. 

The psychologist provided the DASS (depression, anxiety, and stress scale), the EAT-26 (eating attitudes test), an RQ, (risk questionnaire), the treatment outcomes package (TOP), and the Millon Behavioral Medicine Diagnostic Test (MBMD).

The rationale for the health plan's denial is, in summary, "Psychological testing is appropriate when there is a strong indication that significant, useful information would be generated from psychological testing that would impact the patient's care and treatment."  None of the tests administered provided information that was necessary or relevant to the proposed surgery that could not have been obtained through a clinical interview.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness 
Treatment: Acute rehabilitation admission
The insurer is denied coverage for the acute rehabilitation admission.
The denial is upheld.

This is a male patient with a history of coronary artery disease (status post angioplasty and stent placement), hypertension and spinal stenosis status post lumbar spine surgery. The patient presented to the hospital Emergency Department (ED) with left lower extremity pain, dizziness, and weakness after a fall. A series of x-rays were performed and were negative for acute pathology. The patient was admitted for clinical work-up which was negative for acute pathology. The patient was eventually transferred back to the sub acute rehabilitation.

The clinical records available for review do not support that the patient required the level of medical acuity or rehabilitation intensity that necessitated acute rehabilitation admission.

Based on the review of the medical record and literature, acute rehabilitation admission was not medically necessary for this patient. The patient was hemodynamically stable and required no acute level of care. The patient was admitted under custodial care because his care was not manageable at home. The patient's care could have been provided at a lower level of care, which was not considered. The patient's clinical presentation did not indicate a need for acute rehabilitation as there was no need for intensive medical and therapy interventions while in his rehabilitation setting. The patient's admission also did not meet the MCG Low Back Pain guideline and criteria for inpatient admission. The patient was medically stable and functionally fit for a lower level, such as sub acute rehabilitation at an SNF. Given the lack of clinical change, the patient could have been transferred to the SNF for sub acute rehabilitation. Thus, acute rehabilitation admission was not medically necessary.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient as the patient was admitted for custodial care and awaiting placement in sub acute rehab.

Based on the above, the medical necessity for the acute rehabilitation admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Infectious disease
Inpatient hospital

Diagnosis: Sore throat. Treatment: Inpatient hospital stay. The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male. He was admitted to the hospital. He has a past medical history of diabetes mellitus and hypertension.
He presented with a sore throat for one week. He started having difficulty swallowing due to severe pain. He was put on Azithromycin and Clindamycin as an outpatient. Vital signs showed a blood pressure of 160/78, pulse 101, respiratory rate 19 and temperature 98. Oxygen saturation was 100% on room air. Labs showed a white blood cell count of 12.3, hemoglobin 11.3, creatinine 0.8 and glucose 235. A facial computed tomography (CT) showed multiple pockets of fluid consistent with abscess formation in right submandibular space. He was started on intravenous antibiotics and admitted for further management.

The inpatient stay was not medically necessary.   
The patient presented with a sore throat for one week. He started having difficulty swallowing due to severe pain. He was afebrile and had leukocytosis. A CT showed multiple pockets of fluid consistent with abscess formation in the right submandibular space. He was started on intravenous antibiotics. He was seen by ENT (ear nose and throat) physician. Fine needle aspiration was done. No purulence was obtained and there was no concern for airway compromise. His symptoms improved and he was switched to oral antibiotic (Clindamycin). Blood and sputum cultures were negative. He was discharged after a brief hospitalization. This brief hospital stay was more appropriate at a lower level as there was no fever, hemodynamic instability, concern for airway compromise, need for prolonged intravenous antibiotics, positive blood cultures or uncontrolled pain.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe persistent asthma
Treatment: Yupelri 175MCG/3ML IN SOLN
The insurer denied the Yupelri 175MCG/3ML IN SOLN.
The denial is upheld.

The proposed treatment is not medically necessary.

This is a female patient with asthma who is prescribed Yupelri.

The use of Yupelri is not Food and Drug Administration (FDA) approved nor supported in an approved compendia. It does not meet the coverage criteria.  The safely and efficacy of this medication in asthma is not well known. The use of Yupelri for asthma is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic pain.
Treatment:  Kadian.
The insurer denied the Kadian.  The denial is overturned.

The proposed Kadian is medically necessary.

The patient is a female with chronic pain, who has been prescribed Kadian (brand name) 60 milligrams (mg), #62 per month.  This is a continuation of therapy; the patient has numerous allergies.

The patient is a female with chronic pain, and multiple co-morbidities including rheumatoid arthritis and fibromyalgia, who has been prescribed Kadian 60mg, #62 per month.  The patient is followed by a pain management physician.  The patient has been tapered down 50% to this dose to be in the recommended Centers for Disease Control (CDC) range of dosing.  The patient is monitored closely and has routine urine drug tests.  This is a continuation of therapy; the patient has been on this dose and this brand name formulation for many years.  The patient has multiple allergies, over 20, which are described as being related to dyes found in generic formulations of medications; this not unique to her morphine, but to all of her medications.  Given that she has documented allergies to multiple generic medications, and that this allergy is universal and related to a dye that is found in most generic formulations, and that this is continuation of therapy, the requested brand name Kadian 60mg #62 per month, is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Skin Disorder.
Inpatient Hospital.
Diagnosis: Hyperbilirubinemia.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is an infant who presented with hyperbilirubinemia.
Following her discharge from the hospital, she was breastfeeding at home but was having some difficulty with feeding. She was also getting Enfamil, between 30 and 35 mL every 3 hours. She had 4-6 wet diapers per day as well as 4-6 stools. Her stools had just started transitioning to yellow and seedy stools. She had no change in activity level, however, she appeared very jaundiced.

The inpatient stay was medically necessary for this patient. This is an infant who presented with significant hyperbilirubinemia. Her bilirubin level was 16.8 mg/dl at the time of presentation, with a rate of rise of 0.12 mg/dl per hour. That suggested that in less than 12 hours she would exceed the level for which phototherapy is recommended. Due to the concerning level and rate of rise, it was appropriate to admit her for triple phototherapy to prevent the serious consequences of hyperbilirubinemia in the central nervous system. Bilirubin-induced neurologic dysfunction is a serious disorder that leads to brain damage from free bilirubin crossing the blood-brain barrier. It is imperative to prevent this devastating outcome. Prompt initiation of phototherapy is a safe and effective intervention to reduce the bilirubin level and prevent morbidity. This infant was also having difficulty breast-feeding, and could potentially benefit from additional support.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Obstructing Ureteral Stone.
Treatment: Inpatient admission.
The insurer is denied coverage for  inpatient admission..
The denial is reversed. 

This is a female with a medical history of hypothyroidism, developmental delays (DD), and increase lipids, recurrent kidney stone and obstructive uropathy, and essentially solitary right kidney due to chemically obstructed left kidney by a ureteral stone. The patient presented to Emergency Department (ED) with complaints of right flank pain and sharp low back pain associated with nausea and vomiting. Her initial vital signs were: blood pressure 158/71, temperature 97.6F. Laboratory work up was performed that revealed white blood cell (WBC) count 10,200, BUN/Creatinine 34/1.5. A computed tomography (CT) scan was done that revealed right hydronephrosis due to an obstructing 4.5 mm calculus in the distal right ureter. The patient was treated with Intravenous (IV) fluids, IV morphine/Zofran. The patient was admitted to the hospital with a diagnosis of right obstructing ureteral stone in a functioning solitary kidney. The patient was taken to the operating room (OR) for cystoscopy, right stent placement under general anesthesia. Patient tolerated the procedure well without complications, her symptoms improved, and she was discharged home the following day. The insurer has denied coverage for the acute inpatient stay as not medically necessary.

The insurer noted lack of hemodynamic instability, acute renal failure, bilateral obstruction, urinary tract infection (UTI), etc. There was also a lack of infection surgical complications, renal function abnormalities, etc. The patient underwent a procedure typically performed on an ambulatory basis. The insurer stated a lack of medical necessity support for an acute inpatient admission.

The appeal on behalf of the medical center is noted and read in detail.

Per MCG Health 23rd Edition- Renal Colic and Kidney Stones; patient meets the following
guidelines for admission to inpatient care:

1) Obstruction with single functioning kidney

The patient's CT scan in ER showed severe chronic atrophy of left kidney - so the patient
essentially had a solitary, functioning right kidney which was obstructed by a ureteral stone.

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The acute inpatient hospital stay is considered medically necessary for this patient.

Based on the above, the medical necessity for the acute inpatient stay is substantiated. The insurer's denial is reversed.