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

Diagnosis: Transient ischemic attack (TIA)

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a female with a history of hypertension, hyperlipidemia, and diabetes. This patient presented to the Emergency Department with complaints of; slurred speech and the sensation of tongue tingling and swelling. The sign of slurred speech was noticeable by her colleagues. She went to urgent care and was referred to the emergency room (ER). She used to take an aspirin daily but misplaced the bottle and had not taken it for about a week prior to symptoms onset.  

Upon her presentation in the ER , her vital signs are: temperature 98.8 F., respiratory rate was 18 breaths per minute, heart rate was 86 beats per minute, blood pressure was 124/71, and pulse oximetry reading was 98% on room air. A computer tomography scan of the head revealed no evidence of acute intracranial hemorrhage or infarction. A chest x-ray revealed left lower lobe linear scarring or atelectasis. The patient was admitted in stable condition with a transient ischemic attack. The plan was to consult neurology for further management, continue home medications, obtain magnetic resonance angiography of the head and neck, check hemoglobin level, obtain a urinalysis, obtain finger sticks, and administer sliding scale insulin. Neurology consulted over the case for slurred speech. They recommended performing neurological checks per protocol, obtaining a fasting lipid profile, checking hemoglobin A1c, and deep vein thrombosis prophylaxis. Magnetic resonance angiography of the brain revealed a 1-2 millimeter aneurysm versus infundibulum involving the communicating segment of the right internal carotid artery. The care plan was implemented and the patient was discharged in stable condition.

The insurer has denied coverage for the inpatient admission as medically necessary.

This reviewer disagrees with the previous determination. This patient's symptoms were very worrisome for Transient Ischemic Attack (TIA). She had just discontinued aspirin and had an ABCD2 score of 4 or 5 (over age 60, speech disturbance, diabetes, symptom duration "about an hour") The ABCD2 score is a validated, seven-point, risk-stratification tool to identify patients at high risk of stroke following a TIA. 1  Patients with scores >=4 such as this patient are at considerably higher risk of stroke in the period following a TIA, and may potentially require urgent intervention as inpatients, making inpatient admission appropriate.2  

The health care plan did not act reasonably with sound medical judgment or in the patient's best interest in the denial of this admission.

The admission was medically necessary to evaluate this probable TIA and minimize her risk of subsequent stroke. 
Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Prostate Cancer
Pharmacy/Prescription Drugs

The patient is male with metastatic high grade prostate cancer, with BRCA 1 mutation. The patient refuses treatment with Lupron so Lynparza was discussed.
Per notes by provider, patient has been on Casodex, prednisone with Zytiga and Lupron since the time of diagnosis. However, at that time he stopped Lupron and Zytiga due to side effects. Positron emission tomography (PET)/computed tomography (CT) scan did show new bone lesions so the provider's plan was to do Lupron/Casodex again. However, patient wanted Casodex only. Per provider notes, they are trying to get compassionate use Lynparza.
Per the provider note, if compassionate use is not successful, then the plan would be Lupron, Xtandi; an addendum on note stated that eventually due to this medication not previously being approved, patient was open to starting every three month Lupron. However, was then found to have BRCA 1 mutation and so poly (ADP-ribose) polymerase (PARP) inhibitor was requested.
Due to BRCA 1 mutation, per the provider's note PARP inhibitors are approved for BRCA 1 mutation. Lynparza is the treatment in question to be used on this patient. Request is made for Lynparza for prostate cancer.

The health plan's determination is overturned.

It is medically appropriate for this treatment to be used. Phase 3 trial results were published, which show the superior efficacy of Lynparza over other treatments.
Based on the PROfound trial and in accordance with National Comprehensive Cancer Network (NCCN) NCCN guidelines, having BRCA 1 mutation in this patient can certainly change management for this patient by using PARP inhibitor. NCCN now states that genetic testing should be done on these patients and if BRCA mutations are present, PARP inhibitors can be considered.
Based on the phase 3 PROfound trial, Results showed a statistically significant and clinically meaningful improvement in the primary endpoint of radiographic progression-free survival (rPFS) with Lynparza vs. enzalutamide or abiraterone in men with mCRPC selected for BRCA1/2 or ATM gene mutations, a subpopulation of homologous recombination repair (HRR) gene mutations. This was an open label study to evaluate the efficacy and safety of olaparib/Lynparza.
Lynparza more than doubled the time without radiographic disease progression in patients with BRCA1/2- or ATM-mutated metastatic castration-resistant prostate cancer.
It is ultimately up to discretion of patient and his provider regarding the sequence of therapies that can be used; however, using PARP inhibitor is certainly medically appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient was having continued GERD symptoms in spite of high dose PPI Therapy Bravo pH testing revealed a high DeMeester Score. She has had continued symptoms even after changing to a different PPI. A LINX procedure was advised.
In March 2017, The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated safety and effectiveness Analysis of the LINX Reflux Management System. With regards to safety the conclusion was that long term follow-up supports the FDA conclusion that the device is safe. With regards to efficacy there were several conclusions. The LINX implant results in pH normalization improved quality of life, and cessation of regular PPI use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating GERD symptoms and dysphagia are similar following LINX. The long term follow-up data demonstrates that the LINX Reflux Management System is effective in the Management of GERD.

Gastrointestinal Endoscopy Volume 89 Number 1 2019 has an article titled Laparescopic magnetic sphincter augmentation versus double dose proton pump inhibitors for management of moderate to severe regurgitation in GERD: a randomized controlled trial." The conclusion was that patients with moderate to severe regurgitation should be considered for minimally invasive treatment with magnetic sphincter augmentation rather than increased PPI therapy.

Based on the recommendation of SAGES and the medical literature it has been shown that the LINX system improves health outcomes. LINX does have FDA approval. Since the patient has persistent reflux symptoms on PPI therapy, she is a good candidate for the procedure. There are several options for both surgical and endoscopic treatments, but LINX has been shown to be an effective treatment. A minimally invasive treatment such as LINX in appropriate for patients who have continued GERD symptoms on medical management and do not want to have more extensive surgery.

The requested service is likely to be more beneficial than any other standard treatment/ procedure.

The carrier's denial of surgical procedure, CPT 43284 (Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

This case involves a female who has a past medical history of gastroesophageal reflux disease, dyspepsia, pancreatitis and ulcerative proctosigmoiditis.  The letter of medical necessity notes that the patient has a long history of gastroesophageal reflux disease.  Patient continued to have symptoms despite medical therapy for treatment of reflux.  Esophagram showed normal motility of esophagus and a tiny axial hiatal hernia.  Endoscopy showed gastritis. The clinical note noted that the patient struggled with increasing symptoms of reflux despite high-dose proton pump inhibitor therapy, high-dose H2 blocker therapy and the addition of Carafate and as needed gasviscon.  pH study showed a DeMeester score of 23.3.  The treatment plan is for the patient to undergo the LINX procedure.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome to support this service as likely to be more beneficial than any other standard treatment.

In 2012, the US Food and Drug Administration (FDA) approved the LINX Reflux Management System as a treatment for GERD. The device works by augmenting the LES with a ring made up of a series of rare earth magnets. The magnets have sufficient attraction to increase the LES closure pressure but permit food passage with swallowing.

The patient a good candidate for the surgical procedure, CPT 43284 (Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed). Eligible patients should have typical GERD symptoms, abnormal pH study, partial response to daily PPI therapy, and an absence of a large hiatal hernia or severe esophagitis. 

The surgical procedure, CPT 43284 (Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed) is the best available treatment for this patient at this time.

Given the refractoriness of the patient's GERD symptoms, despite maximal pharmacologic treatment, a procedure that is non-surgical and proven to be safe is the next appropriate step. LINX procedure fits the criteria and therefore is an appropriate next step. The requested procedure is likely to be more beneficial than any other treatment/procedure.

The carrier's denial of surgical procedure, CPT 43284 (Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (ie, magnetic band), including cruroplasty when performed) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: TIA; stroke-like symptoms

Treatment: Inpatient hospital admission

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

This patient is a female with a past medical history of neck surgery for enlarged lymph nodes and hyperlipidemia was seen in the Emergency Department complaining of right-sided facial numbness since the morning.  Fingerstick glucose was 136.  The patient complained of numbness.  The patient had a blood pressure 147/95 with heart rate 104, respirations 18, temperature 98.2, and oxygen saturation 98%.  The patient was alert, awake and responded to voice and was oriented to time, place and person.  NIH stroke scale score was 0.  EKG revealed ST depressions.  The patient had a white blood cell count of 10.4, hemoglobin 14.9, hematocrit 45.2, platelets 395.  The patient had PT of 12.3, INR 1.09, PTT 31.2 seconds.  CT of the brain revealed no acute intracranial hemorrhage mass-effect or CT evidence of infarction.  The patient refused CT angiography due to allergy to contrast.  The patient was admitted for monitoring.  The patient underwent a stress test that was normal as well as an additional echocardiogram which was normal.  The patient was discharged.

The patient was admitted to the hospital with concern for stroke-like symptoms. However, there was no documentation of vessel imaging.  It is noted that the patient refused CT angiography due to a contrast dye allergy.  However, evaluation of the carotid arteries can also be completed with a carotid ultrasound.  If there is concern that a patient had transient ischemic attack (TIA) or stroke (as the presenting symptom was right facial numbness), then evaluation of the carotid arteries is typically recommended.  The patient inpatient hospitalization was not medically necessary.  TIA, or neurologic symptoms that come and go in less than 24 hours with no evidence of stroke on an MRI brain or CT scan, is generally cared for under observation status. The patient did not have any lasting neurologic deficit, abnormal imaging, or abnormal lab work that required inpatient admission.  The patient did not have complex nursing needs or complex rehabilitation needs.  As such, there were no factors that required acute inpatient hospitalization.  The patient had a low ABCD2 score, which is used to judge the risk of stroke in the near future.  Therefore, the inpatient hospital admission was not medically necessary.

The health plan acted reasonably with sound medical judgment 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: Upheld

Diagnosis: Asthma Exacerbation 

Treatment: Inpatient admission

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

This patient is a female who presented to the Emergency Department (ED) with complaints of shortness of breath (SOB) and cough.  The patient was seen in the clinic and referred to the ED.  The patient has past medical history of Asthma.
Vital signs at presentation were temperature (T) 98.7, heart rate (HR) 81, respiratory rate (RR) 23, blood pressure (BP) 153/109 mm Hg and oxygen (O2) saturations 99% on room air.  The patient was alert and oriented x3 (A X O X 3).  Lung exam revealed bilateral rhonchi.  Cardiovascular system (CVS) S1 S2 was normal.  Grossly non focal neuro exam.  The patient was treated with Decadron as she initially refused intravenous (IV).  In addition was given Bronchodilators via Nebs. White blood cell count was 9.9K, hemoglobin 12.7, and electrolytes were within normal limits.  Chest x-ray showed no acute Infiltrate.  EKG showed normal sinus rhythm.  There were no acute ST-T changes. The patient was subsequently admitted.  As per the history & physical the patient was awake and alert and in no acute distress.  The patient was ambulating in the Emergency Department (ED).  Lungs were clear. The patient was given IV Solu-Medrol 1 dose and continued on Bronchodilators and Magnesium.  The patient was started on inhaled corticosteroids.  On a specified date vital signs were: Temperature 98, Heart Rate 72, Respiratory Rate 16, Blood Pressure 130/68 and oxygen saturation 100% on room air.  The patient was in no acute distress.  Lungs were clear.  The patient had been seen by Pulmonary.  The plan was to switch to oral Prednisone with a fast taper.  The patient was to be discharged with follow-up in outpatient setting.

Based on this patient's presentation it appears that she did not need acute hospitalization.  She could have been placed in Observation setting and diagnostic testing and treatment initiated.  The patient remained stable after admission.  The patient was afebrile, hemodynamically stable, and not in any acute distress.  The patient was not hypoxic and did not have any evidence of pneumonia or other pulmonary pathology.  WBC was normal.  The patient could have been switched to oral Prednisone and bronchodilators and discharged home after a period in an Observation setting with close follow-up in an outpatient setting.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Bilateral claudication
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female. She was admitted electively for a scheduled peripheral angiogram for bilateral claudication that had been present for five years.

This was an electively scheduled, uncomplicated, balloon angioplasty on a chronic condition. The patient had claudication for five years that was slowly progressive. There was no evidence of acute ischemic changes. The balloon angioplasty was performed successfully, and the patient was observed overnight for potential complications. There were none. Her groin site remained stable. The patient was discharged on prescribed medications with plan for a staged angioplasty on the other leg. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. In this case, the patient's procedure went well and her recovery was uneventful. 

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only care provided was telemetry, CPAP, IVF and a dose of an anti-emetic, all of which are frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent therapy did not require an inpatient level of care. While the patient did have multiple co-morbidities, none complicated the hospital stay.

There was no "complex" care that required inpatient level of care in this patient's care post peripheral catheterization. Her respiratory status was not unstable. This patient had no evidence of active CAD (coronary artery disease).  While there was always a potential for an adverse event, one did not happen, and no actual treatment was added. CPAP was her outpatient treatment, and its use does not imply need for acute care. While she had a potential for increase bleed risk, none happened. 

All testing and therapy that were provided would have been appropriate, safe and guidelines-consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Syncope

Treatment:  Inpatient hospital admission

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

This patient is a female with a history of tobacco and marijuana use but no significant past medical history.  She presented to a physician's office with months-long history of intermittent syncope, with loss of consciousness for several minutes.  On a specified date she had two back to back episodes lasting 45 minutes with an occipitis scalp hematoma, followed by an urge to defecate.  The physician suggested she go the ED. Initial vital signs included blood pressure (BP) 146/86, heart rate 74, oxygen saturation on room air 98%, and temperature 97.3 F.  EKG revealed normal sinus rhythm and only a QS wave in V2, otherwise was normal.  Chest x-ray and CT scan of the brain were normal and ultrasound of the carotid arteries revealed a moderate (50-69%) left internal carotid artery stenosis.  Exercise nuclear stress test was also normal.  She was discharged to home on MiraLAX, for outpatient management.

There is no evidence that this patient required an acute inpatient level of care to evaluate her months-long history of intermittent syncope.  This could have been done in the ED or an observation unit, followed by outpatient care.  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 the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Large carious lesion encroaching on the pulp space -Tooth #4 

Treatment: D3320 - endodontic therapy, bicuspid tooth (excluding final restoration) for tooth #4

The insurer denied coverage for D3320 - endodontic therapy, bicuspid tooth (excluding final restoration) for tooth #4.  The denial was reversed.

This patient is a male who presented to the dentist for evaluation and comprehensive dental treatment.  Endodontic therapy was recommended on #4 due to large carious lesion encroaching on the pulp space.

The insurer has denied these services stating that the service is not medically necessary, as the patient is missing multiple teeth in the maxilla, and this tooth in question has a poor prognosis.

Upon review of radiographs, they support the recommended treatment. Tooth #4 has a large carious lesion involving the pulp chamber radiographically requiring endodontic therapy as identified by the dentist.  This tooth will have adequate residual coronal structure for support of crown and minimal periodontal alveolar bone loss.  The standard of care in general dental practice would be endodontic therapy for this tooth, which would have an excellent long term prognosis with the recommended treatment. 

Reverse denial and approve coverage for D3320 - endodontic therapy, bicuspid tooth (excluding final restoration) for tooth #4 as medically necessary, as the clinical and radiographic documentation support this service which would be a standard of care in general dental practice. 

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

Based on the above, the medical necessity for D3320-Endodontic therapy, bicuspid tooth (excluding final restoration) for tooth #4 is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis:  Injury
Primary Treatment:  Inpatient Hospital

The patient is a woman with a history of breast cancer, chemotherapy use, and neuropathy who was admitted to the hospital.  She was brought into the emergency department after she fell at home.  She fell down approximately 20 steps in the afternoon.  She stated that she had been unable to walk since that time due to lower extremity pain.  She also reported that she was on the floor for a significant amount of time but could not recall the exact duration.  She denied anticoagulation.  In addition, she reported lower abdominal pain, low back pain, and groin pain.  Review of systems was negative for fevers, chills, lightheadedness, chest pain, and shortness of breath.  Vital signs showed heart rate 77, blood pressure 147/88, and temperature 97.9 Fahrenheit.  On physical examination cranial nerves were intact; she had decreased range of motion due to pain in the knees and hips; there was knee swelling present; abdomen was soft; heart was regular, and breath sounds were normal.  Labs showed creatinine kinase 3500, glucose 78, creatinine 0.6, potassium 2.8, calcium 8.2, white blood cell (WBC) 8.2, hemoglobin 11.8, and platelets 222.  Computed tomography (CT) imaging of the chest and abdomen was negative for acute findings.  Head CT was negative.  The patient was admitted for rhabdomyolysis.  The plan of care included intravenous (IV) fluids, monitor creatinine kinase, physical therapy, pain management, and continue other home medications.  The creatinine kinase level declined with IV fluids and she was discharged in stable condition.  The inpatient stay is under review.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  The patient had mild rhabdomyolysis and no acute illnesses from her injury including compartment syndrome, acute kidney injury, or mental status changes from the injury.  She was not hemodynamically unstable or experiencing acute complications.  A lower level of care was appropriate.  The patient was hemodynamically stable, had no rhabdo-associated kidney injury, had no evidence of acute fracture, had no evidence of sepsis, and had no life-threatening bleeding or other significant complications.