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

Diagnosis: Kidney Injury

Treatment: Inpatient Admission

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

This is a young male patient who presented to the Emergency department (ED) with complaints of right rib pain and blood in his urine. It was reported that the patient sustained a hit in his right flank while playing football four days prior to presentation. A physical exam was performed that revealed right flank/right upper quadrant pain. The patient's urine tested positive for blood, protein and tetrahydrocannabinol (THC). Intravenous (IV) fluid bolus was administered. A computed tomography (CT) scan was performed that revealed acute grade I right renal injury, small right perinephric hematuria, small linear hypodense foci seen in the anterior and posterior aspect of right intrapolar region consistent with minor lacerations. Serial hemoglobin and hematocrit levels were monitored. The patient received Tylenol for pain management. The patient's symptoms improved and he was discharge home. 

As per the MCG Health (23rd Edition) Urologic Disease GRG, the patient's clinical presentation failed to meet the clinical indications for admission to inpatient care under subsection "gross hematuria requiring inpatient care."  The patient had a minor renal injury and was clinically stable throughout his hospital course.  The patient had no evidence of persistent bleeding, ileus, fever, and/or injury or concern for adjacent organs that warranted inpatient level of care. Thus, inpatient admission was not 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 the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Dupixent
The insurer denied Dupixent.
The denial was overturned.

The treatment with Dupixent is medically necessary.

The patient is a male child with medical history significant for severe persistent asthma, allergic rhinitis multiple environmental allergies, and anaphylactic reaction possibly to ibuprofen. He has been hospitalized multiple times in the PICU (pediatric intensive care unit) with status asthmaticus. He requires multiple controller medications (Dulera, Singulair, Spiriva, prednisolone every other day). In spite of this management, he experiences frequent exacerbations and has chronic daily wheezing. 

The patient trialed omalizumab (Nucala), an anti-IL-5 medication, and failed to show improvement. He has been prescribed dupilumab (Dupixent) as a medication with a different mechanism of action (anti-IL-4 and anti-IL-13) in the hopes of achieving better asthma control.

Per the health plan preferences, the following must be met in order to consider coverage for dupilumab (Dupixent): either consider using Nucala and Fasenra OR document a past trial with Nucala including trial dates and treatment outcomes. In this case, Nucala was prescribed for three months (four weeks each). Failure was defined by clinical report ("without improvement in asthma symptoms and exacerbations" and "no improvement in symptoms"). For this patient, treatment failure meant poor asthma control, frequent exacerbations and hospital admissions, and inability to exercise or participate in normal activities. Dupixent was prescribed, and clinical notes indicated that the patient was able to resume all activities including gym and swimming.  

Dupixent is a monoclonal antibody treatment initially approved for use with atopic dermatitis. It was approved for treatment of severe asthma in 2018. While it is similar to the existing monoclonal antibody treatments such as Nucala, Cinqair, and Fasenra, its targets differ. Dupixent targets IL-4 and IL-13 rather than IL-5. Studies have shown that is effects on symptom reduction are independent of eosinophil load and reduce exacerbations by almost 50% over placebo. An additional benefit is allowing patients that are glucocorticoid dependent to reduce steroid use in conjunction with decreased exacerbation. This lessens the morbidity associated with long-term steroid use. For patients that fail treatment with one modality (eg anti-IL-5 such as Nucala and Fasenra), a new approach (eg anti-IL-4 and anti-IL-13 such as Dupixent) is essential to gain asthma control.

For this particular patient, steroid-dependent and poorly controlled despite aggressive maximum medical therapy, failing treatment with Nucala, Dupixent is medically necessary and appropriate, essential for the management of his severe persistent asthma. Further, he has demonstrated improvement in symptoms with the use of Dupixent to date. Use of Dupixent is consistent with the medical literature, current standard of care, and clinical presentation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot pain; plantar fasciitis
Treatment: Custom Shoe Inserts
The custom orthotics are medically necessary.

The patient is a male. He has been doing exercises and stretching and suffers from plantar fasciitis. He tried off-the-shelf inserts for one year with no relief, for over one year prior. He also had intermittent sensations of numbness in the medial left arch. He had findings consistent with hyperpronation and plantar fasciitis on examination.

The patient has diagnosis of hyperpronation and plantar fasciitis and did try conservative care.  His visits are 11 months apart. In the first visit, he was prescribed NSAIDs (nonsteroidal anti-inflammatory drugs), shoe modifications, stretching, over-the-counter orthotics, and immobilization.  By his next visit 11 months later, he had not had any progression.  He has met all criteria for custom orthotics.  Therefore, it is medically necessary.

The patient has met all the criteria for Custom orthotics. Therefore, it is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sinus infection
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a male teen with history of recurrent headaches that presented to the emergency department (ED) with five-day history of sore throat, congestion, runny nose with dry cough, and two-day history of headache and right maxillary pain rated six out of ten (6/10). 

Vital signs included temperature 38.4, heart rate 86, respiratory rate 19, and blood pressure 103/70. Examination was significant for clear lungs, no acute distress, regular heart rate and rhythm, benign abdomen, and non-focal neurologic exam. Laboratory evaluation was significant for mild leukocytosis (white blood cell [WBC] count 10.5K) with left shift (85% neutrophils), elevated C-reactive protein (CRP) (17.2), and negative monospot. Non-contrast magnetic resonance image (MRI) was obtained, revealing no intracranial abnormalities, but prominent adenoids and diffuse mild mucosal thickening of the paranasal sinus and layering fluid or mucous in the right maxillary sinus suggesting chronic sinus disease, with an acute component not entirely excluded. 

The patient was treated with Toradol, Zofran, Benadryl, Ceftriaxone, and Clindamycin. He was subsequently admitted to the Pediatric floor for further management. Admission orders included continuation of Ceftriaxone and Clindamycin, Tylenol and Motrin as needed for fever or pain, and Neurology consultation for the headaches. Neurology recommended management for suspected migraine (sumatriptan, outpatient follow-up in two weeks). He did well overnight, with improved pain, tolerating a regular diet. The patient was discharged home to complete a course of Augmentin. 

This male teen with history of recurrent headaches presented to the ED for evaluation of headache with new onset sinus pain following upper respiratory infection (URI) symptoms. He was diagnosed with acute sinusitis and admitted for management. He also underwent evaluation for recurrent headache and was diagnosed with probable migraines. While it was appropriate to treat these medical conditions, he was overall hemodynamically stable, with no underlying chronic medical conditions, able to tolerate a regular diet, with no need for ongoing parenteral pain medication. He did not require acute inpatient admission and could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Abdominal pain
Inpatient hospital stay

This is a patient with a past medical history significant for chronic pancreatitis, producing periumbilical abdominal pain for several years, who presented to the emergency department with complaints of abdominal pain. The chronic underlying pain became worse a day before coming to the emergency department. There was no nausea or vomiting. The patient was passing flatus and had a bowel movement in the last 24 hours. On physical exam, the patient was described as being in no acute distress, resting in bed, with non-labored breathing. The abdomen is soft and nondistended, with tenderness to palpation in the left lower quadrant. The patient was admitted to the hospital the following day and was seen by general surgery for consultation for a possible small bowel obstruction. The surgery team evaluated the patient and noted that the patient has no prior abdominal surgery, no hernias, and normal bowel functions, which makes it unlikely to represent small bowel obstruction. They recommended a trial of oral fluid and food, and follow-up with a gastroenterologist. An ultrasound of the abdomen was also done, which shows no evidence of cholelithiasis or acute cholecystitis. The patient was monitored, and the diet was advanced. Pain control was provided with acetaminophen and Toradol. 

The HP determination is upheld in whole.

Small bowel obstruction was clinically ruled out by the surgery consultants on the day of admission. The patient was experiencing chronic pain, related to chronic pancreatitis. There were no severe electrolyte abnormalities, inability to tolerate fluids or food, there was no need for parenteral narcotic treatment, no indication for additional surgical, or endoscopic evaluations. During the entire stay, the patient remained hemodynamically stable. The patient does not have acute pancreatitis, which would indicate admission to inpatient care. Serum lipase is normal. Abdominal imaging with a CT scan and ultrasound failed to demonstrate acute pancreatic inflammation. The patient does not have an inability to maintain oral hydration, there are no fevers, there is no severe pain, or hemodynamic instability, there is no hypoxemia, acute renal failure or severe electrolyte abnormalities.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past history of rectal abscesses who presented to the emergency department  with complaints of rectal pain, bleeding, purulent drainage, fevers, and changes in bowel habits. Of note, she had previously undergone a computed tomography (CT) scan at an outside hospital during the prior year and was told she had a fistula and would need surgery. Her white blood cell count was elevated on admission at 13.9 and CT of the abdomen/pelvis showed retrorectal fluid collection. At issue is whether or not inpatient level of care was medically necessary .
The health plan's determination is upheld.
The patient was taken to the operating room for examination under anesthesia with incision and drainage of perirectal abscess. In the operating room there was purulent drainage coming from about 3 centimeters (cm) above the dentate and draining internally the rectum consistent with a supralevator abscess. The area of drainage was opened up and a mushroom catheter was placed into the cavity. The patient was felt to be stable for discharge to home on postoperative day number (#) 1 with outpatient follow-up with colorectal surgery.
This was a young patient, without comorbidities who underwent an anorectal procedure that is generally considered ambulatory. The care provided (e.g. intravenous antibiotics and diet advancement after surgery) could have been provided at lower level of care .
In addition, there were no complications experienced after surgery.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems - Other
Dental/Orthodontic Procedure

The patient is a female who presents to the office of her dental provider for evaluation and treatment of teeth #8 and 9. Included for review are previous letters of appeal and denial, a narrative from the patient, one page of American Dental Association (ADA) claim forms, full mouth x-rays (FMX). In question is the medical necessity of the treatment of (2750) porcelain fused to high noble metal crown for teeth #8 and 9.

The health plan's determination is upheld.

Previous denials have been on the basis that there was a lack of medical necessity for the treatment and that direct restorations could have been utilized in order to address teeth #8 and 9. From the radiographic documentation of #8 and 9 there was no evidence of fracture nor decay involving teeth #8 or 9. Further, there is no clinical documentation offered by the provider stating the condition of the teeth prior to preparation for crowns, documenting any loss of tooth structure, or any decay. The presence of craze lines within teeth are normal and are not indications for crowns. The presence of vertical fractures of teeth are indications for extractions as there is no therapy to treat these conditions. For this patient there are no diagnosis, no findings, no prognosis, and no evaluation of occlusion that was offered by the treating provider. Without findings or diagnosis offered by the doctor, no treatment is indicated. From the evidence provided, there was no treatment that was indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:
Treatment:

Summary:
The patient is a male. The patient has a history of various pains, including neck pain, shoulder pain, low back pain and bilateral knee pains.  He is reported to have post traumatic left knee arthritis.  MRI of the right knee showed grade 2 chondromalacia of the patella and medial compartment and a medial meniscus tear.  He underwent a series of three Euflexxa injections to the left knee, which had previously produced good results.  He was noted to have full passive range of motion and crepitus at that time.

There are reports that prior Euflexxa injections have been symptomatically helpful, but this contention is not corroborated by the available records.  There is a history of right knee pains, with imaging results indicating the presence of chondromalacia in the medial compartment, as well as the patella.  The patient did complete a series of right knee Euflexxa injections. However, he still had right knee pain, and it was greater than his left knee pain.  With respect to the left knee, he is reported to have a history of left knee post traumatic arthritis.  There are no radiographic results related to the left knee in the available records.  The records do not corroborate that prior Euflexxa injections have resulted in significant and sustained clinical improvements with respect to the left knee.

Even for radiologically or arthroscopically confirmed tibiofemoral osteoarthritis, recent reviews and clinical practice guidelines have indicated that intraarticular hyaluronan is largely a second line treatment consideration.  There are questions, notably, whether intra-articular hyaluronan viscosupplementation is clinically effective beyond placebo.  In 2015, for instance, Jevsevar D, et al., performed a systematic review of the published evidence and concluded that, "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of [hyaluronan] 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."  More recent high quality reviews incorporating at least these types of standards have not been published.

The records in this case, overall, do not corroborate that the requested service has been clinically effective for the patient's condition to date.  There are no indications that other conservative measures for his condition have been recently employed or ruled out.  The medical literature otherwise does not establish its clinical effectiveness for this condition on an empirical basis.  The service in question is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient in question is a male with a Class I occlusion and 100% overbite. The maxillary arch has mild spacing, and the mandibular arch has moderate crowding. He has treatment planned for orthodontics to correct his malocclusion. This is the subject of this review.

The health plan's determination is upheld. The insertion of Braces and Adjustment of braces is not medically necessary for this patient. 

There is no medical reason to correct his malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another. Furthermore, deep bites may be corrected in adulthood, so it is not as if he will lose the ability to correct his malocclusion should he choose to do so as an adult.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Prostate cancer
Treatment:  Oncotype DX Prostate
The Oncotype DX Prostate Cancer test performed was not medically necessary.

The patient is a male with prostate cancer.  He had the Oncotype DX Prostate Cancer Assay performed.  The biopsy specimen was positive and demonstrated a Gleason 6 adenocarcinoma in one of 14 cores.  The clinical stage was T1c. The PSA (prostate specific antigen) was 3.3.

Per AUA Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)"

The patient has a very low-risk prostate cancer.

Although results are promising, further validation is necessary to understand fully the potential clinical utility of this test.  The NCCN Guidelines note that "Their clinical utility awaits evaluation by prospective, randomized clinical trials, which are unlikely to be done."

The NCCN Guidelines state that "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclear. . .any of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."

Therefore, given the above, the Oncotype DX Prostate Cancer test performed was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Alcohol abuse
Inpatient hospital stay

This is the case of a patient with a past medical history of alcohol abuse, coronary artery disease (CAD), diabetes mellitus (DM), gastroesophageal reflux disease (GERD), and hyperlipidemia (HLP) who presented to the emergency department (ED) with nausea, vomiting, and abdominal pain. Patient denied chest pain, shortness of breath, bloody stools, or other complaints. Exam noted the patient to be alert and oriented with tremor. The patient was given intravenous fluids (IVF), thiamine, and Ativan in the ED with Clinical Institute Withdrawal Assessment (CIWA) subsequently noted to be 5 and the patient able to tolerate ice chips. Patient was subsequently brought into the hospital with concerns for ethanol (EtOH) withdrawal with hypomagnesemia and hypophosphatemia and plans for telemetry, CIWA, IVF, proton pump inhibitor (PPI), folate, and magnesium and phosphate repletion. The next day patient was noted to be less tremulous, alert and oriented, and without nausea or vomiting. Repeat complete blood count (CBC) and comprehensive metabolic panel (CMP) were unremarkable with magnesium and phosphorus also normalized. Plan was to continue tapering Librium and Ativan, continue IVF and PPI, and consult psychiatry. Psychiatry saw the patient with recommendation to continue with Librium and Ativan taper and for the patient to follow up with outpatient substance abuse treatment given he was declining acute rehab. The health plan's determination of medical necessity is upheld in whole. This is a patient with alcoholism and DM who presented with nausea, vomiting, and abdominal pain, noted to be alert and oriented in the ER and tremulous but with CIWA that improved to 5 and the patient able to tolerate ice chips. Patient had mild hypomagnesemia and hypophosphatemia in addition. Given  mild electrolyte abnormalities, nausea, vomiting, abdominal pain, and tremors, patient was appropriate to bring into the hospital for observation at a lower level of care, IVF, electrolyte repletion, and CIWA monitoring with benzodiazepines. It is noted, however, that the patient remained alert and oriented throughout the entire hospitalization, was not noted to have hemodynamic instability, did not have persistent nausea/vomiting, and did not have significant persistent electrolyte abnormalities. Patient furthermore was not noted to require significant IV benzos or escalating doses. In the absence of hemodynamic instability, persistent N/V, persistent electrolyte abnormalities, need for escalation of IV benzos, or other new issue requiring inpatient care, it is unclear why inpatient care was medically necessary. This patient could have been cared for at a lower level of care with subsequent discharge to an acute detox center or home.
Appeal type: Medical necessity
Decision: Overturned

Seizures
Inpatient Hospital

The patient is a female child with complex medical history significant for spina bifida status post surgical repair, hydrocephalus status post shunt placement at one week of life and revision at four months of age , and seizure disorder on Keppra (dosing increased the month prior). She was in her usual state of health until the date of admission when she was noted to be irritable, crying, and had a seizure lasting 40-50 seconds associated with cyanosis. The inpatient stay is under review.

The health plan's determination is overturned. The inpatient stay was medically necessary. This female infant with history of lumbar spina bifida status post repair, hydrocephalus status post shunt placement with revision, and failure to thrive, initially presented to the ED with what appeared to be seizure activity that resolved spontaneously, but had been associated with cyanosis. She had a second episode in the ED. She was admitted to the first hospital for monitoring and management of possible breakthrough seizures. She had a third apparent seizure following admission. Because of rapidly recurrent seizures, physical exam findings of irritability and bulging fontanelle, and known history of shunt issues, there was concern for shunt malfunction or other neurosurgical complication. The sum total of evaluations during this hospital stay revealed a number of conditions, each associated with potential for morbidity and even mortality. The full duration of this hospital stay was medically necessary and in fact life-saving for this complicated and fragile child.