Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/Gastrointestinal - Gastroesophageal Reflux Disease/GERD
Surgical Services

Report # 1
The patient is a male with longstanding gastroesophageal reflux disease (GERD) despite medication use. Upper gastrointestinal (UGI) revealed small hiatal hernia. Manometry showed reflux and weak lower esophageal sphincter (LES) pressure and some decreased peristalsis. A 24 hour pH study revealed an elevated DeMeester score consistent with GERD. Pathology on esophagogastroduodenoscopy (EGD) revealed normal esophagus without Barrett's esophagus. The subject under review is whether the proposed LINX reflux management system is likely to be more beneficial for this patient than any standard treatment.

The health plan's determination is overturned.

The proposed LINX treatment is likely to be more beneficial for this patient than any standard treatment.

This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and Food and Drug Administration (FDA) approved LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. The only current exclusion is adolescents and history of prior gastric/bariatric surgery which this patient has not had.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic idiopathic constipation
Treatment:  Linzess

The treatment with Linzess 145mcg OR caps is not medically necessary.

The patient is a female with chronic idiopathic constipation.  She has failed treatment with fiber, Senokot, MOM (milk of magnesia), magnesium citrate and Miralax.  Her MD is requesting treatment with Linzess.

The patient has chronic idiopathic constipation and has failed fiber and laxatives.  The plan preferred agent is Amitiza.  The patient has not tried and failed Amitiza. 
As the patient has not tried and failed the plan preferred Amitiza, and as there is no medical literature to support that Linzess is more effective than Amitiza for the treatment of chronic idiopathic constipation, the requested Linzess is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with past medical history (PMHx) of depression who presented to the emergency room (ER) with 3 day history of right sided abdominal pain with nausea. Present but more frequent over the past several months. In the ER vitals were stable, labs were normal. Computed tomography (CT) scan revealed a Morgagni diaphragmatic hernia with right colon and small bowel without evidence of obstruction or ischemia. The patient was managed with intravenous fluids (IVF) and intravenous (IV) pain medication, but it is unclear when she was transitioned to oral intake as there are no daily progress notes, but only a discharge summary provided. Thoracic surgery consult not available, however, per discharge summary decision for delayed elective repair was made and patient had improved pain and was discharged home.

The health plan's determination is upheld, in whole.

No, inpatient stay was not medically necessary. Based on the available clinical materials, it is unclear why the patient was not discharged home sooner or why inpatient admission was required for non-obstructing diaphragmatic hernia that remained unchanged during the admission with plan for delayed elective surgical intervention.  The patient had stable vital signs, normal labs and chronic diaphragmatic hernia with non-obstructive findings that was not determined to require urgent or emergent intervention. It is unclear what was required on hospital day (HD) 2, 3, and 4 that required ongoing stay, as there are no provided daily progress notes. Based on the clinical records an inpatient stay is not supported as medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Pregnancy
Inpatient hospital

The patient is a female at 33 6/7 weeks, singleton gestation. She presented with two days of vaginal spotting followed by frank dark vaginal bleeding.

The health plan's determination is overturned. The inpatient stay was medically necessary. Based on provided clinical information, the patient, at 33 + weeks gestation, with known low - lying placenta (which previously was marginal placenta previa) presented with progressively worsening episode of third trimester vaginal bleeding.
Even though the patient was hemodynamically stable, did not have evidence of preterm labor, PPROM, and did not have fetal heart rate tracing abnormalities, management at the acute inpatient level of care (Labor and delivery) with continuous electronic fetal monitoring is supported by literature, as the bleeding can incrementally worsen in a very short period of time, result in frank placenta abruption and serious maternal/fetal morbidity and, possibly, mortality.
This is supported by referenced literature and generally accepted standards of practice.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with gait dysfuncton secondary to Dyskinetic Cerebral Palsy, cerebellar dysmetria, cerebellar ataxia, impaired functional mobility, balance, and endurance, and nondisplaced fracture of second metatarsal bone, right foot which has caused weakness and incoordination of her bilateral lower extremities. At issue is the medical necessity of E2607 - Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth E2615 - Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware K0040 - Adjustable angle footplate, each K0108 - Wheelchair component or accessory, not otherwise specified.
The health plan's determination is upheld. Adjustable angle footplates K0040 in place of the standard footplates are not medically necessary. The wheelchair comes with footrests that are appropriate for the patient. The stated reason of accommodating for orthotics is not medically justified as standard footplates can also accommodate orthotics. Specialized seat cushions E2607 and E2615 are not medically necessary for this patient. There is no documentation of decubitus ulcers or other medical conditions which would warrant these specialized cushions. The standard cushions which come with the wheelchair are medically appropriate. Incontinence is identified as a reason for the specialized cushions, however, that is not medical justification for the cushions. The specialized Jay 3 Back cushion is requested and the reason identified is, "to help prevent scoliosis" however there is no medical evidence that this type of cushion prevents scoliosis. The item of K0108 is not medically necessary and no supporting documentation for this item is provided. Paratransit vehicles are equipped with wheelchair tie-down and occupant restraint systems Therefore, the transit option is not necessary as an additional feature.
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient with a history of anxiety and migraines who presented with four days of headache and vomiting associated with crooked mouth and hard time getting words out.  Headache was associated with rhinorrhea and lacrimation.  Vital signs included:  97.9  97  20  117/74  100%.  Exam was remarkable for left-sided temporal tenderness.  Electrocardiogram (EKG) showed normal sinus rhythm (NSR).  Head computed tomography (CT) showed no appreciable disease (NAD).  Chest x-ray showed NAD.  Labs revealed the following: white blood cell (WBC) 5.5, hemoglobin/hematocrit (H/H) 10.7/32, and platelets (PLT) 203.  Basic metabolic panel (BMP) was within normal limits (WNL).  

The patient was admitted.  Plan of care included magnetic resonance image (MRI), electroencephalography (EEG) and erythrocyte sedimentation rate (ESR).  Intravenous (IV) Toradol was given for pain control; high dose steroids for possible giant cell arteritis.  The next day, vital signs were stable (VSS).  ESR was normal.  Steroids were discontinued.  The patient was awaiting MRI.  Tegretol was started for possible trigeminal neuralgia.  Psychiatry diagnosed with adjustment disorder and recommended amitriptyline.  On the following day, VSS.  MRI was negative.  The patient was cleared for discharge with EEG as outpatient.   

This patient was admitted with headache.  The patient was hemodynamically stable and afebrile.  She had normal oxygenation.  She did not have neurologic symptoms on exam.  Labs and imaging studies were unremarkable.  The patient did not have systemic symptoms.  She did not have severe vomiting or uncontrolled pain.  The patient was clinically stable.  Her hospital course was remarkable for additional lab testing, imaging and empiric medications that did not require an inpatient level of care.  The working diagnoses of temporal arthritis and trigeminal neuralgia are medical conditions that can be diagnosed and treated at an outpatient level of care.  

Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner and the least intensive and/or most appropriate alternatives among diagnostic and treatment options

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this patient's presentation.  The patient did not have findings or receive intervention that required an inpatient level of care.  The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

This is a patient who underwent a right shoulder arthroscopy and rotator cuff repair, extensive debridement glenohumeral (GH) joint and subacromial decompression (SAD) with acromioplasty. The patient received 24 physical therapy visits for post-surgical shoulder related problems. Therapy requested 36 therapy visits. This was denied during previous review stating that the patient can manage her shoulder problem with a home exercise program and that the request did not meet criteria for medical necessity. The health plan's determination is overturned in part.
Additional physical therapy is medically necessary in part. The patient required physical therapy following rotator cuff repair. She developed right shoulder adhesive capsulitis. Standard of care for adhesive capsulitis is aggressive physical therapy. However, physical therapy 3x/week for 8 weeks (total of 24 visits) is medically necessary;  36 additional physical therapy visits without re-evaluation is excessive.
This is based on the patient's most recently follow-up with . While a physical exam did support that the patient's rotator cuff repair had healed with 5/5 strength of supraspinatus, infraspinatus and subscapularis she continued to have severe active and passive range of motion deficits with the diagnosis of right shoulder adhesive capsulitis. Active right forward flexion was 140 degrees (left 180), abduction 150 (left 180), external rotation 30 (left 80), internal rotation T12 (left L5). The need for physical therapy is also supported by the fact that despite the patient completing a home exercise program her active range of motion in her right shoulder had actually worsened.  Additionally manipulation under anesthesia was explained as an option but that "she would still require PT after that." Standard of care for shoulder adhesive capsulitis is continued aggressive physical therapy with or without manipulation under anesthesia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-displaced longitudinal left patella fracture

Treatment: Physical therapy services under CPT code 97140 for manual therapy

The insurer denied coverage for physical therapy services under CPT code 97140 for manual therapy. The denial upheld.

This patient is a male who sustained a left knee injury after a fall in late-2018. He sustained a non-displaced longitudinal left patella fracture.  Treatment was non-surgical and included a knee brace, crutches and physical therapy (PT).  Currently under review is the medical necessity of PT services under CPT code 97140 for manual therapy. The initial physical therapy note indicated left knee active ROM measured 5-110 degrees.   CPT code 97140 is specifically described in an early-2019 physical therapy note (visit 17) as left knee passive range of motion (ROM).  However subsequent knee range of motion measurements were submitted.  In addition, after more than 2 months of physical therapy treatment the patient's left knee range of motion should have been well within functional limits.  The physical therapy treatment notes do not support the medical necessity for physical therapy services under CPT code 97140 (manual therapy), rendered. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. Based on the above, the medical necessity for the physical therapy services under CPT code 97140 for manual therapy, which was rendered, is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems - Arrhythmia/Irregular Heart Rhythm
Inpatient Hospital

The patient is a male who presented to the hospital for elective catheter ablation of persistent atrial fibrillation that had recurred despite prior ablation in 2018. The repeat ablation procedure was successful and uncomplicated. Post-procedure, the patient was admitted to the hospital. During the night he had some self-terminating episodes of atrial tachycardia. He was discharged on oral metoprolol.

No, an inpatient level of care was not medically necessary. This patient underwent a transcatheter ablation procedure for persistent atrial fibrillation. Given the complexity of the procedure, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate with this procedure is higher than that of catheter ablation for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge after atrial fibrillation ablation, most electrophysiologists admit patients for overnight monitoring post-procedure. However, this patient's procedure was uncomplicated, and he was hemodynamically stable. He had some self-terminating episodes of atrial tachycardia post-procedure, but the records do not indicate that he was unstable with these episodes. Accordingly, while overnight monitoring was reasonable and prudent, the records provided do not indicate that an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

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

This patient is a male who presented to the Emergency Department (ED) with complaints of chest pain, shortness of breath and headache. He stated that for the past 4-5 days prior to presentation, he had been having a cough with greenish sputum. He did not know if he had any temperature elevation and did complain of chest congestion and pressure in his head. He stated his daughter was recently sick and he thinks that he caught this infection from her. The family was overseas and returned after a month. He stated that he came to the hospital today because he started to experience substernal, non-radiating heaviness in the chest that started after he was involved in an argument. He stated that after having this argument, he started to get heaviness in his chest and it had been coming on and off since. He denied chills, abdominal pain, nausea and vomiting in the ED.  He was about to be discharged home, but then started getting a more severe headache and dizziness and was admitted to telemetry for further medical management. The patient did not appear to be in distress, but appeared to be depressed and crying because of the argument. He had a past medical history of an appendectomy over a decade ago. His review of systems was negative, except for what has been mentioned above.

A 2010 study showed that almost all (98.9%) patients with an indication for arrhythmia monitoring were being monitored. However, 84.9% of patients without an indication for arrhythmia monitoring were also being monitored. Of the patients with an indication for ischemia monitoring, 34.5% were being continuously monitored for ST-segment changes; but 26.3% of patients without an indication for ischemia monitoring were also being monitored for ST-segment changes. Only 21.4% of the patients with an indication for monitoring for QT prolongation had a QTc value documented by nurses in the previous 24 hours. However, 18.1% of patients with no indication for QT monitoring also had a QTc value documented. The observation is that there over monitoring for arrhythmias could be related to leaving patients on the monitor longer than necessary.

The patient was placed in a telemetry unit at the time of his admission which was not medically necessary. The literature also recognizes the use of an observation unit for this type of patient. However, a monitored level of care or telemetry unit is not the same thing, and the literature cited shows that a monitored level of care for this patient was neither necessary nor appropriate. The insurer acted reasonably, and with sound medical judgment, and in the patient's best interest. There was no medical necessity for any inpatient admission. The patient could have been treated in an observation unit. Therefore, the denial of coverage for the inpatient admission should be upheld. 

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

Prostate Cancer
Radiology Services (including Ultrasound)

The patient is a male with intermediate risk prostate cancer. Medical necessity for HIFU (High Intensity Focused Ultrasound) for treatment of his localized prostate cancer is under review.

The health plan's determination is upheld. The High Intensity Focused Ultrasound (HIFU) is not medically necessary for this patient.
HIFU consists of focused ultrasound waves, emitted from a transducer, that cause tissue damage by mechanical and thermal effects as well as by cavitation. The goal of HIFU is to heat malignant tissues above 65C so that they are destroyed by coagulative necrosis.
HIFU has been increasingly been used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies from Europe showing short to intermediate term outcomes for localized prostate cancer. No controlled trials are available for analysis, and no long-term survival data are available. There are no validated biochemical and surrogate end-point for cure.
The National comprehensive Cancer Network Guideline on Prostate Cancer, 2017 states the following about focal therapy and HIFU, "Other emerging local therapies, such as high intensity focused ultrasound (HIFU) and vascular-targeted photodynamic (VTP) also warrant further study."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mid and lower back pain -L4 and L5 region

Treatment: Chiropractic services.

The insurer denied coverage for chiropractic services. The denial upheld.

This patient is a female that sought treatment for ongoing mid and lower back pain.  According to the UR report, this patient had been treated by the provider 60 times for musculoskeletal complaints related to the neck, upper back and lower back. She returned for updated complaints and diagnoses of pain in the thoracic spine. The provider treated her mid to lower back pain during this time and the patient was also advised to apply moist heat and follow through on a home exercise plan (HEP), at home.

The insurer denied coverage for the above DOS by determining that the services were not medically necessary. The records indicated that the patient returned to the office for updated diagnoses of M54.6 (Pain in thoracic spine), M99.02 (Segmental and somatic dysfunction of thoracic region) and S23.3XXA (Sprain of ligaments of thoracic spine, initial encounter). These were the consistent diagnoses in the claims data from the DOS in question. A review of the records submitted indicated that the office note for a date of service specified finds the patient had complaints related to the mid back, with a reported pain level of 9 on a scale of 10 (10 being the worst).

By DOS specified the complaint was reported to be at a pain level of 5-6 on a scale of 10. The records for a subsequent indicated the patient had presenting complaints of mid and low back pain after "sleeping wrong on a different bed." The given pain levels on this DOS were 7-8 and 8-10 on a scale of 10 for the mid back and low back respectively and by another DOS specified these reported pain levels had reduced to 5 and 3 on a scale of 10 for the mid back and low back respectively.

The Council on Chiropractic Guidelines & Practice Parameters (CCGPP) guidelines indicate, "When the patient's condition reaches a plateau, or no longer shows ongoing improvement from the therapy, a decision must be made on whether the patient will need to continue treatment." The records submitted for review, reflecting the E/M service performed (99212-25) in question, did not support additional meaningful improvement in the patient's clinical condition to rationalize the need for ongoing chiropractic care.  It appears that the patient had achieved a plateau in treatment and continuation of treatment would suggest physician dependency.  Denial of the DOS in question appears to be appropriate. 

According to the documentation presented for review, the health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.  The chiropractic services were not considered medically necessary for this patient.

The carrier's denial of coverage for the chiropractic services is upheld.  The medical necessity is not substantiated.