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

Diagnosis: Brugada pattern or focal pericarditis

Treatment: Inpatient hospital admission

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

This patient is a male with past medical history significant for gastritis and chronic lower back pain who presented to the Emergency Department with complaints of fever, headaches, and muscle weakness.

Vitals on presentation included: Temperature max-102.8 F, Blood Pressure-125/73, Pulse-133, Respiratory Rate-20, Oxygen (O2) saturation-97% on Room Air.  Laboratory results included the following; White blood cell (WBC) count-19.03, hemoglobin (HGB)-16.5, hematocrit (HCT)-48, creatinine-1.49, glucose-134, and lactate-0.9.  EKG showed mild t wave inversion; Chest x-ray was negative.

The patient was admitted for evaluation of abnormal EKG.  He was treated with intravenous fluids, dexamethasone, and nonsteroidal antiinflammatory drugs (NSAIDS).  ECHO showed no wall motion abnormalities or pericardial effusion.  Cardiology consulted and their impression was possible Brugada pattern or focal pericarditis.  He was treated with colchicine.  The patient improved clinically, remained afebrile, and hemodynamically stable.  He was discharged to continue outpatient management. 

According to documentation, the patient presented with high fever (102.8 F), tachycardia (HR-133), and multiple laboratory abnormalities including leukocytosis (WBC-19), elevated creatinine (1.49), and EKG changes.  Based on the above findings in a high-risk patient with possible Brugada syndrome, hospital admission was medically necessary for further cardiac monitoring and diagnostic evaluation. 

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

The carrier's denial of coverage for the inpatient hospital admission at the acute inpatient level of care is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute vertigo 

Treatment: Inpatient admission

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

This patient is a female with a past medical history of hypertension, refractory vertigo, diabetes mellitus, hysterectomy, cholecystectomy, tonsillectomy and cataracts.  The patient was seen in the Emergency Department (ED) with complaints of dizziness.  The patient had been having intermittent vertigo for the past week prior to presentation that worsened two days prior to presentation.  The patient stated that the room was spinning and she was nauseous and vomiting.  The patient was taking steroids without relief.  The patient had a blood pressure of 196/105 with an oxygen saturation of 98%, a heart rate of 95 and respirations of 20.  The patient was given Norvasc and labetalol. A magnetic resonance imaging (MRI) of the brain was negative.  The chest x-ray was negative.  The patient had hemoglobin of 11.8, a hematocrit of 38.7, platelets 420, a white blood cell count of 13.08 and a red blood cell count of 4.71.  The patient was started on intravenous (IV) fluids, Zofran and meclizine. The patient was also started on oral steroids. The patient was then discharged.

The patient could have been evaluated in the Emergency Department, undergone an MRI of the brain, and could have been monitored on an observation basis with treatment with IV fluids, steroids and meclizine for symptomatic treatment of vertigo. The care provided did not warrant an inpatient admission and was suitable for treatment in the ED and on an observation basis.  The crucial aspect of this case revolves in excluding a stroke or mass lesion with an MRI of the brain.  Cases of transient ischemic attack (TIA) or cases of acute vertigo are typically treated in the ED with expeditious outpatient follow up.  Therefore, the requested inpatient admission was not medically necessary and the prior determination is upheld.

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

Diagnosis: Pneumothorax
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

Spontaneous pneumothorax occurs when air enters the pleural space without known cause (e.g., no trauma or procedure to explain presence of air). Management ranges from no intervention, to tube thoracostomy or surgical intervention with video-assisted thoracoscopic surgery (VATS). The purpose of surgery is to remove any lesion or bleb that could have been responsible. Mechanical pleurodesis may follow blebectomy. Without surgical intervention, a certain percentage of pneumothoraces may recur. However, in select patients, observation or pleural air drainage may be sufficient. 

In this patient's case, there was no suspected trauma or underlying pathology, thus defining primary spontaneous pneumothorax. It was small on both x-ray and CT. Thoracic Surgery determined that non-operative management was appropriate, so the patient was placed on 100% oxygen to promote absorption. He responded to the therapy, with smaller pneumothorax on follow-up x-ray. While it was reasonable and appropriate to monitor the patient in the hospital for response to non-operative management, he was overall hemodynamically stable with no respiratory distress or significant underlying trauma, and no history of predisposing chronic medical problems. He did not require acute inpatient admission, and he could have been safely and effectively managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

Asthma
Inpatient Hospital

The patient is a male child with medical history significant for prematurity born at 6-7 months' gestation, reactive airway disease, and seasonal allergies that had a several-day history of worsening cough, developing shortness of breath and wheezing while at school. Emergency Medical Services (EMS) were contacted and he was taken to the emergency department (ED) for evaluation. Vital signs included temperature 98.0, heart rate 127, respiratory rate 40, and 91% oxygen saturation in room air. Examination was significant for moderate distress with accessory muscle use, rhinorrhea, decreased breath sounds with expiratory rhonchi, strong pulses, and non-focal neurologic exam. He reportedly had one episode of vomiting while in the ED. Laboratory evaluation was significant for normal white blood cell (WBC) count and unremarkable metabolic panel. He was admitted to the hospital. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. This young male child with history of prematurity requiring intubation, reactive airway disease, and seasonal allergies presented to the ED with signs and symptoms consistent with an acute respiratory infection (cough, runny nose, low-grade temperature) complicated by wheezing and shortness of breath. He was treated aggressively in the ED with fluids, multiple DuoNeb (albuterol/Atrovent) nebs, enteral steroids, and parenteral magnesium, with improvements but continued evidence of bronchospasm. He was admitted for further management. While continued treatments in the hospital for an apparent first-time asthma exacerbation/status asthmaticus episode were reasonable, he had no signs/symptoms of impending respiratory failure, severe respiratory distress, dehydration, or sepsis. He did not require acute inpatient management and could have been safely and appropriately treated at a lower level of care. The acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis

Treatment: Acute inpatient hospital admission 

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

This patient is a male who was seen in the emergency department with a complaint of right lower quadrant pain associate with nausea and vomiting x7 hours.  The abdomen was soft with hypoactive bowel sounds and mild tenderness to the right lower quadrant.  The patient had a temperature 98.3 with a pulse of 101, respirations 19, oxygen saturation 98%.  Blood pressure was 142/86.  Pain was noted to be 9/10.  A CT of the abdomen and pelvis revealed uncomplicated acute appendicitis.  A surgical consultation was completed.  The patient underwent a laparoscopic appendectomy.  The patient tolerated the procedure well and was in stable condition following surgery.  The patient was then discharged.

The medical literature indicates that a laparoscopic appendectomy is considered an ambulatory procedure.  An extended stay may be indicated for patients of complicated appendicitis or complications following surgery such as wound infection, wound dehiscence, enterocutaneous fistula, continued ileus or postoperative bleeding.  The documentation indicated that the patient was seen in the emergency department.  A CT scan revealed uncomplicated acute appendicitis.  The patient underwent a laparoscopic appendectomy.  The patient was stable following surgery.  Inpatient criteria were not met. The patient's condition was appropriate for level of observational care rather than inpatient level care.  As such, the requested acute inpatient hospital admission is not medically necessary. 
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

 Substance Abuse addiction 
Substance Abuse Inpatient 

The patient presented for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, opioid (heroin), stimulants (crack cocaine), and cannabis (marijuana and K2) class substances of abuse. The patient has a longstanding history of substance use disorders beginning at age 9 years and prior substance use disorder treatments including detoxification and rehabilitation treatments with relapse. His substance-related problems had progressed with use of multiple substances of abuse. Overturn, in whole, the health plan's determination of medical necessity. Yes the requested health care service of the Inpatient substance abuse stay is medically necessary. The admission and the continued inpatient level stay through discharge could not have been safely or effectively provided with lower level services, especially in view of the clinical factors, treatment dimensions, and psychosocial aspects of this case. Thus, the stay is medically necessary in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of ASAM Criteria and application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.

The requested service of inpatient detoxification could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol on a daily continuous basis together with multiple other substances of abuse, including heroin, while participating in a methadone program that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring.
Appeal type: Medical necessity
Decision: Upheld

Back Pain 
Advanced Imaging Services MRI

The patient with a history of chronic low back pain requesting coverage for a magnetic resonance imaging (MRI). The patient  presented with back pain radiating down the right side with intermittent weakness. There were no additional details in the history of present illness. The physical examination was unremarkable. A referral to "spine" and an MRI of the lumbar spine was noted in the plan. The MRI had been completed the day before and revealed no evidence of severe radicular compromise or other worrisome abnormalities. The health plans determination of medical necessity is upheld in whole. The requested health service/treatment of Magnetic Resonance Imaging (MRI) was not medically necessary for this patient.
Based on a review of the information provided, the MRI the lumbar spine was not medically necessary. An MRI of the lumbar spine is indicated for the evaluation of back and/or radicular pain if the patient fails a 6-week program of provider directed home treatment program or physical therapy, if there is evidence of severe weakness, if there is evidence of a malignancy or infection, or evidence of the cauda equina syndrome. In this patient's case, there is no documentation supporting any of the above noted clinical indications.
The cited peer reviewed literature by Wheeler in Up to Date and Jarvik in Journal of the American Medical Association (JAMA) support that the MRI was not medically necessary. This is the standard of care regarding the indications for MRI imaging in the treatment and evaluation of low back pain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple sclerosis
Treatment: Increase in personal care services 

Summary:
The Increase in personal care services to 12 hours/day, 7 days week, for a total of 84 hours/week is deemed medically necessary. 

This is a female with a history of multiple sclerosis resulting in progressively worsening neurologic deficits. Due to the multiple, severe associated impairments related to this condition, she requires assistance with the majority of her activities of daily living (ADLs). Recent documentation from the patient's medical care team, including a letter from the attending physician indicates that the patient has been demonstrating consistent/progressive neurologic decline including inability to stand, rendering her chronically wheelchair bound and dependent on others for bed mobility and transfers. Furthermore, she is now experiencing progressively worsening left leg pain and myalgias involving her hands and legs. Lastly, she is experiencing recurrent UTIs (urinary tract infections), which result in further debility and dependence on others for her care. For these reasons, the currently approved plan of 7 hours/day, 7 days/week, for a total of 49 hours/week is insufficient to meet the patient's needs. Hence, the proposed treatment of an increase in personal care services to 12 hours/day, 7 days week, for a total of 84 hours/week is deemed medically necessary for increased assistance with completion of the patient's ADLs.
Appeal type: Medical necessity
Decision: Upheld

Other
Radiology Services

This is the case patient who was found with multiple pulmonary nodules on a computed tomography (CT) scan of the chest that was performed . The patient had a repeat CT scan of the chest that showed decrease in the size of all the nodules. There was one nodule that decreased in size from 1.2 centimeters (CM) down to 0.7 cm. There was another nodule that also decreased in size from 0.6 CM down to 0.4 CM.The health plans determination of medical necessity is upheld in whole. 
No, the requested health service/treatment of Computed tomography of chest with contrast is not medically necessary for this patient.
Based on Milliman care guidelines, repeat evaluation of specific area or structure of the lung with CT chest is indicated in presence of 1 or more of the following:
Change in clinical status (e.g., worsening symptoms or new associated symptoms)
Need for interval reassessment that may impact treatment plan
Need for re-imaging either prior to or after performance of invasive procedure
This patient was found with multiple pulmonary nodules on a CT scan of the chest . The patient had another CT scan of the chest 5 months later that showed significant improvement in most of the nodules and complete resolution of one of them. There is no evidence in the submitted documentation that the patient had change in the clinical list status with worsening in symptoms. the patient did not have new pulmonary symptoms. There is no evidence that the patient is in need for an invasive procedure on the lung to support medical necessity of a repeat CT scan of the chest. The patient is not on any therapy for the pulmonary nodules where a repeat CT scan of the chest is needed to guide therapy. Therefore, the requested CT scan of the chest is not medical necessity for this patient.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who underwent viral hepatitis testing. Testing for viral hepatitis was denied by the plan as no identifiable risk factors for viral hepatitis were provided in the medical record. The patient's provider wrote a letter on behalf of the patient stating that testing was required as the patient was at risk due to sexual transmission. The healthplan's determination is overturned. Testing for hepatitis B virus (HBV) is indicated for: Those with signs and symptoms of acute or chronic hepatitis; asymptomatic patients who are at high risk for having been exposed to hepatitis B virus (HBV) or are at risk for severe adverse outcomes from undiagnosed infection. The majority of patients diagnosed with hepatitis C virus (HCV) infection have some identifiable risk factor that increases the likelihood of exposure to the virus. In the 1998 to 2002 National Health and Nutrition Examination Survey any history of injection drug use, a history of blood transfusion before 1992, or the presence of an abnormal serum alanine aminotransferase (ALT) level identified 85 percent of hepatitis C virus (HCV) RNA positive participants aged 20 to 59 years. The Centers for Disease Control and Prevention (CDC) now recommends all adults be screened for Hepatitis C. Hepatitis C is rarely transmitted sexually, however, the men who have sex with men (MSM) subgroup (the patient apparently belongs to this group ) are at higher risk and should undergo routine testing. It is appropriate to perform viral screening for hepatitis B and C.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autoimmune hypothyroidism and short stature

Treatment: Nutropin AQ Nuspin injector

The insurer denied coverage for Nutropin AQ Nuspin injector. The denial was reversed.

This patient is a male with autoimmune hypothyroidism and short stature. The health plan did not act in the best interest of the patient as the requested growth hormone is medically necessary as described below.

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

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society,(1) the Lawson Wilkins Pediatric Endocrinology Society, (2,3) and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists. (4) The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on auxological, biochemical and sometimes radiological findings. The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 standard deviation (SD) below the mid-parental height; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 year of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 yr. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml.

This patient met biochemical criteria. GH stimulation testing peaked at less than 10ng/ml. The patient met auxological criterion 2 as his height is more than 1.5 SD below target height SD. The patient met both auxological and biochemical criteria for the diagnosis of GH deficiency. GH in the treatment of GH deficiency is medically necessary. 

Based on the above, the medical necessity for continuation of coverage for Nutropin AQ Nuspin injector is substantiated.  The insurer's denial is reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer # 3
This patient is a male diagnosed with anterior uveal melanoma of the left eye. He initially had brachytherapy to the left eye. He developed a lesion in the liver and he underwent radioembolization with Y-90. However, a follow-up MRI revealed the patient had new melanoma metastasis in the left lobe of his liver.  The oncologist recommended immunotherapy since there was now metastasis on both sides of his liver. The patient agreed to a course of Yervoy and Opdivo every three weeks, which began in early 2019. The doses were based on the patient's weight and the initial doses for the date of service were 89 mg of Yervoy and 266 mg of Opdivo administered intravenous (IV) infusion. The patient received additional infusions.
The Yervoy and Opdivo treatment that this patient received for his metastatic uveal melanoma is standard of care.  
There are several human clinical trials that show the efficacy of Yervoy and Opdivo.  Notably, results from phase 2 and 3 trials in patients with advanced melanoma have shown significant improvements in the proportion of patients achieving an objective response and prolonged progression-free survival with combination of nivolumab and ipilimumab.1 This patient with uveal melanoma clinically has advanced melanoma.  Nivolumab and ipilimumab have been studied in metastatic uveal melanoma.2
Yervoy and Opdivo are FDA approved drugs for the indication that was used in this patient, metastatic melanoma.
Yervoy and Opdivo are indicated as an appropriate next step at the time that they were administered to the patient, according to NCCN (National Comprehensive Care Network) guidelines for uveal melanoma Version 1.2019.  Immunotherapy including Yervoy and Opdivo are listed as a recommended regimen for systemic therapy for distant metastatic disease such as in the liver.
The requested treatment is likely to be more beneficial than any of the standard treatments/procedures for this patient. 
The carrier's denial of coverage for Yervoy (ipilimumab) 1 mg injection (code J9228) and Opdivo (nivolumab) 1 mg injection (code J9299) on the dates of service specified should be reversed.