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

Reviewer #1:

Diagnosis: Chronic bilateral low pelvic/groin pain

Treatment: dorsal root ganglion spinal stimulator 

The insurer denied coverage for a dorsal root ganglion spinal stimulator for the treatment of chronic bilateral low pelvic/groin pain.

The denial is upheld.

This patient is a male with a past medical history of asthma, anxiety, bilateral groin and scrotal pain, umbilical hernia repair without mesh, and orchiopexy. The patient had complaints of chronic bilateral low pelvic and groin pain detailed as deep pressure and aching which started at the mid groin and extended to the scrotal area. It was stated that the pain was prompted by bowel movements, bearing down, and intercourse. Prior relevant treatment included NSAIDs, ice, rest, and gabapentin. The patient had undergone inguinal nerve blocks in the past which provided 60% relief for approximately 3 weeks at a time. Per the progress note the treating physician indicated that a DRG stimulator was discussed for pain management. A psychological evaluation was performed and reported that there was evidence of underlying mood presentations with depression and anxiety which did not appear to be managed. The patient was recommended to undergo mental health counseling to address mood prior to being a candidate for spinal cord stimulator trial. It was stated that the patient had been cleared by a psychologist the treating provider was asking for an overturn of the denial. 

For a specific diagnosis of complex regional pain syndrome and causalgia, a randomized controlled trial comparing dorsal root ganglion (DRG) stimulation to spinal cord stimulation, showed that DRG stimulation is a safe and effective therapy in individuals with lower extremity chronic pain due to complex regional pain syndrome (CRPS) type I or II.

FDA approval for DRG stimulation is limited to the treatment of chronic nerve pain associated with complex regional pain syndrome (CRPS) and/or peripheral causalgia in the groin and lower limb.

A psychology evaluation stated "I am recommending the initiation of mental health counseling to address mood prior to trial candidacy." Mental health counseling as recommended would be most appropriate at this time.

Given that additional treatment, specifically mental health counseling has been recommended and not completed per submitted documentation, it is unclear whether the requested service would likely be more beneficial than mental health counseling.

The carrier's denial of a dorsal root ganglion spinal stimulator for the treatment of chronic bilateral low pelvic/groin pain should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied the inpatient stay. 
The denial is overturned in whole.

The patient is a male who was brought to the emergency department (ED) by ambulance with a presenting complaint of difficulty breathing. Symptoms began the night of presentation, with multiple overnight awakenings due to cough. Early morning, he was noted to have worsening "croupy" cough and stridor. There is no history of prior hospitalization or significant past medical history.
ED vitals were temperature (T) 99.5 Fahrenheit (F), heart rate (HR) 145, respiratory rate (RR) 26, oxygen (O2) saturation 98% on room air. Respirations were noted to be labored with both stridor at rest and substernal retractions. The patient was given oral Decadron and racemic epi treatments x 5 with continued stridor, so was started on 6 liters (L) Heliox via nasal canula. Flu and respiratory syncytial virus (RSV) testing was negative. Chest x-ray showed hyperinflation but otherwise unremarkable. Given the severity of symptoms and treatment support necessary, he was admitted to the pediatric intensive care unit (PICU) for further management. The subject under review is the medical necessity for the inpatient stay. 

The requested inpatient hospitalization was considered medically necessary for this patient. This is a patient with croup; although this viral illness is common in children of this age, this patient had a severe presentation requiring multiple nebulizers of racemic epinephrine in addition to Heliox. He did not respond to typical treatment given in the ED setting and required escalation of care which could only be provided at the inpatient level of care. The severity of symptoms and concern for impending respiratory failure warranted inpatient admission for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Early Delivery/Labor (preterm labor)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female presenting with uterine spotting and contractions at 30 3/7 weeks of gestation. She was afebrile and all of her other vital signs were stable, she also had a non-focal or normal exam. She was not in labor and did not have any changes in her cervix. The fetal tracing was appropriate, and labs were normal. She was admitted for intravenous (IV) hydration and monitoring.

No, the proposed inpatient admission was not medically necessary. 

The admission was not medically necessary since the patient had stable vital signs, she was afebrile, with a non-focal exam, normal labs, normal fetal tracing and was not in labor, and since her contractions did not result in changes in cervical dilation. This admission was not medically necessary since it is not standard of care, it is not supported by peer reviewed literature and it is not supported by professional organizations, given that the patient did not have any acute conditions necessitating inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dyspnea; Pulmonary Embolism.
Treatment:  Inpatient admission.

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

The patient is a male, who presented to the emergency room (ER) for further evaluation/management of worsening dyspnea and pleuritic chest pain.  Intake vitals were afebrile, hemodynamically stable, but patient was notably dyspneic and requiring supplemental oxygen via non-rebreather mask to maintain adequate oxygen saturation.  Examination was non-focal with no significant abnormalities noted, including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen.  Chest computed tomography (CT) was positive for pulmonary emboli. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where he received treatment including therapeutic anticoagulation, supportive care with intravenous (IV) fluids and continued cardiac monitoring.  He responded well to the prescribed therapies and was subsequently discharged in stable condition. 

No, the proposed treatment inpatient admission is not deemed medically necessary. 

This is a male who presented to the ER for further evaluation/management of worsening dyspnea and pleuritic chest pain.  Intake vitals were afebrile, hemodynamically stable with no evidence of profound hypotension or tachycardia.  Although patient was notably dyspneic and requiring supplemental oxygen via non-rebreather mask, he was otherwise able to maintain adequate oxygen saturation.  The use of a non-rebreather does not require inpatient level of care.  Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen.  Electrocardiogram (EKG) and laboratory testing was negative for end organ damage. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where he received treatment including therapeutic anticoagulation, supportive care with intravenous (IV) fluids and continued cardiac monitoring.  He responded well to the prescribed therapies and was subsequently discharged in stable condition.  There is no evidence of intensification of services throughout the course of this patient's hospital stay.  Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.  For these reasons, the proposed treatment inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with right hip pain who had an inpatient admission from. The patient had pain for two days prior to the admission, where the pain radiated down her leg with associated electrical shock sensation and progressive weakness, making ambulation difficult. She has a history of recurrent deep vein thrombosis (DVT) in the past. 

No, the proposed inpatient admission was not medically necessary.

This is a female with who was admitted through the ER for severe hip pain, starting two days prior to the admission. She had pain radiating down her leg with associated electrical shock sensation and progressive weakness, making ambulation difficult. She has a history of recurrent DVT in the past and recurrent DVT was initially suspected.  Doppler was negative. Computed tomography (CT) was negative. Neurosurgery (NSG) consult was placed.  There was no emergent NSG consultation, no emergent magnetic resonance image (MRI) as there was low suspicion for cauda equina syndrome, or any emergent neurosurgical intervention.  Diagnosis was thought to be neuropathic in nature.  The patient was treated with Toradol, gabapentin by mouth (PO) and physical therapy (PT).  A transthoracic echocardiogram (TTE) was also ordered, but this does not require inpatient admission.  Given the above, the requested admission was not medically necessary. 

The patient's treatment could have managed without inpatient admission.  Had there been any real suspicion of myelopathy, an MRI would be ordered stat.  There was no evidence of caudal equine, acute herniated nucleus pulposus (HNP), and no need for immediate surgical intervention. DVT was ruled out in the ED.  The patient did not require intravenous (IV) opiate pain medications.  She was treated with PT, oral medications, and was significantly improved in the first 24 hours. Considering the above, the requested inpatient admission was not medically necessary
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: bilateral quad tendon ruptures 
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned in part. An 11-day stay was medically necessary. 

This patient is a man who, one day prior to admission, fell down a flight of stairs. He presented to an outside hospital and then was transferred to the treating facility for bilateral quadriceps tendon ruptures. The patient underwent primary open repair of bilateral quadriceps tendon ruptures; surgery was without complication, and the patient was placed in bilateral cylinder casts postoperatively.

The acute inpatient admission was medically necessary for 11 days. This is a morbidly obese patient (350+ lbs., body mass index (BMI)>40) with bilateral lower extremity injuries that prohibit safe ambulation. Rupture of BILATERAL quadriceps tendons in a medically complex patient is a very different clinical situation than a single tendon. It is a very rare injury, and with minimal trauma (falling downstairs,) the most common patient would be one with multiple medical comorbidities, such as this patient with morbid obesity, obstructive sleep apnea, hypertension, asthma, and stage 3 chronic kidney disease. Preoperative steroid use, which this patient had, according to the medical record, is also a risk factor for this rare injury. Postoperatively, it is not surprising that a 350+ lb patient wearing bilateral cylinder casts would have difficulty with safe, independent ambulation and activities of self-care and daily living.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque psoriasis

Treatment: Skyrizi

The insurer is denied coverage for the medication Skyrizi

The denial is upheld. 

The patient has a diagnosis of psoraisis/sebopsoraisis of the scalp and ears. She has tried and failed ixekizumab, Guselkumab, Adalimumab, Otezla, Certolizumab, and Brodalumab. She has reported to have worsening gastrointestinal (GI) symptoms from IL-17 inhibitors. A clinic note dated 060/3/2020 notes the psoriasis is possibly TNF induced, that the patient was started on Otezla and boradlumab. In addition she was also started on clobetasol solution and ketoconazole shampoo on her last office last visit. However this worsened the patient's irritable bowel syndrome (IBS). The exam is consistent with psoriasis and psoraitic arthritis. The treating provider is requesting plan approval for Skyrizi.

The patient has tried multiple biologics in different classes including IL-17 inhibitors, TNF alpha inhibitors, IL-23 inhibitors, and PDE4 inhibitors, but she has not attempted therapy with an IL-12/23 inhibitor. Stelara has a unique mechanism of action blocking both cytokines. Stelara has the same frequency of injection as Skyrizi as mentioned previously. There is no contraindication to the use of Stelara. There is no justification why Skyrizi, an IL-23 inhibitor, would be effective when Guselkumab, another il-23 inhibitor was not effective. Multiple reports have also shown that Stelara is effective in the treatment of scalp psoriasis as well as TNF induced paradoxical psoriasis. In addition, Stelara is FDA approved for psoriatic arthritis. 

While the patient has tried and failed numerous therapies for biologic medications, the treating provider's justification for using Skyrizi over a plan alternative is the frequency of injection. Skyrizi is given as injections during Week 0, Week 4, and every 12 weeks.  However the preferred plan drug Stelara is given as the same dosing, week 0, week 4 then every 12 weeks. 

Per Nair PA & Badri T. (2020), "Systemic drugs are used in extensive cases, the involvement of nails and psoriatic arthritis. Methotrexate, retinoids, cyclosporine, and fumarates are possible options. Routine blood, liver functions, and renal functions should be monitored in patients on systemic therapy."

Additionally, the FDA approved label for Skyrizi states, "SKYRIZI is indicated for the treatment of moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy."
 
Finally, The FDA approved label for Stelara states, "STELARA is indicated for the treatment of adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy."

The health plan acted reasonably with sound medical judgment in the best interest of the patient.
     
Based on the above, the medical necessity for Skyrizi for plaque psoriasis is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Prolia. The denial is overturned in whole.

The patient is a female with history of osteoporosis. The coverage request is for Prolia. The medication was previously denied due to lack of medical necessity as determined by the plan.
Per clinical notes, the patient has dual-energy x-ray absorptiometry (DXA) T score of -2.4 at left femoral neck (9.9% decrease in bone density from previous), with FRAX score of 9.9 for major osteoporotic fractures, and 1.9% for hip fractures. In 2018 T score was -2.5 at right femoral neck. The subject under review is the medical necessity for Prolia.

Prolia is medically necessary. Based on the last DXA the patient had T score of -2.4 in the left hip without meeting FRAX cut off. However, in the DXA - she did meet standard osteoporosis criteria because she had a T score of -2.5 in the RIGHT femoral neck (which was not measured on the 2020 DXA for unclear reasons). Additionally, the 9.9% bone mineral density (BMD) decline in the left hip that was measured in 2020 showed accelerated rate of bone loss over what is expected as normal (1-2% per year postmenopausally).
Quality head to head trials between anabolic agents, denosumab (Prolia) and bisphosphonates are lacking, however a recent meta-analysis by Barrionuevo et al. 2019 (and as discussed in the 2019 Endocrine Society osteoporosis guidelines) suggest several agents including denosumab (Prolia), that have the highest efficacy in reducing fracture risk reduction, whereas ibandronate and selective estrogen receptor modulators had among the lowest efficacy rates. Prolia is recommended as one of the first line agents for osteoporosis by the National Osteoporosis Foundation, American Association of Clinical Endocrinologists (AACE), and the Endocrine Society.
The patient meets standard medical necessity criteria for Prolia given T scores in the osteoporotic range.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Community Acquired Pneumonia; Influenza
Treatment: Hospital admission
The insurer denied coverage for the hospital admission.
The denial is upheld.

This female patient presented to the Emergency Department (ED) after presenting initially at an Urgent Care Center with complaints of shortness of breath, generalized weakness and fever with chills for two days.  Evaluation there revealed oxygen (O2) saturations of 88% on room air and chest x-ray showed a right lower lobe (RLL) consolidation.  The patient was referred to the ED for further evaluation.

Vital Signs at presentation were temperature 101 F, heart rate 69, respiratory rate 20, blood pressure 108/58 mm Hg, and oxygen saturations 92% on room air.  The patient was found to be in no acute distress.  Lung exam revealed coarse rales at R base.  Imaging confirmed right-sided pneumonia.  White blood cell (WBC) count was 10.9 K, hemoglobin 11.9, and sodium 132.  The rest of the electrolytes were normal.  BUN / Creatinine were 14/0.8.

Influenza screen came back positive for Influenza B.  The patient was admitted to the hospital for treatment of community acquired pneumonia.  The patient was initially started on Rocephin and azithromycin, intravenous (IV) fluids, bronchodilators as needed, and Tamiflu.  As per History & Physical the patient was alert and oriented x3.  Cardiovascular system S1 S2 was normal.  Abdomen was soft, non-tender with positive bowel sounds.  No neurological deficits were noted.  The patient was continued on treatment for pneumonia.  Antibiotics spectrum was broadened to Vancomycin for Staphlococcus coverage.  Azithromycin was changed to doxycycline.  The patient remained hemodynamically stable and afebrile after admission.  The patient was tolerating oral intake.  Culture and sensitivity was negative for Methicillin-resistant Staphylococcus aureus (MRSA).  The patient was subsequently switched to oral antibiotics and discharged home for further follow-up in an outpatient setting.

This patient did not need acute hospitalization.  When the patient presented to the ED oxygen saturations were 92% on room air.  The patient was febrile, but was hemodynamically stable.  Mild hyponatremia was noted.  The patient improved with fluids.  The patient's pneumonia severity index (PSI) was low.  CURB 65 score (confusion, urea, respiratory rate, blood pressure) of zero.  There was no failure of outpatient antibiotics documented.  This patient could have been placed in observation status while diagnostic testing and treatment were initiated.  The patient could have been in observation status for up to 48 hours if needed.  The patient remained stable after admission.  The patient was stable for discharge on oral antibiotics after a period under observation status.  Oxygen saturations were 92% on room air and improved.  If deemed necessary the patient could have been discharged on home oxygen.  The health 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 services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee Arthroplasty, Osteoarthritis.
Treatment: Inpatient hospital admission.
The insurer denied the inpatient hospital admission.
The denial was overturned.

This is a female patient with a medical history of osteoarthritis of the right knee who presented for elective knee surgery.  The patient underwent total knee arthroplasty and tolerated the procedure well and had no immediate post-op issues. The patient was transferred to the post-anesthesia care unit (PACU) in stable condition and later was admitted to the floor for post-op care.  The patient was noted pain controlled with post-operative regimen. The patient's vital signs were stable. The patient received physical therapy (PT) and occupational therapy (OT). The patient's post-op x-ray of the right knee showed hardware intact with no acute fracture.  The patient was cleared for discharge home with follow up postoperative instructions. 

Based on the review of the medical record, the patient had poor postoperative pain control. There were problems with the patient's femoral catheter.  There was leakage of medication and a report of "catheter likely not in correct position".  The patient's pain level was reported to be 9-10 out of 10 in severity, on several occasions. Recommendations were made for additional pain medication (i.e., Toradol). As per physical therapy note this patient's progress was poor with pain level.  The patient also had difficulty with mobilization.  The patient was noted to be "not feeling good and vomited seated at chair." These issues of inadequate pain control and delays in mobilization substantiate the need for inpatient level of care and treatment. The services provided to this patient during this inpatient stay could not have been adequately provided at a lower level of care. Thus, inpatient hospital admission was medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Pain Crisis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient in this case has a history of sickle cell disease.  She presented to the emergency department with a complaint of joint pain, back pain and abdominal pain.  She took oxycodone at home without improvement.  On the day of admission, the patient had nausea and she also complained of chills while at home.  

Vital signs were unremarkable and physical exam was also overall unremarkable though she was noted to be "ill appearing".  Chest x-ray and abdominal x-ray were both unremarkable.  She was treated with intravenous (IV) pain medication for three doses and had continued pain.  Given that and nausea she was admitted to the hospital for continued treatment with IV pain medication along with IV fluids and Zofran.  She required IV pain medication at the time of admission. 

The patient was doing well on the 3rd day, with improved pain and she was also tolerating her diet.  No acute issues were noted, and it was noted that discharge planning was in progress with plan to discharge the following day.

No, the acute inpatient admission was not medically necessary, as the patient could have been treated at the observation level of care and with an earlier discharge.

The patient could have been admitted in observation status rather than as an acute care inpatient admission as she was receiving pain medication but had no acute medical condition requiring acute care inpatient status.  Furthermore, the admission was not medically necessary for the last 2 days as she was off IV pain medication and pain was well controlled without development of any new medical issues.