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

Skin Disorders - Burn
Inpatient Hospital

The patient is a male child with medical history significant for eczema, recent croup, and recent pneumonia that presented to the ED via emergency medical services with burns to both palms and an anaphylactic reaction to potatoes. Per EMS, the infant placed his hands on the hot oven door. To soothe the burn, his mother put grated potato on his hands. He subsequently developed a full body rash, with pallor and increased respiratory effort. EMS administered a dose of epinephrine, a dose of Decadron, and a dose of racemic epinephrine en route to the ED. Vital signs included temperature 36.9, heart rate 144, respiratory rate 24, and 97% oxygen saturation in room air. On Telehealth screening, he was comfortably breathing, with no respiratory distress, resting in mother's arms in triage. 

The ED physical examination revealed no acute distress, no tongue or lip swelling, clear lungs with no wheezing or retractions, regular heart rate and rhythm, benign abdomen, patchy red cheeks, blistering to bilateral palms, and non-focal neurologic exam. The Burn Team was consulted with recommendations for maintenance IV fluids and admission for burn care. He was monitored in the ED for four hours after administration of epinephrine for possible allergic rebound. After four hours, he was evaluated, noting resolution of urticaria. He was admitted to the Burn ICU for further care. Examination by the burn team noted large bullae to both palms, right palm with bullae encompassing most of the palm with small blisters scattered to the fingers, left palm with denuded blister encompassing upper portion of the palm, full range of motion of the fingers, total body surface area of second degree burn 2%. Admission orders included infant diet, multivitamin supplement, vitamin C supplement, Colace and Senna, and strict input/output measurement. The following day he was premedicated with ibuprofen and burn care was completed with cleansing, debridement, and application of dressings (Bacitracin, Adaptic, Kerlix, Spandage). He was subsequently deemed stable for discharge. 

At issue is the medical necessity of the inpatient stay. The health plan's determination is overturned. 

This young male child, an infant at the time he sustained his injury, sustained second degree burns to the palms and fingers of both hands representing 2% TBSA. Based on the guidelines that remain currently in use, referral to a Burn Center was indicated, reasonable, and medically necessary. The care that he received while admitted to the Burn ICU was most consistent with acute inpatient management. He could not have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Non-viable pregnancy 
Treatment: Acute inpatient stay 

The insurer denied coverage for acute inpatient stay. The denial is modified. 

This patient is a female G11 P5 who presented to the Emergency Department (ED) at 15.5 weeks gestation. The patient's cervix was 2 cm dilated and 100% effaced. The patient was admitted for vaginal progesterone. The poor prognosis was discussed with the patient. The patient was offered conservative management versus termination. Based on the review of the medical chart, progress note documented that the patient was receiving vaginal progesterone. The patient delivered a non-viable fetus without complications, and was discharged home. 

The patient had a short cervix.  The patient was admitted and placed on Lovenox prophylaxis and vaginal progesterone. From the information submitted, it appears that a cerclage placement was not feasible. 

The value of prolonged hospitalization for women with short cervix has been studied and the scientific literature showed that admission to the hospital was not associated with a decreased rate of preterm delivery and there was a trend toward hospitalization as an independent risk factor for delivery at < 34 weeks, an earlier gestational age at delivery, and a shorter time from diagnosis to delivery. Hospitalization was independently associated with an increased rate of cervical shortening. Another study showed that activity restriction did not reduce the rate of preterm birth in asymptomatic nulliparous women with a short cervix. However, women with vaginal bleeding, no reassuring fetal status, or a long travel time to a hospital with appropriate levels of obstetric and neonatal care services are examples of obstetrically unstable patients in whom ongoing in-hospital observation may be useful. 

In this case, this patient did not have any of the above circumstances. This patient had a non-viable pregnancy. The patient could have been sent home on bed rest with temperature monitoring. If fever developed or if the patient's amniotic membranes ruptured or cramping developed, then the patient could have returned to the hospital. In this case, the patient was afebrile and was stable at admission and during the inpatient stay. Thus, inpatient admission was not medically necessary. However once the patient went into labor, admission was medically necessary for delivery and postpartum management as per standard of care. Thus, the acute inpatient stay is not considered medically necessary for this patient. However admission was medically necessary. 

The health care plan acted reasonably with sound medical judgment to deny coverage for the inpatient stay for specified dates, but not in the best interest of the patient to deny coverage for inpatient stay for other specified dates thereafter. 

Based on the above, the medical necessity for the acute inpatient stay is partially substantiated. The insurer's denial should be modified. DENY specified dates. APPROVE specified dates thereafter.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left Knee Pain
Treatment: Euflexxa injection.  The insurer denied Euflexxa injection
The insurer's denial is upheld.

This is a patient with a complaint of left knee pain. She had partial medial meniscectomy surgery and had progressive weight bearing, left knee pain despite supervised physical therapy (PT) and a cortisone injection. Her provider has proposed performing a series of Euflexxa viscosupplementation injections to treat her left knee pain. At issue in this case is the medical necessity of the proposed Euflexxa injections.

The requested health service/treatment of left knee Euflexxa injections are not medically necessary for this patient. This is a patient with knee pain who underwent surgery and has continued pain after supervised PT and cortisone injection. The provided records document that this patient has medial compartment knee arthritis.  The current, peer-reviewed orthopedic literature has documented that viscosupplementation injections such as the Euflexxa injections proposed for this patient are not more effective than a corticosteroid injection or placebo.  These conclusions were published by Tammachote and colleagues and Jevsevar and associates, respectively, in the Journal of Bone and Joint Surgery. Two recent articles published by Tammachote and colleagues and by Jevsevar and associates, both in the Journal of Bone and Joint Surgery found that viscosupplementation injections such as Euflexxa were not clinically effective for the treatment of knee osteoarthritis. More specifically, the article published by Tammachote and colleagues in the Journal of Bone and Joint Surgery concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." A second article published by Jevsevar and colleagues concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid treatment over placebo."
The current, peer-reviewed orthopedic literature does not currently endorse the use of viscosupplementation injections as an effective treatment for the pain associated with knee osteoarthritis. Thus, the Euflexxa injections proposed in this case are not the standard of care and not medically necessary for the treatment of knee osteoarthritis based on the the current, peer-reviewed literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. Treatment: Inpatient hospital. The insurer denied the inpatient hospital admission. The denial was upheld in whole. 

The patient was a female with a history of a prior left lumbar (L)4-5 discectomy. She presented with several months of new onset right leg symptoms with a recent return of some left leg pain as well. Imaging revealed a large disc herniation on the right at L4-5. Other past medical history (PMH) was significant for obesity with a body mass index (BMI) of 38.7, hypothyroidism and migraines.

Previously she had apparently undergone evaluation by cardiology and internal medicine for an abnormal electrocardiogram (EKG). She had a computed tomography angiography (CTA) and was cleared by cardiology and by internal medicine according to the anesthesia preoperative phone evaluation.

She underwent surgery with a laminectomy L4-5, revision decompression of the left L5 nerve root and discectomy on the right to decompress the right L5 root. The operative procedure was uncomplicated, although extensive epidural fibrosis was encountered. She was discharged home in stable condition.

At issue is the medical necessity of the inpatient hospital admission for this patient.

The health plan determination of medical necessity is upheld in whole. The requested service for an inpatient hospital admission was not medically necessary for this patient.

Patients with this diagnosis, imaging findings and anticipated surgical procedure are generally treated at a lower level of care status. This status can always be changed to inpatient if a significant perioperative medical issue or intraoperative complication arises, which was not the case for this patient. While she had an abnormal EKG showing sinus tachycardia as an outpatient weeks before the surgical procedure, she was evaluated and cleared by both the cardiology and internal medicine services well before the scheduled surgery date.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central auditory processing disorder

Treatment: Code 92507- treatment of speech, language, voice, communication, and/or auditory processing disorder, individual

The insurer denied the Code 92507- treatment of speech, language, voice, communication, and/or auditory processing disorder, individual.

The denial is overturned.   

This is a female patient with a history of central auditory processing disorder (CAPD), specifically with deficits of dichotic listening and spatial localization. The patient consulted an audiologist to be evaluated. A complete audiology evaluation which included all aspects of CAPD was performed. The patient scored below the age expectations for the left ear on Dichotic Digits (Integration), Time Compressed Speech (Auditory Closure/Temporal Task), and Filtered Words (Auditory Closure). On a task of binaural separation, the Competing Sentences test, the patient scored below the age expectation in both ears with a more significant left ear deficit. The asymmetry of the Central Auditory Nervous System creates delays in her ability to efficiently attach meaning to input. Dichotic Auditory Training was recommended to strengthen the neural pathways.

CAPD may negatively impact communication and psychosocial well-being, in addition to academic and vocational performance. While previously categorized as a speech/language disorder under the ICD-9 classifications, in 2015, the ICD-10 system reclassified CAPD as a medical disorder, under Disease of the Ear and Mastoids (American Medical Association, 2017). CAPD is a group of disorders with issues in the central auditory pathways in the brain (Charnak, 2011).

Auditory Training is one of the most direct and effective methods for remediation of this neural disorder. Dichotic interaural intensity difference (DIID) is a type of Auditory Training that has been shown in literature to be effective in development of these auditory neural pathways.

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

Based on the above, the medical necessity for Code 92507- treatment of speech, language, voice, communication, and/or auditory processing disorder, individual, is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis. 
Treatment: Inpatient hospital stay. 

The insurer denied coverage for an inpatient hospital stay. The denial is upheld. 

This is a female patient with a history of anxiety, hyperlipidemia, hypertension, gastritis, and osteoarthritis of the left knee.  The patient presented to the hospital for an elective left total knee arthroplasty.  The patient was admitted as an inpatient and was taken to the Operating Room (OR).  The OR stated that the patient underwent a left total knee replacement, synovectomy of three compartments of the knee joint, and lateral release for correction of valgus deformity.  The procedure was performed under spinal anesthesia with femoral needle block, and no complications were reported.  The patient's post-operative pain was controlled with oral analgesics.  The patient was seen by Physical Therapy (PT) and Occupational Therapy (OT) services.  Short-term rehabilitation was recommended upon discharge.  The patient's Hemovac drain was removed on day 2 of admission.  The patient had no acute issues during her inpatient stay.  The patient participated in therapy sessions, and she was discharged on day 6 of admission. 

Based on the review of the medical record and clinical guidelines, inpatient admission was not medically necessary for this patient.  As per this patient's brief operative note, the patient had minimal blood loss of 50cc with the procedure.  The post-surgical check note indicated that the patient had no complaints.  According to documentation in a progress note on day 2 of admission, the patient had no complaints and discharge planning was in place.  Clinical documentation indicates that this patient had an uncomplicated postoperative course.  The patient's operation was completed in a timely manner with minimal blood loss, and the patient's post-surgical management included visits by the resident physician, PT, and social work on the day of the procedure.  The records report discharge planning on each occasion. 

The clinical documentation for this patient's presentation did not support a condition to warrant acute inpatient admission and stay.  The patient had stable vital signs with no problems with her surgical site.  The patient was able to tolerate oral medications, and she did not require treatment of an underlying medical condition.  Thus, inpatient hospital stay was not medically necessary for this patient. 

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 stay should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis
Treatment: Entyvio
The insurer denied the Entyvio.
The determination is upheld.

The patient has a history of severe ulcerative colitis. He was started on Entyvio standard dose, however, he did not have an adequate response. His dose was escalated to 300 milligrams (mg) every 4 weeks. Despite being on this high dose, he continued to have symptoms of active disease. His drug level was reported to be sub-optimal.
The requested service is dose escalation of Entyvio to 400 mg every 4 weeks. At issue is the medical necessity of the Entyvio.

2. Is the requested health service/treatment of Entyvio at a dosage greater than 300 mg medically necessary for this patient?
No. This patient has failed to respond to the standard dose of Entyvio (300 mg every 8 weeks) and has already been escalated to 300 mg every 4 weeks. Higher doses have not been well studied and the safety or efficacy of the requested dose are not established. Furthermore, there is no adequate scientific evidence supporting the correlation between Entyvio drug levels and clinical response.
Per Plevris, Nikolas, et al: "In this cohort, trough vedolizumab levels were not associated with clinical, biological or endoscopic outcomes during maintenance therapy."
Per Al-Bawardy, Badr, et al, no relationship between Entyvio drug level and mucosal healing was detected.
The available studies on dose escalation of Entyvio support dosing up to 300 mg every 4 weeks (3, 4 & 5). There are no adequate studies assessing dosing beyond this level.
Therefore, the requested dose is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with asthma, diabetes, HIV, presented to emergency room with chest pain and shortness of breath. In the emergency room, patient received IV steroids, and nebulization treatments. Patient was admitted to acute inpatient level of care for asthma exacerbation and chest pain. Patient had left the hospital without allowing further evaluation by physician.
Patient's asthma exacerbation was mild. Patient was not on supplemental oxygen. Patient was hemodynamically stable at the time of admission. There was no trial and failure of observation level of care for 24 hours prior to admitting patient to acute hospitalization.

The patient's asthma exacerbation admission from  is not medically necessary. Patient could have been safely and effectively be treated at a lower level of care.

No, the proposed treatment is not "medically necessary."

The patient's asthma exacerbation was mild. Patient was not on supplemental oxygen. The patient was hemodynamically stable at the time of admission. There was no trial and failure of observation level of care for 24 hours prior to admitting patient to acute hospitalization.

The patient's asthma exacerbation admission from is not medically necessary. Patient could have been safely and effectively be treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male. He has a past medical history significant for HTN (hypertension). He presented to the ER (emergency room) with a new onset chest pain.

The patient was hemodynamically stable. His ECG (electrocardiogram) revealed no acute ST-T changes, but he had a possible Q-wave in inferior leads. Troponin was negative. The patient was referred for a nuclear stress test, which was abnormal with findings of stress induced ischemia. The patient was subsequently referred for a cardiac catheterization, which revealed non-obstructive CAD (coronary artery disease). He was discharged home on medical therapy with a plan for an outpatient follow-up.

Yes, the Inpatient admission was medically necessary.
The proposed treatment is "medically necessary".

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. However, given the concern for ACS (acute coronary syndrome) in a patient with hypertension, newly diagnosed diabetes, and new onset chest pain, a nuclear stress test was performed, which was abnormal, consistent with ischemia. Thus, the patient was referred for a cardiac catheterization for suspected unstable angina/ACS (acute coronary syndrome).

Given the presentation, abnormal stress test, as well as clinical suspicion for an acute coronary syndrome/unstable angina, it would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the emergency ward after having a witnessed generalized seizure. At presentation, his neurological examination was normal and computed tomography (CT) of the head was negative for acute pathology. He was admitted for further evaluation.

No, the requested inpatient admission was not medically necessary.

The patient has a single seizure prior to presentation and returned to his neurological baseline at the time of evaluation in the emergency ward. He had no focal neurological deficits or recurrent seizures after presentation. The diagnostic studies, clinical evaluation, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Issue under review: Otezla

Determination:
The Otezla is medically necessary.

The patient is an adult female with psoriasis covering the scalp, neck, ears and arms for whom Otezla is requested. She has tried and failed topical steroids and has been steadily worsening with now 10% BSA (body surface area) involved.

Since the patient is of childbearing age, use of methotrexate and acitretin are not medically appropriate. Additionally, they carry a much higher risk of adverse events, while not offering an advantage in efficacy. Cyclosporine is not an appropriate long term choice for treatment of psoriasis due to its side effect profile. It is generally used to initiate therapy while waiting for another agent to take effect. It is not appropriate as a single agent for long term use. Because of the location of the lesions in the scalp, phototherapy is not a reasonable option.

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  (Celgene, 2015)  Otezla is an oral small molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene, 2016)  

The patient has moderate to severe psoriasis for which therapy with Otezla is appropriate and medically necessary.

In view of the above, Otezla is medically appropriate and necessary.