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

Diagnosis:  Inflammation of the gallbladder and/or gallstones.
Treatment:  Inpatient admission. 

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

No, the proposed inpatient admission was not medically necessary. 

The patient is a female who had a history of uterine fibroids and three prior C-sections.  She presented with eight out of ten abdominal pain with new onset.  There was associated nausea and emesis.  The symptoms predated this presentation by three days.  The pain increased with eating. 

The patient had abdominal tenderness on examination.  There was a mild elevation of blood pressure.  An ultrasound showed chronic changes consistent with chronic cholecystitis with gallbladder wall thickening and small gallstones.  A transaminitis was noted.  A magnetic resonance cholangiopancreatography (MRCP) was suggested but scheduled as an outpatient.  Surgery did not recommend surgical intervention.  The member was discharged home when deemed stable. 

The medical treatment as provided was medically appropriate, but the level at which the care was rendered was not medically necessary. 

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care.  The patient had an episode of biliary colic; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Orthopedic/Musculoskeletal.
Treatment:  Durable Medical Equipment (DME).
The insurer denied the durable medical equipment (knee brace).  The denial is overturned in whole.

The patient is a male who underwent right knee anterior cruciate ligament (ACL) reconstruction surgery along with partial lateral meniscectomy and medial meniscus repair.  The orthopedic provider prescribed a post-operative hinged knee brace for this patient to be used after the operation.  At issue in this case is the medical necessity of this post-operative hinged knee brace.

The health plan's determination is overturned in whole. 

The requested hinged post-operative knee brace is medically necessary in this case.  This determination is based on the provided medical records which document that the patient underwent an extensive arthroscopic knee surgery.  This operation included ACL reconstruction with hamstring autograft, partial lateral meniscectomy, and medial meniscus repair.  The medical necessity of the hinged knee brace is established by the extent of this surgery, and the support for it is based as well on the peer-reviewed orthopedic literature, as documented by Lowe and colleagues in the Journal of the Academy of Orthopedic Surgeons in 2017, which concluded that "Some data suggest that functional bracing may have some benefit with regard to in vivo knee kinematics and may offer increased protection of the implanted graft after ACL reconstruction without sacrificing function, range of motion, or proprioception."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Osteoarthritis, Spinal Stenosis.
Treatment:  Increase in Consumer Directed Personal Assistance Services to 12 hours a day, 7 days a week, for a total of 84 hours a week.

The insurer denied the increase in Consumer Directed Personal Assistance Services to 12 hours a day, 7 days a week, for a total of 84 hours a week.  The denial was reversed. 

This is an elderly female who lives alone and needs substantial assistance with IADLs and ADLs.  The UAS from late 2019 reported that the patient has CDPAS aide 7 hours per week with varied scheduled times, and private hire aide to help with morning ADLs, breakfast and lunch.  Family and a neighbor provide some informal care.  The patient requires maximal assistance for household related tasks (meal preparation, housework, shopping) and her mobility is very limited due to multiple lower extremity problems.  She has a history of a falls, resulting in hairline hip fracture in mid 2019.  She has osteoarthritis with bilateral knees replacements.  She has a history of chronic urinary tract infections (UTI) with urinary incontinence and episodes of bowel incontinence requiring assistance with toileting.  The daughter requested increase of CDPAS to 12 hours per day, 7 days per week, which was denied by the insurer; but approved increase of CDPAS to 8 hours per day, 7 days per week.

Considering the patient's need for substantial assistance with transfers and mobility various times during daytime hours until she goes to bed at night, toileting and incontinence care (throughout the day and night at multiple unscheduled times), and possibly assistance with bed mobility for repositioning during the night, it is medically necessary and in the patient's best interest to have caregiver support throughout the day and night.  The insurer recommended physical therapy evaluation.  This is reasonable; but the patient needs additional assistance now.  If the patient is considered a candidate for rehabilitation and her functional abilities improve with therapy, then at that time reassessment can determine whether CDPAS hours need to be modified again.

The maximum number of CDPAS hours that can be approved from this review is limited by the amount requested; i.e. 12 hours per day.  Consumer Directed Personal Assistance Services, 12 hours per day, 7 days per week, total of 84 hours per week is medically necessary.  The health plan did not act reasonably with sound medical judgement in the best interest of the patient.

Based on the above, the medical necessity for the requested increase in Consumer Directed Personal Assistance Services to 12 hours a day, 7 days a week, for a total of 84 hours a week is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Asthma. 
Treatment:  Inpatient admission. 

The insurer is denied coverage for inpatient admission.  The denial is reversed. 

This is a male obese patient with a history of asthma.  He was brought to the Emergency Room (ER) with complaints of wheezing and chest pain while on the school bus.  It was reported that the patient was treated with daily inhaled steroids.

While in transport Emergency Medical Services (EMS) noted the patient was having labored breathing and a prolonged expiratory phase of respiration.  The patient was started on bilevel positive airway pressure (BIPAP) while in route to the hospital.  Upon arrival to the (ER), the patient was noted to have decreased breath sounds in the lung bases, and he was treated with intravenous (IV) fluids, inhalation treatments with duoneb, albuterol and solumedrol. 

A chest x-ray was done with normal results.  The patient's blood gas was drawn, which showed a pH of 7.38 with an elevated pCO2 level of 46.  The patient's condition failed to improve after a series of medical interventions; he was admitted to the Pediatric Intensive Care Unit (PICU) for further treatment.  The patient was medically stabilized and safely discharged home.

Based on the review of the medical record, the patient was treated appropriately in the
Emergency Room (ER) for an exacerbation of asthma that did not respond to asthma therapy.  It was appropriate and consistent with the standard of care to transfer the patient to a Children's Hospital when his condition did not improve and when it was determined that he was critically ill.  Since the specialized care needed to ensure the recovery of this patient was not available at the hospital, transfer to a children's hospital is considered the standard of care.  The high level of pCO2 in this patient was a clinical warning sign of possible respiratory failure, which would require this patient intensive care.  Thus, inpatient admission was medically necessary.

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 admission from should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Spondylolisthesis, Spinal Stenosis, Neurogenic Claudication.
Treatment:  Nonemergency ambulance transport.

The insurer is denied coverage for nonemergency ambulance transport.  The denial is reversed. 

This is a female patient with a history of hypertension, fibromyalgia, obesity, spondylolisthesis, spinal stenosis and neurogenic claudication.  The patient underwent a laminectomy at L4-L5 with posterior interbody fusion and instrumentation.  Per the non-emergent ambulance transport, the patient had bed confined weakness, needed a back brace and was at risk of falling off a wheelchair or stretcher.  The patient was transferred from the hospital to the rehab center.

According to Heaton & Kohn (2020), "Non-emergent inter-hospital transfers are for stable patients.  Reasons for transfer include non-emergent surgery, elective procedures, inter-regional hospital designations, or for non-acute patients who will receive care closer to their desired location. . . .  Transfers between hospitals and other healthcare facilities are generally performed on a non-emergent basis.  Typical scenarios include transfers between a hospital and a skilled nursing facility or an acute rehabilitation center.  Although most transfers occur without urgency or primary concern for deterioration, the potential for such is still present."  As per Stoicea et al (2018), "Older patients tend to have more comorbidities and poorer health, and will require post-acute care (PAC) following discharge.  The most utilized PAC facilities following [Total Hip Arthroplasty (THA)] and [Total Knee Arthroplasty (TKA)] are skilled nursing facilities (SNFs), in-patient rehabilitation facilities (IRFs), and home with home health care (HHC).  Coordination of care between hospitals and PACs, including the complete transfer of patient information, continues to be a challenge, which impacts the quality of care provided by the PACs.  The increased demand of hospital resources and PACs by the geriatric population necessitates an improvement in this transit ion of care process."

Based upon the review of the medical record, the patient's clinical presentation and the extent of the surgical procedure indicated that non-emergent ambulance transportation to the rehab center was medically necessary.  At the time of transfer, the patient was only several days post-op from her surgical procedure.  Furthermore, the patient required assistance because she was dependent in terms of physical activities following the surgical procedure performed.

Therefore, the nonemergency ambulance transport is considered medically necessary for this patient.  The health plan did not act reasonably with sound medical judgment.

The carrier's denial of coverage for the nonemergency ambulance transport should be reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Pharmacy/Prescription Drugs

This patient is a female with a history of Crohn`s disease diagnosed in 2014. She has previously failed treatment with Remicade, Humira and Entyvio. She was started on Stelara standard dose but was hospitalized shortly after and was started on corticosteroids. Her drug level at 4 weeks after the dose was adequate at 15 ug/mL.
The requested service is Stelara dose escalation of Stelara from every 8 weeks to every 6 weeks. The treating provider feels that the more frequent dose is indicated to improve the drug levels and the chance of remission.

The health plan's determination is upheld.

Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn`s disease and ulcerative colitis in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in pediatric patients with inflammatory bowel disease.
Dose escalation is an accepted approach in managing severe inflammatory bowel disease in order to achieve adequate therapeutic levels. The standard of care is to start at the approved dose then escalate if needed. Clinical indications for dose escalation would be low drug levels or inadequate response to the standard dose.
This patient had a very good drug level at 4 weeks post infusion (15 ug/mL). The available evidence suggest that trough drug levels of 4.5 ug/mL (1) or up to 1.4 ug/mL (2) are adequate and associated with favorable response.
This patient`s level was more than adequate at 4 weeks of age. She also is reported to be improving gradually. There is no evidence that she has a low trough level at 6 or 8 weeks. There is no evidence that driving the levels higher would add any clinical benefits. Dose escalation is not indicated clinically for this patient. Continuation of Stelara at the standard dose is appropriate at this time.
Therefore, the requested service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Endocrine/Metabolic Nutritional, Short Stature 
Pharmacy/Prescription Drugs
This is a patient diagnosed with idiopathic short stature (ISS). This request is for Nutropin. The growth hormone (GH) stimulation test  with arginine and Clonidine peaked at 12.2 respectively. The  magnetic resonance imaging (MRI) was normal. The health plan's determination of medical necessity is overturned in whole. The 
requested Nutropin is medically necessary for this patient. The peer reviewed literature including consensus clinical guidelines, randomized controlled trials and are summarized below.
 
Idiopathic Short Stature
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines (4-9). FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient has a pre-treatment height less than or equal to -2.25 SD. The height velocity was poor especially for his stage of puberty and would not allow him to reach a normal adult height. The patient therefore met idiopathic short stature criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with hereditary angioedema (HAE) who is requesting Haegarda. She has angoioedema without hives. She has tried antihistamines, corticosteroids, fresh frozen plasma. She had low C1 esterase inhibitor levels (function not checked) per the appeal letter. She has tried Cinryze. C4 was not checked when she had her initial diagnosis per the appeal letter (was made in the hospital by another provider). C4 levels were normal per the appeal letter when checked when she was already on treatment.  She is requesting Haegarda due to infusion modality. The C1 labs provided were normal. The health plan's determination is upheld.
Haegarda, as requested, is not medically necessary for this patient.
The provided labs do not support a diagnosis of HAE. The C1 labs are normal. Patients with HAE type I have low C1, C4. Therefore, the Haegarda is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eczema 
Treatment: Dupixent
The insurer is denial coverage for Dupixent. 
The denial is upheld. 
This is a female patient with a history of severe eczema, asthma and food allergies. The patient was under the care of a provider for the treatment of eczema. It was reported that the patient had complaints of being very itchy, and that she had failed oral prednisone, topical steroids including triamcinolone and clobetasol.  Prior to the topical steroid application it was reported that the patient had been using Halobetasol ointment and lidex ointment twice a day with no improvement.  Dupixent was recommended.

According to Spergel, J.M. (2020), "the proper sequence of therapy for severe atopic dermatitis would be topical emollients, topical corticosteroids, wet wraps, phototherapy, cyclosporine, and methotrexate." As per Sidbury, et al (2014), "Systemic immunomodulating medications are a prevalent treatment option for the management of chronic and/or severe inflammatory diseases. Their use in dermatology is commonplace for blistering disorders, granulomatous diseases, and most frequently, psoriasis... [T]hese agents are indicated and recommended in [atopic dermatitis (AD)] care for the subset of adult and pediatric patients in whom optimized topical regimens and/or phototherapy do not adequately control the disease, or when [quality of life] is
substantially impacted."

Per Dimitriades, V. R., & Wisner, E. (2015), "Other forms of therapy, including the systemic calcineurin inhibitor, cyclosporine, have been reserved in the cases of severe refractory [atopic dermatitis (AD)]. Recent literature has shown that cyclosporine controls dermatitis by significantly suppressing inflammatory T cell subsets related to the AD phenotype within lesional skin.21 However, because of the risk of renal toxicity, patients need to be monitored closely for secondary effects. Antimetabolites such as methotrexate, mycophenolate mofetil, and azathioprine have also been used to control severe AD, though these should be selected by individual risk assessment for each patient."

According to the American Academy of Dermatology recommended therapy for pediatric
patients with atopic dermatitis, it is appropriate for this patient to try and fail methotrexate, azathioprine, or cyclosporine. The patient had been diagnosed with severe eczema and had comorbidities of asthma and food allergies. The patient had tried and failed oral prednisone, topical steroids including triamcinolone, clobetasol, Halobetasol, lidex, mometasone, Eucrisa, tacrolimus, hydrocortisone, and phototherapy. Thus, Dupixent is not considered medically necessary for this patient at this time.

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 Dupixent is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory system/Respiratory syncytial virus/ RSV
Treatment: Inpatient Hospital 
The insurer denied the inpatient hospital stay. 
The denial is Upheld in whole.

This patient, at the time of admission was born via Cesarean section C/S. The patient presented to the emergency room (ER) from the  primary medical doctor (PMD) office for rapid breathing. The patient's mother states she was seen in the ER  for abdominal distention which had since resolved. the patient  was exposed to sick contacts for an extended period of time.
The requested health service/treatment of the inpatient stay was not medically necessary for this patient. This patient  who presented to the ER with complaint of rapid breathing, nasal congestion and rhinorrhea. The patient was found to be RSV positive.
Per the history, this child had been symptomatic for approximately 6 days. Babies with RSV are known to have peak symptoms on days 3-5 of illness. This patient  did not have any recorded tachypnea (RR>60) in the ER or after being admitted, no severe or sustained retractions reported, no fever, no desaturations or O2 saturations < 92% on room air or history of poor by mouth (PO) intake. These signs have been noted to be predictors of need for major medical intervention while hospitalized. This child did not exhibit any of these findings. The child responded to blow by nebulizer treatment in the ER. The morning after admission when patient was assessed, and mother reported improvement. The child was hospitalized for < 48 hours and did not require and intensive or specialized care while admitted.
The child had a short hospital course highlighted by PO tolerance, stable vital signs and respiratory status. The patient  did not have symptoms that were severe or persistent after lower level care treatment in the ER nor did the patient  have inability to maintain oral hydration or lethargy. Patient could have been at a lower level of care. Inpatient level of care was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bicycle Accident, Seizure
Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

This patient presented to the emergency department (ED)  following a fall from a bike while having a seizure. The records indicate that he was the non-helmeted rider of a bicycle. There was a reported transient loss of consciousness, but the Glasgow Coma Score at presentation was 14. Comorbid health conditions included alcohol abuse, chronic pain, and lumbar radiculopathy. The ED evaluation identified a non-bleeding 4-centimeter (cm) laceration of the forehead. Vital signs were normal at the time of trauma consultation. The hemoglobin value was 12.5 g/dl. The forehead laceration was closed in the ED.
Orthopedic evaluation was requested and performed for a complaint of neck pain in the setting of an avulsion fracture of cervical (C) 5. The recommendation was for pain control, a cervical collar and outpatient follow up.
A neurology consultation was requested and performed with the recommendation for lab assessment with thyroid stimulating hormone (TSH) and B12 levels, and physical therapy. The patient remained stable with a stable hemoglobin value during the course of the one-day hospitalization. The patient was discharged from the hospital. At issue is the medical necessity of an inpatient stay.

Inpatient care was not medically necessary in this case. The medical records support that the patient was hemodynamically stable with normal vital signs throughout the period of monitoring. The forehead laceration was able to be sutured in the ED. He was tolerating a diet. Pain management was primarily with oral analgesics. The record does not document that there were ongoing medical conditions that required an acute inpatient designation. The hemoglobin value, while slightly low, was stable, there was no ongoing bleeding, and this could have been followed and further evaluated as clinically indicated in the outpatient setting.
The Milliman Care Guidelines (MCG) (Anemia, Iron Deficiency, 23rd edition) support that there was no clinical evidence for inpatient admission in this case. Generally accepted practice standards support that a reasonable and appropriate goal level of care for this patient was a lower level of care. Standard practice guidelines support that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, active bleeding, gastrointestinal (GI) obstruction or surgical or metabolic complications, the evaluation and treatment of a patient such as this patient may be performed with a lower level of care. In this case, the patient was clinically stable with stable hemoglobin, tolerated oral hydration, diet and medication and pain was well controlled. Inpatient care was not required or medically necessary in this case and was not consistent with standard of care practice patterns.