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

Diagnosis: Difficulty swallowing history of irritable bowel syndrome, gastroesophageal reflux disease and Type ll achalasia

Treatment: Peroral Endoscopic Myotomy

The insurer denied the procedure as experimental investigational. The denial was reversed.

Reviewer #1:

This patient has a history of irritable bowel syndrome, gastroesophageal reflux disease and Type ll achalasia.

According to UpToDate; "POEM can be performed in most patients who have symptomatic, manometrically proven primary idiopathic achalasia."

It is noted that "previous therapies for achalasia, such as pneumatic balloon dilation, botulinum toxin injection, or surgical myotomy, are not contraindications to POEM." Patients who have severe erosive esophagitis, significant coagulation disorders, liver cirrhosis with portal hypertension, or prior therapy that may compromise the integrity of the esophageal mucosa or lead to submucosal fibrosis (eg, radiation, endoscopic mucosal resection, radiofrequency ablation) should not undergo POEM.

Still evolving, the short-term success rate of POEM for achalasia is 82 to 100 percent, compared with that of a laparoscopic Heller myotomy. Longer-term studies revealed success rates of 78 to 88 percent at two to five years. 

POEM also appears to be a viable treatment option for patients who develop recurrent or persistent symptoms after other treatments of achalasia, such as pneumatic dilatation, botulinum toxin injection, or surgical myotomy. 

The POEM technique has been successfully used to treat spastic esophageal disorders (eg, spastic achalasia, distal esophageal spasm, jackhammer esophagus, or nutcracker esophagus) and severe gastroparesis refractory to medical therapy.

The Peroral Endoscopic Myotomy (POEM) surgical procedure is supported by recent and relevant peer literature. The Peroral Endoscopic Myotomy (POEM) surgical procedure is the best available treatment for the patient.

Peroral endoscopic myotomy (POEM) is an endoscopic method for performing a myotomy of the lower esophageal sphincter (LES) and "is being studied" for the treatment of achalasia. POEM is a form of natural orifice transluminal endoscopic surgery. POEM uses available laparoscopic instrumentation and, as a surgical procedure, is not subject to regulation by the U.S. Food and Drug Administration (FDA).

The requested service is likely to be "more beneficial" than any of the standard treatments/procedures for this patient."

The carrier's denial of Peroral Endoscopic Myotomy (POEM CPT 43499) should be reversed.
Appeal type: Medical necessity
Decision: Overturned

 Chest Pain
Inpatient Hospital

The patient is a male who presented to the emergency department complaining of chest pain. His electrocardiogram showed changes of pericarditis. His blood pressure was 114/75 millimeters of mercury (mmHg) with a heart rate of 82 beats/minute. His respiratory rate was 20/minute. His temperature was 100.4 degrees F. His cardiopulmonary exam was unremarkable. His white blood cell count was elevated. His troponin level was elevated. He was treated with ibuprofen and colchicine and admitted to the hospital. His symptoms and electrocardiographic changes gradually improved. His serum troponin level initially increased but then began to decrease. He was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is overturned.

While the medical literature indicates that inpatient admission is not necessary for the majority of patients with acute pericarditis, given the risk for complications such as cardiac tamponade, purulent pericarditis, and myocarditis with potentially lethal arrhythmias and heart failure, hospital admission is recommended for patients with high risk features such as fever, leukocytosis, anticoagulation, presence of a large effusion or findings of cardiac tamponade, effusion secondary to trauma, immunosuppression, troponin elevation or evidence of myopericarditis. This patient had several of these features including fever, leukocytosis and significant troponin elevation. Accordingly, an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell disease
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female. The patient in this case has a history of sickle cell disease. She presented to the emergency department on 04/24/2019 with a complaint of pain due to sickle cell disease.  She had been seen in the ED the day before and treated with pain medication and came back because of persistent pain in her back, chest and knees.

This patient presented with a complaint of pain, but there is no indication based on medical records that her pain was not controllable with appropriately used oral pain medications.  Records indicate that this patient was non-compliant with previously prescribed oral pain medications.  She had no active infection or other acute medical process noted in provided medical records. Furthermore, while she had anemia, she did not have any hemodynamic instability or ongoing clinically significant blood loss.  Her anemia did not require acute care inpatient treatment.  Given these considerations, there is no support for the medical necessity of acute care inpatient admission in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain
Treatment: Radiofrequency ablation
The proposed treatment is medically necessary.

The patient is a female with low back pain who underwent right lumbar radiofrequency ablation (RFA).  

According to the attached documentation, the patient is a female with axial low back pain. The patient has failed conservative treatment for over one year which included physical therapy.  A magnetic resonance image (MRI) report was attached in the additional information.  There is no severe stenosis.  In addition, it is reported that the patient had over 80% relief with the medial branch blocks prior to radiofrequency ablation.  Given the above, the requested radiofrequency ablation was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diabetes
Inpatient hospital

The patient is a woman who presented to the hospital. She had a history of hypertension and diabetes, and she presented with vomiting, diarrhea and hyperglycemia. She reported that her symptoms had been ongoing for the past few days and she had previously had diabetic ketoacidosis. Review of systems was negative for headache, chest pain, shortness of breath, and weakness. Vital signs showed temperature 97 Fahrenheit, heart rate 88, and blood pressure 183/88. On physical examination, heart was regular, breath sounds were normal, and abdomen was soft and nontender. Labs showed potassium 4.4, sodium 135, glycosylated hemoglobin 12.81, potassium 4.5, creatinine 2.40, and glucose 722. The patient was admitted for uncontrolled diabetes and acute kidney injury.

The health plan's determination is upheld. The Inpatient Hospital Admission was not medically necessary for this patient. The reason is that the patient had a largely benign physical examination, no evidence of acidemia, no significant metabolic anion gap, and she had no sepsis or hemodynamic instability as a trigger for DKA. The blood glucose in the medical record at the time of admission was elevated but was managed with insulin with rapid correction, and there was no evidence of concurrent complications from the hyperglycemia such as encephalopathy. She required further management but it could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Schizophrenia
Mental Health: Inpatient

The patient is a male with diagnoses of schizophrenia (SCZ) and Bipolar Disorder (BPD). Case notes document that the patient suffers from chronic SCZ and BPD. He has required multiple past admissions. He was receiving outpatient intramuscular (IM) aripiprazole at unknown intervals. The presenting concerns for this admission were disorganized behavior and persecutory and grandiose delusions. His delusions included beliefs that the devil was pursuing him, that he was related to the devil, and he was responsible for breaking the "matrix." He believed he needed to be in Jerusalem. He was admitted for reasons of safety and stabilization of his two major disorders. His treatment included oral aripiprazole, requests for willingness to accept IM aripiprazole, diphenhydramine, and lithium. His treatment included group psychoeducation and therapy, as well as discharge planning.

The health plan's determination is overturned. The inpatient hospital admission was medically necessary for this patient. The dates of service (DOS) through discharge are medically necessary for several reasons. This patient's disorders were severe, chronic, and interactive. His persecutory delusions appear to have come from his SCZ and were threatening to him. His grandiose delusions were most likely the result of his bipolar disorder, manic phase. These two disorders were both being treated in a standard manner but required adequate time to demonstrate adequate resolution of his disorganization and of his threatening and grandiose delusions to allow transition to outpatient followup.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history of hypertension (HTN), hyperlipidemia (HLP), polysubstance use, and on Gleevec for malignancy, who presented to the emergency room (ER)  after being involved in a motor vehicle accident (MVA) and subsequent police car chase. 
On presentation, he was febrile to 101.8 degrees Fahrenheit with blood pressure (BP) 153/72, heart rate (HR) 141, respiratory rate (RR) 24, and oxygen saturation 100% on room air (RA).  A urine drug screen was positive for cocaine. A urinalysis (UA) otherwise noted large blood/myoglobin. An electrocardiogram (EKG) showed sinus tachycardia with a rate of 140. A computed tomography (CT) scan of the head, cervical (C)-spine, and abdomen/pelvis showed no evidence of acute process. The patient was given normal saline (NS), Haldol, Ativan, Benadryl, and insulin, and was subsequently brought into the hospital with concerns for rhabdomyolysis, acute kidney injury (AKI), anion gap acidosis, hyperuricemia, and encephalopathy and plans for intravenous fluids (IVF), telemetry, serial troponins, nothing by mouth (NPO), strict intake and output (Is/Os), Renal ultrasound (US), and serial CK monitoring.

The health plan's determination is overturned. 
This is a patient who presented with significant rhabdomyolysis with a CK of greater than (>) 8000 with concomitant myoglobinuria, acute kidney injury, hyperuricemia, and acidosis. He additionally presented with significant agitation. His agitation and altered mental status improved quickly, but he notably had persistent acute kidney injury despite aggressive fluid resuscitation with CK actually increasing from 8903 to >10,000 with worsened hyperuricemia as well. In this setting, he continued to require aggressive IVF and monitoring and was at risk of worsened AKI, worsened hyperuricemia, in addition to hyperphosphatemia and hypocalcemia and cardiac arrhythmias. It was not until 6/24 that CK levels decreased to just over 5000 (with levels >5000 as noted in references below associated with significant risk for ongoing AKI), hyperuricemia had resolved, and his renal function was stabilized, after which he was ultimately discharged on 6/25. This patient who presented with rhabdomyolysis with associated AKI and hyperuricemia in addition to acidosis was at significant risk of ongoing kidney injury, electrolyte abnormalities, and potential cardiac arrhythmias without aggressive treatment with IVF and ongoing laboratory monitoring, and in this setting required acute inpatient care and care that was expected to extend beyond a reasonable period of observation of 48 hours and did. Inpatient care was medically necessary and observation level of care was not appropriate.
Acute inpatient admission was medically necessary for dates of service for this patient with significant rhabdomyolysis that worsened after presentation and a lower level of care was not appropriate and is considered outside of standard medical practice.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Central Nervous System/ Neuromuscular Disorder
Treatment:  Inpatient Hospital 

The patient was brought to the hospital by ambulance because of significant weight loss, mild intermittent headache, memory loss, and unsteady gait.  It was indicated that the patient had a previous history of polysubstance abuse, and the patient was enrolled in a Methadone program.  On the physical examination, the patient was found to be emaciated with signs of severe malnutrition that was attributed to her poor eating habits.  Uphold in whole the health plan's determination of medical necessity.  The review of the medical records available demonstrated that in this clinical case the patient was afebrile and hemodynamically stable.  There was no medical necessity for the inpatient hospital admission.
There was no documentation available for review to assess fully the results of the physical examination.
The patient's laboratory results were unremarkable, except for very mild dehydration that was corrected quickly.  The results of the diagnostic studies did not show any significant abnormalities that would justify medical necessity for the admission at the acute inpatient level of care.
This patient likely had dementia, which in combination with continuous drug abuse led to poor nutritional status and mild dehydration.  This patient most likely required placement in order to meet the nutritional needs and to limit drug abuse.
At the same time, the review of the limited amount of medical records that were available did not demonstrate a clear reason why the patient required admission at an acute inpatient level of care.
Apparently, while in the hospital, the patient became more oriented and was discharged home with home services.  There was no instability in the patient's vital signs seen.  The results of the laboratory evaluation did not show significant electrolyte abnormalities except for mild kidney insufficiency, which was corrected quickly.
The results of the diagnostic studies, including CT scan of the chest and CT scan of the head, did not reveal clinically significant abnormalities that would justify admission at the acute inpatient level of care.  Taking into consideration all these facts, there were no strong indications that the patient required admission at the acute inpatient level of care.  Admission for a lower level of care to ensure clinical stability and improvement in the mental status, as well as organizing home care, was reasonable in this particular case.  Neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care, based on the documentation provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Costochondritis.

Treatment: Inpatient admission

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

This patient is a female who presented to the emergency department with recurrent non-radiating left sided chest pain that is positional and that had been on and off for one year.  The patient states it had gotten worse the day of her admission to the emergency department with an 8/10 VAS pain score.  It is unclear what medication, if any the patient had taken prior to her visit to the emergency department. The patient reported that she had discussed this intermittent chest pain with her primary care physician and was told it was inflammation and instructed to take over the counter anti-inflammatory medications. On admission, the patient was given an aspirin 325mg orally for prophylaxis.  She was also provided an albuterol inhaler every six hours as needed for wheezing (for a history of asthma), ibuprofen for pain, and pantoprazole for gastroesophageal reflux.  There was no report of wheezing or abnormal breath sounds or epigastric pain on admission.  The patient had an EKG that was borderline due to sinus bradycardia and abnormal T- waves, a normal troponin blood test, and an echocardiogram that revealed probable left ventricular enlargement with mitral valve prolapse.  A chest x-ray revealed borderline enlarged heart, other blood tests (bleeding panel) was normal. 

The patient did not report any prior history of cardiac related problems other than the reported chest pain over the past year that was discussed with her primary care provider.  The patient did not report any previous EKG's or heart testing done in the past year.  On the day of admission to the emergency room, the patient did not attempt to contact her primary care provider or seek care at an urgent care clinic.  The patient was seen by a cardiologist who ruled out an acute coronary syndrome and was discharged with a diagnosis of costochondritis.

Literature supports that clinicians cannot use clinical judgment alone to determine whether an individual patient who presents to the emergency department has an acute coronary syndrome. The history and physical examination do not distinguish sufficiently between the many conditions that can cause acute chest pain syndromes. Cardiac risk factors do not have sufficient discriminatory ability in symptomatic patients presenting to the emergency department. Most patients with non-ST-segment-elevation myocardial infarction do not present with electrocardiographic evidence of active ischemia. However, the improvement in cardiac troponin assays, especially in conjunction with well-validated clinical decision algorithms, now enables the clinician to rapidly exclude myocardial infarction.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The inpatient hospital admission is not medically necessary for this patient.  

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glioblastoma multiforme 
Treatment: Optune device
The proposed Optune device is not medically necessary.

This is a female with glioblastoma multiforme (GBM), and treated with surgery, radiation with Temodar, followed by Temodar.  Temodar was stopped due to cytopenias.  The attending physician (AP) requested to start Optune.

There is no evidence to support the use of Optune as adjuvant therapy for GBM one year following resection/radiation and Temodar.  The ef14 study randomized patients immediately to Optune following completion of Temodar and radiation, not 12 months later.  There is no evidence that with a 12 month delay Optune is of clinical benefit in the treatment of GBM.  Therefore, initiation of Optune, ten months following initial diagnosis and treatment, is not necessary and is not of proven benefit.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction 
Substance Abuse: Inpatient

The patient who was admitted to inpatient level services for detoxification of the stimulant (cocaine) and the opioid (heroin) and the alcohol class substances of abuse. The patient had been using up to one pint of vodka on a continuous daily basis as well as crack cocaine and two bags of heroin with intranasal administration (snorting). The patient reported no history of withdrawal seizures or delirium tremens. 
Uphold in whole, the health plan's determination of medical necessity.
The requested health services/treatment of medically monitored intensive inpatient services and detoxification treatment of alcohol use and cocaine use and opioid use disorders are not considered medically necessary for this patient.
The detoxification treatment could have been safely and effectively provided with lower level services. Thus, the determination of medical necessity is reasonable and consistent with prevailing standards of medical practice in this case scenario, as well as the application of the OASAS LOCADTR 3.0 Guidelines/Criteria.
The patient in this case was using alcohol and cocaine and heroin on a continuous daily basis. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have warranted medical necessity for admission for inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment or monitoring. There were no safety concerns in this case and no history of complicated withdrawal from drugs or alcohol. The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in the community.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck pain
Treatment: MRI of the neck

The MRI of the neck is not medically necessary.

The patient is a male. There is a request for an MRI of cervical spine without contrast, CPT 72141.

There is an encounter, indicating that the patient was a male presenting to the office for peripheral arterial disease.  He had some issues with walking and discomfort in his feet and calf, which is more present when he is standing, but not necessarily with ambulation.  There is a long history of being on his feet doing construction-type work. He had a left hip replacement in the past, and he had a toe fracture in the right foot.  There is no prior history of DVT (deep venous thrombosis), rest pain, tissue loss, TIA (transient ischemic attack), amaurosis fugax, or stroke.  He was being referred to Neurology and requested for an MRI of cervical spine.  Physical exam indicated gait and station were normal.  There was no kyphosis. He had normal muscle strength.  Peripheral pulses were 2+ (two-plus) per the physician.

The available medical records provided for review indicate physical examination indicating the patient has normal gait, has normal motor strength, and does not have any abnormality of reflexes or sensation being demonstrated by exam consistent with an upper motor neuron lesion.  The available medical records do not indicate any suspicion of malignancy or infection of central nervous system in the absence of long tract findings, any upper motor neuron findings or any other history of cervical trauma.  The available medical records would not support the presence of a focal neurologic lesion demonstrating focality that may be localized to the cervical spine and in support of an MRI of cervical spine (1).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Unspecified bipolar disorder 
Treatment: Gencept Assay (Genomind) 
The health plan should not cover the proposed treatment.

There is no high quality literature to date supporting the routine use of genetic testing in the treatment of bipolar disorder. The low predictive power and uncertain clinical validity and utility of genetic tests for psychiatric disorders have led to both controversy and difficulties of interpretation of results, with no conclusive evidence of clinical benefit.