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

Diagnosis:  Myelomeningocele, hydrocephalus, microcephaly.
Treatment:  Genetic testing Exome Sequence Analysis (Pre-Service).

The insurer denied the Genetic testing Exome Sequence Analysis (Pre-Service).  The denial is upheld.

The patient is an female toddler.  She has been diagnosed with multiple congenital
anomalies that include spina bifida, hydrocephalus, neurogenic bladder, microcephaly, and dysmorphic features.  Genetic test was initiated with microarray, which failed to identify any abnormalities.  The provider has subsequently requested whole exome sequencing (WES).  The request has been denied due to the testing being considered experimental/investigational.

Submitted medical records include a very detailed discussion regarding the patient's clinical presentation, which does describe the multiple organ abnormalities, benign family history, and goals of genetic exome sequencing.  The discussion does include a review of specific syndromes of which many of this child's findings are consistent with a specific syndrome (Smith-Lemli-Opitz).  Other syndromes also have findings that are partially met in this patient.  The provider maintains that clinical utility of the requested testing has been established and offers a single example of how such testing benefited a particular patient.

No, the health plan should not cover the Exome Sequence Analysis.

Denial of the proposed treatment is appropriate based on the testing being experimental/investigational and unproven to benefit health outcome.

No, the Exome Sequence Analysis is not likely to be more beneficial.

Benefit to patient management and health outcome is not established to result from
WES (whole exome sequencing) testing.  The testing is best considered an academic activity with little likelihood of patient having clinical benefit.  Current published peer-reviewed medical literature does not demonstrate that a patient with these findings (spina bifida, hydrocephalus, neurogenic bladder, microcephaly, and dysmorphic features) is likely to see improved clinical condition as accruing from WES (whole exome sequencing) testing.  While testing may identify genetic errors, benefit to health outcome does not necessarily follow.

Submitted medical records include a very detailed discussion regarding the patient's clinical presentation which does describe the multiple organ abnormalities, benign family history, and goals of genetic exome sequencing.  The discussion does include a review of specific syndromes of which many of this child's findings are consistent with a specific syndrome (Smith-Lemli-Opitz).  Other syndromes also have findings that are partially met in this patient.  The provider maintains that clinical utility of the requested testing has been established and offers a single example of how such testing benefited a particular patient.  However, in this scenario, there is no known cure for microcephaly, and associated neurodevelopmental deficits.  Benefit to this patient's disabilities resulting from spina bifida also would not benefit from requested testing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unspecified psychotic disorder

Treatment: Continued inpatient hospital admission

The insurer denied coverage for the continued inpatient hospital admission.

The denial is upheld. 

This is a male patient with no prior psychiatric history who was admitted for inpatient mental health treatment due to threatening, aggressive, and agitated behavior, and psychotic symptoms. The patient reportedly was involved in a physical altercation with his brother and threw a hammer that broke a printer. The patient reportedly had odd behavior, was smiling and laughing inappropriately, had frequent anger outbursts, and exhibited labile affect and mood fluctuations, sleeping problems, impulsivity, frequent arguments, and poor anger control. The patient had been smoking 2 joints of cannabis per day and had past use of synthetic cannabinoid and crack/cocaine. The patient was admitted and was treated with Abilify. The patient had a reported diagnosis of unspecified psychotic disorder. The patient lived with his parents and was unemployed.  The patient was stabilized and was discharged to home on day 5 of admission.

The Milliman Care Guidelines (MCG) Behavioral Health Inpatient Level of Care Adult criteria guidelines report that a patient needs to present as an imminent danger to self, imminent danger to others with severe psychiatric or behavioral symptoms, have a severely dysfunctional living situation including inability to care for self, unwillingness to participate voluntarily, or a less restrictive level of care is not feasible to meet criteria for inpatient behavioral health level of care. 

In this case, there were no reports of suicidal ideation, plan, or intent, psychotic symptoms, manic episodes, major depressive episodes, aggressive, self-injurious, or agitated behavior, inability to adequately care for his basic needs, acute medical instability, or withdrawal symptoms as of day 4 of admission. Notes on day 4 of admission reported that the patient denied suicidal or homicidal ideation, hallucinations, and the patient was counseled about cannabis for which he was agreeable. The patient reported regret for the incident prior to admission with his brother, and other than some mood fluctuations, impulsivity, and anger, the patient had no other manic or depressive symptoms. The patient was then discharged home on day 5 of admission. Also, as of day 4 of admission, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital or that could not be achieved in a less restrictive level of care. There was no further specific evidence that the patient was still considered an imminent danger to self or others then. Thus, continued behavioral health inpatient admission was not medically necessary for this patient from day 4 of admission to day 5 of admission.  

The health plan acted reasonably with sound clinical judgment and in the best interest of the patient.  

The carrier's denial of coverage for the continued inpatient hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain, Dyspnea.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned. 

This is a male patient with a past medical history significant for hypertension (HTN), hyperlipidemia, type II diabetes mellitus (DM), active tobacco abuse and daily alcohol use. He presented to the hospital with complaints of substernal chest pain radiating to the back and difficulty breathing. The patient was admitted to telemetry to rule out acute coronary syndrome (ACS). 

This patient presented with moderately suspicious cardiac chest pain and dyspnea in the setting of multiple uncontrolled risk factors including markedly elevated HTN, hyperlipidemia and uncontrolled diabetes. His electrocardiogram (ECG) was abnormal but non-specific for ischemic changes and his troponins were elevated at twice the upper limit of normal for most assays at 0.08. His HEART (History, Electrocardiogram, Age, Risk Factors, Troponin) score based on the emergency department (ED) presentation is 5 which does place him at moderate probability of an acute myocardial infarction requiring percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG). A heart score of 4-6 points often implies criteria for clinical observation. However, he also presented with a markedly elevated blood pressure of 206/111, markedly elevated blood glucose of 400, and likely some very mild renal failure with a serum creatinine of 1.2 and a reduced glomerular filtration rate (GFR) which improved the following day with improving blood glucose and blood pressure. 

While each presenting abnormality confers some degree of risk that alone may not have met criteria for admission, the interaction of these abnormalities with each other placed him at increased risk for adverse cardiovascular events and at the very least would have met criteria for admission. 

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

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

Diagnosis: Axillary hyperhidrosis.
Treatment: Botox Injections.
The insurer denied the Botox injections. 
The denial is overturned. 

The patient is a male with axillary hyperhidrosis, treated with Qbrexza and Drysol.  The provider is requesting Botox injections.

Yes, the proposed treatment with Botox is medically necessary.

The documentation does demonstrate overall impact of disease on patient, and lack of efficacy of Drysol and Qbrexza.  

It is generally accepted as national standards of care that Botox treatment for hyperhidrosis is medically necessary and is far superior in efficacy to other treatment modalities.  Hyperhidrosis can have a devastating effect on a patient's quality of life, causing physical discomfort, social embarrassment, and disruption of occupational and daily activities.

Hyperhidrosis treatments have undergone major improvements in the 21st century. The  Food and Drug Administration (FDA) approval of Botox injections for the treatment of axillary hyperhidrosis has helped to transform the lives of many thousands of sufferers. By "turning off" the process that leads to sweating excessively, Botox treatments allow sufferers to lead more normal lives, free, at least temporarily, from the overwhelming symptoms of hyperhidrosis. 

(Results of Botox injections last on average six to nine months, and maintenance injections are necessary for continuous control).

It is the position of the International Hyperhidrosis Society that treatment of this condition with Botox injections is the gold standard and considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Schizophrenia

Treatment: Continued behavioral health inpatient hospital admission

The insurer denied coverage for the continued behavioral health inpatient hospital admission.

The denial is upheld.

This is a female patient who was admitted for inpatient mental health treatment after being brought in by the police after her mother called 911 due to the patient's physical aggression towards her and threatening behavior. The patient was noted to be responding to internal stimuli, talking to self, was loud and verbally abusive, had noncompliance with medications, had pressured speech, erratic behavior, bizarre behavior including laughing and clapping, slamming doors, agitation, and she stopped eating and sleeping. The patient was also smoking cannabis. The patient's psychiatric diagnoses included Schizophrenia and Cannabis Use Disorder. The patient's inpatient treatment included intramuscular (IM) Haldol, Ativan and Benadryl, and oral Lithium. The patient clinically improved and was discharged on day 15 of admission.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment. In this case, as of day 12 of admission, there were no reports of further serious psychotic symptoms such as delusions, hallucinations, or disorganized behavior, suicidal or homicidal ideation, intent, or plan, manic symptoms, aggressive, threatening, self-injurious, or agitated behavior, withdrawal symptoms or acute medical instability. Notes on day 12 of admission reported that the patient had no agitation, was socially interactive with peers, had no suicidal or homicidal ideation or hallucinations, and that the patient had good mood with appropriate affect, appropriate hygiene, and adequate behavioral control. Notes on day 13 to day 14 of admission reported that the patient denied hallucinations, suicidal or homicidal ideation, and she was calm and in good control. The patient was discharged on day 15 of admission.  

Based on the review of the medical record, as of as of day 12 of admission, there were no reports of acute or severe mental health or behavioral symptoms that justified this patient's need for 24-hour acute hospital treatment and there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital treatment setting as of then or that could not be achieved in a less restrictive level of care as of then. Thus, continued inpatient psychiatric treatment in this hospital from day 12 to day 15 of admission 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 continued behavioral health inpatient hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Solitary pulmonary nodule

Treatment: Inpatient hospital admission

The insurer denied coverage for the inpatient hospital admission.

The denial is overturned.

This is a male patient with a medical history of obesity and a body mass index (BMI) of 37; a lung nodule; and persistent cough, productive at times and otherwise dry for several months. He presented to the hospital for a planned lung surgery/procedure for evaluation of a solitary pulmonary nodule. The patient had undergone a previous endobronchial ultrasonography procedure which was negative for malignancy. On the day of admission, the patient underwent a wedge resection, lobe and lung, using video-assisted thoracoscopic surgery (VATS), bronchoscopy and endobronchial ultrasound with 1-2 biopsies. The patient tolerated the procedure well without complications and was admitted to the Post-Anesthesia Care Unit (PACU) for post-operative monitoring. The patient was noted with a right chest tube to continuous suction with minimal output and no discernable air leak. A clamp trial was preformed showing no pneumothorax on electromagnetic radiation (x-ray) imaging of the chest. He was pain controlled with minimal pain. The chest tube was removed the next day. The patient was ambulating without assistance and tolerating a regular diet. The patient was noted to be hemodynamically stable and was cleared for discharge home on day 2 of admission with instructions to follow up with the cardiothoracic surgery office in 2 weeks.

The surgical procedure performed was right VATS, pleural biopsy, right lower lobe (RLL) wedge resection. The patient was discharged within 25 hours after leaving the Operating Room (OR). Lung resection required close monitoring in this high risk patient until chest tube removal and a stable chest x-ray could ensure safe discharge. From a surgical standpoint, this patient was at risk of developing a life threatening complication (slowly developing tension pneumothorax) if discharged too soon and not ensured his pneumothorax was stable. In their discussion regarding the benefits of VATS relative to standard open thoracotomy, Up to Date notes decreased length of stay but does not indicate that ambulatory care is an accepted approach.

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 is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal -Crohn's disease
Treatment: Pharmacy/prescription drugs-Stelara
The health plan denied Stelara 90 milligrams every 4 weeks as not medically necessary. 
The reviewer has upheld the health plan's determination in whole. 

This is a patient with a history of Crohn's disease who has had disease that has been refractory to therapy with Humira, Remicade, Simponi and Entyvio. The patient has most recently been treated with Stelara and the provider seeks approval of therapy with Stelara with dosing of 90 milligrams (mg) every 4 weeks. 

The requested health service/treatment of Stelara 90 mg every 4 weeks is not medically necessary for this patient. There have been some cohort studies that have looked at dose intensification with Stelara in patients with Crohn's disease. There are, however, no well-designed randomized controlled trials that have proven the safety and efficacy of the requested therapy for treatment of the patient's medical condition. In addition, there have been no studies comparing the Stelara 90 mg every 4 weeks dosing to other biologic agents dosed as per Food and Drug Administration (FDA) labeling and that have been proven to be safe and effective in treatment of Crohn's disease. Therefore, based on the above the requested therapy is not medically necessary. This is consistent with generally accepted standards of medical practice as supported by nationally-recognized peer reviewed literature and guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

This patient is a male child who was brought to the Emergency Room due to a witnessed seizure-like activity. The Emergency Department notes indicated that it was unclear how long the patient was seizing prior to arrival. There was no fever or upper respiratory infection symptoms. There was no vomiting or diarrhea. The physical examination revealed the patient was seizing. His eyes were deviated to the right. His right side was straining more than the left. His teeth were clenched. Intravenous Ativan was given and the seizure stopped. The patient became postictal. The laboratory studies were non-concerning except they showed respiratory alkalosis, most likely due to the seizure. The patient was admitted for cardiorespiratory and neurologic monitoring. A neurology consultation was requested. The patient was to undergo an electroencephalography (EEG), and Magnetic Resonance Imaging (MRI) of the brain. The patient underwent a Computed Tomography (CT) scan of the head without contrast which was unremarkable. The MRI of the brain without contrast was unremarkable. The patient was stabilized and was discharged on Keppra with the need to follow-up with the Pediatric Neurologist. 

Current literature indicates a pediatric patient may be admitted when there is evidence of a metabolic disorder persisting despite observation, recurrent seizure, increased intracranial pressure, new and persistent focal neurologic deficits, altered mental status that is severe/persistent or there is evidence of hemodynamic instability. Within the documentation it was noted the patient presented with some confusion, but the symptoms resolved quickly without intervention. However, the submitted documentation does not detail the patient had a trial and failure of care at a lower level such as observation. The documentation detailed the patient did continue to slowly improve and was discharged the following day. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Abdominal And Back Pain (preterm labor). 
Treatment: Inpatient admission. 

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

The patient is a female, G6P0141 (gravida 6, para 0-1-4-1 [full-term, pre-term, spontaneous/induced abortion(s), living children]), who presented to the hospital at 34 weeks, 0 days, with abdominal and back pain.  She complained of contractions every five minutes.  Past medical history was significant for previous history of preterm labor, premature rupture of membranes, and shortened cervix.  

Pelvic exam in the emergency room revealed cervix 3 centimeters (cm) / 60% effaced / -2 station.  She was admitted to the hospital for preterm labor. Betamethasone was administered.  The cervix continued to dilate to 4 centimeters (cm) / 80% effaced / 2 station, with bulging membranes.   On hospital day #1, the cervix was unchanged, but contractions had ceased.  On hospital day #2, contractions were again not seen, and the cervical exam was now 1-2 centimeters / 50% effaced, and the patient was discharged home.  

The facility contends that the admission was medically necessary due to the concern for preterm labor and cites Milliman Criteria Guidelines (MCG) related to a number of obstetrical complications including threatened preterm labor requiring monitoring more than 24 hours as well as Milliman Criteria Guidelines (MCG) discharge criteria.  The health plan contends that the admission was not medically necessary because the patient was not unstable, did not have unstable vital signs that did not improve, problems with the fetus, infection, placental abruption confirmed with ultrasound, vaginal bleeding, or requirement for delivery of the baby and cites Milliman Criteria Guidelines (MCG) 24th edition.  

Yes, the proposed treatment, inpatient admission, was medically necessary.  

A patient presenting preterm with a three-centimeter dilated cervix and symptomatic uterine contractions meets the definition of preterm labor requiring admission and therefore this patient was at high risk of delivering a preterm baby within hours after presenting.  The diagnosis was further supported by subsequent progression of the cervical dilation.  Delivery outside the hospital at any gestational age is associated with significant risks to both mother and baby.  Although tocolytics are generally not given after 34 weeks, the Antenatal Late Preterm Steroids (ALPS) trial (Gyamfi-Bannerman C et al) demonstrated efficacy of antenatal steroids, as were given in this case, in this patient population to improve neonatal outcomes.  In addition, delivery outside of the hospital at this gestational age could have severe consequences to the baby, including severe short- and long-term handicap and death, due to prematurity and inability to promptly receive intensive resuscitative interventions.  Therefore, the admission was medically necessary.