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

Diagnosis: Right-sided trigeminal neuralgia versus parietal infarct versus a cerebral infection

Treatment: Inpatient hospital admission

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

This patient is a female who presented to the emergency department complaining of right facial numbness with a tightening sensation to the right side of her head.  She also complained of shortness of breath.  Upon triage her vital signs revealed a blood pressure of 129/77.  Her heart rate was 82 bpm.  Temperature was normal and oxygen saturation was 100% on room air.  The patient also endorsed spasm with twitching to the right eye.  She did indicate she arrived from outside of the United States 1 week prior.  The physical examination revealed the patient was alert and oriented.  She was in no apparent distress.  Neurologically, she was able to follow commands and had normal strength and sensation.  It was recommended the patient undergo laboratory and diagnostic studies.

The laboratory studies did not reveal any significant abnormalities.  The documentation indicated the patient had a prior CT performed outside of the country stating she had a lacunar infarct.  It was recommended they admit the patient for further evaluation and to undergo an MRI.  The patient was seen for a neurology consultation where it was noted the patient apparently had a CT scan previously out of the country revealing a right lacunar stroke however a CT scan performed with CTA done on admission appeared unremarkable.  The physician indicated the patient had concern for right-sided trigeminal neuralgia versus parietal infarct versus a cerebral infection.  It was recommended they continue with an MRI of the brain as well as transthoracic echocardiogram, a fasting lipid panel and hemoglobin A1C.  The patient continued with evaluation and there were no further adverse events noted.  The patient did undergo the MRI which revealed an unremarkable study.  The documentation detailed she denied any further significant adverse events.  She remained stable throughout the entirety of the stay.  She was eventually discharged with a Medrol Dosepak.  The patient was also recommended to follow-up.

There was a concern for stroke with a report of a prior imaging study performed in another country which, per report, showed a lacunar stroke.  However, all of her diagnostic studies from current admission including CT of the head, CTA of the head and neck, MRI of the brain were unremarkable, showing no evidence for acute stroke.  These studies could all have been performed in the ED along with neurology consultation with outpatient follow up an expeditious follow up with neurology.  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 hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient Hospital

The patient is a male with a history of hypertension, hyperlipidemia, diabetes, depression, coronary artery disease and coronary artery stents. He presented to the emergency department complaining of one month of intermittent chest pain that had been worse for the past day. His blood pressure was 116/60 millimeters of mercury (mmHg) with a heart rate of 63 beats/minute. His cardiac exam was unremarkable. His troponin level was normal. There were no acute electrocardiographic changes and his chest x-ray was normal. He was admitted to the hospital with a diagnosis of atypical chest pain. His repeat troponin level was normal.  He was seen by an endocrinologist for uncontrolled diabetes and adjustments to his insulin regimen were made. An echocardiogram showed borderline pulmonary hypertension and was otherwise unremarkable. Myocardial perfusion imaging was performed. This showed a small, fixed inferolateral defect with minimal peri-infarction ischemia.  Adjustments were made to his insulin therapy. He was seen by a nephrologist for mild hyponatremia (after correction for his blood sugar levels). This was attributed to sertraline, which he took for depression. Free water restriction was recommended. The patient was discharged home. Coverage for an inpatient admission is at issue.

The health plan's determination is upheld. 

An inpatient level of care was not medically necessary.This patient with known coronary artery disease presented with atypical chest pain that was thought to possibly represent acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. There is no indication in the records provided that other potentially life-threatening diagnoses were thought to be likely. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both safe and is in accordance with the American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. Moreover, from the records provided, the indication for continued hospitalization after ACS had been ruled out and results of myocardial perfusion imaging indicated low risk is unclear. While the patient was mildly hyponatremic and his blood sugars were poorly controlled, these are not indications for inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with Behcets syndrome with organ involvement and has uveitis. The patient has been prescribed infliximab. The health plan's determination is overturned.
Infliximab 10 milligrams (mg) is medically necessary for this patient. This is a standard of care product for the treatment of uveitis. There are many studies that show that this is safe and effective for this disease. Uveitis is an inflammatory disease and this patient has Behcets associated with uveitis.
The diagnosis is a common condition in both adults and children. This is an autoimmune disease and tumor necrosis factor (TNF) agents and other biologics have been shown to be effective. Infliximab has been safe and effective in the treatment of this condition. The risk of blindness and adverse effects from topical and systemic steroids are possible if inflammation in the eye is not controlled.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression
Treatment: Inpatient admission 

The Inpatient admission was medically necessary.

The patient represented an acutely elevated risk of dangerous behaviors, and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression and substance abuse with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.

The patient represented an elevated risk of dangerous behaviors including self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality, the patient remained depressed.  The patient had multiple static risk factors for potentially dangerous behaviors including substance abuse, substance abuse, and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained depressed with ongoing medication changes were acute risk factors for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis:  Blood disorder/other
Treatment:  Pharmacy/Prescription Drugs

The patient has familial primary periodic paralysis from hypokalemia.  The health plan has denied Keveyis for this condition because the patient does not meet the prior authorization criteria that the patient has tried and failed at least two of the following formulary medications: acetazolamide, triamterne, spironolactone, KCl, and Klor-Con.  That decision is being appealed.

The health plan's determination is upheld.  Keveyis is not medically necessary for this patient.  The requested medication, Keveyis, is in the same general class of medications as one of the formulary medications, acetazolamide.  Both are carbonic anhydrase inhibitors.
The records show that the patient experiences frequent bouts of hypokalemia symptoms from his familial disorder.  These records also show this patient or his parents are not compliant with picking up or administering prescribed medications to treat his condition. There is no evidence that the patient experiences hypokalemia while taking recommended medications that are on formulary, so there is no evidence that he needs a non-formulary medication, Keveyis, to manage his condition.  There is nothing special about Keveyis that would suggest he would be more compliant with this medication or that it would result in clinical benefit when compared to the formulary medications with which the patient has not been compliant (acetazolamide, the standard carbonic anhydrase inhibitor used as prophylaxis for period paralysis is dosed twice a day just like Keveyis).
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with a diagnosis of gross hematuria. Cytopathology Urovysion fluorescence in situ hybridization (FISH) was requested. At issue is whether the cytopathology testing for urinary tumor markers is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The health plan's determination is upheld.
The proposed cytopathology testing for urinary tumor markers is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The standard of care for evaluation of bladder cancer in patients, such as this patient, with hematuria includes a computed tomography (CT) scan and a cystoscopy. Studies have shown that FISH as a replacement for cystoscopy and cytology is not an effective tool. Although, the sensitivity is higher than cytology, the specificity is not significantly better. Hence, the use of FISH is associated with higher false positive tests leading to unnecessary evaluation. The test is mostly used for surveillance of bladder cancer in patients who already have a prior diagnosis of bladder cancer. The value of the test in detection of bladder cancer in patients with hematuria is largely unknown.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient  with a history of gross hematuria. She had a computed tomography (CT) scan which showed a 3 millimeter (mm) non obstructing right renal stone. Her urine culture was negative. The plan was for urine cytology and cystoscopy. Her urine cytology showed rare atypical cell and she had a urine fluorescence in situ hybridization (FISH) test which was negative. The health plan's determination is upheld. This patient had a urine FISH because of atypical in her urine cytology.
The authors (Mchale) states "We found urinary cytology to be more sensitivity and specific than FISH in the detection of UC, though the difference was not statistically significant. Up to 24% of high-grade urothelial carcinomas (HG UCs) are FISH negative due to an absence of FISH-detectable abnormalities in the tumor cells. Paucity of neoplastic cells in the urine also contributes to false-negative FISH results in both HG and low grade tumors. Negative urinary FISH cannot be taken alone as indicating the absence of significant disease in patients with atypical cytology."
Similarly, Virk et al state "U-FISH allows risk stratification in patients with AUC (atypical urothelial cells). However, its usefulness is diminished by the high false-positive rate, making it important to interpret U-FISH results in the patient's clinical context." This patient is of a young age to have bladder cancer. She had a cystoscopy to evaluate her lower tracts and imaging to evaluate her upper tracts.  Her urine cytology showed atypia, an option is to repeat it.  She does not have a history of (h/o) bladder cancer. 
The health plan's determination is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with gross hematuria who had a negative bladder fluorescence in situ hybridization (FISH) and atypical urine cytology. Computed tomography (CT) imaging demonstrated a non-obstructing 3 millimeter (mm) renal calculus. At issue is whether cytopathology testing for urinary tumor markers likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The health plan's determination is upheld. According to the National Comprehensive Cancer Network (NCCN) Guidelines, "Most of these tests have a better sensitivity for detecting bladder cancer than urine cytology, but specificity is lower. However, it remains unclear whether these tests offer additional information which is useful for detection and management of non-muscle invasive bladder tumors." Urine FISH is not a "generally accepted standard of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed literature generally recognized by the relevant medical community, or otherwise consistent with physician or specialty society recommendation and the views of physicians practicing in relevant clinical areas and any other relevant factors. Chou's meta-analysis concluded that "Urinary biomarkers miss a substantial proportion of patients with bladder cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors."
Appeal type: Medical necessity
Decision: Upheld

The patient who completed detoxification treatment and had received inpatient rehabilitation substance use disorder treatment  with admission/transfer for continued inpatient level services for rehabilitation substance use disorder treatment of opioid (heroin) use disorder.The health plans determination of medical necessity is upheld in whole.  The structure and intensity of services necessary for a successful rehabilitation/substance use disorder treatment can be/could have been effectively provided at a lower level of care in a less restrictive treatment setting with sober supports. There is no evidence that inpatient level structure and 24-hour monitoring is medically necessary for a successful outcome in this case. And, there were no biomedical, psychiatric or general medical issues that warranted the admission/transfer for inpatient level treatment.
 Again, there were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted inpatient level services and treatment,  Thus, the requested benefit of Inpatient substance abuse rehabilitation services was not medically necessary for this patient.  This  is consistent with prevailing standards of professional practice, ASAM Criteria, and the scientific literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild cognitive impairment
Issue under review: Increase in personal care services

Determination:
The Increase in personal care services is not medically necessary.

The patient has mild cognitive impairment with MMSE (mini-mental state examination) 19/30. The patient's needs are currently met with the health plan's approved CDPAS 7 days per week, 6 hours per day. No significant change is identified in the patient's documented medical needs requiring greater medically necessary assistance.  Based on the records provided and the community surveys completed, the patient's needs are met by seven days per week, six hours per day.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who was treated for an ingrowing toenail on both great toes. The patient already has pre-fabricated orthotics for flatfeet. The patient has not yet outgrown his current orthotics and has no pain on physical exam but did complain of discomfort associated with the orthotics. A request has been made for custom functional orthotics.

The health plan's determination is upheld.

The requested custom shoe inserts are not medically necessary. For the submitted diagnosis of plantar fasciitis, the custom shoe inserts are not medically necessary. Plantar fasciitis in a patient this young would be extremely uncommon. The medical documentation does not describe physical findings seen in plantar fasciitis. In addition, he has already attempted treatment with prefabricated orthotics, which did not provide relief. There is insufficient evidence in the medical literature that demonstrates that custom orthotics are more effective than prefabricated orthotics in the treatment of plantar fasciitis or pes planovalgus.
Appeal type: Medical necessity
Decision: Upheld

This is a female patient diagnosed with lumbar radiculitis. Records provided that a request for permanent implantation of a spinal cord stimulator was denied by the insurance carrier with the appeal upheld as not medically necessary as there was no documentation of chronic pain that is beyond what be expected by the nature of the patient's condition and the documentation did not show that the patient had clearance from a mental health provider which is required for the service. It was noted the patient did not have a diagnosis/condition that supports this device.

Psychological evaluation indicated the patient to have Diagnostic and Statistical Manual of Mental Disorders (DSM-V) diagnosis of pain disorder. It was noted there were no psychological contraindications for use of a spinal cord stimulator.
Lumbar myelogram revealed spondylosis with dynamic motion at the L4-L5 level. Compression of the thecal sac on extension. Degenerative changes with vacuum disk at the L1-L2, L2-L3 and L5-S1 levels.
Computed tomography (CT) of the lumbar spine with myelography revealed moderate spinal stenosis with lateral recess encroachment left greater than right at the L4-L5 level. Mild stenosis with right lateral recess encroachment at the L3-L4 level. Severe right foraminal narrowing at the L5-S1 level.

The health plan's determination is upheld.

No, the requested health service/treatment of Implanted device that generates electrical stimulations accessed through the skin (63650) is not medically necessary for this patient. A spinal cord stimulator is considered an appropriate treatment option when certain criteria are met for very specific diagnoses including chronic intractable pain secondary to failed back surgery syndrome, complex regional pain syndrome (CRPS)/reflex sympathetic dystrophy (RSD), chronic critical limb ischemia (CLI), chronic stable angina pectoris. The patient does not have any of these conditions/diagnoses that would support a spinal cord stimulator implant. The patient is noted be diagnosed with lumbar radiculopathy and spinal stenosis. These are not diagnosing that would be expected to benefit from a spinal cord stimulator and spinal cord implantation for these diagnoses would not be considered medically necessary and would not be considered standard of care in the general medical community.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
 
Treatment: Inpatient admission 

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

The patient is a man with a medical history notable for obesity, sleep apnea, cardiomyopathy, diabetes, hypertension, and tobacco use.  He presented for an elective cardiac catheterization which revealed severe stenosis of the obtuse marginal branch of the circumflex artery. The stenosis was treated with a bare-metal stent and balloon angioplasty.  There were no procedural complications.  He was admitted overnight, and was deemed appropriate for discharge the next day. 

The inpatient admission was not medically necessary.  The patient underwent an uneventful cardiac catheterization procedure, with no complications, remained hemodynamically stable, was ambulatory, and was tolerating oral intake.  There were no hemodynamic or clinical complications or concerns noted.  Per MCG 23rd Edition Guideline Cardiovascular Surgery or Procedure GRG: SG-CVS (ISC GRG), cardiac catheterization is an outpatient procedure.  The patient did not meet inpatient admission criteria following the procedure. 

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

Diagnosis: Shortness of breath; chest pain
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

This patient presented with chest pain, dizziness and shortness of breath.  He had a known history of ischemic heart disease and prior open heart surgery.   Upon presentation, ECG was abnormal, revealing ST depressions in the precordial leads, right bundle branch block and a prolonged QT interval.   High sensitivity troponin levels were mildly elevated.  He had an elevated HEART (History, EKG, Age, Risk factors, initial Troponin  score) consistent with a high risk of future cardiac events. (Reference 1, 2) He was admitted and ultimately further work up revealed no dynamic ECG changes.  

Based on the patient's high risk score using both the HEART and TIMI (thrombolysis in myocardial infarction) risk stratification, admission for observation and work up was indicated.   Risk assessment of patients presenting with chest pain and ST changes on ECG as well as negative cardiac enzymes was performed by Sanchis et al. (Reference 2).  Using their risk stratification schema, this patient would have a moderate to high risk of future myocardial infarction or death within one year.  Admission to the hospital for further testing and treatment was indicated.