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

Diagnosis: Chest pain
Issue under review: Nuclear perfusion imaging
The Health Plan denied Nuclear perfusion imaging
The health plan's determination is overturned.

The patient is an adult male. He presented with new onset of chest pain, dyspnea. A nuclear stress test was ordered. Clinical indications listed were "evaluation for arrhythmia, chest pain, dyspnea, ischemia, and safety of exercise." He has history of hypertension, hyperlipidemia, positive family history, and previous stress test with repolarization changes (but normal nuclear scans). His present EKG (electrocardiogram) showed poor R wave progression. Echocardiogram showed normal EF (ejection fraction) with LVH (left ventricular hypertrophy). Holter monitor showed PVCs (premature ventricular contractions) and PACs (premature atrial complexes). 

The patient exercised for 10 minutes on Bruce protocol. The rest revealed repolarization changes on EKG. Results were normal EF, no evidence for ischemia, and considered a normal exercise nuclear myocardial study.

The patient meets criteria for a stress test based on new symptoms of chest pain, dyspnea with multiple major risk factors for CAD (coronary artery disease) present. The patient's baseline EKG was abnormal, LVH was present on echocardiogram and the previous treadmill test showed repolarization changes consistent with ischemia (false positive), likely related to his LVH. While a "plain" exercise treadmill test would be appropriate with his presentations and risk factors alone, the presence of a previous false positive treadmill test, an abnormal baseline EKG, and LVH on echocardiogram would lead to a high probability of inaccurate findings. Adding the nuclear scan component to the work up increases the predictive value of the test. An exercise treadmill test by itself would likely show abnormal repolarization changes leading to the nuclear test or cardiac catheterization being performed. The choice of an initial noninvasive test of the nuclear scan is appropriate in this setting and consistent with community care and guidelines.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chest pain
Issue under review: Nuclear perfusion imaging
The Health Plan denied Nuclear perfusion imaging
The health plan's determination is overturned.

The patient is an adult male with a past medical history of hypertension, dyslipidemia, former smoker, with family history of coronary artery disease (CAD). He presented for evaluation of new onset chest pain. 

The patient's ECG (electrocardiogram) was unremarkable. The patient had a prior stress test with abnormal ECG response (ST depressions) and normal perfusion and was treated medically. Echocardiogram revealed LVH (left ventricular hypertrophy) with normal LV (left ventricle) systolic function. 

The patient underwent an exercise nuclear stress test, which revealed abnormal exercise ECG response with ST depressions in inferior and lateral leads, and normal nuclear perfusion imaging. 

This patient has an intermediate pre-test probability of CAD, based on his prior diagnoses, co-morbid conditions and family history of CAD. Use of a nuclear stress test in a patient with intermediate pre-test probability of CAD (as defined by the ACC/AHA guidelines on the basis of age, gender and symptoms) with symptoms of chest pain would be considered an appropriate indication as defined by the ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 Appropriate Use Criteria for Cardiac Radionuclide Imaging. In addition, the patient had a prior exercise stress test, which had shown an abnormal ECG response. This is also consistent with his diagnosis of LVH (left ventricular hypertrophy) documented on his echocardiogram. Therefore, additional imaging modality, such as nuclear perfusion imaging would be required in his case for accurate diagnosis.  Confirming (or ruling out) the diagnosis of coronary artery disease in a patient such as this would have a prognostic significance, as patients with abnormal perfusion study have a higher incidence of adverse cardiac events (CV [cardiovascular] death, MI [myocardial infarction], CVA [cerebrovascular accident] or urgent revascularization), compared to patients with normal perfusion studies. Also, there would be a meaningful change in medical management expected, based on the result of this test, as a positive test would require significantly more aggressive goals of risk factor control, including lipid levels. The preventive measures, which would normally be instituted in the result of an abnormal stress test have been shown to be beneficial in terms of health outcomes, which was the reason for their inclusion in the current guidelines. 

Finally, if a significant area of ischemia were identified on the test, revascularization by the means of PCI (percutaneous coronary intervention) or CABG (coronary artery bypass graft) would be expected to result in a positive health outcome as well, in terms of symptom relief, and in some specific cases mortality. 

Therefore, given the fact that the use of this testing modality is considered appropriate according to the ACC/AHA/ASN criteria, this test would be expected to result in health outcome benefit in this patient with intermediate probability of CAD.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic Procedure

The patient in question with a Class I occlusion with appropriate overjet and a slightly deep bite. The maxillary and mandibular arches have moderate spacing. The patient is treatment planned for 18-24 months of orthodontics to correct the malocclusion. The insertion and adjustment of braces is under review. 

The health plan's determination is upheld. There is no medical reason to correct the mild spacing with braces. The patient does have a mild deep bite, however, that alone is not a medical necessity to treat. Deep bites may be corrected in adulthood, so it is not as if the patient will lose the ability to correct the malocclusion should the patient choose to do so as an adult. Additionally, while the patient does have incisor protrusion, research shows that there is not an increased risk of incisor trauma unless the overjet is greater than or equal to 5 millimeters. This patient does not have an overjet that large.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post abdominal myomectomy  
Treatment:  Inpatient stay  

The patient is a female, who was admitted as an inpatient to the hospital.  She underwent an abdominal myomectomy.  The procedure was completed without complications, and an EBL (estimated blood loss) of 250 cc.  

The patient underwent an exploratory laparotomy.  Exploratory laparotomy is not an ambulatory procedure.  The postoperative care of patients who have undergone laparotomy includes inpatient observation for postoperative complications including intra-abdominal hemorrhage, postoperative pelvic infection and progression to normal bowel function.  The patient underwent an uncomplicated laparotomy procedure.  She was transferred to the PACU (post anesthesia care unit) in satisfactory condition and recovered there without incident.  She was transferred to the inpatient floor.  She was in significant pain requiring parenteral medication and was not ambulating.  She could not tolerate a normal diet.  The Foley catheter was in place.  

On postoperative day 1 the patient was still in significant pain requiring parenteral medication and was not ambulating.  She still could not tolerate a normal diet.  The physician progress notes indicate that the patient was tolerating a normal diet, ambulating and was transitioned to oral pain medications by the end of the first postoperative day 2.  Her vital signs were normal, and she was normally voiding and ambulating at the end of the second postoperative day.  The Foley catheter had been removed and she was voiding normally.  Therefore, the patient's condition was appropriate for discharge at the end of the postoperative day 2.  Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Rheumatoid Arthritis
Treatment Acthar Gel   The insurer denied Acthar Gel
The determination is upheld.

The patient has severe, advanced seropositive rheumatoid arthritis (RA). He has failed or had adverse effects to steroids (e.g. prednisone), Xeljanz, Actemra, SSz, methotrexate (MTX), Arava, intravenous immunoglobulin (IVIG), morphine, Sulfasalazine, (SSz), Dilaudid, Nucynta, oxycodone, oxymorphone and methadone. He is currently on prednisone 17.5 milligrams (mg) daily. The patient's provider is requesting Acthar gel. At issue is the medical necessity of the Acthar gel.

Acthar gel is not medically necessary; it is not the standard of care for the treatment of RA. Treatment of RA includes nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, disease modifying anti-rheumatic drugs (DMARDs) and biologics. He has tried several already but he has yet to try a tumor necrosis factor (TNF) antagonist (e.g. Humira or Enbrel) or a T cell inhibitor (e.g. Orencia or rituximab).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eczema  
Treatment: Dupixent injections  

The patient is a female with asthma and a six month history of an itchy coin-shaped rash on the face, hands and trunk that has failed treatment with Clobetasol, triamcinolone and betamethasone.  She has had eczema for years.  Her provider is requesting Dupixent injections.  

Dupilumab is an interleukin (IL)-4 and IL-13 receptor-alpha antagonist that was approved by the US Food and Drug Administration in March 2019 for the treatment of adolescents aged 12 years and older with moderate to severe atopic dermatitis (AD) not adequately controlled with topical prescription therapies.  

Despite its relapsing and remitting nature, the majority of patients with AD can achieve clinical improvement and disease control with nonpharmacologic interventions (eg, emollient use), conventional topical therapies (including corticosteroids, PDE4 inhibitors and calcineurin inhibitors), and environmental and occupational modifications, when necessary.  Phototherapy is recommended as a treatment for both acute and chronic AD in children and adults, after failure of the measures mentioned above.  Systemic immunomodulatory agents, such as cyclosporine, are indicated and recommended for the subset of adult and pediatric patients in whom optimized topical regimens using emollients, topical anti-inflammatory therapies, adjunctive methods, and/or phototherapy do not adequately control the signs and symptoms of disease, and contact dermatitis has been considered.  Phototherapy and systemic immunomodulating agents may also be used in patients whose medical, physical, and/or psychological states are greatly affected by their skin disease, which may include negative impact on work, school performance, or interpersonal relationships.  

The patient has only used topical steroids in the past and has not attempted any other available topical therapies, environmental and occupational modifications that would optimize therapy, or systemic immunomodulatory therapies, such as cyclosporine. Therefore, Dupilumab is not considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain 
Issue under review: Inpatient admission 

Determination: The inpatient admission was medically necessary. 

The patient is an adult female with a past medical history significant for breast cancer, s/p (status post) lumpectomy, on Anastrozole, GERD (gastroesophageal reflux disease), and cholecystectomy. She presented to the ER for epigastric pain and chest pain. 

The patient's ECG (electrocardiogram) revealed left bundle branch block (LBBB). Serial troponins were obtained and were negative. Her initial hepatic transaminases were normal, but repeat test revealed severely elevated transaminases with AST (aspartate amino transferase) of 1416 and 1538. The patient was admitted for work-up and management of acute hepatitis of unknown etiology. Imaging, including a CT scan and abdominal ultrasound was performed, revealing fatty liver infiltration. Viral hepatitis panel was sent and was negative. The enzymes were trended and gradually decreased. The patient was discharged with a plan for outpatient follow-up. 

The patient presented for evaluation of epigastric and chest pain in the setting of LBBB on ECG. Her cardiac enzymes were negative. However, the laboratory work-up revealed severe elevation of transaminases, consistent with acute hepatitis, which complicated her hospital course and required additional imaging and follow-up. Given the presentation complicated by an acute severe hepatitis, with transaminase level in the 1400-1500 range, risk of progression to fulminant hepatic failure, she would not be an appropriate candidate for an ED chest pain observation unit. It would be consistent with the current standard of care that this patient be managed in an inpatient setting. Therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain
Issue under review:  Inpatient admission

Determination:  The Inpatient admission was not medically necessary.

The patient is an adult female.  She presented to the emergency department with a one day history of 8-9 out of 10 abdominal pain with nausea, emesis and a decreased appetite.  The patient's prior medical history was significant for obesity and hypertension. 

The patient's presenting vital signs were within a normal range.  The patient evidenced right lower quadrant abdominal pain with a level of 6 out of 10.  A CT scan showed changes consistent with cecitis and ileitis.  The white count was elevated at 15.16 with a left shift.  The patient received IV antibiotics, IV fluids and supportive care while in the emergency department.  She was admitted and continued to receive supportive care.  She was started on a clear liquid diet on hospital day #3.  She was advanced to a soft diet the following day.  She was discharged when deemed stable.

The care as provided was medically appropriate, but the level at which this care was delivered was not medically necessary.  The care could have been provided at a lower level of care, such as an observation level, as explained in detail below.

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 infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) 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: Upheld

Diagnosis: Acute coronary syndrome (ACS)

Treatment: inpatient hospital admission

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

This patient is a male who presented to the Emergency Department (ED) with a complaint of shortness of breath followed by a sensation that he could not breathe followed by a feeling of weakness.  The patient's symptom was present for about three days prior to ED presentation. The patient's initial vital signs included blood pressure of 157/88, heart rate of 63, respirations of 16, temperature of 98.2 and oxygen saturation of 97% on room air. On patient exam, no abnormalities were described. The patient denied chest pain, fever, palpitations or other acute complaints.  The patient previously used an inhaler for unknown reasons but no longer used it. The patient's current home medications included omeprazole, Tylenol PRN and cough syrup.  The patient's review of systems was otherwise unremarkable. The patient had a history of colonoscopy a couple years ago with several polyps removed at that time. Otherwise, the patient had no known past medical or past surgical history.

The patient's workup in the ED showed EKG with some inferior T changes, and repeat EKG showed minor changes in these T-waves.  The Cardiology consult recommended observation. The patient remained asymptomatic with negative troponin levels.  A note stated that the patient was in the bathroom when SVT was noted on the telemetry monitor.  The patient was noted to be asymptomatic during this event.  Another note written stated that the patient was stable for discharge and was advised to follow up with his primary care provider as an outpatient.  The note stated that since cardiac workup was negative acute coronary syndrome was ruled out, and no further workup was needed at this time.

Multiple observation protocols have been developed which have been shown to be safe and deliver effective care.  Recognizing the value of an Observation Unit, studies report that over one third of hospitals now have implemented an ED observation unit. (7)

This patient presented to the Emergency Department (ED) complaining of shortness of breath in addition to being aware of a sensation that he could not breathe.  The patient was also aware of weakness with these episodes and reported that these symptoms had been recurring for the past several days.  The patient's workup for acute coronary syndrome (ACS) was negative, with troponin X2 results within normal limits, EKG X3 showing no interval change and no evidence of myocardial injury or ischemia and negative chest x-ray.  The patient was admitted to the hospital and placed in a telemetry unit, which is not considered medically necessary.  The literature recognizes the use of an observation unit for this type of patient. Thus, the patient's inpatient admission was not medically necessary.

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

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

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.
The inpatient admission was medically necessary.

The patient is a male whose inpatient admission is under review. The patient had an altercation/fist fight about ten days prior to the emergency department (ED) visit. Four to five days prior to admission, there was increased pain and swelling in an around his elbow with drainage and pus for a few days.

Physical exam revealed:
Temperature (T) - 98.1  
Pulse (P) - 75  
Blood pressure (BP) - 130/86  
Respiratory rate (RR) - 18
General - no acute distress (NAD)
Chest - normal
Cardiovascular system (CVS) - normal
Abdomen - normal
Musculoskeletal (MSK) - right arm and elbow swelling, with punctate opening around olecranon; decreased range of motion (ROM) secondary to pain. 

Labs revealed:
White blood cell (WBC) - 9.9
Hemoglobin (Hg) - 10.7
Hematocrit (Hct) - 32.2
Platelets (Plt) - 317
Sodium (Na) - 139
Potassium (K) - 4.8
Chloride (Cl) - 102
Carbon dioxide (CO2) - 28
Blood urea nitrogen (BUN) - 19
Creatinine (Cr) - 1.36 (high)
Creatine phosphokinase (CPK) - 492 (high)

Computed tomography (CT) of the upper arm showed diffuse forearm edema, most prominent along dorsal proximal forearm.

In the ER, the patient was started on cefazolin for right upper extremity cellulitis/abscess and the patient was initially placed in observation. The extent of the infection at the time was unknown. The patient had an elevated CPK. General surgery was consulted. He was then thought to have olecranon bursitis and was admitted for IV antibiotics. Orthopedics consultant did not think the patient needed drainage. The patient improved and was sent home on oral (PO) antibiotics.

The patient meets the initial criteria for intravenous (IV) treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (IDSA) (1), as he was suspected of having a deep infection (joint space or bursa). The team acted reasonably, first placing patient in observation and then upgrading to admission when they thought he had a deeper process in his olecranon bursa or joint space. Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer # 3:

This is a male patient who had a history of chronic axial low back pain. He described his pain to be constant, aching, throbbing with discomfort. It was reported that the pain was aggravated by increased activity such as bending, walking, standing for prolonged period of time. His physical exam showed decreased range of motion with pain on flexion extension; the patient's straight leg raise was noted to be negative bilaterally. He underwent a magnetic resonance imaging (MRI) that showed L3-4 no change in disc bulge resulting in mild central canal stenosis with moderate left and mild right foraminal stenosis. This abuts the exiting left L3 nerve root unchanged from prior study. The L4-5 showed no change in disc height loss with disc bulge effacing the thecal sac resulting in mild central canal stenosis. Recommendations were made for an Intracept Procedure.

Based on the current literature and FDA clearance, the requested procedure, Intracept Procedure, is found to provide relief for a certain number of patients that have history of chronic pain with Modic type I and II changes on magenetic resonance imaging (MRI). The procedure is used for patients with history of chronic back pain within the six months that failed to respond to conservative treatment.      

Per Becker, S. et al (2017), "Ablation of the [basivertebral nerve] for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period."

Per Fischgrund, J. S., et al. (2018), "Patients treated with [radiofrequency] ablation of the [basivertebral] for [chronic low back pain] exhibited significantly greater improvement in [Oswestry Disability Index] at 3 months and a higher responder rate than sham treated controls. [Basivertebral] ablation represents a potential minimally invasive treatment for the relief of chronic low back pain. These slides can be retrieved under Electronic Supplementary Material."

Per Fischgrund, J. S., et al. (2019), "Patients treated with [radiofrequency] ablation of the [basivertebral nerve] for [chronic low back pain] exhibited sustained clinical benefits in [Oswestry Disability Index] and [visual analog scale] and maintained high responder rates at 2 years following treatment. Basivertebral nerve ablation appears to be a durable, minimally invasive treatment for the relief of [chronic low back pain]."

The patient would be a good candidate for the Intracept procedure. The patient has a history of chronic pain and despite prior conservative treatments including physical therapy in addition to injections, the patient continued to have some worsening symptoms. The imaging showed that the patient had Modic type I L5-S1 changes along with positive findings on exam. As such, this patient is a good candidate for the Intracept procedure.     

The carrier's denial of coverage for the Intracept Procedure should be reversed.