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

Respiratory System
Inpatient hospital

Diagnosis: Pneumonia
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This is the case of a male who was brought to the emergency department (ED) due to a concern for fever, cough, and runny nose. History included fever to 102 for 3 days and nasal congestion with cough for 4-5 days.

According to the medical records, the inpatient stay was not considered medically necessary for this patient. This patient presented to the ED with cough and abnormal breath sounds, chest x-ray was consistent with right lower lobe (RLL) pneumonia. The patient was afebrile with stable vital signs on room air, no evidence of dehydration or inability to tolerate oral intake. There was no evidence of dehydration, vomiting/inability to tolerate oral intake, or need for supplemental oxygen. Vital signs were stable and physical exam noted as reassuring. Thus, this child could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ehlers-Danlos Syndrome (EDS)

Treatment: Xyrem 500 milligrams/milliliters

The insurer denied Xyrem 500 milligrams/milliliters.

The denial was upheld.

This is a male patient with a diagnosis of narcolepsy without cataplexy.  As documented by his provider, the patient has Ehlers-Danlos Syndrome (EDS) with disturbed nocturnal events that began at a young age. It was reported that the patient has mood changes on Xyrem and needed higher doses of Xyrem for efficacy due to fast metabolism.  He had residual sleepiness needing the addition of Vyvanse.  He was seen by a Psychiatrist who had diagnosed him with anxiety.  The patient was currently utilizing Xyrem 6 g twice per night (sometimes may take 4 units 3 times per night) (will keep sending the 2 prescriptions of 3 g at night and the second is a 4.5 g twice per night).  It was reported that the patient's sleep had improved since his last office visit; he was sleeping about 8 hours per night with the current medication.

The provider letter noted the patient had been on Xyrem medication at an increased dose based on laboratory results that were received noting he was a fast metabolizer.  It was stated the patient needed to take Xyrem 500 mg/mL at 12 g nightly divided in 3 doses.  The request was made to approve the medication.

Xyrem 500 milligrams/milliliters is not considered medically necessary for this patient.
Although the patient was diagnosed with narcolepsy and the request for Xyrem is reasonable, there are no controlled studies supporting the safety, efficacy and use of a dose of Xyrem over 9 gr.  In a dose titration study, Mamelak found that the peak dose was 9g/night.  Similarly in an open label extension of a trial for narcolepsy, dose titration was limited to a maximum of 9g/night. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

Based on the above, the medical necessity for Xyrem 500 milligrams/milliliters is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Carious Lesion

Treatment:  D2791 All Metal Crown; tooth #14

The insurer denied D2791 all metal crown; tooth #14.  The denial was reversed.   

This is a female patient who presented to a dentist with complaints of having problems with food impacting and bad odor coming from the interproximal area between tooth #14 and tooth #15.  Upon examination it was reported that the patient's #14 tooth was failing and recurrent caries were clearly demarcated on x-ray.  Crown placement was the appropriate treatment for the patient's affected #14 tooth.

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

The carrier denial of coverage for D2791 all metal crown, Tooth #14 is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Thumb Infection

Treatment:  Inpatient Admission

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

This is a female patient with a history of diabetes mellitus, asthma, hypertension, and hyperlipidemia.  She presented to the Emergency Department (ED) with complaints of right thumb pain after cutting her cuticles.  Plastic Surgery consulted on the patient.  The patient received intravenous (IV) antibiotics empirically.  An x-ray of the right thumb was performed which revealed soft tissue swelling.  Plastic Surgery performed an incision and drain (I&D) procedure on the patient.  Wound cultures were obtained and were positive for Streptococcus anginosus.  The patient continued to complain of pain and swelling at the affected site; a repeat I&D was done.  The patient was medically stabilized and discharged home on oral antibiotics. 

According to Stevens et al (2014)'s practice guidelines, "outpatient is recommended for patients who do not have systematic inflammatory response syndrome (SIRS), altered mental status, or hemodynamic instability" and "[h]ospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing."  In this case, the patient was afebrile, hemodynamically stable, and had no clinical signs or symptoms of systematic toxicity.  The patient's lab values were unremarkable, including a normal white blood cell (WBC) count. 

Though the patient required multiple incisions and drainage of the abscess under local nerve block, these interventions could have been provided at an outpatient basis.  There was no clinical documentation that indicates that this patient had a history of poor adherence to therapy or a history of outpatient treatment that failed.  The patient was noted to have diabetes mellitus, asthma, hypertension, and hyperlipidemia but was not considered severely immunocompromised as a reason for admission.

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 services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic Procedure

The patient is a female with Class I occlusion. There is moderate maxillary crowding and moderate mandibular crowding. There is moderate overjet and moderate overbite. The case has an anterior crossbite at teeth #10 and #22. The subject to be determined is the medical necessity for braces.

The health plan's determination is upheld.

The requested treatment with braces and monthly periodic dental visits are not medically necessary for this patient. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 22 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeter (mm) or greater and underbite 3.5mm or greater. Based on the standard of care there is a requirement of a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the standard criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal
Treatment: Inpatient hospital stay

This patient with medical history significant for atrial fibrillation, chronic alcohol abuse, and cocaine abuse came to the emergency department requesting alcohol detoxification. The patient was admitted to telemetry for further management of anemia. Review of systems was positive for blood mixed with stool. The patient complained of weakness, dizziness, and shortness of breath with exertion and severe bleeding from the left leg a few days prior to admission. The rest of the physical exam was reported as unremarkable. Rectal exam revealed an anal skin tag with no masses. Fecal occult blood test was negative. Laboratory evaluation revealed white blood cell count of 9.3, hemoglobin 6.8, hematocrit 19.9, and platelets 288. Sodium was 133, potassium 4.5, chloride 104, bicarbonate 24, blood urea nitrogen (BUN) 15.6, creatinine 1.03, and glucose 107. Urinalysis unremarkable. The patient's creatine phosphokinase (CPK) slightly elevated at 696. The patient was admitted with a diagnosis of alcohol dependence and withdrawal, atrial fibrillation, bilateral lower extremity edema and stasis dermatitis with a venous ulcer in the lower extremity, hypertension, and cocaine use disorder. Gastrointestinal (GI) consult was requested. The patient was started on the Clinical Institute Withdrawal Assessment (CIWA) protocol but never developed alcohol withdrawal symptoms during the hospital stay. The patient was evaluated by a GI specialist. The patient reportedly refused endoscopic and other procedures. The patient was also seen by a hematologist/oncologist who recommended an infusion of Venofer which the patient refused. The patient underwent transfusion of packed red blood cells with improvement in hemoglobin and hematocrit (H&H) level. The patient was seen by a podiatrist for chronic venous stasis dermatitis. Conservative care was recommended. Surgical intervention was not required. The patient was seen by a psychiatrist who found the patient capable of making his own medical decisions. The health plan's determination of medical necessity is upheld. The inpatient hospital stay was not medically necessary at the acute inpatient level of care, due to overall clinical stability including hemodynamic stability, as well as normal respiratory status, lack of active bleeding, hemolysis, cardiac or peripheral ischemia. It was indicated that the patient was subjectively symptomatic, however objectively the patient was hemodynamically stable, was afebrile, had normal respiratory rate, normal blood pressure, normal oxygen saturation, and normal neuro exam.  The patient adequately responded to treatment with a transfusion of one unit of packed red blood cells. Admission at a lower level of care was justified to ensure hemodynamic stability as well as perform anemia workup, and to offer the patient endoscopic studies that were definitely indicated, considering the circumstances.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD
Treatment: Stretta procedure
The health plan should not cover the proposed treatment with the Stretta procedure.

The requested health service or procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.

Available citations support the role of Stretta in select cases of refractory GERD. As summarized by the company website: "When patients suffer from chronic GERD that is not well controlled with medications, or where long-term medications are not a viable option, Stretta offers an alternative other than surgery and implants. Stretta is a unique and minimally invasive outpatient procedure that takes about an hour, with patients returning to normal activities within a few days. Studies show that Stretta resolves reflux symptoms and improves quality of life; Stretta reduces or eliminates medications and reduces acid exposure; is a minimally invasive option that treats the underlying cause of GERD not just the symptoms. More than 33 clinical studies all conclude Stretta is 'safe and effective'."

Stretta was approved by the United States Food and Drug Administration (FDA) in 2000. This endoscopic technology was originally produced and marketed by Curon Medical, Inc., but the company filed for bankruptcy in 2006. The device has been the subject of recalls (Reference: https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRes/res.cfm?ID=154736) as well as observational studies aimed at re-assessing device safety and efficacy (Ref. https://clinicaltrials.gov/ct2/show/NCT03574831). Available database in the patient's case provides no absolute contraindication to the proposed service.

As per Sandhu: "Of the several available medical, endoscopic, and surgical therapies for GERD, Stretta therapy has established itself as an attractive option for patients who would like to avoid the dependence and risk of long-term medical therapy and complications or loss of efficacy overtime of surgery. The safety and efficacy of the Stretta procedure has been demonstrated in several thousand patients over the last 15 years. Stretta is a viable low cost and safe procedure for adult patients with GERD who require long term PPI treatment. Most importantly, Stretta does not preclude other therapies if needed and can be repeated when necessary."

However, relative to the case under review, the patient has suspected laryngeo-pharyngeal reflux but she has undergone Nissen fundoplication and as such she has no clinically significant esophageal reflux by either radiologic criteria nor close inspection of pH data. Further, her lower esophageal sphincter is intact relative to pressures and function, and therefore does not require further augmentation. Accordingly, the appropriateness of the Stretta procedure as proposed is not confirmed upon examination of the patient's available records.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD
Treatment: Stretta procedure
The health plan should not cover the proposed treatment with the Stretta procedure.

The requested health service or procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.

The technique of endoscopic radiofrequency for GERD has been studied almost exclusively in patients with typical GERD symptoms (not LPR without GERD as in this case), abnormal esophageal pH, and no previous Nissen fundoplication (this patient had an intact Nissen).  Even in those studies, there remains controversy in regards to whether or not there is sufficient long term followup data showing adequate benefit.  There have not been sufficient studies in patients who have an intact Nissen Fundoplication that suffer from laryngopharyngeal reflux showing short term or long term benefit.  Therefore, this technique should be considered experimental/investigational.

There have not been sufficient studies in patients who have an intact Nissen Fundoplication that suffer from laryngopharyngeal reflux showing short term or long term benefit, hence this technique is considered investigational.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: GERD
Treatment: Stretta procedure
The health plan should not cover the proposed treatment with the Stretta procedure.

It cannot be said with any medical certainty that the proposed anti-reflux procedure (STRETTA) will be more beneficial than any standard treatment for this patient's condition.  

The Stretta procedure is unproven in the setting of prior esophagogastric intervention such as prior Nissen fundoplication and hiatal hernia repair as performed for this patient.  

While STRETTA has received FDA approval (2000) for the treatment of GERD in appropriate clinical circumstances, in this case the patient has had prior surgical manipulation of the stomach/esophagus with prior anti-reflux operation and esophageal hiatus surgery.  There is no peer-reviewed literature to support the safety/efficacy of STRETTA in this setting. 

In addition, the Plan medical policy states that this therapy is experimental/investigational.  

In this case the proposed STRETTA has not been demonstrated through peer reviewed literature to be safe and effective for the treatment of reflux symptoms in the setting of complicated prior anti-reflux surgical interventions as detailed above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematuria, Renal Retention

Treatment: Inpatient Admission

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

This is a male patient with a history of hypotension and congestive heart failure (CHF). He presented to the Emergency Department (ED) with complaints of a clogged Foley catheter. It was reported that the patient was status post transurethral resection of the prostate (TURP). Urology and Surgery were consulted. A new Foley catheter was inserted that drained gross hematuria and clots. An electrocardiogram (EKG) was performed that showed a normal sinus rhythm. The patient was admitted to the hospital for a treatment plan that included bladder irrigation with 3 liter of sterile water and removal of the blood clots.  It was reported that the patient's urine was clear the following day and he was discharged home with outpatient instructions to follow up with private urologist. 

According to the MCG Health (24th Edition) Urologic Disease GRG (MG-UD), the patient fails to meet clinical indications for admission to inpatient care. This patient had gross hematuria but did not have evidence of renal obstruction, clot retention after urinary catheterization and irrigation, severe anemia and/or systematic cause (e.g. Goodpasture syndrome) needing inpatient care. As per Surgical History & Physical note the patient's bladder irrigation with 3 liters of sterile water removed copious amount of clots, and the return was "eventually clear." The patient's urine was rendered clear after his catheterization and irrigation, and remained clear until the following day. The patient's lab showed low hemoglobin and hematocrit levels at 9.9 and 29.8% respectively, but the patient's vitals were stable and the patient did not require blood transfusion. The patient's coagulation profile results were within normal limits. The patient's cardiac enzymes were not elevated. The patient's urine remained clear to the following day, when the patient was discharged. Based on this information, the patient's gross hematuria resolved with urinary catheterization and irrigation. The patient was hemodynamically stable and did not have complications associated with the episode of hematuria. The patient could have been safely monitored at a less intensive setting, such as observation. Thus, inpatient admission was not considered medically necessary to treat this patient's medical condition. 

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

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

Diagnosis: Headache and gait imbalance 
Treatment: Inpatient admission 

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

No, the inpatient admission was not medically necessary. 

The patient is a female with a history of hypertension and polysubstance use disorder who presented with the complaint of headache and gait imbalance for two days. At presentation her computed tomography (CT) was negative for acute findings, vital signs were normal and she had unsteady gait but no focal findings. Magnetic resonance image (MRI) of the brain was negative. 

The presenting symptoms, clinical history, and diagnostic studies did not warrant acute inpatient admission. There was no evidence of thunderclap headache and risk stratification for transient ischemic attack (TIA) does not support acute inpatient level of care based on presenting signs and symptoms. The patient could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Paroxysmal atrial fibrillation 
Treatment: Inpatient admission 

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

The patient is a male with a history of paroxysmal atrial fibrillation who presented to the hospital for elective redo left atrial catheter ablation. Following successful electrophysiologic study with catheter ablation, the patient had an uncomplicated post-operative course and was discharged home the following day. 

No, the inpatient admission was not medically necessary. 

This patient presented to the hospital for an elective electrophysiologic (EP) study and ablation of atrial fibrillation. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable and no post-operative issues were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity. (Reference 1) Another study demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. (Reference 2) The current standard of care in an uncomplicated atrial fibrillation ablation is to manage patients at a lower level of care.