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

This is a patient who was diagnosed with lumbar spondylosis, lumbar intervertebral disc displacement and lumbar intervertebral disc degeneration. The patient is noted to have a history of radiculopathy.  The patient was recommended to undergo radiofrequency ablation at L3, L4, L5 on the left.  The health plan's determination is upheld.
There were no special tests performed on examination that suggest that the patient's pain is coming from the facet joints. There were no imaging studies submitted to rule out other causes for the pain. There was also a lack of documentation showing that the patient has tried and failed an appropriate course of conservative management to include physical therapy and/or chiropractic treatment in combination with the daily home exercise and stretching program. Radiofrequency ablation would not be a standard treatment for patients who have radicular symptoms and would not be expected to be as beneficial or more beneficial than other standard treatment options for this condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple lumbar vertebrae compression fractures
Issue under review: Group two support surface

Determination:
The group two support surface is not medically necessary.

The mattress is for the convenience of the patient and not medically necessary towards the medical condition of "rest" and "pain relief" due to lumbar vertebrae compression fracture. There is no defined need to prevent pressure ulcers and other medical conditions for which a powered pressure air mattress would be medically necessary.

The patient's request is for a powered pressure-reducing air mattress to help provide pain relief and rest. There is no documented evidence of the patient having pressure ulcers. He has no ongoing relevant medical issues for which the powered pressure-reducing air mattress would be needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Granulomatous Gastrointestinal (GI) Inflammation
 
Treatment: Inflectra Intravenous Infusion

The insurer denied the Inflectra Intravenous Infusion. The denial was upheld.   

This is a male patient with a history of elevated mass body index (BMI) and migraine headaches. He was diagnosed with granulomatous gastrointestinal (GI) inflammation in mid-2019. His initial treatment consisted of omeprazole and Carafate with corticosteroids and was then transitioned to Inflectra. He was monitored on Inflectra reaching a maintenance therapeutic drug level without drug antibodies. 

Based on the review of the medical records provided, patient's symptoms (i.e. abdominal pain) of inflammatory bowel disease (Crohn's disease) were controlled at his starting dose of 5mg/kg of inflectra. At that dose, patient achieves good serum drug level with no antibodies. The patient even showed clinical improvement noted by his weight gain. Rather, there was clinical concern for increasing the inflectra dosage since patient was noted to have worsening axillary rash on current dose, which indicates an anticipated intolerance to the proposed dose escalation of 10mg/kg. The record indicates that the provider's reason for increasing the dosage is because the provider opined that the therapeutic drug level identified at 4 weeks will not be maintained at 8 weeks interval.  However, as to date, literature support for this proactive therapeutic drug monitoring is lacking, especially for patients whose symptoms are adequately controlled by the induction dose of inflectra. 
	
The American Gastroenterological Association (AGA) issued in August, 2017 published new guideline recommendations on therapeutic drug monitoring (TDM) for patients with inflammatory bowel disease (IBD) treated with anti-TNF agents and thiopurines.  Pertinent to this review, AGA conditionally suggested the use of reactive TDM to guide treatment changes in patients with active inflammatory bowel disease, but acknowledged that there currently exist no defined cut-offs by which to judge low versus high titer anti-drug antibodies. AGA avoided sanctioning routine proactive TDM of anti-TNF therapy in patients like this case appellant with clinically improved inflammatory bowel disease.

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 increase the dose and frequency of Inflectra intravenous infusion to 10mg/kg every 6 weeks for the patient's Crohn's disease is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient presents with a history of hypertension and polysubstance abuse to the emergency department complaining of a severe headache. The patient had been non-compliant with the antihypertensive drug regimen. In the emergency department, blood pressure was 234/120 millimeters of mercury (mmHg) with a heart rate of 91 beats/minute. Physical exam, including a neurologic exam, was unremarkable. Renal function was normal. Serum troponin and brain natriuretic peptide (BNP) levels were normal. Urine drug screen was positive for cocaine, opiates and methadone. Head computed tomography (CT) scan showed no acute pathology. An electrocardiogram showed anterior T wave inversions without acute ST segment changes. The patient was treated with diltiazem 20 milligrams (mg) intravenously. The headache improved. Repeat blood pressure was 165/79 mmHg. The patient was admitted to the hospital for management of hypertensive urgency. Home medications were restarted. Patient was discharged home.
The health plan's determination is upheld.

An inpatient level of care was not medically necessary.
This patient presented with marked hypertension due to substance abuse and medical noncompliance.There was no evidence of end-organ damage and, based on the records provided, an inpatient level of care was not medically necessary for blood pressure management. There is no evidence that rapid lowering of blood pressure in patients with severe hypertension and no evidence of end-organ damage, is of benefit and in fact, it can be harmful. Outpatient titration of antihypertensive medications with lowering of blood pressure to goal over a period of weeks has been shown to be both safe and effective. The patient could have been treated at a lower level of care status; inpatient was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department of 2/24/18 for evaluation of chest pain radiating to the left arm and jaw. There was an associated productive cough, night sweats, and a single episode of vomiting with streaks of blood. The patent has a history of coronary artery disease status post percutaneous intervention. He was afebrile and hemodynamically stable. The health plan's determination of medical necessity is upheld. There were no ischemic EKG changes, serial troponin ruled out myocardial infarction, and there was no structural heart disease on echocardiogram. Chest imaging was negative for infiltrate, pulmonary edema, central pulmonary embolism, or thoracic aortic aneurysm/dissection. The patient was hemodynamically stable and there was improvement in the chest pain with continuation of prior medical management for coronary artery disease. The stress test was negative for ischemia.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with hemoglobin sickle cell (SC) disease who presented to the emergency room (ER) with complaints of progressive bilateral lower extremity pain 9/10 in severity.  The patient was diagnosed with sickle pain crisis and admitted for inpatient care.  The patient was treated with oral hydromorphone, intravenous (IV) Toradol, IV fluids, and diphenhydramine.  The health plan's determination of medical necessity is upheld.  The patient was admitted with complaints of lower extremity pain.  She was initially treated with oral analgesics - an intervention that does not require inpatient care.  The patient subsequently received Toradol and was discharged with improvement. She patient did not require intensive nursing care.  She remained hemodynamically stable and received limited intravenous fluids.  She did not have signs of infection and did not require surgical intervention, exchange transfusion, or other aggressive interventions.
Appeal type: Medical necessity
Decision: Upheld

This hypertensive, diabetic patient with a history of chronic obstructive pulmonary disease, chronic pain syndrome, post-traumatic stress disorder and both prescription and street-abused drug usage was evaluated in the emergency room for a change in mental status after losing consciousness after taking Xanax and Percocet. The health plan's determination is upheld. Following Narcan administration the patient was hemodynamically stable without significant electrocardiographic or biochemical findings suggesting a cardiac etiology for the patient's loss of consciousness. There was no acute neurologic process discernible. The patient's loss of consciousness was readily explainable by the accidental drug overdose. Several risk factors for coronary artery disease (CAD) were present and it was appropriate to assess the patient for the presence of CAD with a stress test and management of the patient's atrial fibrillation, which do not require an acute care inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

The patient has severe atopic dermatitis, treated with topicals, oral antibiotics (hospitalized with septic shock from cellulitis), and methotrexate. Dupixent (dupilumab) SC Injection is being requested and is under review.

The health plan's determination is overturned. Dupixent is medically necessary for this patient. Dupilumab is United States Food and Drug Administration indicated for treatment of recalcitrant atopic dermatitis and can potentially make a significant impact of this patient's life. This patient has a large body surface area which makes topicals a much less appropriate therapy. He has already been treated with methotrexate and due to his history of infection further traditional immunosuppressants are not ideal.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic fatigue and gait ataxia
Issue under review: Increase in consumer directed personal care assistance services hours

Determination:
The Increase in consumer directed personal care assistance services hours is not medically necessary.

The patient is a female with a history of chronic neck and joint pain from degenerative osteoarthritis and chronic, uncontrolled asthma. Although the patient has chronic fatigue and associated gait ataxia for which she requires assistance to complete some of her activities of daily living, a recent New York Comprehensive Community Assessment Report determined that the currently approved hours of consumer directed personal care assistance services hours is sufficient to meet all of the patient's needs. There are no medical records or evidence with indicate that the patient has sustained a further decline in her overall function since this last assessment date. For these reasons, the proposed treatment of an increase in consumer directed personal care assistance services hours is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath and dyspnea
Treatment: Inpatient admission
The proposed treatment was medically necessary.
The patient presented with symptoms of acute CHF exacerbation, with known severe systolic dysfunction and CAD. This patient with multiple co-morbidities, who presented with CHF exacerbation was appropriately treated with IV diuresis. He required close monitoring of his CHF. Given this presentation, acute CHF, as well as multiple risk factors, co-morbid conditions and known CAD, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Morbid obesity, automatic implantable cardioverter defibrillator (AICD) placement in 2010, acid reflux (Not actually documented), hypertension, type 2 diabetes, and cardiomyopathy

Treatment: Inpatient admission, diagnostic evaluation, and medication management

The insurer denied weight loss surgery. That denial was upheld.

This female patient has a past medical history of sleeve gastrectomy in 2015.  This patient is now being considered for revision bariatric surgery, having regained approximately 70 pounds as documented since 2018 in spite of ongoing almost monthly medical management/consultation. 

The insurer stated that there has been stretching of the stomach pouch since the patient's first weight loss surgery.  They add this is usually caused by the amount of the food the patient eats.  Repeat surgery can be approved under plan criteria when there is a cause for this stretching besides over-eating and other criteria are met. 

A real key to this review is this upper GI series of 2018, which was read as a normal sleeve.  The Gastroesophageal (GE) junction was normal.  There was no hiatal hernia.  Contrast flowed into the duodenum without obstruction.  The esophagus was normal/nondilated.  There is no GERD.  The pouch is only "mildly dilated".  As per this upper GI series, there are no real problems with the previous gastric sleeve.  It appears that the roughly 70 pounds that this patient has gained since 2018 is due to lack of dietary control and no real exercise plan and not the sleeve.  The documentation notes the patient was clearly documented as going back to her old habits including snacking more.  During this time, even when being medically monitored with serial clinic visit, this patient fairly steadily gained approximately 70 pounds again with a documented normal gastric sleeve.  Overeating with a gastric sleeve can be conceivably associated with GERD:  As with this patient who appeared to have it intermittently with no anatomical indication for having GERD, as per this Upper GI Series.

The weight loss surgery is not considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Submandibular abscess
Treatment: Inpatient admission
The inpatient admission was medically necessary.
One indication of admission is failure of outpatient therapy, as noted by the insurance company as well as the Infectious Diseases Society of America's recommendations for the treatment of soft-tissue infections (1). However, when more critical structures are involved (such as those close to the airway), standard medical practice would preclude sending these patients home with PO (oral) antibiotics, because if they would fail, then the consequences are high (anoxia or death). The team was concerned about the dysphagia, and admitted with IV antibiotics, close observation, and steroids to decrease the swelling. Standard of care was followed in this case, and the patient recovered without any of the aforementioned complications.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for chronic obstructive pulmonary disease (COPD), benign prostatic hyperplasia (BPH) and gastroesophageal reflux disease. This review is for the medical necessity of an increase in consumer directed personal-care assistant hours from 70 hours per week to 84 hours a week. The health plan's determination of medical necessity is upheld. The patient is dependent on care for almost all instrumental activities of daily living (IADLs) and most activities of daily living (ADLs). The patient currently has a total of 70 hours per week of services. These service hours are adequate to meet the patient's needs. Additional service hours are not medically necessary. The patient's needs which include ADLs and IADLs can be met during the allotted time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth decay
Issue under review: Restoration on teeth

Determination:
The Restoration on teeth was not medically necessary.

The x-rays do not show any decay or fractures in the teeth in question. The photos also do not show any decay or fractures present. There is not any restorative reason to treat these teeth that is apparent in the records.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left renal colic
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  
Following admission, there were no unstable vital signs reported.  The patient did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. She did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control and IVF followed by stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a male with signs/symptoms of hypogonadism. The treating physician states the patient has had two morning specimens of testosterone that were below 300, that he has normal follicle-stimulating hormone (FSH), luteinizing hormone (LH) and Prolactin levels.  The patient has failed a course of topical testosterone replacement and has been subsequently managed with intramuscular injections of testosterone undecanoate.  

The peer-review literature supports the requested treatment; it is documented that the requested treatment has been successful in this patient.  Based on information from the physician, the patient has been on Aveed, 750 mg every 10 weeks and his testosterone level has increased to the 500 range along with symptomatic improvement.  The medication in this dosage has been FDA approved for this indication.  The injection is considered more beneficial for this patient's diagnosis, and supports an improvement in health outcome.

The patient is a good candidate for injection.  Per the physician's notes, the patient has had a desired result, and an appropriate increase in testosterone level. Testosterone undecanoate is an appropriate treatment for the patient, and the patient has shown improvement with the requested treatment; therefore the requested service is likely to be more beneficial.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a male who was seen late last year for his complaint of fatigue.  Work-up in the past revealed low testosterone below 300 on two occasions; these samples were taken before 10AM (results are not available for review).  According to the provider, the patient was diagnosed with primary hypogonadism.  He has had no relief with AndroGel.  His level remains below 300.  Long-acting Testosterone shots were prescribed.  The patient has been receiving on-going treatment every 10 weeks. The only testosterone level available for review was from early this year (not clear at what time it was collected) and it was 45.9.

The Endocrine Society recommends making a diagnosis of hypogonadism only in men with symptoms and signs consistent with testosterone (T) deficiency and unequivocally and consistently low serum T concentrations. The Society recommends measuring fasting morning total T concentrations as the initial diagnostic test and confirming the diagnosis by repeating the measurement of morning fasting total T concentrations.  The guidelines also recommend therapy for men with symptomatic T deficiency to induce and maintain secondary sex characteristics and correct symptoms of hypogonadism.
 
Based on the provider's notes, this patient had two low morning testosterone levels.  He is symptomatic for low testosterone, and fulfills the above guidelines for testosterone replacement. It is the best available treatment for this patient at this time, and is likely to be more beneficial than any of the standard treatments/procedures.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hypogonadism
 
Treatment: TST Injections for low serum TST

The insurer denied the TST injection for the date of service. The denial was reversed. A panel of 2 out of 3 reviewers determined it was the best available treatment for this patient.



This is a male patient seen for complaints of fatigue which has been affecting his lifestyle for five years.  Previous evaluation revealed low testosterone (TST) <300 ng/dl on two occasions; both of the samples taken before 10:00 AM.  The patient was diagnosed with primary hypogonadism.  The patient was treated with AndroGel and had no relief.  TST level remained below 300.  Long-acting testosterone shots were recommended.  The patient has been receiving ongoing TST every 10 weeks.  

This patient did not have two consecutive low total fasting serum TST levels prior to being started on long acting TST shots.  This is considered standard of care for coverage of male hypogonadism. 

TST-injection undecanoate 1 mg for date of service is not the best available treatment for this patient.  It is a long acting injection but it is not likely or proven to be more beneficial than any of the standard treatments/procedures for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment:Inpatient admission 

Summary:
Inpatient admission was not medically necessary.
Patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. Had stress test and catheterization been performed those would be outpatient procedure. There was no complex care that required inpatient care. This patient had no evidence of CAD (coronary artery disease). In fact, all tests showed absence of ischemia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission

The proposed treatment was not medically necessary. 

The patient has a past medical history significant for hepatitis B, latent tuberculosus (TB) (status post [s/p] treatment), glucose intolerance and presented to the emergency room (ER) with complaints of left sided, non-exertional sharp chest pain, as well as dyspnea, for two days duration. 

The patient was hemodynamically stable. The electrocardiogram (ECG) revealed no acute ischemic changes. The cardiac troponin was negative, brain natriuretic peptide (BNP) was normal, and chest x-ray revealed no acute pulmonary disease. The patient was admitted to telemetry to rule out acute coronary syndrome (ACS). His prior ischemic work-up included a cardiac catheterization two years prior, at an outside institution, which was reportedly normal. Repeat troponins were also normal times three (x3). The plan was for a stress test, to complete his ischemic work-up, however the patient chose to leave against medical advice (AMA) and was advised to follow-up as outpatient.

This patient presented for evaluation of chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by serial cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS, decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.