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

Diagnosis:  Attention deficit hyperactivity disorder 
Treatment:  Daytrana medication patch
The treatment with Daytrana is not medically necessary.

The patient is a female with a diagnosis of attention deficit disorder, adult.  She has been treated by her nurse practitioner with Focalin.  A progress note reports that the patient wishes to switch back to Daytrana patches.  The patient reported that she felt like the Focalin did not work as well as Daytrana and that it wore off around 2 PM.  The patient had previously been treated with Daytrana patches, 30 mg, applied daily for nine hours.

The patient's health plan approves Daytrana only for those patients, who are 13 years of age or under or who are unable to swallow pills.

Daytrana is simple methylphenidate in a transdermal form.  It has no physiological advantages over oral methylphenidate or other oral stimulant medications indicated for the treatment of attention deficit disorder.  One option for patients that feel that their Focalin is wearing off too early in the day, is to augment it with a second dose of one of the short-acting oral preparations such as methylphenidate tablets.
Appeal type: Medical necessity
Decision: Upheld

Neurological
Durable Medical Equipment

This is a patient who has a diagnosis of multiple sclerosis. The patient has upper motor neuron dysfunction causing the foot drop. Patient was prescribed a walk aid functional electrical stimulator for foot drop.
The patient's provider indicated a progressive foot drop secondary to multiple sclerosis and spinal cord involvement. Patient was using a fixed foot orthotic that had not been suitable for needs. Because of  needs to walk while at work, a walk aid functional electrical stimulator to treat the progressive foot drop was recommended. The patient was seen for an evaluation for a WalkAide for left foot drop. It was noted that the patient has an ankle foot orthotic. There was no evidence that the patient has seen a physiatrist, or had adjustments made to the orthotic with optimization of the ankle foot orthotic to improve its effectiveness. At that time, a two week trial of a WalkAid functional stimulator was recommended. The health plan's determination of medical necessity is upheld in whole. The WalkAide functional muscle stimulator is not medically necessary for the patient. WalkAide it is not consistent with medical evidence in that it does not show any benefit for functional electrical stimulation of this patient's circumstance. Although it is safe and effective for the treatment of foot drop due to multiple sclerosis, it is no more effective than an ankle foot orthotic. This is a patient with a history of foot drop due to multiple sclerosis. The patient has had an ankle foot orthotic. There is no evidence that the patient been evaluated by a physiatrist and has had either a change in the orthotic or optimization of the orthotic to improve function. There is no evidence in the medical literature that functional electrical stimulation for foot drop is superior to a fully optimized ankle foot orthotic. There is no evidence that outcomes with regard to gait speed or gait safety are superior with functional electrical stimulation. Given the use of an ankle foot orthotic without failure after full optimization of the orthotic (which is typically performed by a physiatrist), the medical necessity for functional electrical stimulation in the form of the requested WalkAide is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient admission
The Inpatient substance abuse treatment was not medically necessary for this patient.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and cocaine and co-occurring depressive disorder and general medical issues with hypertension. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes, as noted. Thus, inpatient admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.

This answer is consistent with New York State OASAS LOCADTR 3.0 Criteria/Guidelines and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status and no general medical complications or co-occurring disorders that would have warranted inpatient level services. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were therefore not medically necessary in this case scenario, as the health plan asserts. NY State OASAS LOCADTR 3.0 Criteria/Guidelines are not met for the inpatient level of care, referenced below.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malaria; urinary tract infection
 
Treatment: inpatient hospital admission 

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

This patient is a male who presented to the Emergency Department with complaints of fevers, abdominal pain and vomiting after returning from a trip to Africa. The patient's vitals on presentation included: Temperature 103.1 F, Blood Pressure-115/76, Pulse-96, Respiratory Rate-20, and Oxygen (O2) saturation-99% on room air.  The patient's laboratory values were notable for the following: White blood cell (WBC) count-3.9, hemoglobin (Hgb)-16.9.4, hematocrit (Hct)-50.8, platelets-66K, lactate-4.5, creatinine-0.93, and glucose-114.  Urinalysis was notable for nitrites, leukocytes, trace ketones and protein.  
The patient was admitted for travel-related fever and possible urinary tract infection.  The patient was empirically started on antibiotics (i.e., ceftriaxone and azithromycin) and was pan-cultured.  The patient's chest x-ray was negative for infiltrates but his rapid blood screening confirmed Plasmodium falciparum antigen (malaria) infection.  The patient was treated with intravenous fluids and anti-malarial medications (atovaquone-proguanil).  The patient improved clinically and was discharged to continue outpatient management. 

Based on this medical case review, literature supports inpatient admission for this patient's treatment and monitoring for his test-confirmed malarial infection. Every year, malaria accounts for approximately half a million deaths worldwide. P. falciparum microbe is considered the most virulent of the malarial species, and contributes to significant morbidity and mortality, especially when there's evidence of severe manifestations.  In this case, this patient had significant thrombocytopenia and lactic acidosis, as well as a possible urinary tract infection on presentation.  The patient required intravenous fluids with monitoring of lactate levels, as well as anti-malarial medications.  Based on these findings, hospital admission was medically necessary for this patient in order to closely monitor for potential complications associated with his P. falciparum infection. 
  
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 reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient hospital

The patient is a woman with a history of asthma who presented to the emergency department with a chief complaint of syncope. She reported that she was having a cold and productive cough for the past three days. She reported feeling lightheaded when walking to a store and then losing consciousness. She denied chest pain. On physical examination, she was in no distress, heart was regular, breath sounds were normal, she had normal cranial nerves, and there was normal cerebellar function. An electrocardiogram (EKG) showed normal sinus rhythm. The vital signs showed blood pressure 96/62, heart rate 93, temperature 98.9 Fahrenheit, and respiratory rate to 20. Social history was notable for heavy drinking which started after her mother died from pancreatic cancer. She was admitted to the hospital. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The reason is that the patient presented with syncope but had no evidence of cardiac ischemia, acute seizure, acute alcohol withdrawal, or acute arrhythmia. Her syncope was due to orthostatic hypotension and anti-hypertensive therapy, and while it was complicated by her chronic alcoholic use, the admission note explicitly states that there was no evidence of alcohol withdrawal and she had no evidence of alcohol withdrawal in the remainder of the hospital stay. For these reasons she could have safely and effectively been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness and Menorrhagia
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a female with menorrhagia and uterine fibroids. She underwent a uterine fibroid embolization (UFE) also called a uterine artery embolization (UAE). 

The uterine fibroid embolization (UFE) procedure is usually done as a short-stay/outpatient procedure, or if needed, a 23 hour observation.  "In many interventional practices, UFE is followed by overnight observation in a hospital setting.  The purpose of this admission is to assure adequate pain control.  However, many practices have been successful in discharging patients the day of the procedure. The decision regarding discharge must be made on a case-by case basis, and should be based on the patient's level of comfort rather than the potential difficulty of making an admission. All patients should successfully complete a trial of pain control with oral agents before leaving the hospital (1)."  

This patient met the overnight observation criteria as described below:

This patient underwent an uneventful UFE procedure and had a transfusion of three units of PRBC (packed red blood cells). There were no periprocedural complications and she had a normal postembolization stay with mild abdominal pain. The provided patient's progress notes do not indicate a necessity for continued hospitalization following the procedure. There was no indication of "red flag" symptoms.

The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Trauma / Injuries - Knife Wound
Inpatient Hospital

The patient is a male that presented to the emergency department (ED) via Emergency Medical Services (EMS) after sustaining an accidental stab wound to the right upper extremity. He had been sitting on the counter and fell. His mother caught him but was holding a knife and stabbed him in the process. Vital signs included temperature 99.2, heart rate 118, respiratory rate 33, and blood pressure 121/103. Examination was significant for a laceration to the right upper arm that was not actively bleeding and a hematoma to the right upper arm. Sensation and pulses were intact. Laboratory evaluation revealed normal white blood cell (WBC) count with thrombocytosis (574K), normal coagulation studies, normal metabolic panel, and slightly decreased partial pressure of carbon dioxide (pCO2) on venous blood gas. Humerus x-rays were negative for fracture but revealed soft tissue injury with soft tissue gas. The wound was sutured in the ED. He was treated with a normal saline bolus, Ancef, morphine, and DTap vaccine. Surgical consultation recommended admission for observation once neuro checks were determined to be stable for ongoing monitoring. Admission orders included neuro checks every four hours, pain management, and ongoing surgery support. He did well overnight, with no evidence of compartment syndrome, no loss of sensation, maintenance of good perfusion, and able to tolerate a regular diet. He was deemed stable for discharge to follow-up with surgery for suture removal.

The health plan's determination is upheld.

No, an inpatient stay was not medically necessary. This patient sustained an accidental stab wound to the upper extremity with no significant loss of blood, no change in sensation, and no alteration in perfusion. He was monitored in the ED for a number of hours with recurrent neuro checks. Once stable, he was admitted continued neuro checks. With no evidence of compartment syndrome or alteration in perfusion or sensation, he was deemed stable for discharge. The upper extremity is at high risk for developing compartment syndrome in children, particularly following fractures. Management requires rapid identification and surgical intervention. This patient had no evidence of compartment syndrome, with good pulses, perfusion and sensation. While it was reasonable to monitor him over night to document good extremity perfusion, he was overall hemodynamically stable. He did not require acute inpatient admission and could have been safely managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who had a previous bilateral total knee replacement. He sustained an acute trip and fall at home resulting in a peri-prosthetic right distal femur fracture. He was admitted to the hospital for this injury and subsequently underwent open reduction and internal fixation of this right femur fracture. He was ultimately discharged to a rehabilitation facility. 
The health plan's determination is overturned in part. The records show that the patient was on Plavix anti-coagulation treatment for a prior cerebrovascular accident (CVA). The inpatient admission  for the completion of the surgery was medically necessary for the patient to be off Plavix two days prior to surgical intervention for a displaced right peri-prosthetic femur fracture. Inpatient admission after surgery was medically necessary for post-operative antibiotic administration, pain control with IV medications, and progressive ambulation with physical therapy. The provided progress notes document that the patient was in no distress and his pain was well controlled as of post-operative day #2. The patient's lab values and vital signs were also normal on that date. The provided medical records show that the patient was then stable for discharge. There are no documented changes to the treatment plan and no complications post-operatively that justify the additional inpatient days.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: bilateral sensorineural hearing loss, cyclic neutropenia, etc
Treatment: Comparative genomic hybridization testing

The comparative genomic hybridization testing was not medically necessary.

The patient is a female. She is cognitively normal but has clinical symptoms potentially consistent with a mitochondrial disorder, including bilateral sensorineural hearing loss, cyclic neutropenia, muscle pain, muscle burning, weakness, myoclonic jerks without seizures, chronic fatigue, severe myopia, fibromyalgia, progressive tremor and ataxia, eyelid retraction, vasculitis, headaches, lung nodules, low immunoglobulins, bipolar disease, OCD (obsessive compulsive disorder), depression and anxiety. Previous testing was normal, including brain MRI, EEG, MRA of the chest, echocardiogram, kidney ultrasound, CT of the chest, and brain CT. Her sister has similar symptoms and may have a myopathy. Her AP geneticist has ordered chromosomal MicroArray to determine whether a chromosomal deletion or duplication is the etiology of her clinical difficulties.

Chromosomal MicroArray testing in this patient is not medically necessary. She is cognitively normal, does not have autism or intellectual disability, has no major or minor malformations or congenital anomalies, and her multiple medical problems are not compatible with a genetic disorder, specifically a chromosomal duplication deletion, susceptible to being identified by chromosomal MicroArray. Therefore, this testing is not medically necessary or clinically appropriate in her context.

Performing Chromosomal MicroArray for this patient does not meet generally accepted criteria for this testing put forth in the generally accepted, authoritative, peer-reviewed, published medical literature and is therefore unproven. CMA/CGH is only considered a first-line/first-tier test in individuals with developmental delays, intellectual disability, autism, anatomic birth defects, or congenital anomalies, which is not the case for this patient.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a history of hypertension, hyperlipidemia, pre-diabetes, chronic kidney disease and cigarette smoking. He underwent myocardial perfusion imaging for two years of progressive dyspnea and fatigue. This showed evidence of an inferior infarction with peri-infarction ischemia. His left ventricular ejection fraction was 50%. He presented to the hospital for scheduled cardiac catheterization. His blood pressure was 165/85 millimeters of mercury (mmHg) with a heart rate of 68 beats/minute. His cardiac exam was unremarkable. He had no acute electrocardiographic changes. His serum creatinine level was 1.3 milligrams per deciliter (mg/dl). His platelet count was 97,000/cml. Angiography showed a significant obstruction in the first obtuse marginal artery that was treated with a stent. There was a 90% obstruction in a small second obtuse marginal artery that was not treated. The procedure was uncomplicated. He was discharged home the following day. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

This patient presented for scheduled cardiac catheterization approximately one month after an abnormal cardiac stress test. He was hemodynamically stable, without acute electrocardiographic changes. While some period of monitoring immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. Per the recommendations, patients with increasing symptoms who have been stabilized on oral medications, and whose procedures are uncomplicated, can be monitored overnight for a period of less than 24 hours, and do not require an inpatient admission. This group would presumably include this patient, as he was admitted electively from home, had no acute electrocardiographic changes, and there is no indication in the records provided that his symptoms had been escalating. Moreover, the Elective percutaneous coronary intervention (PCI) in Outpatient Study (EPOS), a large randomized trial involving 800 patients who underwent elective PCI via a femoral arterial approach, found that same-day discharge after elective PCI is feasible and safe in the majority of patients and does not lead to additional complications, as compared to an overnight stay. Accordingly, the care this patient received could have been provided at a lower level of care status and an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Short stature 

Treatment:  Nutropin AQ Nuspin 

The insurer denied coverage for Nutropin AQ Nuspin.  The denial was reversed.

This patient is a male child who was initially seen for a pediatric endocrinology consult due to his short stature.  He continued to be seen at this practice every few months for a follow up visits.  It was documented that a growth hormone stimulation test revealed he has a growth hormone deficiency.  The patient's height was noted as 4'11" and weight was 98lb 12.3oz.  A magnetic resonance imaging (MRI) of the brain did not reveal any brain lesions.  A bone age revealed age of 12 years 6 months at an older chronological age.  The standard deviation was noted as 11.1 months.  The pediatric endocrinologist discussed growth hormone therapy.

The health plan did not act reasonably and with sound medical judgment or in the best interest of the patient as growth hormone is medically necessary as described below. 

The peer reviewed literature including consensus clinical guidelines; randomized controlled trials are summarized below:

Classic growth hormone (GH) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society(1), the Lawson Wilkins Pediatric Endocrinology Society (2, 3), and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists(4).  The above referenced guidelines are the latest available guidelines from these respective societies.  The diagnosis is based on auxological, biochemical and sometimes radiological findings. The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are:  1) severe short stature, defined as a height more than 3 SD below the mean; 2) height more than 1.5 SD below the midparental height; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 year of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 year.  The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml.

This patient met biochemical criteria.  GH stimulation testing peaked at less than 10ng/ml.  The patient met auxological criterion 2, as his height is more than 1.5 SD below target height.  The patient met both auxological and biochemical criteria for the diagnosis of GH deficiency.  GH in the treatment of GH deficiency is medically necessary. 

Based on the above, the medical necessity for the medication Nutropin AQ Nuspin is substantiated.  The insurer's denial is reversed.