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

Diagnosis: Atrial fibrillation
Issue under review: Transcatheter closure of the left atrial appendage

Determination:
The health plan should cover the Transcatheter closure of the left atrial appendage.

The patient has a documented history of paroxysmal atrial fibrillation, and an elevated CHADS-VASC (congestive heart failure, hypertension, age greater than or equal to 75, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age 65-74, sex category ) score, and it would be consistent with the current guidelines that chronic anticoagulation be used for reduction of his risk of thromboembolic complications, such as CVA (cerebrovascular accident). 

The Watchman Left Appendage closure device is FDA-approved and is currently considered to be an appropriate therapy for patients in whom the use of long-term anticoagulation is not an option, which would be consistent with the medical history in this case. Therefore, the use of the requested device would be more beneficial than any standard treatment or treatments (i.e. continued anticoagulation, which has contraindications and significant risks in this specific case) for the patient's condition in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial fibrillation
Issue under review: Transcatheter closure of the left atrial appendage

Determination:
The health plan should cover the Transcatheter closure of the left atrial appendage.

This patient has a history of atrial fibrillation and an elevated risk of stroke based on her CHADSVASC score. (Reference 1)  Following society guidelines, oral anticoagulant therapy is indicated.  Given her history of recurrent falls and resultant trauma resulting in hip fractures, oral anticoagulant therapy was contraindicated.  Left atrial appendage occlusion has been shown to be non-inferior to oral anticoagulant therapy. (Reference 2)  Current guidelines, published by the AHA/ACC and Heart Rhythm Societies support the use of left atrial appendage occlusion in patients that have an elevated risk of stroke and have a contraindication to long term anticoagulation. (Reference 3)  This patient suffers from atrial fibrillation and has an elevated risk of stroke.  Given her history of frequent falls and multiple hip fractures, she cannot be treated with oral anticoagulant therapy.  The next best option for stroke prevention in this setting is left atrial appendage occlusion.  In conclusion, the proposed treatment should be covered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Discomfort

Treatment: Inpatient Admission

The insurer denied Inpatient Admission. The denial was upheld.

This is an elderly male patient who presented to the emergency department (ED) with complaints of fever, chest tightness, and dizziness. The patient was admitted for evaluation of chest discomfort. He has a past medical history of hypertension, malignant melanoma, adrenal adenoma, hypothyroidism, pneumonia, and pericarditis. He had a Computed tomography (CT) scan of the chest which revealed small to moderate pericardial effusion, atelectasis and elevation of the right hemidiaphragm; no pulmonary embolism. Cardiology consulted on the patient noting his prior admission for treatment for pericarditis. Infectious disease also consulted; all cultures were negative, no antibiotics needed. He remained afebrile, hemodynamically stable, and was discharged to continue outpatient management.

According to documentation, the patient presented with low-grade fever and tachycardia. Otherwise, he had unremarkable laboratory results including normal WBC and troponins. Cardiology evaluated and no acute intervention was required. The patient was resumed on oral medications for a previous diagnosis of pericarditis. Infectious Diseases also felt there was no evidence of infection or sepsis. Based on the above findings, the patient met criteria for observation level of care. He did not meet criteria for acute inpatient hospitalization.

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld. 

This is a young female patient who presented to the emergency department in early 2019 with abdominal pain in the left lower quadrant and left upper quadrant, she rated the pain 6/10.  She had a past medical history of intermittent intussusception. She had a computerized tomography scan of the abdomen and pelvis with intravenous contrast revealed mild constipation and no intussusception. In addition she had a transabdominal and transvaginal ultrasound which was unremarkable. The patient was admitted for possible transient intussusception due her persistent abdominal pain.  She was ordered to have nothing by mouth and was started on intravenous fluids and pain medication. Her diet was advanced to clear liquids and she was then discharged home on a regular diet and instructed to follow-up with gastroenterology.  

MCG indicate that observation care is appropriate for patients with abdominal pain for a suspected condition requiring continued monitoring, or for undiagnosed pain after evaluation and initial symptomatic treatment when the patient is unable to maintain oral hydration status; or, when there is a concerning finding on examination or diagnostic testing. Admission is appropriate for patients who have inability to maintain oral hydration that persists after emergency department and observation care treatment for severe pain requiring acute inpatient management.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient with body mass index (BMI) of 35 and family history of coronary artery disease (CAD), who presented to the hospital on with chest pain, palpitations and shortness of breath. The patient was lifting boxes that day. On presentation vital signs were stable with a mildly elevated blood pressure. The physical exam was normal. A chest x-ray (CXR) and d Dimer were normal. The first set of cardiac enzymes were normal. An electrocardiogram (EKG) was suggestive of Wolff-Parkinson-White (WPW) pattern. No ischemic changes or arrhythmias associated with WPW were documented. Patient was admitted to inpatient with 2 midnights stay expectations. The x(3) sets of cardiac enzymes were negative. A stress test was performed and was negative. EKG shows WPW pattern but no changes suggestive of acute ischemia. The main concern in this patient would be to rule out acute coronary syndrome.  Framingham risk score for myocardial infarction (MI) and death over 10 years is 1.1%. Given risk factors the patient would be considered low risk for future or coronary events. The above presentation would be reasonable to consider a lower level of care, where the patient can have the rest of the work up. The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary tract infection, pyelonephritis
 
Treatment: Inpatient admission, medication, monitoring

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

This is a child with no significant medical history who presented to the Emergency Room (ER) with complaints of decreased intake, fever, vomiting, and diarrhea. The patient had a urinary tract infection that manifested as multifocal pyelonephritis as seen on the renal and bladder ultrasound. She had leukocytosis and segmented neutrophil predominance on complete blood count (CBC) that was consistent with bacterial infection. She was febrile above 103F. She had a dry oral mucosa documented on physical examination, suggestive of mild dehydration, as her blood urea nitrogen (BUN) and creatinine were within normal limits. There was a clear plan documented to administer fluid boluses and to monitor her status. 

Urinary tract infection in toddlers, including pyelonephritis, should be treated with fluid management and antibiotics. (Reference 1) Inpatient management may be necessary because of a need to administer IV fluids until oral intake is assured, for an initial period of parenteral antibiotics until afebrile, and for close monitoring. (Reference 2: section on Clinical Management)

Treatment on an inpatient unit was medically necessary. Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with past medical history significant for morbid obesity with body mass index (BMI) 43, asthma, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), tobacco dependence, gout, and depression, who presented to the emergency department with shortness of breath and cough productive of yellow sputum in the setting of recent upper respiratory infection (URI) symptoms. He denied chest pain, fevers, or other complaints. The health plan's determination is upheld. 

This patient is a morbidly obese patient who presented with shortness of breath in the setting of untreated sleep apnea, as well as mild COPD exacerbation. Though he was noted to have hypercarbia, the lowest his pH reached on ABG was 7.32, suggesting chronic hypercarbia in the setting of obesity and untreated obstructive sleep apnea (OSA). He had not failed outpatient steroids or outpatient diuretics and it seems that the primary intervention he required was BIPAP at night to treat his chronic hypercarbia. Ambulatory saturation of 88-89% was maintained when measured, and this is an acceptable oxygen saturation for discharge given his COPD and morbid obesity. Acute inpatient admission was not medically necessary.

This patient as noted above with obesity and COPD with exacerbation had not failed outpatient treatment and was not noted to be hypoxic to less than (<) 88%. He did not have concomitant pneumonia or clear evidence of CHF exacerbation that required IV diuretic therapy. His hypercarbia was clearly chronic given he was well compensated with pH no less than 7.32 despite hypercarbia. The primary intervention he required was arranging for BIPAP for home use. Acute inpatient stay was not medically necessary for this patient with chronic respiratory failure and mild COPD exacerbation who primarily needed BIPAP at night, was not hypoxic to < 88% and had not failed outpatient therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep vein thrombosis
 
Treatment: Inpatient admission, medication, monitoring

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

This case involves a male with a past history of hypertension, hyperlipidemia, and diabetes. The patient presented to the emergency department indicating he woke up that morning with excruciating pain in the right ankle.  The patient denied trauma or previous surgical history.  He relayed pain to the right calf as well as the inability to walk or move his right ankle. There were no significant abnormalities related to vital signs. The patient had a positive study for deep vein thrombosis (DVT).  His leg pain improved with analgesics. There was no complaint of dyspnea or pain. An angiogram of the chest was negative for pulmonary embolism. The patient was admitted and initiated on Xarelto. The next day his swelling and pain had improved. He was discharged on oral anticoagulation, with a recommendation for outpatient follow-up.

According to referenced literature, a patient may be admitted for inpatient services when there is evidence of limb-threatening thrombosis, thrombolysis or pharmacomechanical thrombectomy as needed with a patient noted to be high risk for acute complications of anticoagulation such as a recent surgery, recent GI bleed, recent stroke or history of intracranial bleeding. If there is a personal or family history of significant allergic, autoimmune or coagulopathic reaction in response to anticoagulation the patient may be admitted for further monitoring. 

There is a lack of documentation to support the patient needed to be admitted as an inpatient. He was found to have a DVT, and anticoagulation therapy was initiated. The patient received treatment and no further adverse events were noted.  

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment: Dupixent
The proposed Dupixent is medically necessary.

The patient has severe atopic dermatitis affecting 32% BSA. He is a candidate for systemic therapy as the BSA is too large for reasonable control with topical medications. Topical calcineurin inhibitors and crisaborole are not appropriate therapy for moderate to severe, widespread atopic dermatitis, which should be treated with systemic therapy. 

Dupilumab is a monoclonal antibody that inhibits IL-4 and IL-13 signaling by blocking the shared IL-4Ra and originally demonstrated efficacy in phase II clinical trials. In 03/2017, it was approved by the US Food and Drug Administration (FDA) for adults with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. It is a subcutaneous injection administered initially at a dose of 600 milligrams (MG) and then every two weeks thereafter.

Approval of dupilumab was based on clinical trials investigating dupilumab as monotherapy (SOLO 1 and SOLO 2) and in concomitant administration with topical corticosteroids (CHRONOS). Results from the SOLO 1 (n=671) and SOLO 2 (n=708) trials showed 36-38% of patients who received dupilumab had scores of zero or one (clear or almost clear) on the Investigator's Global Assessment scale compared with placebo (eight to 10%) (P< .001). Additionally, improvement from baseline to week 16 of at least 75% on the Eczema Area and Severity Index (EASI) was reported in significantly more patients who received each regimen of dupilumab than in patients who received placebo (P < .001).

Given its unprecedented efficacy, dupilumab is emerging as a first-line therapeutic for moderate-to-severe AD. This patient has failed topical steroids and systemic methotrexate, and topical calcineurin inhibitors are not indicated for severe disease. Therefore, Dupixent is medically necessary.

Cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil are not FDA approved for use in atopic dermatitis (insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. Strength of Recommendation: B Level of Evidence: I or II, depending on agent), while Dupixent is.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:Rheumatoid arthritis 
Treatment: Orencia ClickJect 125MG/ML SC SOAJ 

Summary:
The patient is a female with rheumatoid arthritis (RA).  She has failed treatment with ibuprofen, prednisone, methotrexate, sulfasalazine and Humira.  The patient has demonstrated clinical improvement after treatment with Orencia for a few months.  She has not tried or failed the Plan-preferred alternatives Kevzara or Xeljanz, and there is no documented contraindication to either of these alternatives. 

Orencia is FDA-approved for the treatment of RA, as seen in this patient.  Per FDA guidelines, prior treatment failure with other biologic therapies is not required prior to treatment with Orencia.  This patient has failed treatment with DMARDs (disease-modifying antirheumatic drugs) (i.e., methotrexate and sulfasalazine), as well as the biologic Humira.  Per attached AP appeal letter, she is responding to treatment with Orencia, which may have been provided via manufacturer samples, as there are no pharmacy claims for Orencia. 

Although there is no contraindication to treatment with the Plan-preferred non-TNF inhibitor agents Kevzara or Xeljanz, this patient is already clinically responding to treatment with Orencia.  Thus, discontinuation of Orencia to switch to a Plan-preferred agent would put this patient at unnecessary risk of RA disease flare.  Therefore, the proposed continuation of Orencia for the treatment of RA in this patient is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD
Issue under review: Increased consumer direct personal care aide services

Determination:
The Increased consumer direct personal care aide services is not medically necessary.

The patient is a female with a medical history pertinent for COPD with associated exertional dyspnea and fatigue. Due her pulmonary condition, she requires assistance from home health aides for completion of her activities of daily living (ADLs) such as grocery shopping, ambulation up stairs and other moderate exertional activities. However, a recent functional assessment of the patient determined that she has actually improved from her prior assessment and no longer requires assistance with toileting and meal preparation. For these reasons, the proposed treatment of Increased consumer direct personal care aide services is not deemed medically necessary, as the currently approved plan of consumer direct personal care aide services is sufficient to meet this patient's needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, dyslipidemia, diabetes mellitus type 2.
Treatment:Coronary CT Angiogram (CTA), code 75574

Summary:
The patient has multiple risk factors for CAD (coronary artery disease), including diabetes mellitus. His prior work-up was significant for a nuclear stress test, which revealed abnormal systolic function, as well as transient ischemic dilatation of the left ventricle, suggestive of multi-vessel coronary disease. The perfusion imaging, however, did not reveal a myocardial perfusion defect. Given the discrepancy between the two parts of the stress test, as well as presence of significant risk factors, further work-up for a more precise definition of his coronary anatomy is required. The proposed coronary CTA test would provide anatomic definition of coronary anatomy, without the need for invasive angiogram. The use of CCTA as imaging modality in this clinical circumstance (i.e. equivocal nuclear stress test in patient with intermediate pre-test probability of obstructive CAD) is consistent with the current ACC/AHA recommendations and would be considered medically necessary in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cyclic vomiting
 
Treatment: Inpatient admission, medications, monitoring

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

The patient had a history of cyclic vomiting and presented with abdominal pain and vomiting. He had a recent endoscopy and colonoscopy which were negative. In the ER, the patient had tachycardia, but this resolved by the time of admission. The patient had mild tenderness without rebound or guarding. He was treated with famotidine and Zofran. The vomiting resolved. A MRCP done for a brief elevation of the lipase level was normal.

Clinical indications for admission for vomiting (M-370) include gastrointestinal obstruction, a significant metabolic derangement, hemodynamic instability, high fever, and acute renal failure. The patient did not have these conditions.

This patient had cyclic vomiting. He required intravenous (IV) hydration, Reglan, and Famotidine. Afterwards, his symptoms improved. The initial tachycardia resolved. There was no evidence of a significant pancreatitis. The patient did not meet MCG Criteria for admission for vomiting. He could have received treatment with observation level of care. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient admission

The insurer denied continued inpatient detoxification treatment. The denial was reversed.

This patient was admitted for inpatient substance detoxification treatment for opiate and benzodiazepine use. The patient had withdrawal symptoms including tremors, sweats, nausea, joint pain, teary eyes, runny nose, irritable mood, anxiety, and an elevated heart rate of 105. The patient also had an elevated blood pressure of 150/90 and a Clinical Institute Withdrawal Assessment (CIWA) score of 11. The patient was using a substantial amount of intravenous (IV) heroin per day, Xanax 2-3 times per week, and methadone 1-2 times per week. The patient was started on a Librium and methadone protocol and also received Clonidine as needed. The patient signed out against medical advice (AMA).

The American Psychiatry Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This was the case with this patient. The patient had prior substance detoxification treatments and was still using heroin, methadone, and Xanax. The patient lacked coping skills and the ability to identify relapse triggers; the patient could not safely and effectively be treated in an outpatient setting. According to the LOCADTR the patient required 24-hour treatment as evidenced by the fact the patient needed two to three detoxification medications to modify withdrawal and had a long history of heavy IV heroin use, as well as using methadone and Xanax. The patient was at high risk for overdose and complicated and life-threatening withdrawal symptoms, such as delirium tremens.  

Based on the above, the medical necessity for the continued inpatient detoxification services is substantiated. The insurer's denial is reversed.