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

Diagnosis:  Benign prostatic hypertrophy (BPH) with lower urinary tract symptoms (LUTS)

Treatment:  Inpatient admission

The insurer denied coverage for inpatient admission.  The denial was upheld.

This patient is a male who presented to the hospital for an elective procedure (cystoscopy, transurethral resection of the prostate (TURP)) due to a diagnosis of benign prostatic hypertrophy (BPH) with lower urinary tract symptoms (LUTS).  The vital signs pre-procedure were temperature 37.30C, and blood pressure 120/79.  The patient was admitted post procedure under the care of Urology.  The patient was placed on continuous bladder irrigation (CBI) and had Foley catheter to traction.  The patient received intravenous fluids and intravenous antibiotics.  The patient appeared to recover well.  He was ambulating, tolerating a regular diet, and his pain was controlled.  He was discharged to home with indwelling catheter and follow-up with Urology the next day for a trial of voiding.  The patient had a TURP with resection of only 2 grams of prostate tissue, which is minimal amount of tissue resection.  The patient appeared to tolerate the procedure well without complications.

According to the following guidelines:  MCG Health (23rd Edition) Prostatectomy - Transurethral Resection, the patient appears to have met the Optimal Recovery Course discharge parameter within 24 hours postoperative.  The patient did not meet criteria for extended stay after procedure (postoperative bleeding requiring transfusion or return to the Operating Room for control of bleeding, TUR syndrome with fluid overload, electrolyte imbalance, sepsis).  Also per MCG Health (23rd Edition) Urologic Surgery or Procedure GRG the patient appears to meet the General Recovery Course discharge parameter within 24 hours postoperatively.  The goal length of stay for this procedure is ambulatory or an overnight period of Observation status in the hospital to help ensure a safe discharge.  Postoperative bladder spasms are expected post-TURP, and are easily managed.

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

The inpatient admission is not considered medically necessary for this patient.
   
The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Epilepsy
Pharmacy/Prescription Drugs

The patient is a male who has a diagnosis of partial complex seizures. He has been on brand-name Keppra XR. The provider noted that there is a risk of breakthrough seizures and other reactions if he was to switch to generic levetiracetam extended-release. A bypass override for a higher tier medication so the patient could afford the cost was requested. There was no documentation that the patient had a previous trial and failure of generic extended-release levetiracetam.

The health plan's determination is upheld. The request to waive ancillary charges associated with coverage of brand name Keppra is not medically necessary. The patient has a history of epilepsy. Keppra extended-release and generic extended-release levetiracetam have the same active ingredient, levetiracetam. A specific serum levetiracetam level in a patient who is receiving brand-name Keppra XR will have the same efficacy as the same levetiracetam level and the patient who is receiving generic extended-release levetiracetam. Levetiracetam levels are readily available. There is no rationale why the patient cannot be maintained on the dosage of extended release levetiracetam that maintains the same levetiracetam level as the current dose of brand-name medication. Any adverse reaction would be from a non-active ingredient, and anticipation of an adverse reaction would not predict its occurrence. There is no rationale why the patient cannot utilize a generic form of levetiracetam extended-release with maintenance of serum levels at the same level the patient was on when receiving Keppra XR.  The requested waiver of ancillary charges associated with coverage of brand-name Keppra is therefore not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Erectile dysfunction
Treatment:  Formulary exception for Stendra

The health plan should not cover the proposed Stendra.  

This male with erectile dysfunction has requested coverage for Stendra 100 mg tablets.  Sildenafil and tadalafil had side effects of severe headaches and blurred vision.

The Policy requires a trial of all formulary alternatives.  The patient has not tried vardenafil.  Vardenafil is a PDE-V inhibitor similar to Stendra.  There are no listed contraindications for this patient for vardenafil.
Appeal type: Medical necessity
Decision: Overturned

Colitis/Inflammatory Bowel Disease
Pharmacy/Prescription Drugs

The patient is male with ulcerative colitis (ulcerative proctitis). The patient is on concomitant treatment with Lialda, Simponi, and 6-MP. Simponi had been added to 6-MP monotherapy. Initially, Simponi was beneficial for 4 weeks. More recently, the patient only has a satisfactory response from Simponi for 2 weeks and therefore the provider has upped the dose to Q 2weeks.

The health plan's determination is overturned. Simponi, 100 milligrams (mg) Every Other Week is medically necessary for this patient.
Anti-TNF therapy with or without an immunomodulator (eg, azathioprine) is used to induce remission in patients with moderate to severe ulcerative colitis. It is common for patients to lose response to an anti-TNF agent which requires increasing the dose. Potential causes of loss of response include:
1) Low drug levels (due to either immune or non-immune mediated clearance mechanisms). 2) Mechanistic failure (eg, non-TNF-mediated cytokine pathways may be playing a greater role in pathogenesis of inflammatory bowel disease (IBD)).
On Simponi Q2 weeks, the patient is maintaining a clinical and endoscopic remission. It is medically necessary to continue at this dose.
Appeal type: Medical necessity
Decision: Upheld

Depression
Mental Health: Inpatient

The patient is a female with diagnoses of Major Depressive Disorder (MDD) and Alcohol Use Disorder (AUD). Case notes document that the patient has suffered from AUD for an extended period of time, about 20 years. She has required 2 or 3 detoxifications and a 30 day rehabilitation program. She has been treated by an outpatient provider with trazodone and Wellbutrin. Prior to the admission under review, the patient was drinking unknown but excessive amounts of alcohol for at least a weekend prior to admission, resulting in her missing a week of work. Additionally, she experienced insomnia and loss of appetite. She attributes her drinking to the stress of ongoing arguments between her husband and her son, the husband's stepson. She fell and hit her head when she was drunk. After she was medically stabilized and became sober, she was admitted to IMHT. On admission, she was documented to complain of low mood, anorexia, insomnia, emotional distress at the ongoing arguments at home. She denied suicidal or homicidal ideation, hallucinations or delusions. After becoming sober, she expressed an interest in an evaluation by a psychiatrist. She did not suffer any brain injury from her fall. She was treated at the IMHT level with Wellbutrin, trazodone, lorazepam, vitamins, and assessed according to the Clinical Institute Withdrawal Assessment (CIWA) protocol. She appeared calm and cooperative and cognitively intact and was discharged to outpatient followup.

The health plan's determination is upheld. The IMHT was not medically necessary for this patient. Her AUD and possible MDD could have been treated safely and effectively in an Intensive Outpatient Substance Abuse Treatment (IOSAT) program. She was not at risk of harm to self or others. She showed no signs of DT's. She had no psychosis. She had no head injury of significance. Her cognition was intact. The IOSAT program could manage both her alcohol use disorder and her depressive symptoms, as well as setting up a family therapy program for one of the triggering or more likely continuing factors in the patient's chronic disorder, the arguments at home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic intractable migraines

Treatment: Aimovig

The insurer denied coverage for Aimovig. The denial was reversed.

This patient is a male child with a history of intractable daily headaches who was seen by Pediatric Neurologist. An appeal letter by the Pediatric Neurologist stated that the patient has chronic intractable migraines and that the patient failed Amitriptyline and Cyproheptadine and could not tolerate Trokendi or Propranolol due to side effects.  Also noted was that the patient was on Botox which only helped marginally.  The Pediatric Neurologist also noted that Aimovig was medically necessary for the patient. In late 2019 the Pediatric Neurologist noted that the patient was doing much better and his last severe headache was in early-2019. The Pediatric Neurologist noted that the patient was on Emgality.  The neurological exam was normal.  The patient's migraine improved remarkably on the combination of Botox and Emgality.  

New practice guidelines identify that Aimovig is an appropriate medication in this situation. 

Aimovig is considered medically necessary for this patient.  The patient has failed nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants, magnesium, Cyproheptadine, Botox, Maxalt, Trokendi XR, Propranolol, Maxalt, Zolmitriptan and Naratriptan.  The patient has had some short term response to biofeedback.  The patient has refractory migraine.  As supported by current review literature, Aimovig is appropriate.

"CGRP is a 37-amino-acid neuropeptide which is potent vasodilatator present in perivascular trigeminal-nerve fibers that supply the pial arteries, the meningeal arteries and the extracranial cephalic arteries.  Therefore, BIBN4096 BS, a calcitonin gene-related peptide- receptor antagonist might be effective in acute migraine treatment... In recent clinical trials BIBN4096 BS was administered in a dose of 2.5 mg intravenous [IV] over a period of 10 minutes and the rate of response to pain, two hours after treatment was good.  Nausea, photophobia, phonophobia and functional capacity all improved in parallel with the extent of response to treatment. Also, the rate of use of rescue medication was lower among patients who received BIBN 4096 BS than among those who received placebo." (Teleanu, R. I., Vladacenco, O., Teleanu, D. M., & Epure, D. A., 2016). The literature does support the use of Aimovig in this patient population.

The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient since this medication is medically necessary.

The carrier's denial of coverage for Aimovig is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Back Pain
Treatment:  Inpatient hospital

The patient is a female who had no significant medical history and presented after jumping off of the roof of a structure onto a trampoline and then falling onto her back.  She was initially ambulatory on the scene.  There was no head injury or loss of consciousness.  The patient denied numbness or tingling.  She did report eight out of 10 back pain.  Initial vital signs showed temperature 37.7 Celsius, heart rate 112, Blood pressure 146/57, and oxygen saturation 100%.  On physical examination she was moving all extremities equally.  She did have back pain when lifting the right leg.  Labs showed neutrophil count 8.47, chloride 112, creatinine kinase 262, white blood cell (WBC) 15.5, Hemoglobin 12.6, and Glucose 104.  Liver enzymes were normal.  Chest x-ray was negative.  Abdominal imaging was negative for obstruction.  The patient was admitted for trauma/fall.  The plan of care included trauma surgery consult, follow-up imaging studies, cardiac monitoring, cervical spine precautions, neurologic checks, ibuprofen, and acetaminophen for pain management.  Final reads of imaging results were ultimately negative for serious injuries, and she was discharged by trauma surgery.

The health plan's determination is upheld.  The inpatient hospital admission was not medically necessary.  The patient did need further care for her traumatic fall, but she primarily received observation therapy and pain management during the hospital stay.  She had no significant therapeutic interventions beyond pain management, and there were no other complications such as acute infection, cerebral hemorrhage, or long bone fracture.  She could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible early delivery/Labor (Preterm labor)
Treatment: Inpatient admission

The proposed treatment was not medically necessary.  

The patient was briefly (less than one day) observed and treated at the facility.  When it was determined that the patient met diagnostic criteria for preterm labor based on cervical change, she was transferred to a higher level of care rather than receiving and completing definitive care at the facility.  The care received at the facility in question primarily served to make the diagnosis of preterm labor which constituted the need for admission; after that diagnosis was made, the transfer occurred and the definitive care for this diagnosis, requiring inpatient care, was given at the other facility.  Therefore the admission at the facility in question was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Back Pain
Chiropractic Services

The patient is a female who began chiropractic treatment for low back pain on, although her prior history is not known as regards back pain or treatment. Chiropractic notes indicated that she was seen for low back pain, Visual Analog Scale (VAS) 8/10. The VAS was 4/10 for low back pain, and fluctuated between 3/10 and 7/10. Notes indicate back pain VAS 6/10, and findings of spasm and reduced ranges of motion, and treatment with spinal manipulation and heat. The chiropractic care (CPT 98940) is under review.

The health plan's determination is upheld. The Chiropractic Services were not medically necessary for this patient. The documentation provided did not objectively identify sustained and ongoing clinical improvements. The chief complaints, diagnoses and treatments were essentially unchanged for at least six months. The lack of clinical improvement as measured by standard assessment outcome tools makes such care not medically necessary. The notes reviewed did not show that there was a new condition being treated, and included no full examination or re-examination notes, including orthopedic/neurologic testing. Further, there was no indication that a much-needed, non-supervised home rehabilitation program had been instituted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multifocal pneumonia 
Treatment: Inpatient Stay

Summary:
The patient is a female. She presented with cough for weeks, and she had failed outpatient therapy, and she was sent to emergency room for evaluation. The patient's chest x-ray showed multifocal pneumonia and was started on IV antibiotics. The patient underwent TB (tuberculosis) isolation and lung biopsy complicated with pneumothorax requiring chest tube placement. The patient continued to receive IV antibiotics and required pulmonary consultation. 

The patient had failed outpatient therapy. The patient had abnormal chest x-ray and CT-chest performed in the Emergency room, which showed cavitary infiltrates and emphysematous lung changes. Since the patient had failed outpatient therapy and had worsening cough with dyspnea, the IV antibiotics were necessary. The patient's pulmonary infiltrates did not evidence a common infection as a source, and required lung biopsy and subsequent chest tube placement for pneumothorax.  Since patient had complicated pulmonary symptoms and radiology, along with failed outpatient therapy, the acute inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations and rapidly conducted atrial fibrillation
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This patient presented with symptomatic atrial fibrillation and was effectively treated with AV nodal blocking agents.  Following evaluation and additional testing, the patient reverted to normal sinus rhythm and was released from the hospital.  

Bellew et. al. studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department.  In this study of almost 600 patients, there was no difference in outcome.  American Heart Association (AHA) guidelines note that admission to the hospital for management of atrial fibrillation in patients that achieve rate control do not require hospital admission (Reference 2).  This patient reverted to normal sinus rhythm several hours after presentation.  In conclusion, this patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: non-small cell carcinoma, hypoxic brain injury, seizures  

Treatment: CTP code T1001 (Nursing Assessment) 1 unit, for date of service as specified

The insurer denied coverage for CPT Code T1001 - Nursing Assessment - 1 unit. The denial was reversed.

This patient is a male with diagnoses: non-small cell carcinoma, hypoxic brain injury.  The patient has been treated for lung cancer and laryngeal edema.  He has history of seizure and hypoxic brain injury.  He has chronic arm and chest pain.  The patient's condition is stable; not appropriate for hospice.  He follows-up at cancer center and with other medical specialists.  The plan is for the patient to continue living in the community with support. Prohibited activities include: no heavy lifting.  The patient is self-directing, able to summon help.  He walks independently.  He is continent of bowel and bladder. 

Based on the explanation in the insurer's final adverse determination notice, it appears the patient was due for a nursing re-assessment in order to continue personal care services.  NYS regulations for personal care services require a physician's order prior to assessment by a nurse.  The order must address specific information including: diagnoses, treatment, patient's condition and need for skilled and/or personal care services.  The necessary information is included in the form: DOH-4359 Physician's Order for Personal Care/Consumer Directed Personal Assistance Services.

The insurer indicated that several requests for the order were sent to the physician but it was not received as of a specified date; and so approval for the nursing assessment was denied.  
The physician's order for personal care services has been completed and sent to the insurer. This meets criteria for approval of the nursing assessment needed to determine continuation of personal care services.

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

Based on the above, the medical necessity for CPT code T1001 (Nursing Assessment) 1 unit, for date of service as specified is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

This is  patient who was prescribed Ingrezza. Per a prior authorization request, the patient was noted to have chorea and that Ingrezza was helpful in reducing the chorea. A letter indicated "patient is stable on this drug. This is the only drug that provided  significant benefit."  A  note from the neurology physician indicated that the right leg movements had considerably diminished, and the patient  was finding it much easier to walk though there are still some movements with a sense of weakness on the right. The health plans determination is overturned in whole. This is a patient with a hemiballismus (a unilateral choreiform hyperkinetic movement disorder). There is no evidence that the patient has Huntington's disease. There is no evidence that the patient has tardive dyskinesia. However, the preferred medication of Clonazepam is not an evidence-based treatment for hyperkinetic movement disorders of any type, and a literature search fails to reveal any evidence based on prospective clinical trials or even case reports that clonazepam is effective for any type of hyperkinetic movement disorder. There is a higher level of evidence for the use of a vesicular monoamine transporter 2 (VMAT2) inhibitor for the treatment of hyperkinetic movement disorders.

Botox was also listed in documentation as a preferred medication. Review of the medical literature fails to reveal any evidence that Botox is effective in Choreiform movement disorders or other hyperkinetic movement disorders, such as hemiballismus.
Other than VMAT2 inhibitors, there is no treatment supported by any level of evidence for choreiform hyperkinetic movement disorders. Therefore, the use of Ingrezza would be medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Preventive Care
Surgical Services  (All)

This is a male with bilateral mandibular hyperplasia. Specifically, the patient has elongation of the right and left mandibular rami. Facial Surgery (CPT 21209) is being requested and is under review. 

The health plan's determination is overturned. This is surgery performed to correct functional problems and it is appropriate, the standard of care and commonly performed for this deformity. The procedure is not performed for the convenience of the provider or patient and is expected to relieve the functional problems through establishment of a normal dento-facial skeletal relationship. There are no alternatives as orthodontics alone will not correct the deformity. 
According to the American Association of Oral and Maxillofacial Surgeons Criteria for Orthognathic Surgery, the indications for surgical correction of maxillofacial deformities are any of the following: 
1) malocclusion that cannot be corrected by non-surgical means, 
2) speech pathology, 
3) masticatory and swallowing abnormalities, 
4) social and psychological impairment or 
5) obstructive sleep apnea. 
There must be either: 
1) physical evidence of musculoskeletal, dento-osseous, and/or soft tissue deformity,  
2) imaging evidence of musculoskeletal, dento-osseous, and/or soft tissue deformity,
The patient has a malocclusion that cannot be corrected by non-surgical means, speech pathology and masticatory and swallowing abnormalities as well as a mandibular hyperplasia. The guidelines for surgery are met.
Appeal type: Formulary Exception
Decision: Upheld

Other 
Pharmacy/Prescription Drugs 

The patient with chronic hepatitis B requesting Vemlidy therapy. The Vemlidy is non-formulary. The patient is treatment naive. Since the patient requires this medicine for long-term there is a concern for bone and kidney disease. Vemlidy is requested as a safer and more effective alternative.The health plan determination is upheld in whole.  
Meta-analyses comparing these agents have found no significant differences in HBV DNA suppression, ALT decline, HBeAg seroconversion, and toxicity (eg, nephrotoxicity and hypophosphatemia).In summary Tenofovir alafenamide (tenofovir AF) has been evaluated in HBeAg-positive and HBeAg-negative patients with chronic hepatitis B virus (HBV). This agent has been found to have similar efficacy to tenofovir DF in both treatment-naive and treatment-experienced patients at 48 weeks. Therefore, initiating Tenofovir alafenamide (tenofovir AF) (Velmidy) over Viread is not medically necessary.