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

The patient is a gravida (G) 3 para (P) 0 Biochemical 2 Ectopic 1 who has had issues with infertility for 3 years. It is unclear what the nature of her infertility is, but she has undergone multiple treatment cycles. She has had 5 in vitro fertilization (IVF) cycles with intracytoplasmic sperm injection (ICSI). For three of these cycles, she had fresh embryo transfers. 

The health plan's determination of medical necessity is upheld. Recent recommendations 2018 from the American Society of Reproductive Medicine (ASRM) does not support routine genetic embryo testing for euploid status in all patients. Therefore the use of genetic testing for euploidy is not medically necessary. The patient does not have known disease carrier status.  Although she has a prognosis of greater than 5%, does not show evidence of decreased ovarian reserve, and has a normal AMH level, since she has embryos still in storage and therefore still has the potential to conceive, another fresh IVF cycle is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Septal Defect Closure
 
Treatment: Inpatient admission for Atrial Septal Defect Closure via Cardiac Catheterization.

The insurer denied coverage. The denial was upheld.
This is a teenage patient who was electively admitted for atrial septal defect closure via cardiac catheterization. The patient has a past medical history of atrial septal defect, syncope, palpitations and chest pain. Post-operatively the patient was admitted to telemetry for monitoring. Chest x-ray showed no displacement of the implant. Echocardiogram performed showed no residual shunting and showed the implant in place. The patient was discharged home to follow up with cardiologist as an outpatient.
The insurer has denied coverage for the inpatient admission, as not medically necessary.  They state the admission for diagnosis of cardiac catheterization for atrial septal defect does not meet clinical criteria for admission. The patient could have been evaluated, had testing and been treated symptomatically while awaiting results of tests. There was no positive test or other findings after evaluation by the professionals that would have required an acute level of care.
The MCG Health Inpatient and Surgical Care 23rd Edition Guideline "Cardiac Septal Defect:  Atrial, Transcatheter Closure" states "most procedures are performed on an ambulatory basis. An inpatient stay may be necessary for patients with active comorbidities requiring inpatient postprocedural care." The Guideline under the heading of Length of Stay references a large commercially insured pediatric population in which 96% of transcatheter atrial septal defect closures were performed on an outpatient basis. Therefore this otherwise healthy teenager with no documented comorbidities or intra-procedural complications did not require an inpatient admission. 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 a past medical history significant for recently diagnosed deep vein thrombosis (DVT) and a pulmonary embolism (PE) which is being treated with Eliquis,, and hyperlipidemia, who presented to the Emergency Room (ER) with a complaint of hemoptysis.The patient was admitted to the hospital with a diagnosis of pulmonary hemorrhage. The health plans determination of medical necessity is upheld in whole. 
 At the time of admission and during the hospitalization, the patient was afebrile and hemodynamically stable, there was no evidence of severe anemia or ongoing blood loss. Therefore , the hospital stay was not indicated at the inpatient level of care and could have been handled at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Issue under review: Inpatient admission

The patient did present with an allergic reaction associated with shortness of breath.  Wheezing was documented on the clinical examination, but the patient's vital signs were stable. She was not noted to be in any respiratory distress on presentation. A day prior, she had seen a dermatologist and was on some steroids.  Her oxygen saturation on presentation was 98% on room air, respiratory rate was 20 per minute, which was normal. Heart rate and blood pressure were within normal limits.  She was not using any muscles of respiration.  Laboratory data was unremarkable.  She did not meet the criteria of acute in a patient hospital stay, for her acute allergic reaction with urticaria and bronchospasm could have been as effectively and safely managed at a lower level of care, such as observation.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient is a male who has been receiving testosterone therapy since a few years ago.  A chart note dated in late 2018 detailed that the patient was seen for fatigue, as well as a depressed mood.  The patient has been recently diagnosed with hypogonadism.  The patient was utilizing clomiphene; however, it was not working.  The patient stated he does have depressed mood; however, it is better with testosterone injections. Patient documentation details he has had low testosterone readings on two different occasions that were before 10 AM a couple of years ago.  The physician detailed that the patient has hypogonadism; he is fatigue and should receive testosterone injections because the hypogonadism was not relieved with AndroGel.  In early 2019, patient documentation details his total testosterone remained low at 199.4.

According to current literature, testosterone therapy is supported for male patients who present with classical androgen deficiency syndromes to include low libido, decreased morning erections, loss of body hair, low bone mineral density, gynecomastia, low or zero sperm count, small testes, fatigue, and/or hot flashes, and when the patient has low testosterone (less than 300) that has been confirmed by serial morning (8 to 10 a.m.) serum testosterone concentration testing.  The goal of testosterone therapy is to restore the serum testosterone concentration within the normal range (300 to 700).

Scientific evidence in peer reviewed literature does support a result of improvement in the requested medication and does have final approval from the appropriate regulatory bodies.  The patient was a good candidate for the injection which was the best available treatment.

The carrier's denial of coverage for anabolic steroids (injection, Testosterone Undecanoate) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a young male with symptomatic hypogonadism that has been successfully treated with Aveed injections since a few years ago.  Prior treatment with supplements, clomiphene, and AndroGel were not effective.  A follow-up testosterone level was low in early 2019 (199.4 ng/dl).  The request is for coverage of continued treatment with Aveed.

The scientific evidence in peer-reviewed literature supports a result of improvement in the health outcome in men with hypogonadism who are treated with androgen replacement.  A recent meta-analysis by Traish, A. M. (2018) concluded, "A large body of evidence provides significant valuable information pertaining to the therapeutic value of testosterone therapy [TTh] in men with testosterone deficiency [TD].  TTh in men with TD provides real health benefits for bone mineral density, anemia, sexual function, glycometabolic and cardiometabolic function, and improvements in body composition, anthropometric parameters, and quality of life."     

Aveed has been Food and Drug Administration (FDA) approved for testosterone replacement since 2014.
According to The Society for Endocrinology (2018), "Testosterone is important for general as well as sexual health in men.  Symptoms of testosterone deficiency commonly include decreased libido, loss of morning erections and erectile dysfunction, but may also involve tiredness (fatigue), reduced physical strength and endurance, loss of motivation and concentration, irritability, and low moods.  As these symptoms may be caused by conditions other than testosterone deficiency, it is important that any diagnosis of hypogonadism is supported by biochemical evidence of low circulating testosterone levels." They conclude, "Testosterone treatment in patients with a well-founded diagnosis of classical hypogonadism is effective and safe." 

According to The Society for Endocrinology (2018), "Testosterone is important for general as well as sexual health in men.  Symptoms of testosterone deficiency commonly include decreased libido, loss of morning erections and erectile dysfunction, but may also involve tiredness (fatigue), reduced physical strength and endurance, loss of motivation and concentration, irritability, and low moods.  As these symptoms may be caused by conditions other than testosterone deficiency, it is important that any diagnosis of hypogonadism is supported by biochemical evidence of low circulating testosterone levels." They conclude, "Testosterone treatment in patients with a well-founded diagnosis of classical hypogonadism is effective and safe." 

The carrier's denial of coverage for anabolic steroids (injection, Testosterone Undecanoate) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Primary Hypogonadism
 
Treatment: Anabolic Steroids (injection, Testosterone Undecanoate)  
The insurer denied Anabolic Steroids (injection, Testosterone Undecanoate). The denial was reversed. 
The patient is a young male who was seen in late 2018 by MD for his complaint of chronic fatigue and depression.  A work-up in the past revealed low testosterone below 300 on two occasions.  Both of these samples were taken before 10 AM.  According to the provider, the patient was diagnosed with primary hypogonadism.  He has had no relief with AndroGel. The recommendation was for long-acting Testosterone shots. The patient has been receiving on-going treatment every 10 weeks.
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 using an accurate and reliable assay 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 after discussing the potential benefits and risks of therapy and of monitoring therapy and involving the patient in decision making. 
Based on patient documentation, this patient had two low morning testosterone levels.  He is symptomatic for low testosterone.  He does fulfill the above guidelines for testosterone replacement and the requested Injection, testosterone undecanoate would be considered appropriate.
The carrier's denial of coverage for anabolic steroids (injection, Testosterone Undecanoate) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
Syncope and near syncope are not uncommon occurrences in childhood, with up to 35% of children experiencing at least one episode of syncope.  Because of the decreased risk of underlying heart disease in the pediatric population, most of these episodes are benign.  The yield of diagnostic studies is therefore quite low.  The current guidelines recommend increased use of the electrocardiogram to screen for underlying cardiac abnormality because it provide the highest yield, and modified use of imaging studies.  "The goal of the evaluation is to identify high-risk patients with underlying heart disease, which may include identifiable genetic abnormalities such as the LQTS [long QT syndrome], Brugada syndrome, or hypertrophic cardiomyopathy."  Syncope is an unusual presentation of patients with neurological problems.  Such causes should be pursued only if suggested by the history or physical exam.  Seizure would be the most common neurologic cause of unconsciousness or unresponsiveness, and electroencephalography (EEG) would be the diagnostic study of choice, followed by imaging studies to identify structural abnormalities.
This young teenager experienced an episode of syncope in conjunction with severe abdominal pain at the start of her menses.  No tonic-clonic movements, loss of bowel/bladder control, or post-ictal period were reported.  Electrocardiogram performed in the ED was unremarkable.  Laboratory studies were also unremarkable.  The cardiologist ultimately diagnosed vasovagal syncope with no cardiac abnormalities noted.  The patient remained stable for the duration of her time in the ED and on pediatric floor, with complaints of mild dizziness but no further spells.  She was overall stable and did not require acute inpatient admission.  She could have been safely managed in the outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psychotic symptoms, hallucinations

Treatment: Inpatient admission, evaluation and medication management.

The insurer denied inpatient mental health treatment. That denial was reversed.

This patient was admitted to inpatient mental health treatment due to psychotic symptoms.  He had auditory hallucinations of someone wanting him dead, visual hallucinations of ghosts and creatures, disorganized thinking and speech, persecutory delusional thinking, homicidal statements such as he will stab them if they come at him, internal preoccupation, talking to self, poor activities of daily living (ADL's), non-compliance, and agitation.  He was drinking alcohol, using $160 of crack/cocaine per day, and $25 of cannabis per day.  He reportedly had multiple past psychiatric hospitalizations.  He was unemployed with a low education.  He reportedly took Haldol including the decanoate, Depakote, and Trazodone.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia report that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization.  

In this case this patient still had psychotic symptoms during the denial period including responding to internal stimuli, talking to self, smiling at self, had visual hallucinations of seeing ghosts, and had disorganized thinking.  He reported that the drugs were controlling him as well.  He continued to have psychotic symptoms and was at high risk for even worsened psychotic symptoms if discharged prematurely.  He had continued psychotic symptoms with a history of multiple substances of use daily including alcohol, crack/cocaine, and cannabis who had limited skills and multiple past psychiatric hospitalizations.  He continued to require 24 hour hospital treatment until discharge.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

Determination of level of care is primarily dependent on the acuity of the illness and the actual treatment provided. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. In this case, the patient's symptoms were intermittent; including an episode in hospital that had normal findings.  The patient's vital signs and cardiac findings were normal. The "abnormal" EKG actually represents a normal variant, Lown Ganong Levine, which is benign and not associated with syncope. The physicians' treatments were limited to IVF and an implantable loop recorder. The procedure was uneventful and without complications.

It is noted that the implantable loop recorder was placed with an invasive technique. It is not a technique that the general cardiology and EP communities would consider to be necessary given the circumstances. The implant is considered such a minimal procedure that it is appropriate to do not only as an outpatient, but in a physician's office. Although the technique used is documented to have been with vascular access, that is also an outpatient procedure. Ambulatory ECG monitoring is available in many forms, including continuous (Holter) monitoring for 24 to 48 hours, event (loop) monitoring for several weeks, or implantable loop recording for months to years. All of these modalities are outpatient. 

All of the testing and therapy that were provided would have been appropriate, safe and guidelines consistent to been provided in an outpatient setting. Thus, the inpatient level of care was not medically necessary. The treatment that provided was limited to IVF and observation, and the telemetry monitor is not an inpatient level of care. It is also noted that a witnessed syncope occurred in the hospital. 

The letter of appeal was carefully considered, but it offered no evidence to support a higher level of care. All of the tests and treatment that were provided and actually performed were at an outpatient care level. While there is significant number of causes for syncope, none were determined to be the etiology, and no treatment was necessary. The work up would have been guideline-consistent as an outpatient.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of asthma and peripartum cardiomyopathy.  The patient presented with dyspnea and was diagnosed with nonischemic cardiomyopathy, felt to be a peripartum cardiomyopathy.  Ejection fraction (EF) was 14%. The patient was placed on medical therapy, including Lasix, metoprolol, and lisinopril. Left ventricular (LV) function remained low, however, with recent cardiac magnetic resonance imaging (MRI) scan showing an EF of 22%.
The patient was electively admitted for an implantable cardioverter defibrillator (ICD) placement for primary prevention of sudden cardiac death. A single chamber ICD was placed. The procedure was uncomplicated, and the patient was discharged the following day. 
The health plan's determination is upheld.

No, the inpatient stay is not medically necessary. Per Milliman Care Guidelines, for patients admitted for electrophysiology study and ICD placement (in this case, the patient only had ICD placement, not electrophysiology study), the usual length of stay is ambulatory or one day post-operative. Inpatient admission is indicated, with extension of stay, for issues such as lead or generator problems, intrathoracic complications (such as pneumothorax), infection, or comorbid condition requiring inpatient admission (such as acute congestive heart failure [CHF] or renal failure). The patient does not meet any of these criteria for inpatient admission. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, legal blindness,
diabetes insipidus, insomnia, congestive heart
failure and arthritis
Treatment: Consumer directed personal assistant services
168 hours per week

The proposed treatment of an increase in consumer directed personal assistant services to 168 hours per week is deemed medically necessary. 

The patient is a female with a history of Alzheimer's dementia, legal blindness, diabetes insipidus, insomnia, congestive heart failure and arthritis. Due to impairments related to her various comorbid conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

This is a female with a history of Alzheimer's dementia, legal blindness, diabetes insipidus, insomnia, congestive heart failure and arthritis. Due to impairments related to her various comorbid conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Specifically, during a recent in home assessment of the patient's abilities, the patient was noted to have significant cognitive impairment with fluctuating mood and behavior. She was also noted to be experiencing chronic hallucinations and delusions. She has significant gait ataxia requiring varied levels of assistance ranging between walker, manual wheelchair, gait belt and aide with guided assist given her legal blindness, weakness and cognitive impairment. She has limited range of motion of her shoulders, unable to lift elbows to shoulder height bilaterally. For these reasons, the currently approved plan of consumer directed personal assistant services 80 hours/week is insufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in consumer directed personal assistant services to 168 hours per week is deemed medically necessary for improved assistance with completion of the patient's ADLs.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Issue under review: LINX

Determination:
The health plan should not cover the LINX.

This patient has an esophageal motility disorder, based on the esophagram.  In this case, LINX is not an established therapy.

In this case, the submitted clinical data includes a surgical history and physical exam that details the patient's symptoms that include daily epigastric pain, chest pain, burning in the throat, pressure, nausea.  The motility study has identified esophageal dysmotility with 20% of swallows being either failed or weak/ineffective.  The contrast study also identified esophageal dysmotility [corkscrew esophagus].

Listed contraindications or precautions to implantation of the LINX device (per the manufacturer) include conditions such as Scleroderma, suspected or confirmed esophagogastric cancer, prior esophageal or gastric surgery or endoscopic intervention, esophageal motor pathology, symptoms of dysphagia more than once per week, esophageal stricture or other gross anatomic abnormalities, esophageal or gastric varices, lactating, pregnant or plan to become pregnant, morbid obesity, or age < 21.  

In this case, the patient has a possible alternative diagnosis (esophageal motor pathology per the manometry study and the contrast esophagram).  The use of LINX for the treatment of GERD in the setting of this condition is not established and is not known to be more beneficial than available alternative or standard therapy for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD
Issue under review: LINX

Determination:
The health plan should cover the LINX.

This patient suffers from GERD symptom of epigastric pain, burn in the throat that can wake her up as evidenced by the very high DeMeester score indicating a very high amount if esophageal acid exposure.  Even with PPI and H2 blocker, there is refluxing gastric contents.   Surgical therapies exist that resolve this very well.  Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended.  Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety.  The side effects of LNF make it a less than ideal operation.  Linx is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been show to dramatically improve patient satisfaction long term.  It is approved by the FDA.  

There is published data on patients who have had the device for six years, showing a very low complication rate and a high resolution of GERD.