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

Diagnosis: Bronchiolitis.
Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.  The denial is overturned.

This is a patient who had been sick for 3 days with a cough, congestion, and a runny nose. His mother brought him to the pediatrician, who noted wheezing and increased work of breathing and arranged for the child to be transported to the Emergency Room (ER).

In the ER he was irritable, crying and appeared fatigued. He was noted to have persistent respiratory distress with tachypnea with increased work of breathing. He was initially treated with Decadron and nebulized albuterol with little improvement noted. He then received treatment with duoneb, a dose of racemic epinephrine and intravenous (IV) fluids. He tested positive for the metapneumovirus. When he continued to have an elevated respiratory rate of 40, wheezing, rhonchi and diffuse crackles upon auscultation of the lung, the decision was made to admit the child to the hospital with a diagnosis of bronchiolitis for continued treatment with oxygen and albuterol every 3 hours.

Patient was treated appropriately in the ER for respiratory distress with hypoxemia related to a metapneumovirus infection. The presence of persistent respiratory distress and chest congestion with wheezing and rales are all signs of significant respiratory distress, and in view of the ongoing need for oxygen therapy the decision to admit for continued oxygen supplementation was consistent with the standard of care for a young child with bronchiolitis and hypoxemia. The decision to admit to the hospital for ongoing treatment with oxygen was appropriate and consistent with the standard of care.

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

The insurer's denial of coverage for full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac Circulatory Problems -Heart Attack
Physical therapy

The patient has with hypertension, hyperlipidemia, and tobacco use who was hospitalized with chest pain. The patient ruled in for a non-ST elevation myocardial infarction, with elevated troponin (0.18) and EKG showing inverted T waves in leads V1-V3. Patient underwent cardiac catheterization during that hospitalization which showed a 95% stenosis of the mid-LAD.  This was treated with drug-eluting stent placement. Paitent also had a 60% stenosis of the mid-RCA which was treated medically (not hemodynamically significant by IFR). Discharge medications included aspirin, Effient, omeprazole, valsartan, metoprolol and rosuvastatin. 

Patient was referred for phase II cardiac rehabilitation.  The patient underwent cardiac rehabilitation with exercise, as well as guidance for blood pressure control, diet, and smoking cessation. The provider uses the Pritikin ICR (intensive cardiac rehab) program. The health plan has denied intensive cardiac rehab. The health plan's determination is upheld. The proposed health service of Intensive cardiac rehabilitation with exercise based on the Pritikin program is not likely to be more beneficial than a standard intensive phase II cardiac rehabilitation program, which would include exercise, diet recommendations, weight loss, and smoking cessation.  
Cardiac rehabilitation in general improves outcomes in patients post-myocardial infarction, with benefits including lowering risk for recurrent myocardial infarction, improving functional status, and reducing anginal symptoms.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac Circulatory Problems -Heart Attack
Physical therapy

The patient had a non-ST segment elevation myocardial infarction. At that time a stent was placed in his left anterior descending coronary artery.
Uphold in whole the health plans determination regarding the proposed service.
No, there is insufficient evidence to conclude that an Intensive Cardiac Rehabilitation program would be more beneficial than standard phase II cardiac rehabilitation for the patient's condition.
Standard phase II cardiac rehabilitation is a physician-supervised program that consists of up to 36 sessions over a 12-week period. These sessions involve gradually increased supervised exercise and education regarding lifestyle modification. Intensive cardiac rehabilitation programs incorporate standard rehabilitation programs with additional emphasis on health enhancement. Patients participate in daily exercise for up to 72 sessions.
Appeal type: Experimental/Investigational
Decision: Upheld

Cardiac Circulatory Problems -Heart Attack
Physical therapy

This case involves a patient with a past medical history of hypertension and tobacco use who developed worsening chest pain 2019. The patient  was admitted with non-ST elevation myocardial infarction (NSTEMI). The patient  underwent left heart catheterization revealing 95% stenosis of the mid left anterior descending (LAD) artery and nonobstructive disease of the right coronary artery (RCA). The patient received one drug-coated stent for his LAD stenosis.
 The physician referred the patient to phase 2 cardiac rehabilitation program and ordered blood work.
The health plans determination is upheld in whole.
No,the proposed treatment is not likely to be more beneficial than standard treatment. Despite cardiovascular benefits gained with intensive cardiac rehabilitation, it is not accepted based in published medical literature to be more effective than a phase 2 cardiac rehabilitation program There are many benefits of standard cardiac rehabilitation for patients with cardiovascular disease. It is well established that supervised exercise in the context of cardiac rehabilitation improves symptoms, controls cardiac risk factors, and enhances functional capacity.
Sumner et al. published a meta-analysis on 10 observational studies in patients enrolled into cardiac rehabilitation after acute myocardial infarction (1). Based on outcomes data from this group of studies, cardiac rehabilitation was associated with reduction in all-cause and cardiac-related mortality. The significant improvement in symptoms and functional capacity that patients gain from cardiac rehabilitation is also well accepted. Nilsson et al. investigated the long-term benefits of cardiac rehab training on cardiovascular fitness assessed by cardiopulmonary exercise testing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis.
Treatment: Octagam.
The insurer denied the Octagam.
The determination is upheld.

The patient has presumed relapsing remitting multiple sclerosis. Treatment with intravenous immunoglobulin is the subject of this review. The drug was denied by the plan based on the diagnosis of relapsing remitting multiple sclerosis. The denial was appealed by the provider. The patient has previously been treated with Copaxone and Rebif. She was most recently on Ocrevus but had progressive leg weakness and gait instability. At issue is the medical necessity of Octagam.

The requested Octagam is not medically necessary for this patient. The patient has a diagnosis of relapsing multiple sclerosis. Because the patient has accumulating disability, with difficulty ambulating, the more precise diagnosis is likely secondary progressive multiple sclerosis. The patient has tried and failed Copaxone, Rebif, and Ocrevus. Treatment with intravenous immunoglobulin is prescribed; however, the rationale for use of this medication is lacking. The patient has not exhausted Food and Drug Administration (FDA) approved medications for treatment of relapsing forms of multiple sclerosis. As such, there are many other medication classes available that have not been tried and failed including fumarase, S1PR modulators, various other monoclonal antibodies, and cladribine. There is no rationale provided for use of intravenous immunoglobulin, which is not an FDA approved therapy for treatment of multiple sclerosis, over all of these available treatments of relapsing multiple sclerosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: fever, rhinorrhea and congestion
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

At the time of the services under review, the patient presented to the emergency department (ED) with 2-3 days of a fever, fussiness, worsening rhinorrhea and congestion. The patient was seen at an outside facility with negative coronavirus (COVID)-19 testing and discharged home. She presented to the admitting facility with persistent and worsening symptoms.
The emergency department (ED) vital signs were temperature (T) 40.1 degrees Celsius (C), heart rate (HR) 206, respiratory rate (RR) 52, and oxygen saturation (O2 sat) 99% on room air. The physical exam was notable for a distressed infant with tachycardia and posterior oropharyngeal erythema. Lab results showed a white blood cell count (WBC) of 18.2 with 40% segmented neutrophils (segs) and 49% lymphocytes (lymphs), hematocrit (Hct) of 36.6, platelets (Plt)of 222, C-reactive protein (CRP) less than (<) 0.5. A comprehensive metabolic panel (CMP) showed a carbon dioxide (CO2) of 19 and potassium (K) of 6.4 with hemolysis; a urinalysis was normal. The patient received ceftriaxone and intravenous fluids (IVF), a chest x-ray (CXR), and ultrasound (US) of the abdomen. The abdominal ultrasound was negative for intussusception. Repeat vital signs were T 37.4 degrees C, HR 166, RR 40, and O2 sat 99% on room air. The patient was admitted to the hospital for further management of a febrile illness after partial sepsis evaluation. The patient continued to be febrile for 12 hours as an inpatient, after which the fever curve trended down. Blood cultures were negative at 24 hours and antibiotics were discontinued. The patient was discharged home.
At issue is whether the inpatient stay is considered medically necessary for this patient.
The requested inpatient stay was medically necessary for this patient.
This child presented to the ED with multiple vital sign abnormalities and concern for shock/sepsis. The baby's age, clinical history, and assessment in the ED were concerning and warranted continued treatment with close monitoring of vital signs to ensure no decompensation. She presented with persistent fevers and upon arrival to the ED had a fever, tachycardia, and tachypnea. Based on the clinical picture, sepsis was a concern. This baby required IVF, antibiotics, and continued close monitoring at the inpatient level of care until her condition improved. Therefore, the inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient was a male with a past medical history significant for alcoholism and seizures related to alcohol withdrawal who presented to the emergency department after he had recurrent seizures. The patient did not remember those seizures. It was reported that he took one dose of intramuscular (IM) Naltrexone as an outpatient that initially helped, and the patient remained sober for two months. Subsequently, he went back to drinking. He reported consuming 1 liter (L) of hard liquor daily. In the emergency department, the patient received multiple doses of Lorazepam. When seen by the admitting physician, the patient was sitting at the edge of the bed. He looked comfortable. The patient had a regular heart rate and rhythm, without murmurs, rubs, or gallops. Lungs were clear to auscultation. The abdomen was non-tender.
The patient had mild tremors in the extremities. The rest of the physical exam was unremarkable. Chest x-ray demonstrated no acute disease. Electrocardiogram (EKG) demonstrated sinus rhythm with no significant abnormalities. The patient was admitted to the hospital due to alcohol abuse and alcohol withdrawal seizures.
Clinical Institute Withdrawal Assessment (CIWA) protocol was initiated. The patient was seen by the addiction medicine team and was recommended the administration of Naltrexone. He was initially agreeable to diazepam taper and monitoring for continued alcohol withdrawal. He was seen by the addiction medicine team and was agreeable to the injection of Naltrexone. Reportedly, the patient decided to sign out against medical advice.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care.
At the time of the initial evaluation, the patient was awake and alert. He was hemodynamically stable and had no signs of central nervous system (CNS) infection.
Even when the patient was seen in the emergency department, he was alert and oriented to person, place, and time. He was cooperative on the exam.
The patient totally recovered from the seizure by the time he was seen by the admitting physician, and the imaging studies did not show any acute abnormalities that required intervention. There was no evidence that the seizures were associated with significant electrolyte abnormalities. Taking into consideration all these facts, there is no evidence that either the severity of the patient's condition or the complexity of the services provided justified admission at the acute inpatient level of care.
Admitting the patient for monitoring was justified, however this could have been accomplished at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Other/Class 1 Occlusion. 
Treatment: Dental/Orthodontic Procedure. 

The health plan denied the requested orthodontic dental work as not medically necessary. 
The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion with 5mm (millimeter) overbite and 5mm overjet. She has moderate maxillary and mandibular crowing. She is treatment planned for 30-36 months of orthodontics with extraction of four first premolars to correct her malocclusion. 

At issue is the medical necessity for the requested comprehensive orthodontic treatment and monthly visits. 

I uphold, in whole, the health plan's determination of medical necessity. 

The health plan has acted in the best interest of this patient. She has crowding but no teeth are impacted. Her overbite is deep but there is no indication of damage to the incisors in the photographs. The patient's cephalometric radiograph shows the lower incisors are not contacting the palate in occlusion. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior or posterior crossbites present. The mandibular second molars are unerupted, but they are not ectopic or impacted. 
There is no medical reason to correct her malocclusion with braces. While the patient is crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. [1] This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. [2] The patient has a 5mm overjet, but this amount of overjet does not affect oral health related quality of life. [3] If her teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission.
The denial is upheld. 

This case involves a female who presented to the hospital for seizure activity and fever.  Per parent report, the patient developed a generalized tonic-clonic seizure, which lasted approximately 5-10 minutes. The patient was brought by emergency medical services to the hospital and given rectal diazepam. Vital signs included a pulse of 120, and respirations 30. The patient received intravenous valproate 10 mg (milligrams) along with normal saline bolus and Tylenol suppository. She was subsequently admitted to the pediatric unit for stabilization after breakthrough seizures with a plan of care to include neurological checks every 4 hours, oxcarbazepine 15 mg every 12 hours, Ativan 2 mg intramuscular as needed, and valproate 191 mg. However, the inpatient stay was denied coverage with claims that care could have been rendered on an observational basis overnight. This review pertains to denial of coverage for an inpatient admission.

The Milliman Care Guidelines state that inpatient admission for seizures in the pediatric population may be indicated when the patient is hemodynamically unstable, has a febrile seizure and have 1 more the following to include an age of 5 years or older, focal seizure activity, prolonged seizure of 15 minutes or more, more than 1 seizure within 24 hours, and there was a suspicion for meningitis to include neck stiffness on examination. Other indications for inpatient care include at the patient is status epilepticus, has a brain disorder that requires monitoring or intervention available only at an inpatient level of care, the etiology requires monitoring or intervention available only at inpatient level of care or that persist despite observation care, when the patient is altered mental status that is severe persistent, has new focal neurologic deficits post seizure, or has a metabolic disorder that persists despite observation care. Medical literature has noted that hospital admission is usually not required for children with febrile seizures, although factors to consider when making the decision and includes younger age, the need for further observation because of abnormal examination findings, or unreliable follow-up.  The records provided for the review noted that the patient had a history of a seizure disorder and was not feeling well at home. She had a seizure at that time, and aside from a low-grade fever, had otherwise normal vital signs. She had normal CT (computed tomography) of the head and responded to antiseizure medications. She had no subsequent seizures, and therefore given care for in an observational setting and did not require the inpatient level of treatment. Therefore, the prior determination is upheld.

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Idiopathic gastroparesis. 
Treatment: Outpatient procedure (43999 x 1) G-POEM (gastric peroral endoscopic myotomy). 

The insurer denied coverage for G-POEM. 

The denial is overturned. 

The patient has idiopathic gastroparesis. She has had increasing symptoms from her gastroparesis over several years. She suffers from intractable nausea. Her doctor has now advised that she have G-POEM procedure. 

The physician has submitted an article from Clinical Gastroenterology and Hepatology titled "Gastric Peroral Endoscopic Myotomy Reduces Symptoms, Increases Quality of Life, and Reduces Health Care Use for Patients with Gastroparesis." Thirty Patients were studied who had the G-POEM procedure performed between 2015 and 2017 at a tertiary center. The conclusion was that the procedure significantly improved symptoms, increased quality of life, and reduced health care use related to gastroparesis. 

UpToDate article titled "Peroral Endoscopic Myotomy (POEM)" discusses POEM for gastroparesis. Multiple studies were reviewed. A significant improvement in the Gastroparesis Cardinal Symptom Index Score was found 78% had better gastric emptying score. Adverse effects were encountered only in a small number of patients. Most of which were mild and conservatively managed. 

The scientific literature supports the use of G-POEM, and it has resulted in improved patient outcomes. The POEM procedure has been approved by the Food and Drug Administration (FDA). The patient is a good candidate because she did poorly with medical therapy for gastroparesis. There are multiple treatments for gastroparesis, but this procedure has been shown to be effective in patients who failed medical therapy. The adverse effects of the procedure are usually mild and managed conservatively. It is likely that this procedure would be more beneficial for this patient compared to continuing with medical therapy that has already not been successful. The risks are not increase over any surgical procedures. 

The carrier's denial of Outpatient procedure (43999 x 1) G-POEM (gastric per-oral endoscopic myotomy) should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Idiopathic gastroparesis. 
Treatment: Outpatient procedure (43999 x 1) G-POEM (gastric peroral endoscopic myotomy). 

The insurer denied coverage for G-POEM. 

The denial is upheld. 

This is a female diagnosed with a history of idiopathic gastroparesis and intractable nausea. The patient presented to her gastroenterologist with worsening gastroparesis and complaints of daily nausea. The patient currently takes cyclobenzaprine and marijuana, with some relief of nausea reported. The treating provider is requesting therapy with G-POEM procedure. 

The latest literature as reviewed does not show that G-POEM is as effective as current available therapies, and there are strong recommendations for further studies to determine which patients could benefit from this procedure. 
  
The Food and Drug Administration (FDA) has approved the G-POEM. 

This patient is not a good candidate, based on a lack of supporting literature showing efficacy and durable benefit of the requested procedure.

Per Ragi, O. et al., (2021), "Data on the long-term outcomes of G-POEM for refractory gastroparesis are lacking." 

Vosoughi et. al, "G-POEM is a safe procedure, but showed only modest overall effectiveness in the treatment of refractory gastroparesis. Further studies are required to identify the best candidates for G-POEM; unselective use of this procedure should be discouraged." 

Li et. al., "G-POEM was shown to be feasible and safe for the treatment of gastroparesis with various etiologies, which could be a potential first-line therapy for certain patients. Future studies are needed to investigate the appropriate patients for G-POEM to explore the "most beneficial" subgroup of patients." 

This is not the best available treatment for this patient at this time, due to a lack of efficacy and durable benefit in current literature. 

The latest literature as reviewed does not show that G-POEM is as effective as current available therapies and there are strong recommendations for further studies to determine which patients could benefit from this procedure. 

There are no major adverse risks associated with the G-POEM over the standard options. 

There is insufficient literature to support that the requested procedure is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of Outpatient procedure (43999 x 1) G-POEM (gastric per-oral endoscopic myotomy) should be upheld.