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

Central Nervous System/Neuromuscular Disorder
Pharmacy/Prescription Drugs

The patient is a woman with mild Parkinson's disease. The provider notes that her condition is slowly progressive. Treatment with brand Azilect is being requested. The patient is currently on low-dose Sinemet.

The health plan's determination is upheld. Azilect is not medically necessary for this patient. In order for a service to be medically necessary, the requested drug must be at least as likely as the formulary drug to produce equivalent therapeutic results for treatment of that patient's condition. There is no documentation that the patient has tried or failed or has a contraindication to treatment to any of the plan's alternative medications such as selegiline or amantadine. These medications are Food and Drug Administration (FDA) approved for the treatment of Parkinson's disease. Three monoamine oxidase (MAO) B inhibitors are available for use in patients with Parkinson's disease: selegiline, rasagiline, and safinamide. They have not been directly compared with each other, and the choice among the three is based on clinician and patient preference. The MAO B inhibitors have been shown to be modestly effective as early symptomatic treatment for Parkinson's disease.
Appeal type: Medical necessity
Decision: Upheld

Mental health
Mental health Residential level of care

The pediatric patient has a request for mental health (MH) residential level of care. The patient is diagnosed with major depressive disorder (MDD), recurrent, moderate, generalized anxiety disorder (GAD), attention deficit hyperactivity disorder (ADHD), combined type and Cannabis dependence. The patient was referred from Intensive Outpatient Program (IOP) due to continued tetrahydrocannabinol (THC) use. The patient had been in Partial Hospitalization Program (PHP) prior to the IOP level of care. The patient is noted to have depression, anxiety, low self-esteem, passive suicidal ideation and social isolation. The patient is avoidant of situations that cause the patient to be easily overwhelmed. It is noted there is school pressure. The patient engages in episodes of slapping self for a minute every couple of months, last episode unknown. The patient has increased appetite. The patient has been using THC vape pen. The patient was on Lexapro and Abilify at the time of admission. On admission, there is no indication of deterioration of activities of daily living (ADLs). The patient was cooperative. The patient was not suicidal at the time of the initial evaluation. The patient was noted to glorify drug use and suicide to peers with inappropriate statements.
The patient had also been struggling with sexual identity. For the dates in question, the patient was noted to be euthymic. The patient was not suicidal or homicidal. The patient was noted to be struggling to come up with positive beliefs about herself. The patient continued to have poor self-esteem. She refused a group. The patient had been eating less. The patient had adequate sleep and appetite. The health plan determination is upheld in whole. MH RTC was not medically necessary. The patient was not suicidal, homicidal, psychotic, self-injurious or aggressive. Patient  was medically stable. The patient had no significant withdrawal symptoms. The patient and family were participating in the patient's care and  was medication compliant with no side effects. There was no indication for around the clock monitoring and care could have been addressed in a less restrictive  environment.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal
Pharmacy/Prescription Drugs

This patient is a male with a history of Crohn`s disease. He was admitted to the hospital and started on corticosteroids and Entyvio. He had reported clinical improvement after starting the treatment. The requested service is continuation of Entyvio.

The health plan's determination is overturned. Entyvio is medically necessary for this patient. Entyvio is Food and Drug Administration (FDA) approved for the use in the treatment of inflammatory bowel disease in adults. There are many peer reviewed literature reports supporting the use of Entyvio in pediatric patients with inflammatory bowel disease. Despite the lack of FDA approval in pediatric patients, Entyvio is being widely used for the treatment of pediatric patients. The safety and efficacy of Entyvio are well established in pediatric patients with inflammatory bowel disease. Per Ledder O et al, "Vedolizumab was safe and effective in this cohort of pediatric refractory inflammatory bowel disease (IBD)". Similar findings were reported by Singh N et al and Maire A et al. This patient has a severe disease that required hospitalization. He was already started on Entyvio and responded well. Continuation of this effective therapy is appropriate. Denying the service is likely to cause worsening disease flare and many complications. Therefore, and based on the unique circumstances and the adequate support from peer reviewed literature, Entyvio is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Infectious Disease - Bacterial Infection
Treatment:  Pharmacy/Prescription Drugs

The patient is a female who developed a surgical site infection secondary to Mycobacterium abscessus after a breast augmentation and abdominoplasty.  The patient underwent removal of breast implants, which resulted in resolution of infection at this site, but the soft tissue infection in the abdominal area has persisted despite extensive antibiotic therapy.

Antimicrobial therapy has been challenging secondary to the multi-drug resistance of the isolate and adverse effects of antibiotics, including linezolid, which resulted in peripheral neuropathy.  Linezolid therapy was exchanged with Sivextro (tedizolid) therapy.  Her physician requests extended treatment with tedizolid.  The health plan denied the request as not medically necessary.

The health plan's determination is overturned.

The clinical information submitted for review documents that this patient has a refractory and persistent soft tissue infection secondary to M. abscessus.  Infections secondary to nontuberculous mycobacteria, including M. abscessus, are challenging and require the utility of multiple drugs at the same time in order to prevent the development of resistance.  Moreover, the length of therapy is often extended before it can be resolved.

There are currently no FDA-approved drugs, including tedizolid, for the treatment of M. abscessus because these infections are relatively rare, and no clinical trials have been performed to assess efficacy.  That being said, there are peer-reviewed publications outlining the effectiveness of tedizolid (along with other agents) in treating M. abscessus soft tissue infections.  Soft tissue infections secondary to nontuberculous infections must be treated for many months (reference #1). 

This patient has a documented soft tissue infection secondary to multi-drug resistant M. abscessus.  She has experienced a significant adverse effect (peripheral neuropathy) secondary to linezolid, which is one of the few active drugs against this pathogen.  Tedizolid (Sivextro) has the same antibacterial activity as linezolid without the side effects, including peripheral neuropathy.  Nontuberculous mycobacterial infections must be treated with multiple agents (typically 3) in order to prevent rapid development of antimicrobial resistance.  Based on this patient's clinical scenario, tedizolid is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient stay

Summary:
The patient is a male. He has a past medical history significant for HTN (hypertension), dyslipidemia, CAD (coronary artery disease), s/p (status post) CABG (coronary artery bypass graft). He presented to the ER for evaluation of an episode of chest pain of three hours duration, associated with dyspnea and dizziness, spontaneously improved. 

The patient was hypertensive on admission. His BP (blood pressure) subsequently normalized. His cardiac troponins were negative. ECG (electrocardiogram) revealed no acute ischemic changes. Chest X-ray revealed no acute cardio-pulmonary disease. The patient was admitted to telemetry for monitoring and to rule out ACS (acute coronary syndrome). No inpatient stress test was planned. The patient was discharged home with a plan for outpatient follow-up.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. No stress test, coronary CTA (Computed Tomographic Angiography) or other inpatient ischemic work-up was planned. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain 
Treatment: Inpatient Admission 

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

This is a male patient with a history of coronary artery disease, hypertension, and cocaine use. He presented to the Emergency Department with complaints of intermittent chest pain. An electrocardiogram (EKG) was performed that revealed a normal sinus rhythm with ST-T wave changes. Troponin levels were obtained with negative results. He underwent a cardiac catheterization which revealed 100% stenosis of the ostial right coronary artery and 90% stenosis of the mid right coronary artery. The patient's symptoms resolved and he was discharged home. 

The patient presented with chest pain. The initial evaluation in the ER was unremarkable, including a non-diagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing including cardiac catheterization which is an ambulatory procedure. Further evaluation was warranted; however, inpatient admission criteria were not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

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

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

Diagnosis: Alcoholic gastritis

Treatment: Inpatient Admission

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

This is a male patient with a history of type 1 diabetes, hypertension, chronic pancreatitis, seizures, and chronic alcohol use.  He presented to the Emergency Department with complaints of abdominal pain, nausea, and vomiting for two days. He admitted to drinking alcohol the night prior to his ED presentation; his is alcohol level was 296. He received intravenous (IV) hydration, IV Pepcid, IV morphine, and Lispro. Gastroenterology consulted on the patient. An abdominal ultrasound was performed that revealed a dilated common bile duct (CBD) and mild edema of the pancreas; noting that pancreatic enzymes were normal. A magnetic resonance cholangiopancreatography (MRCP) was performed which was negative for common bile duct stones or obstruction. The patient was hemodynamically stabilized and discharged home.

According to the clinical guidelines, clinical indications for admission for undiagnosed abdominal pain (M-05) include the need for surgery that cannot be performed on an ambulatory basis and peritoneal conditions.  He also did not have hemodynamic instability, severe pain, intestinal obstruction, or a severe electrolyte abnormality.

Clinical indications for admission for gastritis and duodenitis (M-560) include gastric outlet obstruction, perforation, and severe dehydration.  This can be manifested as acute renal failure.  The acute renal failure is defined as a 3-fold rise in serum creatinine or a serum creatinine greater than 4.  The patient did not have these conditions.

This patient had alcoholic gastritis.  He required intravenous (IV) hydration and his renal function and anion gap improved.  He had chronic pancreatitis but the amylase and lipase were not elevated at this time.  There was elevation of the liver enzymes consistent with alcoholic liver disease but he did not have a bile duct obstruction.  Intravenous (IV) fluids and PPI therapy could have been given with observation status.  He did not meet MCG criteria for admission for either undiagnosed abdominal pain or gastritis.  He improved by the next day and did not have any further nausea or vomiting.  The denial is upheld.

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

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism spectrum disorder
Treatment: 97153 - ABA therapy, five hours/week 
The proposed treatment, ABA therapy, is not medically necessary.

This is an adult male diagnosed with autism spectrum disorder (ASD) at age three years; the source of that diagnosis is not documented. 

Despite the lack of evidence from randomized controlled trials, there is growing evidence from observational studies and systematic reviews and a consensus in the professional community that children with autism spectrum disorder (ASD) should participate in therapeutic programs as early as possible.  Almost all evidence concerning efficacy of psychosocial interventions in ASD is based on studies of children 18 months to seven years of age.  A systematic review concluded there was insufficient evidence (ie, not studied, poor-quality studies) to support the use of ABA therapy in the treatment of adolescents (such as this patient) or adults with ASD.  A systematic review of the effectiveness of behavioral, educational, life skills, or vocational interventions in people with ASD found variable effects on activities of daily living (ADLs), and have indicated that generalizability of positive findings in this area is limited due to insufficient evidence (ie, lack of study of some domains, poor quality studies).  Thus, the use of ABA for children age 12 years and older (such as this patient) must focus on the core features of ASD rather than on ADLs (which is not the case for this patient) [Smith 2015, Murza 2016, Reichow 2018, Volkmar 2018].
...
DURATION OF THERAPY.
The patient should receive ABA therapy for a minimum of 12 months, until:
1) Treatment goals are reached
2) Patient plateaus and fails to progress (i.e., maintenance therapy)
3) Four years of therapy

The diagnosis of ASD is not substantiated for this patient because clinical records fail to document a diagnostic evaluation for ASD by a qualified diagnostician (e.g., clinical child psychologist, board-certified child psychiatrist, board-certified child neurologist, board-certified developmental-behavioral pediatrician, board-certified neurodevelopmental pediatrician) administering an appropriate module of the ADOS-2 accompanied by review of the DSM-5tm diagnostic criteria along with standardized testing of intelligence and language.  Even if the diagnosis of ASD were substantiated, continued ABA therapy for more than four years is not medically necessary, appropriate, or standard of care.  Finally, the patient has shown poor RTI despite many years of ABA therapy, further supporting that the requested services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Seizures
Inpatient hospital

The patient is a man with a history of attention deficit hyperactivity disorder (ADHD) and seizures. Late, he presented to the emergency room with a history of two very recent seizure events witnessed by his girlfriend. He reported that he was prescribed Xanax for seizures, but took it "as needed", and had not taken any very recently. He fell striking his head during the second seizure. His vital signs were normal. He was noted to be aware, alert, oriented x3, and in no apparent distress. A left temporal hematoma was noted. The rest of his exam, including the neurologic exam, was normal. His urine drug screen was positive for amphetamines and benzodiazepines. The head computed tomography (CT) scan was negative.

The health plan's determination is upheld. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, or imaging an imminently life-threatening cause of the patient's complaints. There were no further seizures once he was given appropriate medication. Acute inpatient care was not required for the MRI or EEG, as these services could have been provided at a lower level of care. Based on the standard of care and peer reviewed literature, the inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: GU/Kidney disorder, Kidney stones 
Treatment: Inpatient hospital stay 

The patient presented with right sided abdominal and flank pain. The radiography revealed an obstructing 9 x 5 millimeter (mm) right mid-ureteral stone and a smaller proximal stone, with obstruction. Patient was taken to the operating room. An uneventful cystoscopy and stent placement occurred. Postoperatively, the patient had stable vital signs and was afebrile, tolerated orals and pain was controlled. The health plan's determination is upheld in whole. The requested health service and treatment was not medically necessary for this patient. Following the procedure the patient had minimal discomfort, was afebrile, and had stable vital signs. The inpatient level of care was not indicated as the patient did not require additional specialized services. The patient also did not require fluid resuscitation. The inpatient hospital level of care was not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Small bowel obstruction
 
Treatment:  Inpatient hospital services 

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

This patient is a male with a prior medical history that includes hypertension and a prior laparoscopic band surgical procedure eight years prior to presentation.  This patient presented to the Emergency Department with abdominal pain, nausea and constipation.  The patient's vital signs included a blood pressure of 149/75 with a heart rate of 48 beats per minute.  The patient's temperature was 97.6F and the oxygen saturation was 98%.  The patient reported nausea and bloating.  Physical examination indicated that the patient was alert and oriented.  The patient was in pain.  There was left lower quadrant and right lower quadrant abdominal tenderness with bowel sounds present in four quadrants.  It was recommended that the patient undergo laboratory and diagnostic studies.  The patient's white blood cell count was 12.38 with ketones present in his urinalysis.  There was also protein and a small amount of blood.  The patient's EKG revealed he was in a normal sinus rhythm.  It was recommended that the patient follow-up with a CT scan.  The patient's CT scan did reveal a small bowel obstruction with transition point in the left lower abdomen.  The recommendation was made to admit the patient for continued treatment.  The plan was to keep the patient on nothing by mouth status and administer fluids.  It was also noted that surgery consulted on the patient and that the patient's abdominal distention had resolved.  The recommendation was also made for the patient to receive an enema.   

According to current literature, a patient may be admitted to inpatient services when there is evidence of a partial bowel obstruction with clinically significant signs or symptoms.  The patient presented with bowel obstruction symptoms, and this was confirmed by CT scan with the transition point in the lower bowel.  For this reason, this obstruction was unrelated to the laparoscopic band.  The standard of care is for the patient to be admitted, kept nothing by mouth (NPO), and to receive intravenous (IV) fluids to see if the obstruction resolves.  If it does not resolve within a reasonable period of time, surgery is indicated.  It is not possible to predict who will improve and who will need surgery.  This patient improved and had a bowel movement.  After this, he was tried on oral feeds and made a good recovery.  Overall, the management is according to well established standards of care and is described in common medical textbooks.  Therefore, the prior determination is overturned.

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest. 

Based on the above, the medical necessity for the inpatient hospital services at the acute medical surgical level of care is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness, numbess
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female with a past medical history significant for Diabetes Mellitus with peripheral neuropathy, hypertension, hyperlipidemia and GERD. She presented to the ER for further evaluation/management of left arm heaviness and numbness. 

The patient's intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, profound hypertension, hypotension, tachycardia or hypoxemia. Her examination was notable for decreased +4/5 strength and sensation in the left upper extremity. However, Head CT, EKG and laboratory testing were negative for acute abnormalities with the exception of elevated serum glucose. This includes no evidence of intracranial bleed, significant arrhythmia, end organ damage or metabolic acidosis. The patient was subsequently admitted to the inpatient medical service in stable condition, where she received Insulin therapy for tight glycemic control, supportive care measures and close neurologic monitoring. She improved with the prescribed therapies and was subsequently discharged in stable condition. 

There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of Inpatient admission is not deemed medically necessary.