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

Diagnosis:  Sickle cell crisis.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld.

The patient is a female with a history of hemoglobin SS (sickle cell) disease, cholelithiasis, multiple admissions for Vaso-occlusive crisis, acute chest syndrome, avascular necrosis of the bilateral hips and knees, and chronic pain, who presented to the emergency department (ED) with whole body pain. She tried oxycodone at home, but it did not improve her pain symptoms. At the time of arrival, she was afebrile, with a blood pressure of 103/59, and heart rate of 85. She was noted to be in significant distress due to her pain. 

The inpatient hospital admission was not medically necessary for this patient.
This patient was admitted for treatment of her sickle cell pain crisis, that failed outpatient management in the emergency department. She has a complicated past medical history for sickle cell disease, with multiple complications noted. However, at the time of admission, her hemoglobin was at baseline, she did not have signs or symptoms of acute chest, no secondary infection, and a relatively straightforward pain crisis.

This patient had a Vaso-occlusive crisis that required intravenous pain medications, but the patient did not clearly fail the observation level of care prior to the acute inpatient level of admission. While she required a patient-controlled analgesia (PCA) pump, she was quickly weaned off the pump, in part due to malfunction of the equipment, but her pain level was at a 0 out of 10 for several hours, and she felt well enough to leave the hospital against medical advice. She did not require a prolonged hospitalization, and only spent 1 night in the hospital. Her care days could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Edema
Treatment: Inpatient Admission

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

The patient was admitted to the hospital with complaints of bilateral lower extremity swelling and dyspnea on exertion. The patient denied any chest pain, nausea, vomiting, or diaphoresis. The patient has a history of alcohol (ETOH) abuse, hypertension (HTN), and congestive heart failure (CHF).

At presentation, the patient's vital signs were: Temperature (T) 97.9 degrees () Fahrenheit (F), heart rate (HR) 68, blood pressure (BP) 155/73, respiratory rate (RR) 18, and oxygen (O2) saturation 100 percent (%). The patient was intoxicated. The patient was awake and in no acute distress. There were trace bibasilar crackles in the bilateral lungs. The first (S1) and second(S2) heart sounds were normal. The patient's abdomen was soft and non-tender. Lower extremity edema was present. Chronic venous stasis was noted. The patient was alert and had a non-focal neurologic exam.

Initial labs revealed a white blood cell (WBC) of 3.89 and hemoglobin (Hgb) 11. Electrolytes, blood urea nitrogen (BUN), and creatinine were within normal limits. The patient's chest X-ray (CXR) showed some interstitial prominence. The deep vein thrombosis (DVT) study was negative. The echocardiogram showed a normal left ventricular ejection fraction of 60-65%. The patient's B-type natriuretic (BNP) was 108. Ultrasound of the abdomen showed no ascites. 

The patient was admitted to the hospital for Pulmonary Edema, alcohol intoxication, and lower extremity (LE) edema. The patient was seen by cardiology and gastroenterology. The patient was treated with intravenous (IV) diuretics, and blood pressure medication (meds) were adjusted. The patient was on a Librium taper. The patient improved with treatments and was discharged. 

This patient did not need acute hospitalization. The patient could have been placed in observation status while diagnostic testing and treatments were initiated. The patient was intoxicated and had a history of ETOH abuse. The patient was afebrile and hemodynamically stable. The patient was in no acute distress and was not hypoxic, as their O2 saturation was 100%. The patient's ejection fraction was within normal limits, and cardiac enzymes and BNP were unremarkable. The CXR findings only revealed mild congestion.   

This patient could have been treated in observation status with a few doses of IV Lasix and subsequently switched to oral (PO) meds and discharged home with outpatient follow-up. Observation status could be for up to 48 hours. The patient could have switched to PO meds within that time frame. The patient was generally stable, and heart failure (HF) was mild if present.

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Food impaction esophagus

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is an adult who reported getting a piece of steak stuck in her throat and has had chest discomfort and vomiting since then. The patient was afebrile with stable vital signs. The patient was admitted to surgery.  As per the emergency department (ED) provider note this is an adult female with history of esophageal stricture with balloon dilation who reported complaining of multiple episodes of vomiting associated with chest discomfort that began last night after eating steak. The patient immediately began to vomit with drooling and chest discomfort. Otherwise the patient has been afebrile. On exam the patient was in no acute distress. White Blood Cells were 6.64. The diagnosis was food impaction.

The plan was upper endoscopy with intubation today. The patient underwent endoscopy. 

Event note indicated food bolus lodged in the esophagus and majority retrieved and removed and the remainder pushed into the stomach. The plan was for repeat in 2 months. 

The patient did not require inpatient hospital admission but rather 23-hour observation following an uneventful removal of food and endoscopy. This should have been done on an observation/ambulatory setting without inpatient admission. The patient had the endoscopy on the same day and was sent home later that day- all of which could have been done with an observation status and not an acute inpatient admission. 

According to Milliman Care Guidelines (MCG) Health Ambulatory Care 27th Edition Esophagogastroduodenoscopy (EGD), Upper Gastrointestinal (UGI) endoscopy ACG: A-0203 (ASC), Esophagogastroduodenoscopy may be indicated for 1 or more of the following: Foreign body ingestion, known or suspected. This procedure is an ambulatory procedure. MCG also noted that "although most ingested foreign objects pass through the gastrointestinal tract without causing symptoms, endoscopy may be indicated, depending on the object and its location."  

In addition, MCG health General Recovery Care 27th edition General Surgery or Procedure GRG: SG-GS (ISC GRG),  notes that Operative Status Criteria is ambulatory for many procedures. Examples include: Endoscopic procedures...In this case the patient should have been managed as an outpatient with a 23-hour observation without acute inpatient hospitalization as this is an ambulatory status and only required observation.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain
Treatment: Surgery (left hip arthroscopy)
The insurer denied: Surgery (left hip arthroscopy)
The denial is upheld.

The patient is an adult female with left hip pain. She initially reported symptoms for seven months with no history of trauma. She felt something catching. She reportedly had physical therapy for three months without benefit. The physical examination was significant for positive labral symptoms, stiffness, and tenderness to trochanter. The magnetic resonance imaging (MRI) report was significant for mild arthritis, effusion, and irregular undersurface labral tear. The physician recommended left hip arthroscopy debridement.

The requested health service is not medically necessary.

The records show no evidence of a traumatic labral tear. There was no evidence of femoral-acetabular impingement (FAI). The patient's symptoms are not consistent for isolated labral pathology, that is (i.e.), history of low back issues, tenderness to trochanteric area, and problems with walking inclines. There is also concern for the magnetic resonance imaging where there was mild arthritis. Isolated arthroscopic surgery would thus be unlikely to be effective. Hip arthroscopy to repair a labral tear is medically necessary for traumatic labral tears causing mechanical symptoms or an adjunct to FAI (Femoral-Acetabular Impingement) surgery. This criterion has not been met. Hip arthroscopy to repair degenerative labral tears (for example (e.g.), due to early osteoarthritis), which is what is reported in this case, is considered to be unproven. Therefore, the requested health service is not medically necessary. A review of current literature reports most labral tears are symptomatic (75 percent (%)). A debridement has little effect unless it is a confirmed pain generator and unable to be repaired. Debridement alone is not standard of care. Per Berthelot, and others (et al), "Hip labral tears are found in 22-55% of individuals with hip pain. They are associated with sleep dysfunction. When isolated, their arthroscopic debridement (labrum likely to heal, and stable), repair (labrum viable but unstable), or reconstruction (labrum non-viable and unstable), usually induces a marked relief in young sportsmen. This early repair might delay the onset of osteoarthritis and prevent later opioid addictions. "However, most hip labral tears are asymptomatic, and in aged patients the pain usually originates from other structures (intra-articular and/or peri-capsular) than the torn labrum. In fact, nearly all labral tears are the consequences of underlying impingements, and/or anatomic or functional dysplasia, that should be treated first, but can remain unrecognized when they are not obvious on plain X-rays."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Kidney Disease.
Treatment: Inpatient Admission.

The insurer denied coverage for inpatient admission. The denial is overturned.

This case involves an adult with a history of left upper extremity fistula placement one month prior, hyperlipidemia, hypertension, and chronic kidney disease on hemodialysis three times per week, with the most recent dialysis the day before admission. The patient presented to the emergency department with a note that the patient's right chest wall Perma-Cath fell out while the patient was sleeping. The patient was noted to have a positive bruit, moderate blood staining on the shirt, and tachycardia. A pressure dressing was applied to the wound. The treatment plan included admitting the patient to telemetry and replacing the Perma-Cath for hemodialysis, as the arteriovenous (AV) fistula was not yet mature. The patient required hemodialysis two days later. The day after admission, the patient underwent insertion of a right jugular tunneled dialysis catheter replacement with no complications. The following day, the patient underwent maintenance hemodialysis with the new catheter. It was noted that the patient tolerated the treatment well and was discharged later that day. 

Milliman Care Guidelines indicate a catheter-related complication that cannot be managed on an outpatient basis is an indication for inpatient care, noting treatment may include surgical intervention, catheter repair, or removal of the catheter or implanted device.

Evidence-based literature indicates displacement of a central line requires prompt identification and correction. Additional literature indicates catheter exchange is a treatment for central venous catheter dysfunction. 

This patient is hemodialysis-dependent. The patient had a complication with an intravenous catheter that could potentially be life-threatening if not monitored and cared for appropriately. The patient presented to the emergency department 1-month post arteriovenous (AV) fistula placement, with a note of a displaced Perma-Cath. The patient had moderate bleeding, tachycardia, and elevated blood pressure on the exam. It was noted that the patient needed treatment with hemodialysis two days after presenting to the emergency department, and the AV fistula had not yet matured. Due to the nature of the patient's condition, the need for regular hemodialysis treatment, and the displacement of the Perma-Cath, the inpatient stay was medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, and in the patient's best interest. 

The medical necessity for the inpatient stay is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder (ASD)
Treatment: Speech/Hearing/Voice/Communication Therapy (code 92507)

The insurer denied coverage for speech/hearing/voice/communication therapy (code 92507). The denial is overturned.

Speech therapy services were denied as not medically necessary/duplicate of speech services provided via the school district. The family is appealing this decision.

The patient is a young child with issues of social/emotional regulation, pragmatic language, and articulation skills, which her outpatient (OP) speech pathologist has well documented in the outside reports provided. She has been making good progress on her goals. 

Her doctor has provided clinical information supporting the diagnosis of autism spectrum disorder (ASD), which is a neurogenic developmental disorder.

The frequency and intensity of therapeutic treatment in ASD have long been supported in the literature. As it is a spectrum, individuals with ASD may exhibit close to normal language skills or be completely non-verbal. Social communication and behavioral impacts of impaired communication can significantly impede academic learning and social inclusion. Multiple studies have demonstrated that early and frequent sessions of intervention result in greater outcomes, such as the establishment/maintenance of social relationships and the ability to achieve optimal levels of independence in all aspects of life.

Per public law, for free and equal education for all individuals, the public school system must provide services that ensure optimal success within the academic learning environment. That law allows for the provision of minimal amounts of services. It does not address the other aspects of speech, language, and social/pragmatic communication, nor is the public-school environment able to provide the level of intensity that benefits ASD.  

The therapy provided is medically necessary, as are ongoing OP services. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, and in the patient's best interest. 

The medical necessity for speech/hearing/voice/communication therapy (code 92507), rendered on 4/20/23 and 6/8/23 services, is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic pain syndrome
Treatment: Procedure to Place Wires Near Spinal Cord 
The insurer denied Procedure to Place Wires Near Spinal Cord 
The health plan's determination is overturned. 

The patient is a female with a significant medical history of multiple sclerosis, status post fall with injuries to the cervical and lumbar spine who has a chief complaint of neck pain. The intensity of her neck pain is at 10 out of 10 (10/10) with radiating pain down to the upper extremities and intermittent numbness in the upper extremities. She had tried physical therapy, naproxen and gabapentin without adequate pain relief. An magnetic resonance imaging (MRI) brain and cervical spine revealed findings consistent with demyelinating disease. She has diagnoses of chronic pain syndrome, cervical radiculopathy and multiple sclerosis. 

Procedure to Place Wires Near Spinal Cord is medically necessary for this patient.
This patient has severe neck pain with radicular symptoms in the upper extremities. She had failed conservative treatments including physical therapy and naproxen and gabapentin. The intensity of her pain is at 10/10. Further treatments are necessary to improve her pain and function. She was evaluated by pain management specialist, neurosurgeon and a psychologist. All of these specialists recommended spinal cord stimulation. Given this clinical scenario, spinal cord stimulation is medically necessary. Spinal cord stimulation is an effective and medically necessary intervention based on this clinical presentation and current clinical studies on spinal cord stimulation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-healing ulcer, peripheral artery disease,
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

This is a male patient for whom an inpatient hospitalization is under review. He has a history of congestive heart failure (CHF), bypass procedure, claudication, automatic implantable cardioverter defibrillator (AICD), ischemic cardiomyopathy, kidney disease, alcohol use, and prior cocaine use. He had a nonhealing ulcer of his right second toe with rest pain. A prior angiogram demonstrated chronic occlusions of this superficial femoral artery (SFA). He was admitted electively for attempted intervention of his right lower extremity. His vital signs and the oxygen saturation were normal. The creatinine was 2.4. He underwent unsuccessful percutaneous intervention, remained stable, and was discharged with a plan for a repeat attempted intervention in the near future. At issue is the medical necessity of inpatient admission.

This patient underwent an elective lower extremity percutaneous intervention. There were no vascular complications, acute coronary syndrome, CHF, hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, acute renal failure, critical limb ischemia requiring urgent surgery, severe infection requiring in-hospital treatment, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care towards improved overall procedure or peripheral vascular disease (PVD) outcomes. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: osteoarthritis knees

Treatment: Euflexxa (procedure code J7323)

The insurer denied coverage for Euflexxa (procedure code J7323).

The denial is upheld.
 
This adult female has chronic bilateral knee pain due to osteoarthritis. She has had Physical therapy.  She is doing home exercise and Yoga. She uses Ice/Heat and Ibuprofen for pain.  She had Bilateral Hyalgan injections which gave her 100% (percent) analgesia for more than 6 months.  The request is for Euflexxa injections.

In 2019, the American College of Rheumatology (ACR) published updated guidelines for the management of osteoarthritis of the hand, hip and knee (Kolasinski 2019). The guidelines conditionally recommend against intraarticular hyaluronic acid injections in individuals with knee osteoarthritis. ACR states hyaluronic acid injection benefit has been primarily found in studies with higher risk of bias. The current guidance is based on a systemic review limited to trials with low risk of bias. This meta-analysis has shown the effect size of hyaluronic acid injections compared to saline injections approaches zero.
 
The American Academy of Orthopedic Surgeons (AAOS) published their Clinical Practice Guideline for Treatment of Osteoarthritis of the Knee in 2013. In their recommendations, the AAOS states that they "cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee." It was noted that the recommendation was based on lack of efficacy, not on potential harm. In their 2021 Management of Osteoarthritis of the Knee (Non-Arthroplasty) guideline update, AAOS revised their recommendation to state hyaluronic acid intraarticular injection is not recommended for routine use in the treatment of symptomatic osteoarthritis of the knee. The updated review of the evidence found that statistically significant improvements were associated with high-molecular cross-linked hyaluronic acid but when compared to mid-range molecular weight, statistical significance was not maintained. This newer analysis did not demonstrate clinically relevant differences when compared to controls.

The injection is not medically reasonable and necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Euflexxa (procedure code J7323) is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention deficit hyperactivity disorder
Treatment: Mydayis
The insurer denied: Mydayis
The denial is overturned.

This case involves an adolescent male diagnosed with attention deficit hyperactivity disorder (ADHD). He is currently prescribed and treated with stimulant medication, Mydayis (dextroamphetamine-amphetamine mixed salts extended release) at a dosage of 12.5 mg (milligrams) daily. There is no report of comorbid psychiatric disorders or substance use disorder in this case. The patient's health plan has denied coverage of the requested Mydayis; the health plan limits coverage of the medication per the prior authorization criteria, requiring that at least three formulary alternatives are tried and fail due to adverse effect or lack of efficacy before consideration of coverage of a non-formulary alternative (Step Therapy). Formulary alternatives include the following: dexmethylphenidate extended release (Focalin), dextroamphetamine (Dexedrine Spansules), methylphenidate er (Concerta), amphetamine-dextroamphetamine mixed salts (Adderall or Adderall ER) or Azstarys which are available on the health plan's formulary. The patient's prescribing physician has requested a coverage exception based on ongoing treatment with Mydayis indicating that formulary alternatives have had adverse effects including loss of appetite and mood changes.

The health plan should cover the proposed treatment with Mydayis.

According to the appeal from the prescribing clinician, formulary drugs have produced adverse effects for this patient, as noted in the clinical summary. Moreover, in keeping with Frick and others (et al), 2020, referenced below, the "triple bead" delivery system of Mydayis with a 9-14 hour half-life is a distinct advantage over all other stimulant formulary alternatives that are considered first-line treatment options for attention deficit hyperactivity disorder. The service provided is in keeping with prevailing standards of medical practice for the condition under treatment in this case with an evidence-base treatment; and the requested service/treatment being provided in this case is clinically appropriate and is backed by credible scientific evidence known to benefit patients with the condition diagnosed in this case. This answer is in keeping with prevailing standards of professional practice, as well as the published guidelines and the scientific literature, referenced below, as well as New York State instruction for this review pertaining to a formulary exception.