Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/Gastrointestinal
Surgical Services (All)

This case involves a man with a history of gastroesophageal reflux disease for more than a decade with manometry that is normal, but with biopsies showing mild active esophagitis. Under review is the denial of LINX treatment of reflux.

The health plan's determination is overturned. The Linx procedure is likely to be more beneficial than standard surgical therapy due to the equivalent effectiveness of these two approaches to GERD treatment and the documented lower risk of adverse events after Linx compared with standard surgical therapy (fundoplication). The device is FDA approved, and there is good evidence in the peer reviewed literature that it does benefit patients with GERD. Currently, numerous published clinical studies have confirmed that the Linx device reinforces the lower esophageal sphincter, effectively reduces the percent time of esophageal acid exposure, and improves GERD health-related quality of life similar to that of fundoplication. However, the question at hand is whether the Linx device is "more beneficial" than fundoplication. In experienced hands, the operation time for Linx placement is shorter than that of Nissen fundoplication, primarily due to the fact that an extensive dissection of the fundus and re-creation of the angle of His and anti-reflux barrier is not necessary. Postoperative dysphagia has been reported, as with fundoplication, and for the majority of patients, these symptoms appear to be short-lived and resolve with observation or with dilation of the gastroesophageal junction.
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/Gastrointestinal
Surgical Services (All)

This patient is a man (body mass index (BMI) 20.5 kg/m2) with a 16-year history of gastroesophageal reflux disease (GERD). The records indicate that the patient underwent laparoscopic Endostim implantation per the Endostim Clinical Trail. This was performed as treatment of GERD with significant subjective improvement. He is off medicinal antacid therapy and is without symptoms of GERD. Per the gastroenterology note, the Endostim Trial has closed due to inadequate funding and inability to monitor/manage the implanted device once the trial is closed. The patent is interested in removal of the Endostim device and implantation of the LINX magnetic sphincter augmentation device.

The health plan's determination is upheld. LINX magnetic sphincter augmentation (MSA) is a standard of care treatment option for well selected patients with proven pathologic esophageal acid exposure, normal esophageal peristalsis, a distal esophageal amplitude of at least 35 mmHg, no alternative diagnosis, and no contraindication to the performance of magnetic sphincter augmentation (MSA). However, in this case, the submitted records indicate that this patient had previously undergone endoscopic intervention with implantation of the Endostim device as treatment of GERD. This endoscopic surgical history is a listed contraindication to LINX per the device manufacturer. Therefore, this procedure (LINX) would not be standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Digestive System/Gastrointestinal
Surgical Services (All)

This patient is a male with history of long standing gastroesophageal reflux disease (GERD) requiring medication status/post (s/p) laparoscopic endostim procedure as part of a clinical trial, which is closing secondary inadequate funding. The patient will need the device removed, as it will no longer be supported. The patient was able to have GERD controlled with the endostim device and come off his medications. The request is to convert the patient to LINX device for treatment of GERD at the time of endostim removal.

The health plan's determination is overturned. The LINX Reflux Management System likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This patient has GERD refractory to medical management and underwent an investigational surgical treatment (endostim) as part of a clinical trial, which now is no longer being supported and needs to be removed. Surgical treatment options for GERD, that are considered standard today include laparoscopic Nissen fundoplication and the Food and Drug Administration (FDA) approved LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bone lesion
Treatment: Bone imaging
The Bone imaging is not medically necessary.

The patient is a male with multiple sclerosis with a sclerotic bone lesion seen on CT. His physician has requested a bone scan.  The lesion is stated to be non-aggressive-appearing by CT scan.  

There is no reason to perform a bone scan in an individual with a benign-appearing sclerotic lesion on CT scan.  The recommended follow-up is serial imaging to detect for abnormal growth.  The reading radiologist did not request a bone scan in his report.  The differential of this lesion would be enostosis versus a sclerotic metastasis.  As it is stated to have benign characteristics, the most likely explanation is enostosis, and bone scanning is not helpful to distinguish these lesions.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Painful contractions
Issue under review: Inpatient admission

Determination: 
The Inpatient admission was not medically necessary.

The patient was an adult pregnant female. She presented to the emergency room at 35 weeks 3 days gestation complaining of painful contractions.  She had received antenatal steroids two days prior to admission and was on maintenance Procardia 20 mg every six hours and Makena.  

On presentation, the patient's cervix was 2 cm 60% effaced.  She was given subcutaneous terbutaline and Procardia, but continued to have irregular, painful contractions.  She was admitted and placed on bedrest, IV hydrations, ampicillin, Procardia, and vaginal progesterone. Her cervix progressed to 2.5 cm.  However, she was discharged home undelivered on hospital day 3.  

The facility contends that the admission was medically necessary because continued fetal monitoring and tocolytic therapy were needed beyond 24 hours and cites MCG 23rd edition Preterm labor M-287 (ISC).  The health plan contends that the admission was not medically necessary because the patient was not in labor, fetus had no signs of stress, there was no unstable heart rate of blood pressure, no signs of infection in the womb, no signs of large bleeding, and no treatment to prevent early labor and the early labor could not be stopped, and no notes of delivery of the baby.

The patient was already more than 35 weeks and had already received a complete course of antenatal steroids.  There is no evidence that tocolysis beyond the initial 48 hours required to administer the antenatal steroids is effective.  There is no evidence that tocolysis, or admission to administer tocolysis, is effective after 35 weeks.  Therefore there is no evidence that any of the interventions given including hospitalization incident to giving these interventions is effective in improving outcomes. Thus, the admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Depression
Mental Health: Inpatient

The patient is a male with diagnoses of Major Depressive Disorder (MDD), severe, recurrent, without psychotic features, Cannabis Use Disorder (CUD) and a pain syndrome. Case notes document that the patient has suffered from depressive symptoms for about three years, with acute exacerbation about 6 months prior to the admission in question due to a motor vehicle accident (MVA). In addition, the patient has experienced pain in his back and headaches from the MVA. He has experienced anhedonia, anxiety, poor sleep, anorexia, and decreased energy, as well as suicidal ideation with a plan. He self-discontinued his outpatient medications several months before this admission.

The health plan's determination is overturned in part. An additional three days of inpatient mental health treatment was medically necessary. His MDD was complicated by his co-morbid substance use disorder and his pain syndrome, making his MDD more difficult to treat. He had a suicide plan. His illness was chronic and severe. Case notes document that he was isolative, with flashes of negative thoughts, not interacting with peers, with diminished appetite. His attending noted continuing depressive and anxiety symptoms. He rated his anxiety as 6/10. The patient felt anxious about moving to outpatient treatment. He continued to be anxious despite some improvement in depression. He had fleeting death thoughts. He was not back to a baseline mood state. Eventually, he had no suicidal ideation, was not hopeless or helpless, was low in anxiety, with improved sleep, with euthymic affect and good behavioral self-control. Therefore, he could safely and with good judgment be discharged on the 3rd day in question to a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough, congestion, fever 
Issue under review: Inpatient admission 

Determination: The inpatient admission was not medically necessary. 

The patient is a young male child with medical history significant for mild autism with speech delay. He presented to the ED with one and a half weeks of cough and congestion, and two-days of poor oral intake, decreased urine output, fever to 104.9. He had no vomiting or diarrhea. He had a gastroenteritis-like illness three weeks prior that had resolved. 

The patient's vital signs included temperature 101.3 (38.5), heart rate 159, respiratory rate 30, and 99% saturation in room air. Physical examination was significant for no apparent distress, clear ears, normal oral mucosa, no oropharyngeal exudate, tachycardia, rhinorrhea, clear lungs, benign abdomen, and non-focal neurologic exam. Initial laboratory evaluation revealed mild hyponatremia (sodium 130), mild metabolic acidosis (CO2 [carbon dioxide] 20), and normal WBC (white blood cell) count (6.82K). Chest x-ray was normal. He was treated with two normal saline boluses, but refused to take an oral challenge, taking only two ounces (insufficient for his size). Repeat lab studies revealed improved sodium (133) but increased metabolic acidosis (CO2 17). 

The patient was subsequently admitted for management of hyponatremic dehydration secondary to viral URI (upper respiratory infection). Suspicion for serious bacterial infection was low, with unremarkable lab results and well-appearing on exam. By the time he was admitted, he was asking for Pediasure. Admission orders included maintenance IV fluids, regular diet for age, and anti-pyretics as needed. 

Following admission, the patient's diet was advanced as tolerated and his IV fluids were discontinued when he was taking adequate food/fluids by mouth. He was voiding well and remained afebrile. He was subsequently deemed stable for discharge to follow-up with the pediatrician in one to three days. 

Fever is not unusual in children, with multiple potential etiologies ranging from mild viral infections to bacterial infections to inflammatory disorders and serious bacterial infections. In the absence of serious impairment such as lethargy, intractable vomiting, or unremitting pain, older children can typically be treated symptomatically at home, with evaluation in the office should symptoms not resolve. 

This young male child with multiple recent illnesses, persistent cough, and new-onset fever and refusal to eat/drink presented to the ED. Evaluation in the ED revealed hyponatremic dehydration, treated with normal saline boluses. Because he refused to take sufficient fluids with an oral challenge, he was admitted for further hydration and monitoring. While it was not unreasonable to monitor him in the hospital for adequate fluid intake, he was overall hemodynamically stable, with no ongoing vomiting or diarrhea, no evidence of impending sepsis, and was already asking for Pediasure at the time of admission. He did not require acute inpatient admission, and could have been safely and appropriately managed at lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral Syndrome; gastrointestinal symptoms

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. 
The denial was upheld.   

This is a male patient with a history of significant use of marijuana. He presented to the Emergency Department with complaints of weakness, nausea, and vomiting following cannabis use. His presenting vital signs were: 98.6F (temperature maximum -101.5), a blood pressure of 139/91, a pulse of 58, a respiratory rate of 16, and an oxygen saturation of 98% on room air. A laboratory work up was performed that revealed a white blood cell (WBC) count of 9.85, a hemoglobin of 10.7, a hematocrit of 32.2, platelets of 173, a creatinine of 0.4, a potassium of 2.5, a calcium of 5.2, a carbon dioxide level of 18, and a glucose of 82. A chest x-ray was performed with negative results. A computed tomography of the abdomen/pelvis showed no acute pathology. Infections disease consulted on the patient, recommending empiric antibiotics and Tamiflu. Intravenous (IV) fluids were administered for hydration with potassium supplementation. The patient was medically stabilized and discharged home with outpatient instructions.
 
According to the documentation, the patient presented with non-specific gastrointestinal symptoms following marijuana use.  Otherwise, he was afebrile (although he had one isolated fever while in the ED) and hemodynamically stable with no evidence for a systemic infection.  He had some metabolic laboratory findings consistent with his history of nausea and vomiting.  The clinical impression was viral syndrome and marijuana use.  

The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

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

Pregnancy 
Inpatient hospital 

The patient is a pregnant female who presented with complaints of gush of fluid per vagina. She was admitted to the hospital. 

The health plan's determination is overturned. The inpatient stay was medically necessary for this patient. Based on provided clinical information, the patient's pregnancy was of a very high-risk category. 

In the setting of PPROM in the third trimester (and the patient was at 29 weeks gestation), American College of Obstetricians and Gynecologists (ACOG) and literature recommend admission to acute inpatient level of care until delivery at 34 weeks (or as indicated earlier). 

Also, as the patient had chronic hypertension and developed increase in blood pressure in severe range, the physician had absolutely legitimate concern for superimposed severe preeclampsia that might have required delivery prior to 30 weeks.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Injuries s/p assault
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This patient is an adult male. He presented to ED following an assault.   He reported facial and left rib pain associated with shortness of breath.  There was no loss of consciousness.  Comorbid health conditions included no listed medical conditions.  The ED evaluation identified stable vital signs, nasal tenderness, and left chest wall tenderness.  Glasgow coma score (GCS) was normal at 15.  He was found to have three left-sided rib fractures and a fractured nasal bone with slight displacement.  

The patient was treated with hospital admission, rib fracture protocol, pulmonary toilet, incentive spirometry and pain control.  

The day after admission the patient had pain control with oral medications.  He was also prescribed prn (as needed) IV Dilaudid for pain control.  He vomited once on that day.  

The patient was tolerating a regular diet as of the following day, and the progress note states that he was stable to be discharged that day.  The patient was discharged from the hospital the subsequent day.

The care and treatment provided could have been rendered with a lower level of care (observation), rather than with inpatient admission.  	

The medical records support that this patient presented following an assault and was found to have three rib fractures and a broken nose.  He was clinically stable, was tolerating a diet and pain control was adequate with oral medications as of the day after admission.  The record does not document that there were ongoing medical conditions beyond the day after admission that required an acute inpatient designation.

The submitted medical records do not support the need for an inpatient designation for this patient.  There was no clinical evidence for an ongoing health condition that required an inpatient designation, no evidence for neurologic or vascular compromise, no evidence for wound or other infection, pain was managed, diet was tolerated and vital signs were stable throughout the period of monitoring.  

Inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Durable Medical Equipment (DME) (including Wearable Defibrillators)

The patient is a female with a diagnosis of paraplegia status/post (s/p) spinal infarct. Under review is the RT300 Therapy System: Functional Electrical Stimulation (FES) Cycling System.

The health plan's determination is overturned. The RT300 Therapy System: Functional Electrical Stimulation (FES) Cycling System is medically necessary for this patient. A RT 300 System is a cycling system. The patient will be seated for this system. Therefore, the patient does not need to be able to maintain weight bearing, sensory perception and transfer ability is not required. Similarly, neither standing nor hand/finger control is required.
It is noted that the patient "now has reduced to absent volitional motor function below L1 in bilateral lower extremities and her light touch sensation and proprioception are impaired below T11 spinal level bilaterally." It was also noted that the patient's "peripheral nerve supply is intact" and she responded to electrical stimulation during her RT300 trial. In fact, the patient had 8 trials of the RT300 and tolerated 29 minutes of treatment and "max of 4.32 miles of FES cycling were accomplished at 25-50 revolutions per minute." It was also noted that the patient's initial energy expenditure was 0.15kcal/hour and most recently she peaked at 2.10kcal/hour.
This degree of energy expenditure will allow the patient to be able to reduce the risk for muscle atrophy and suggests improvements in muscle conditioning that would be expected to continue with regular FES cycling. Additionally, she was able to cycle up to 4.32 miles with improved distance and endurance which reduces contracture risk and decreases spasticity. She also was able to propel the FES without motor support for as long as 33 minutes which is proof that the electrical stimulation is working and resulting in muscle contractions strong enough to propel the ergometer.
Appeal type: Medical necessity
Decision: Upheld

Cholecystitis/Inflammation of the Gallbladder
Inpatient hospital

The patient is a female who had recently been admitted to the hospital for cholelithiasis with gallstone pancreatitis that spontaneously resolved. The patient was home for a few days but symptoms of right upper quadrant pain, nausea and vomiting started about 3 days later. The patient presented to the emergency room with ongoing symptoms. Vital signs were stable. Physical exam was with right upper quadrant tenderness. The patient's labs were normal except for a total bilirubin 1.6, aspartate aminotransferase (AST) 68 and alanine aminotransferase (ALT) 53. Abdominal ultrasound showed marked distension of gallbladder with gallbladder wall thickening and sludge with non-mobile stones. The patient was given intravenous (IV) pain medication, IV fluids and made nothing by mouth (NPO). Surgical consultation was obtained, and cholecystectomy was recommended. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with recurrent right upper quadrant pain associated with nausea and vomiting with mild elevation of AST/ALT and abdominal ultrasound showing acute cholecystitis. The patient had normal vital signs without fever, and a normal white blood cell (WBC) count and lactic acid. The patient subsequently underwent a laparoscopic cholecystectomy the same day as admission. The patient continued with normal vital signs. The patient's liver enzymes were mildly elevated postoperatively. Vital signs remained stable and the patient was tolerating oral intake. At the time of admission, the anticipated length of stay was less than 2 midnights. The patient had recently been admitted with gallstone pancreatitis with presumed plan for outpatient laparoscopic cholecystectomy but had recurrent pain with nausea and vomiting and the patient was admitted to undergo this proposed procedure due to recurrent symptoms. The severity of symptoms and intensity of care at the time of admission did not warrant an inpatient level of care. In summary, the inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acromegaly (papillary carcinoma of the thyroid and complete thyroidectomy)
Treatment: Glumetza, Singulair, Evoxac, Maxzide, Vorvasc, Cytomel, Carafate, and Medrol 

The Glumetza, Singulair, Evoxac, Maxzide, Vorvasc, Cytomel, Carafate, and Medrol are not medically necessary.

This patient is a female with diabetes, Sjogren's syndrome, acromegaly and history of papillary thyroid carcinoma status-post thyroidectomy. Per appeal letter, due to brain tumor and severe asthma, she is at high risk for anaphylactic shock if prescribed generic drugs, and has been hospitalized numerous times. Years ago, many of her health problems began with correlations to generic medication substitutions, and that has led her to have two anaphylactic episodes with hives. Then, was given the generic for Synthroid and developed hives. 


Generic medications are copies of brand-name medications. They contain the same active ingredients. The documentation does not indicate that the patient has an allergy or contraindication to one of the inactive ingredients that is present in one of the generic medications that is not present in the brand-name medication. Therefore, no, the proposed brand medications Glumetza, Singulair, Evoxac, Maxzide, Vorvasc, Cytomel, Carafate, and Medrol are not medically necessary over the generic drugs.