Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Rosacea

Treatment: Soolantra 1% (percent) Cream (G)

The insurer denied coverage for Soolantra 1% Cream (G).

The denial is overturned.

The patient has a diagnosis of rosacea.  The patient is noted to have failed topical metronidazole and Finacea as well as oral Doxycycline.  The requested medication is topical Soolantra cream.  The insurer has denied Soolantra cream due to lack of evidence that the patient has tried and failed metronidazole and doxycycline.  

The patient has failed topical therapy with metronidazole and Finacea as well as Tazorac.  The patient has also been treated with oral doxycycline.  The patient has been successfully treated with Soolantra for some time and wishes to continue therapy.  A review of the provided documentation indicates that the patient has failed topical and oral formulary alternatives and has been successfully treated with topical Soolantra.  The continued use of Soolantra cream is within the rosacea guidelines and would be within the standard of care to continue the treatment of the patient's rosacea regimen.  

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug(s) are expected to be ineffective.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Soolantra 1% Cream (G) is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Renal Failure. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient is a female with a history of chronic kidney disease (CKD), hypertension (HTN), hyperlipidemia, and diabetes mellitus (DM) who presented with abnormal blood work. She was seen by her primary care physician (or provider) (PCP) and was found to have an elevated creatinine of 3.68 and a potassium of 5.8. She reported increasing urinary frequency and volume without dysuria. She denied changes to her diet, medications or recent infections. She did endorse right groin pain radiating to her right thigh muscles. She denied fevers, chills, chest pain, shortness of breath, nausea, vomiting, diarrhea, hematuria, back pain, or weakness. 
An electrocardiogram (EKG) showed normal sinus rhythm without T wave changes. A computed tomography (CT) scan of the abdomen and pelvis was unremarkable except for a distended bladder. A doppler lower extremity ultrasound did not show any evidence of deep vein thrombosis (DVT). A chest x-ray did not show any acute cardiopulmonary findings. She was admitted for further management. She was started on intravenous (IV) fluids and nephrology was consulted. Nephrology recommend holding her angiotensin converting enzyme (ACE)-inhibitor, giving lokelma and a low potassium diet. She was considered stable for discharge home. At issue is the medical necessity of an inpatient stay. 

The inpatient admission is not medically necessary based on the documentation provided. The patient presented due to abnormal labs which showed an elevated creatinine and an elevated potassium. She was hemodynamically stable. She did not have respiratory distress. She did not have cardiac arrhythmia. She did not have severe electrocardiogram (EKG) changes requiring inpatient management of her elevated potassium nor did she have any other severe electrolyte or metabolic abnormalities. She did not have uremic encephalopathy, pericarditis or bleeding. She did not have severe or persistent pain, changes in mental status, nausea or vomiting. She did not have a greater than 3 fold increase in her serum creatinine nor did she have documented anuria. She could have been managed at a lower level of care such as an observation level of care with subsequent transition to outpatient follow up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain and nausea

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The patient has a history of diabetes and gastroparesis and peroral endoscopic myotomy (POEM) procedure. She presented with abdominal pain and nausea. She had a recent admission for similar symptoms and underwent a gastrointestinal (GI) workup. An endoscopy revealed gastritis. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The liver enzymes were normal. A recent computed axial tomography (CAT) scan was negative for acute disease and was negative for mesenteric stenosis. Proton pump inhibitor (PPI) treatment, Zofran, and pain control were given. 

Medical necessity was based on Milliman Care Guideline (MCG) guideline M-05 for Undiagnosed Abdominal Pain. Clinical indications for admission include hemodynamic instability, severe pain not responding to analgesics, peritoneal signs, bowel perforation or obstruction, bacteremia, or an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had known gastroparesis and gastritis. She already had an extensive workup. Treatment with a Proton pump inhibitor (PPI), Zofran, and pain medications could have been given with observation care. No acute interventions were needed. She did not meet Milliman Care Guideline (MCG) criteria for admission for Undiagnosed Abdominal pain. 

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 the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endodontically treated teeth
Treatment: Crowns on teeth #'s 8 & 9
The insurer denied coverage for: Crowns on teeth #'s 8 & 9
The denial is: Overturned

Based on the submitted documentation which includes copies of panoramic and periapical radiographs, narrative letter, and insurer correspondence, it appears that this patient presented to the dentist for comprehensive dental care. Endodontic therapy was completed on teeth #8 and #9 with recommendation of full coverage crowns for these teeth at that time. Crowns were not placed at that time and remain the recommended treatment for the patient. The insurer has denied the full coverage crowns stating that the services are not medically necessary as the documentation did not demonstrate medical need to support the treatment and what is provided does not meet their medical necessity criteria. The dentist is appealing the decision on behalf of the patient. 

Upon review of the clinical photographic images and radiographs, it supports the recommended treatment. Review of radiographs indicate that endodontic therapy was adequately performed and successful. Subsequently, there is ample coronal structure remaining on this tooth after the endodontic therapy for support of a crown on each of these teeth and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of crowns on endodontically treated teeth which would have an excellent long-term prognosis with the recommended treatment. As the clinical and radiographic findings support the recommended treatment, full coverage crowns for teeth #8 and #9 are considered medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Crowns on teeth #'s 8 & 9 is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lung Mass

Treatment: Current Procedural Terminology (CPT) code 0239U

The insurer denied coverage for Current Procedural Terminology (CPT) code 0239U

The denial is upheld



This is a patient with a lung mass and one biopsy was not successful. The provider, instead of performing another biopsy, which they believe is not safe, wants to rely on a liquid biopsy for diagnosis. The request is for current procedural terminology (CPT) code 0239U, which is under review.

All available medical documentation was reviewed.

The scientific evidence in peer-reviewed literature does not support a result of improvement in the health outcome of the patient. 

Unfortunately, liquid biopsies or even tissue-based molecular profiles are not designed to establish diagnoses, but to find targets for treatment. Coannal et al say: "Currently liquid biopsies are not considered a standard method for the diagnosis and conformation of diseases such as cancer. Instead, they are predominantly used as a complementary test to tissue biopsy."      

The CPT code 0239U does have final approval from the appropriate regulatory bodies for this diagnosis.     

Without a tissue pathological diagnosis, this test is of little use.     

The CPT 0239U is not the best available treatment for this patient at this time.     

The risk is related to a potential misdiagnosis from the use of unstudied technology.      

The use of an unproven test to make treatment decisions carries more risk than benefit.

Therefore, the request for the CPT code 0239U is not medically necessary and is denied.

"The evidence indicates that testing for circulating tumor deoxyribonucleic acid (ctDNA) is optimally performed on plasma collected in cell stabilization or ethylenediaminetetraacetic acid (EDTA) tubes, with EDTA tubes processed within 6 hours of collection. Some ctDNA assays have demonstrated clinical validity and utility with certain types of advanced cancer; however, there is insufficient evidence of clinical validity and utility for the majority of ctDNA assays in advanced cancer. Evidence shows discordance between the results of ctDNA assays and genotyping tumor specimens and supports tumor tissue genotyping to confirm undetected results from ctDNA tests. There is no evidence of clinical utility and little evidence of clinical validity of ctDNA assays in early-stage cancer, treatment monitoring, or residual disease detection. There is no evidence of clinical validity and clinical utility to suggest that ctDNA assays are useful for cancer screening, outside of a clinical trial" (Merker, J. D., et al 2018).                                                    

In summary, the denial of Current Procedural Terminology (CPT) code 0239U and coverage for the requested service should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lung Mass

Treatment: Current Procedural Terminology (CPT) code 0239U

The insurer denied coverage for Current Procedural Terminology (CPT) code 0239U

The denial is upheld



This is a patient who has a long smoking history and a growing lung mass. The treating physician did not think it was safe to perform a bronchoscopy or a biopsy and therefore sent a liquid biopsy instead. The request is for current procedural terminology (CPT) code 0239U, which is under review.

All available medical documentation was reviewed.

The scientific evidence in peer-reviewed literature does not support a result of improvement in the patient's health outcome.      

The current CPT code 0239U is a Food and Drug Administration (FDA)-approved test.     

The patient is a good candidate for CPT code 0239U, as this is a blood test and it can be done on anyone.     

The CPT code 0239U is not the best available treatment for this patient at this time.

Most do use such assays to screen for or diagnose lung cancer. Although blood-based assays to diagnose a variety of cancers have been described, further investigation is needed prior to routine clinical use and to determine whether this helps patients.     

Because it is not widely used, there are no data to compare with.     

There are no data to suggest that doing this test is likely to be more beneficial than standard approaches.

Therefore, the request for CPT code 0239U is not medically necessary and is denied.

"Circulating free deoxyribonucleic acid (cfDNA) sequencing leveraging informative methylation patterns detected more than 50 cancer types across stages. Considering the potential value of early detection in deadly malignancies, further evaluation of this test is justified in prospective population-level studies" (Liu MC., et al 2020).

"Of 57,820 annotated genes, 39,564 (68%) are not detected in circulating free ribonucleic acid (cfRNA) from non-cancer individuals. Within these low-noise regions, we identify tissue- and cancer-specific genes, defined as "dark channel biomarker" (DCB) genes, that are recurrently detected in individuals with cancer. DCB levels in plasma correlate with tumor shedding rate and RNA expression in matched tissue, suggesting that DCBs with high expression in tumor tissue could enhance cancer detection in patients with low levels of circulating tumor deoxyribonucleic acid (DNA). Overall, cfRNA provides a unique opportunity to detect cancer, predict the tumor tissue of origin, and determine the cancer subtype" (Larson MH., et al 2022).                                                    

In summary, the denial of Current Procedural Terminology (CPT) code 0239U and coverage for the requested service should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Trauma/injuries
Inpatient hospital

Diagnosis: leg fracture
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a male teen with medical history significant for retinitis pigmentosa, mild intermittent asthma, possible scoliosis, and vitamin D deficiency who was taken to the emergency department (ED) via Emergency Medical Services (EMS) after falling off his bike, with the bike falling on top of him. He was not wearing a helmet, but did not hit his head, with no loss of consciousness. His leg was splinted by EMS and he was given fentanyl en route. Vital signs included temperature 36.8, heart rate 64, respiratory rate 20, and blood pressure 108/71. Examination was significant for no bruising to the abdomen, right lower extremity deformity, tenderness to palpation over the distal tibia/fibula with soft tissue swelling, decreased range of motion due to pain, strong distal pulses, and no focal neurologic deficits. X-rays revealed proximal non-displaced fibular spiral fracture with partially comminuted distal third tibial fracture and curvilinear fracture involving the distal tibia distal to the comminuted fracture. 

The inpatient stay is not medically necessary. This young man sustained multiple fractures to his lower right leg following a bike accident. There were no other associated traumatic injuries. The fractures were manually reduced in the ED and he was admitted for further monitoring for compartment syndrome and adequate pain control. While it was reasonable to monitor him in the hospital for signs and symptoms of compartment syndrome, to provide adequate pain control, he was overall hemodynamically stable with no other traumatic injuries and stable lower extremity casted fractures. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure
Treatment: Inpatient stay
The insurer denied the inpatient stay.
the health plan's determination is upheld. 

The patient is a male with a past medical history of end-stage renal disease on hemodialysis, hypertension, and heart failure with preserved ejection fraction, who presented to the emergency department with complaints of shortness of breath and a productive cough. He reported a sudden onset of shortness of breath (SOB), particularly aggravated while lying flat and with exertion, including walking. He noted a similar episode in the past, leading to hospitalization, where he received diuretics with subsequent improvement. The patient also mentioned paroxysmal nocturnal dyspnea and reported still producing some urine. He affirmed compliance with his medications and denied fever, weight changes, chills, nausea, vomiting, chest pain, palpitations, recent travel, sick contacts, abdominal pain, diarrhea, constipation, or dysuria.

The inpatient hospital stay was not medically necessary for this patient.
The patient presented to the hospital with acute exacerbation of diastolic congestive heart failure. The review of the medical records showed no evidence of hemodynamic instability, acute kidney injury, severe electrolyte abnormalities requiring inpatient care, cardiac arrhythmias of immediate concern, presence of acute decompensated conditions precipitating congestive heart failure (CHF) such as pneumonia, or pulmonary embolism.
There was no evidence that the patient had severe pulmonary edema that required invasive or noninvasive assisted ventilation, massive skin edema, intractable pulmonary edema, persistent tachypnea, altered mental status, or acute peripheral ischemia.
The patient did not require pulmonary artery catheter monitoring. Overall, this patient remained in stable clinical condition and did not need any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The patient was hemodialysis dependent and underwent hemodialysis sessions which did not require admission at the acute inpatient level of care.
Based on the severity of the patient's condition and the complexity of the services provided, the care could have been conducted at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sinopulmonary infections, asthma
Treatment: High Frequency Chest Wall Oscillation System, with Full Anterior and/or Posterior Thoracic Region Receiving Simultaneous External Oscillation, Includes All Accessories and Supplies
The insurer denied High Frequency Chest Wall Oscillation System, with Full Anterior and/or Posterior Thoracic Region Receiving Simultaneous External Oscillation, Includes All Accessories and Supplies.
The health plan's determination is overturned.

The patient is a male with repaired congenital heart disease (coarctation of the aorta and VSD (ventricular septal defect)), recurrent sinopulmonary infections, asthma, and short stature. According to the submitted clinical notes, he was evaluated for primary ciliary dyskinesia and cystic fibrosis, and the results were negative. To improve his airway clearance, a PEP (positive expiratory pressure) valve and manual chest PT (physical therapy) were tried, but were unsuccessful. A high-frequency chest-wall oscillation system (VEST) was tried and was successful in decreasing the frequency of the sinopulmonary infections.

High Frequency Chest Wall Oscillation System, with Full Anterior and/or Posterior Thoracic Region Receiving Simultaneous External Oscillation, Includes All Accessories and Supplies is medically necessary for this patient.
The provided clinic note describes the failure of alternative forms of chest PT (PEP and manual chest PT) and specifically notes that compliance with therapy has not been a concern.
Effective airway clearance is often a problem in children with congenital heart defects, and achieving effective airway clearance is important, especially in that population. Given the apparent failure of PEP therapy and manual chest PT, the VEST is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient is an adult with a past medical history significant for peripheral vascular disease, status post aorto-femoral bypass and left sided axillary to profunda bypass surgery, and chronic obstructive pulmonary disease (COPD) who was sent to the hospital after several weeks of chest pain. The patient's chest pain was intermittent and each episode lasted for several seconds. In the office, an echocardiogram had revealed a wall motion abnormality. On arrival to the hospital, the patient's vital signs were stable: blood pressure (BP) 135/81 and heart rate 68. The physical examination revealed no significant abnormality.  A 12 lead electrocardiogram (EKG) demonstrated normal sinus rhythm with no significant changes from baseline performed six months earlier. Serum blood testing demonstrated no elevation in serum troponin. Computerized tomography angiography (CTA) demonstrated patent axillary femoral grafts and no evidence of aortic dissection. The patient was admitted to the hospital for further work up. 

Risk assessment of patients presenting with chest pain and no significant ST (heart segment) changes on electrocardiogram (EKG) was reviewed by Hedayati et al. These findings are concerning, and warrant management and evaluation that includes serial troponin measurement, and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. 

Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those who were placed in an observation unit at a lower level of care. They found no significant difference in outcome at 30 days between the two groups. Fernando Bellolio et al. noted that patients presenting with chest pain, who were managed in an observation unit, had similar 30 day myocardial infarction rates as those admitted to the hospital. 

This patient presented with atypical chest pain. Using the HEART (History, ECG, Age, Risk factors and Troponin level) score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction [MI]), need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation. Utilizing the HEART score, the patient was considered low risk. The patient's pretest probability of coronary artery disease was intermediate.  The patient could have been managed at a lower level of care. A full hospital admission was not medically 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 an inpatient admission is not substantiated.