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

Diagnosis: Left Sided Lower Back Pain and Left Hip Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with a history of Factor VIII deficiency who presented on with back and hip pain. A CT was performed which showed no evidence of an iliopsoas bleed. The patient was admitted and started on Factor VIII infusions every eight hours. The patient was discharged without any complications.

No, the inpatient admission was not medically necessary. 

The patient was admitted with hip pain and was started on every eight-hour Factor VIII infusions. The patient could have received this treatment in a lower level of care. The medical records do not indicate the patient had a severe bleed such as a stroke or iliopsoas bleed. The results of the CT scan were negative, and the patient was discharged without complication. In addition, the patient did not require Factor VIII at a frequency or continuous infusion which would require admission to the hospital.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath, Fever and Cough 
Treatment: Inpatient admission 

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

The patient is a male with hypertension who presented to the emergency room with fevers, chills, cough, and body aches. The patient was found to have influenza A pneumonia. The patient was started on Tamiflu as well as intravenous (IV) antibiotics for secondary pneumonia. The patient was admitted to acute in-hospital level of care for the further management of flu infection. 

No, the proposed treatment, inpatient admission, was not medically necessary. 

The patient's condition significantly improved with emergency room care. The patient was hemodynamically stable at the time of admission. The patient was not in any significant respiratory distress. The patient was discharged home within 24 hours of in-hospital level of care. The acute in hospital level of care is not medically necessary. Observation level of care was medically indicated as patient had influenza A pneumonia with persistent fevers.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Cancer. 
Treatment:  Guardant360 testing (Cancer Screening). 

The insurer denied the Guardant360 testing (Cancer Screening).  The denial is overturned in whole.

The patient is a male diagnosed with stage IV lung cancer four years ago with epidermal growth factor receptor (EGFR) mutation.  He was initially treated with Erlotinib (Tarceva) and upon progression three years ago therapy was switched to Osimertinib.  Scan in last year showed progression of disease, which was treated with radiation therapy.  Cell free deoxyribonucleic acid (DNA) testing (Guardant360) was performed by treating physician.  Mutation in KRAS K117N was identified.

The subject under review is whether this testing is likely to be more beneficial for the patient than standard care.

The health plan's determination is overturned in whole. 

Yes.  The Guardant360 testing is likely to be more beneficial than any standard treatment for the patient's disease.  Molecular profiling is a standard practice for patient with metastatic cancer.  National Comprehensive Cancer Network (NCCN) guidelines recommend comprehensive molecular profiling to identify driver mutations for patients with metastatic lung cancer, particularly patients who are progressing on standard therapies.  In this case, the patient is progressing after receiving two standard therapies, Erlotinib and Osimertinib.  Testing for cell free DNA, such as Guardent360, would help identify acquired mutations leading to resistance to the standard therapy.  Identifying such mutations and molecular alternation would allow the patient to receive effective targeted therapies already available (such as BRAF mutation, certain type of KRAS), and also allow patient to identify available clinical trials (clinicaltrials.gov).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Cancer. 
Treatment:  Guardant360 testing (Cancer Screening). 

The insurer denied the Guardant360 testing (Cancer Screening).  The denial is upheld in whole.

The patient is a male who was diagnosed with Stage IV, epidermal growth factor receptor (EGFR) mutated non-small cell lung cancer after right retrocrural lymph node biopsy.  There were pleural metastases.  He was given Tarceva and then Tagrisso.  The Guardant360 test was ordered, which is under review.  This review is to determine whether the Guardant360 testing is likely to be more beneficial for this patient's disease than standard treatment.

The health plan's determination is upheld in whole.

The proposed health service, Guardant360, is not likely to be more beneficial than any standard treatment for the patient's life threatening or disabling condition or disease.

The National Comprehensive Cancer Network (NCCN) recommends obtaining molecular markers from lung cancer tissue for the following markers: EGFR, ROS1, ALK, BRAF, KRAS, NTRK, PD-L1, MET, Her2neu, and tumor mutational burden.

The use of cell free/circulating tumor deoxyribonucleic acid (DNA) testing should not be used in lieu of a histologic tissue diagnosis.  Such testing methods have up to 30% false-negative rates.  Standards for analytic performance characteristics have not been established.  No guidelines exist regarding the recommended performance characteristics of such testing.  Cell-free tumor DNA testing can identify alterations that are unrelated to the lesion of interest.  The use of this type of testing can be considered in special circumstances, such as if the patient is medically unfit for invasive tissue sampling or if there is insufficient material for molecular testing.  Neither of those scenarios are described in this case.

There are no clinical trials demonstrating a survival benefit in patients given targeted agents based on other molecular profiling compared to standard of care agents based on specific molecular profiling outlined by NCCN guidelines.

Use of the test in this case is not likely to be more beneficial to the patient than standard treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Cancer. 
Treatment:  Guardant360 testing (Cancer Screening). 

The insurer denied the Guardant360 testing (Cancer Screening).  The denial is upheld in whole.

The patient is a male with stage IV adenocarcinoma of the lung.  The patient has been treated with a multiple lines of therapy including Tarceva and Tagrisso, but he has progressed.  The patient's tumor has previously been evaluated with FoundationOne testing.

The Guardant360 assay was also obtained and is under review to determine whether it is likely to be more beneficial than any standard treatment for the patient's condition.

The use of sequential next generation sequencing gene panels to guide the treatment of patients with lung cancer has not been demonstrated to be of benefit.  Although there are a number of trials that are investigating the role of next generation sequencing (NGS) panels, including, but not limited to, National Clinical Trial [NCT] 02465060 and NCT 02693535, none of these trials are evaluating the role of utilizing both liquid and tissue approaches.  The assay in question is not Food and Drug Administration (FDA) approved, and a tissue assay (that is FDA approved) was already obtained.

Further complicating the role of liquid biopsies is that their results are limited in sensitivity to between 60 and 80 percent.  The limited sensitivity of liquid biopsies is thought to reflect the biology that some cancers do not shed deoxyribonucleic acid (DNA) into the bloodstream rather than a feature of any given assay.  However, mutation detection in blood has been associated with more advanced disease characteristics, including worsened performance status and prognosis and the presence of more metastatic sites.  A second limitation of liquid biopsies is that the types of studies have a higher chance of being falsely negative compared with traditional biopsies, given the minuscule and variable amounts of DNA that tumors may shed into circulation.  Finally, tests for programmed death-ligand 1 (PD-L1) expression cannot be conducted on liquid biopsies.

Another important point is that simply having a potentially targetable mutation does not guarantee that the patient will benefit from a therapy that presumably targets that mutation.  Another potential issue is if targeted testing identifies a potentially actionable genetic abnormality for which a molecularly targeted treatment is available but not yet approved.

Based on the paucity of supporting data, neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate recommend the use of the Guardant360 assay in this clinical scenario.  Treatment based on published literature and guideline recommendations has been encouraged.  For these reasons, the use of this assay in this scenario is not likely to be more beneficial for this patient than any standard treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Feeding difficulties.
Treatment:  Telehealth swallowing teaching.

The insurer denied the Telehealth swallowing teaching.  The denial is overturned. 

The patient is a male infant with medical history significant for ventriculoseptal defect complicated by congestive heart failure status post repair, respiratory insufficiency and obstructive sleep apnea dependent on supplemental oxygen, and feeding difficulties with subsequent failure to thrive, and laryngomalacia.  He was hospitalized in the PICU (pediatric intensive care unit) with respiratory insufficiency.  Upon improvement after a complicated course, he was transferred t for ongoing feeding therapy and respiratory care. 

Upon admission, the patient was receiving all nutrition and fluids via a nasogastric tube.  He underwent extensive feeding therapy, and at the time of discharge because he was feeding well orally with adequate weight gain, the nasogastric tube was removed.  Unfortunately, he was not able to take enough orally to maintain adequate weight gain.  Because of poor weight gain in conjunction with concerns for silent aspiration, the nasogastric tube was replaced and used for supplemental feedings. 

Yes, the Telehealth swallowing teaching is medically necessary.

This is an infant with increased caloric needs from his congenital heart disease and other medical problems and inability to take enough orally to sustain adequate weight gain.  At the time of discharge as a result of aggressive inpatient feeding therapy, he was reportedly taking all feedings by mouth with demonstration of adequate weight gain.  However, it was imperative to follow this infant as an outpatient to provide ongoing support to maintain adequate nutrition and weight gain.  Feeding disorders are very complex, and patients with feeding disorders require close monitoring of weight gain and support of caregivers to meet nutritional and developmental goals. 

During the period of time in question, close feeding team follow-up was medically necessary and appropriate, limited to Telehealth due to the Covid19 pandemic.  Unfortunately, according to a communication, he has required replacement of the nasogastric tube for safe supplemental feedings because of inadequate oral intake and concern for silent aspiration.  Without close outpatient follow-up at home with the feeding team, he may have ended up with aspiration pneumonia and further morbidity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia.
Treatment: Home Care/Personal Care HHC - Personal Care Aide - Increase to 24 Hours per Day (Split Shift).

The insurer denied the Home Care/Personal Care HHC - Personal Care Aide - Increase to 24 Hours per Day (Split Shift). The health plan's determination is overturned. 

The patient is an elderly male with past medical history of dementia, oxygen dependent chronic obstructive pulmonary disease (COPD), hypertension, congestive heart failure, coronary artery disease, depression, urinary incontinence, bowel incontinence, hemiparesis secondary to cerebrovascular accident (CVA), abnormal gait, spinal stenosis, narcotic pain medication use and constipation. The patient had worsening skin breakdown with areas of skin breakdown on the sacrum and buttocks and gluteal cleft as documented in PCP notes. The PCP note indicated the patient needed to be turned in bed every 2 hours to prevent skin breakdown and pressure ulcers. 

The Home Care/Personal Care HHC - Personal Care Aide - Increase to 24 Hours per Day (Split Shift) is medically necessary for this patient. Due to his underlying urinary and stool incontinence, the patient needs to be cleaned and changed throughout the night at unscheduled times. The attending physician also documents medical necessity of turning the patient every 2 hours to heal current decubitus ulcers and prevent further skin break down. The patient requires cognitive prompting to assure safe completion of activities of daily living (ADL) and instrumental activities of daily living (IADL) and the PCA services are not solely for safety monitoring and supervision. The patient does not have informal helper outside of the assigned PCA hours. Because of the patient's overnight needs, a personal care assistant would not be able to obtain 5 hours of uninterrupted sleep. PCA services 24 hours/day, split-shift, 7 days/week are medically necessary for this patient to maintain his health and safety in his own home as well as prevent and correct medical conditions that could cause acute suffering, endanger life or result in illness or infirmity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain/instability.
Treatment: Total hip replacement revision.
The insurer denied coverage for Total Hip Replacement (Procedure 27134) as not medically necessary. 
That denial was upheld.

This patient with right hip pain had undergone a prior hip replacement complicated by infection (previously sustained an acetabular fracture from MVA). He then had removal of the arthroplasty with placement of antibiotic spacer. The date of the latest procedure was late 2019. He had reported several episodes of antibiotic spacer dislocation. He was reported to be non-compliant. His physical examination was significant for "range of motion pain free, antalgic gait. He refused x-rays in mid 2020. The patient requested re implantation of the right hip. Laboratory tests were recommended as well as Infectious Diseases consultation.

The medical records demonstrate several problems that need to be addressed prior to the planned elective procedure. The patient has infection until proven otherwise. He did not receive the recommended treatment of a prolonged course of IV antibiotics. He was non-compliant. Any additional surgery would be at extremely high risk for abscess, infection and/or sepsis.

Principles of Orthopedic Surgery for hip revision after antibiotic spacer require a course of IV antibiotics. Several diagnostic studies are required prior to surgery (laboratory testing, special imaging). An Infectious Diseases consultation would be required.

The issue of compliance is extremely important. The patient's history of poor follow-up and underlying medical conditions increases the rate of complication and failure. It would not be in his best interest not to undergo any hip surgery at this time.

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 Total Hip Replacement (Procedure 27134) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/musculoskeletal 
Surgical Services  (All) 

Diagnosis: Neck/back pain 
Treatment: neck (spine) surgery and inpatient admission (procedure codes 22856 and 22858) 

The insurer denied neck (spine) surgery and inpatient admission (procedure codes 22856 and 22858). The health plan's determination is upheld. 

The patient is a male with a history of a C4-5 ACDF (anterior cervical discectomy and fusion) as well as a lumbar fusion. He apparently continued to have neck pain and some right arm radiating pain subsequently that has worsened over time according to the progress notes provided for review. He is left handed, but gets severe neck pain and right arm pain while working as a tattoo artist and has had to stop working. Attempts at conservative therapy include a HEP (home exercise program), home cervical traction, medications including narcotics pain medication and muscle relaxants. 

The neck (spine) surgery and inpatient admission (procedure codes 22856 and 22858) is not medically necessary for this patient. There is a lack of level 1 or 2 evidence in the literature supporting its superiority over the more standard traditional multi-level ACDF procedures. 

The patient has a previous fusion at C4-5. While there is ample evidence now in the literature including long term results of PRCT (Preclinical randomized controlled multicenter trials) that show at least equivalency (and frequently superiority when patients are monitored over time) of 1- or 2-level CADRs compared to ACDFs (Nunley et al, Badhiwala et al, Koreckij et al, and Gornet et al), there is no such evidence to support hybrid constructs of fusion and arthroplasty on the same patient. Conceptually, this seems favorable as an attempt to maintain motion segments in patients with degenerative disc disease rather than proceeding to multilevel fusion procedures. However, there is not yet robust evidence that this is indeed the case. In a recent meta-analysis of this topic, Zhang et al reviewed 7 clinical trials and noted that the while HS (hybrid surgery) provided equivalent outcomes and functional recovery when compared to multi-level ACDFs with significantly better preservation of ROM (range of motion), they added the caveat that "more well-designed studies with large groups of patients are required to provide further evidence for the benefit and reliability of HS for the treatment of cervical disk disease". Others have also reported improved mid-term clinical outcomes and motion preservation in patient undergoing HS compared to ACDF, but these are also retrospective reviews (Wang et al and Ji et al). Therefore, one cannot make the case at this point in time that HS is medically necessary and the most appropriate procedure for patients with cervical degenerative disc disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Total Thyroidectomy

Treatment: Inpatient admission

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a history of a substernal thyroid goiter.  It was reported that the patient had dysphagia, especially solid foods.  An esophagram was performed that revealed a large mainly right-sided superior mediastinal mass markedly displacing the esophagus to the left with narrowing of the lumen. A computed tomography (CT) scan of the chest was done that showed a large thyroid goiter with intrathoracic extension on the right; anterior to the trachea. Both lobes were similarly enlarged, and intrathoracic, but the mid-portion anterior to the trachea extended all the way down to the aortic arch. The patient presented to the hospital for a scheduled total thyroidectomy. The patient was admitted to the hospital post surgery for monitoring. The patient was to start on Synthroid medication.  The patient's parathyroid hormone (PTH) was  followed up with results of 29 and a calcium of 8.0.  The patient was medically stable and discharged home.

Based on the review of the medical chart and the clinical guidelines, the inpatient stay is not considered medically necessary for this patient. The patient had a substernal thyroid with tracheal compression.  A thyroidectomy is generally an ambulatory procedure.  Although inpatient status was not medically necessary, the patient needed observation for 24 hours to monitor for airway compromise. The patient's care could have been safely provided as an observation status. 

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 stay should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned. 

Yes, the proposed inpatient admission is "medically necessary".

The patient is a female with a past medical history significant for thyroid disease, presented to the ER with complaints of palpitations. The patient was found to have severe tachycardia, with heart rate as high as 200 bpm. She was treated with IV Cardizem with reduction of HR to 133 bpm. Her TSH (thyroid stimulating hormone) was found to be less than 0.01, with elevated T3 and T4, consistent with thyrotoxicosis. 

The patient was admitted to telemetry for management of atrial fibrillation. She was seen in consultation by endocrinology and cardiology. Echocardiogram was done, revealing severely reduced LV function, consistent with systolic CHF (congestive heart failure). 

The patient was diagnosed with tachycardia induced cardiomyopathy and her metoprolol dose was gradually increased. The patient was started on methimazole for thyrotoxicosis. Once her heart rate was controlled the patient was discharged home with a plan for outpatient follow-up.

The patient presented with new onset atrial fibrillation with rapid ventricular rate in the setting of thyrotoxicosis, requiring management with IV medications for rate control. There was evidence of end-organ damage, specifically severe reduction in LV function, consistent with tachycardia induced cardiomyopathy. EF (Ejection fraction) was found to be reduced in 20-25% range. Given the presentation, uncontrolled atrial fibrillation, CHF/systolic dysfunction and new onset thyrotoxicosis, she would not be an appropriate candidate for an ED observation unit, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.