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

Diagnosis: Abdominal Pain 
Treatment: Inpatient Admission

The proposed inpatient treatment was not medically necessary. 

The incidence of complications following hemorrhoidectomy is overall low. The main complications following a standard technique for hemorrhoidectomy include urinary retention, urinary tract infection, fecal impaction, and delayed hemorrhage. Surgical site infection is uncommon after hemorrhoid surgery; however, submucosal abscess (less than [<] one percent) and deep space infection can occur, although severe fasciitis or necrotizing infections are rare.

A bulk fiber supplement and/or increased dietary fiber and fluid intake will help reduce postoperative constipation and pain upon defecation. Fecal impaction after a hemorrhoidectomy is associated with postoperative pain and opiate use. Most surgeons recommend stimulant laxatives, stool softeners, and bulk fiber to prevent this problem. Should impaction develop, manual disimpaction with anesthesia may be required.

This patient presented with a normal postoperative complication. 

In the absence of a suspected perforation or massive bleeding, the management of fecal impactions involves disimpaction and colon evacuation, followed by the implementation of a maintenance bowel regimen to prevent recurrent impactions. Digital disimpaction to fragment a large fecal bolus to facilitate its passage through the anal canal is suggested. Subsequently a warm-water enema with mineral oil may be administered to soften the impaction and assist emptying of stool from the rectum and distal colon. Once the distal colon has been partially emptied with disimpaction and enemas, polyethylene glycol (PEG) may be administered orally or by a nasogastric tube.

If the above measures fail, local anesthesia to relax the anal canal and pelvic floor muscles, together with abdominal massage, can help to pass the stool bolus. In rare cases, it may be necessary to use a colonoscope with a snare to fragment fecal material in the distal colon. In such cases, a mineral oil enema prior to the colonoscopy may help to soften the stool bolus. If such measures fail or if there is significant abdominal tenderness suggestive of an impending perforation or ischemia, surgery may be necessary.

There were no signs of sepsis, perforation or ischemia and the patient could have been managed at a lower level of care. The white count was normal with no left shift, the patient was afebrile, and, no antibiotic coverage was instituted during her stay.
Appeal type: Medical necessity
Decision: Upheld

This is patient who had undergone an allogeneic stem cell transplantation whose treating provider would like to utilize aspergillus prophylaxis with Noxafil (posaconazole). The plan notes that Itraconazole, Variconazole are both on the formulary and need to be tried first. The health plan's determination is upheld.
The requested health service/treatment of Noxafil 100 milligrams is not medically necessary. Voriconazole is an active agent which is on the plan's formulary and could be used first instead of posaconazole. A 2007 meta-analysis that included 64 randomized trials compared systemic antifungal prophylaxis (eg, fluconazole, itraconazole, posaconazole) with a control arm (placebo, no intervention, or a nonsystemic antifungal agent such as clotrimazole) in cancer patients receiving myelosuppressive chemotherapy (predominantly for acute leukemia) or undergoing hematopoietic cell transplantation (HCT).  There was no significant difference between voriconazole or posaconazole. The toxicity profiles differ but the ability for prophylaxis does not.
Appeal type: Medical necessity
Decision: Overturned

The patient has past medical history of obesity and cesarean section. Genetic testing revealed that the patient is positive for the BRCA 1 gene mutation. The patient is to undergo nipple sparing mastectomy. The surgeon plans reduction mammoplasty prior to mastectomy to improve the safety and efficacy of the mastectomy reconstruction. The subject under review is the medical necessity of the reduction mammaplasty. The health plan's determination is overturned.

Breast reduction and lift prior to mastectomy is a standard technique for managing breast ptosis for women undergoing prophylactic mastectomy. It is part of the reconstruction of the mastectomy and should be covered per the Women's Health and Cancer Rights Act (WHCRA).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Amebiasis
Treatment: Pharmacy/Prescription Drugs

Summary: This patient was seen by his provider for amebiasis.  He continued to have loose stools daily and was anxious to start treatment.  The physician detailed the patient weighed 218 pounds so he would be treated with metronidazole 750 mg three times a day for seven days followed by Paromomycin 750 mg three times a day for seven days.  The dosage and side effects were reviewed. 

The insurer has denied coverage for Paromomycin Sulfate 250 mg OR CAPS as not medically necessary. The denial was reversed.

The insurer has indicated that in order for the patient to be treated with the requested medication, there must be documentation of trial and failure or contraindication to metronidazole.  However, the chart note did indicate the requested medication would be needed after treatment with the formulary medication.  According to the literature, a patient that is symptomatic should be treated with medication to include metronidazole followed by treatment with iodoquinol or paromomycin. The prescribed treatment is standard of care for the patient's diagnosis. Based on the above, the medical necessity for Paromomycin Sulfate 250 mg OR CAPS is substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of knee osteoarthritis and underwent primary left total knee replacement surgery.  The hospital course was uneventful with no complications, and the patient was deemed stable for discharge.  At issue in this case is the medical necessity of the left total knee replacement surgery.  The health plan's determination is overturned.
 
The requested health treatment of left total knee replacement is medically necessary for this patient. 

The rationale for this determination is based on the provided progress notes.  The history of present illness in the notes documents that the patient had a previous series of viscosupplementation injections with some relief of symptoms.  There is documentation of advanced left knee osteoarthritis on plain radiographs as well as increased left knee pain that is limiting the patient's level of activity.  Prior cortisone injections and physical therapy failed to relieve the pain as well.  The note contains documentation of conservative treatments which failed to relieve this patient's knee pain prior to total knee replacement surgery. 

The recommendation for total knee replacement surgery in this patient is consistent with the current, peer-reviewed literature on total knee replacement indications and the guideline published by the American Academy of Orthopedic Surgeons.  Therefore, the medical necessity of the surgery is established.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3:

This patient had a biopsy of the left ear. The pathology report was significant for malignant melanoma measuring at least 1.0mm in thickness extending to the base of the specimen. The Decision DX Melanoma class is 1 and sub-class is 1A.

Although Decision-DX Melanoma assay is promising, given the lack of evidence, and based on NCCN guidelines, which do not support use of this test, Decision DX Melanoma, the use of this test has not been shown to improve health outcomes in melanoma and is not considered a standard of care.  The Decision DX Melanoma testing does not have final approval from the appropriate regulatory bodies for this diagnosis.

To date, results remain inconclusive regarding the efficacy of this tool for improving health outcomes on a large scale. The patient is diagnosed with malignant melanoma. The American Joint Committee on Cancer (AJCC) divides melanoma into four stages, which takes into account tumor thickness and anatomical level of involvement (localized cutaneous disease) for stages I and II. Stage III involves local regional lymph nodes and stage IV includes distant metastasis (skin, subcutaneous tissue, nodal, visceral, and skeletal or CNS) (National Comprehensive Cancer Network, 2017).

Although Decision-DX Melanoma assay is promising, given the lack of evidence, and based on NCCN guidelines. The use of this test has not been shown to improve health outcomes in melanoma and is not considered a standard of care.   The Decision DX Melanoma testing performed is not the best available treatment for this patient at this time.

More typical Hematoxylin and eosin stain or haematoxylin and eosin stain (H&E stain or HE stain) with appropriate subsequent stains is considered standard of care for melanoma diagnosis and prognosis testing.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

This patient has a malignant melanoma to the left ear, Breslow 1.0 mm. There is no ulceration or regression. The mitotic index is less than 1. This is a review for coverage of the Decision DX Melanoma assay.

The clinical practice guidelines from the NCCN recommend against routine prognostic testing for low versus high metastatic risk outside of a clinical trial. The standard prognostic indicators for melanoma include age, gender, Breslow thickness, ulceration, and mitotic rate. Gene expression profiling has not been shown to have independent prognostic value within the context of the other known prognostic factors for melanoma. Its' independent prognostic value has not been confirmed in a large population of patients with average to low risk disease. Therefore, the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

There is insufficient evidence to determine how gene expression profiling may be used to guide clinical decisions related to the diagnosis and treatment of cutaneous melanoma. Specifically, it is not known how or whether decisions concerning treatment and surveillance are improved over the current standard of care, and it is unknown whether health outcomes are improved as a result of those decisions.  There are no high-grade evidence-based peer reviewed studies in the medical literature noting the efficacy of the DecisionDX melanoma assay.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Melanoma
Treatment: Biopsy, diagnostic testing
The insurer denied the DX Melanoma gene expression test. That denial was upheld. A panel of three out of three reviewers determined the Decision DX Melanoma testing is not likely to be more beneficial than any other standard testing.

Reviewer #1:

The patient had a biopsy from the left ear. The diagnosis was malignant melanoma with at least 1 mm in thickness.  Decision DX-Melanoma gene expression profile test was done. The results revealed the patient is class 1A, which suggests a very low risk of metastatic potential. Based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this patient.

The initial evaluation for risk of metastasis in patients with cutaneous melanoma uses the American Joint Committee on Cancer (AJCC) staging criteria, which includes Sentinel Lymph Node status. Per Trotter, et al. (2013), "The stage at presentation of melanoma has a significant impact on the course of the disease. Most melanoma patients present with localized disease 82 to 85 percent of the time, followed by regional involvement 10 to 13 percent of the time, and distant metastatic disease 2 to 5 percent of the time. The staging of melanoma holds prognostic value and dictates the recommendation in treatment. Staging is determined by the tumor, node, and metastasis (TMN) system developed by the American Joint Committee on Cancer (AJCC). Criteria include micro staging of the primary melanoma and pathologic information about the regional lymph nodes after partial or complete lymphadenectomy as well as a new emphasis on dermal mitotic index (measured in mm2) for T1 melanoma (=1 mm). Survival and recurrence rates for melanoma follow the pathologic stages set forth by the AJCC (Table 2) and are used to guide follow-up recommendations."

In this case, the Decision DX Melanoma assay was not known to be effective based on a lack of scientific evidence showing that the results would accurately guide patient care and health outcomes. The use of this testing was not supported by scientifically based guidelines of national medical research or governmental agencies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable chronic migraine, past history of congenital torticollis, release of right sternocleidomastoid muscle, reflux, congenital hip dysplasia, and gestational hypertension

Treatment: Medication

The insurer denied the medication Aimovig Autoinjector stating that the use of Aimovig for migraine prevention in combination with Botox has not been adequately studied by the United States FDA. That denial was upheld.

The patient has intractable migraine since childhood.  She has tried virtually all migraine treatments including Periactin, Ibuprofen, Fioricet, Amitriptyline, Flexeril, Topamax, Tramadol, Lortab, Skelaxin, Hydrocodone, Imitrex, Naproxen, Zomig, Maxalt, Bisoprolol, vitamin B2, Percocet, Zolmitriptan, DHE protocol, intravenous (IV) Compazine, Ketorolac, IV Diphen, intravenous (IV) Metoclopramide, caffeine, nerve blocks and Depakote ER.  She had some benefit from Botox and is receiving it monthly.  She tried Aimovig samples with benefit - migraine frequency was halved.  Her neurologist would like her to continue her current headache regimen including Botox with the addition of Aimovig.

While there is no evidence that the combination of Botox and Aimovig is unsafe, there is also no evidence of efficacy.  This patient has only ever tried Aimovig with Botox - it is unknown if Aimovig without Botox would be equally or more effective.  A search of PubMed using the search terms erenumab and botox revealed no studies of the combination.  In addition, the long term safety of erenumab is unknown.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a malignant melanoma to the right leg, Breslow depth is 0.4 millimeter (mm). There is no ulceration, no regression, and the mitotic indexes 0. This is a review for the Decision DX melanoma assay.

The health plan's determination is upheld. Based on the submitted guidelines, clinical information, and lack of support for its use in nationally recognized healthcare organizations and peer-reviewed medical literature, the Decision DX melanoma assay is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of diabetes mellitus (DM) type 2, hypertension (HTN), hyperlipidemia, and hypothyroidism. The patient presented to emergency department (ED) on 1/23/19 with chest pain, dyspnea on exertion, and headache. Patient had been having headaches for about three days and was noted to have an elevated blood pressure at home of about 165/90 mmHg. The patient did have blurry vision of left eye but had seen a eye doctor 2 weeks prior to admission and it was felt to be diabetic related.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient did require further work up in the hospital for hypertensive urgency management and to rule out acute coronary syndrome as she had risk factors which were concerning. However, a lower level of care for further assessment is appropriate. The patient required diagnostic testing, laboratory testing, and physical examination follow up with monitoring of her blood pressure. This could be managed at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath and wheezing

Treatment: Inpatient stay

Summary:
At the time of admission, patient was hemodynamically stable. Although, patient had wheezing, the patient was not in any significant respiratory distress. The patient's asthma exacerbation improved within 24 hours of admission and was discharged home within 24 hours of admission. The acute inpatient level of care was not medically necessary. The observation level of care would have been more appropriate
Appeal type: Medical necessity
Decision: Upheld

The patient with past medical history significant for diabetes mellitus, hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), and sciatica presented to the emergency department with chest pain that was associated with left shoulder pain and some shortness of breath and dizziness. Pain was relieved with aspirin and worse with bending forward. Review of systems was otherwise positive for right flank pain radiating to the back as well as occasional black stools for which the patient was scheduled for an outpatient esophagogastroduodenoscopy (EGD). Other history was significant for having recently been treated for a urinary tract infection, having had an ultrasound (US) of the abdomen that showed cholelithiasis without cholecystitis and a computed tomography (CT) abdomen pelvis which showed no acute pathology. The patient denied fevers, chills, nausea, vomiting, or other complaints.
Given concerns for chest pain in a patient with numerous risk factors for coronary artery disease, the patient was subsequently admitted to the hospital and underwent telemetry monitoring and serial troponins which were negative. Echocardiogram was performed which showed diastolic dysfunction, moderately reduced ejection fraction, and mild mitral regurgitation. The patient did not have recurrent chest pain concerning for ischemia and was subsequently discharged home with outpatient follow up. The health plan's determination is upheld.

This patient presented with chest pain and abdominal pain. Troponins and EKG were not suggestive of acute ischemia and abdominal labs and imaging were not suggestive of acute pathology. The patient did not have recurrent chest pain suggestive of acute ischemia or other cardiopulmonary or abdominal process requiring acute inpatient monitoring. Given the patient's numerous risk factors, the patient was certainly appropriate for treatment at a lower level of care status, but did not require care at the acute inpatient level of care.The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and high blood pressure
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient was asymptomatic at home when his spouse noted increase veins on his neck and face. No symptoms occurred, but his BP measurement was high. In the ED, he still had no symptoms, but he was admitted for observation. The patient remained symptom-free without any intervention. 

Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this case, the patient's symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS).  The patient's exam (BP normalized) and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia.  His CXR was normal. The physicians' treatment did not reflect any serious concern about the patient's cardiac condition. Orders did not include medical therapy for ACS, such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV NTG (nitroglycerin).   

The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care that was provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD. In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added.

Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present. The patient's recent stent was stable, and there was no evidence of any CAD issue. All testing and therapy that were provided would have been appropriate, safe and guidelines-consistent to have been provided in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and represents the usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, vomiting

Treatment: Inpatient admission, diagnostic evaluation, and medication management

The insurer has denied inpatient admission. That denial was upheld.

This patient presented to the Emergency Department with complaints of abdominal pain.  The patient was reported to have flu-like symptoms.  The patient had multiple episodes of vomiting and diarrhea.  The patient also had a headache.  Abdominal pain was diffuse and associated with episodes of vomiting.  The patient had a temperature of 99.1 with a heart rate of 113, blood pressure 124/73, respirations 18 and oxygen saturation 100%.The patient had a sodium 138, potassium 3.9, chloride 103, CO2 21, glucose 105, BUN 17, anion gap 14, creatinine 0.90.  The patient had a calcium of 10.1, white blood cell count 11.86, red blood cell count 5.41, hemoglobin 15.7, hematocrit 45.7, platelets 212.  The patient had a venous pH of 7.36, PCO2 48, venous PO2 99, venous HCO3 22.  The respiratory virus panel was negative.  Feces culture was negative.  Urine culture and blood culture were negative with no organisms isolated.  The chest x-ray was clear.  A CT of the abdomen and pelvis revealed normal appendix with fluid-filled colon.  The patient was given a bolus of intravenous (IV) fluids, IV acetaminophen, IV metoclopramide, and IV Zosyn.  The patient was continued on IV fluids and the patient's symptoms improved.  

The documentation indicated that the patient was seen in the Emergency Department due to complaints of nausea, vomiting and diarrhea with abdominal pain.  The patient was feeling dehydrated.  However, all of the testing completed in the Emergency Department was noted to be negative.  The patient's condition was appropriate for a level of observational care rather than inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has hypertension, hyperlipidemia, tobacco use, and significant alcohol use and presented to the Hospital with complaints of chest pain, described as a constant heaviness, radiating to the left arm, associated with dyspnea and dizziness on standing. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with chest pain, but was hemodynamically stable, with negative initial cardiac biomarkers and no diagnostic EKG changes for ischemia or acute infarction. The EKG shows changes consistent with left ventricular hypertrophy and repolarization changes. The patient meets criteria for observation, but not for an inpatient admission. In addition, HEART score is low (3), indicating low risk for adverse cardiovascular events. The patient could have been cared for at a lower level of care.