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

Endocrine/metabolic
Inpatient hospital

Diagnosis: Renal failure
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a woman with a history of right breast cancer status post mastectomy, chemotherapy and radiation, heart failure, diabetes, hypertension, hyperlipidemia, coronary artery disease and end stage kidney disease who was admitted to the hospital. She presented after missing three sessions of dialysis and was due for a session of dialysis that day. She had been feeling weakness for several days. She reported that she experienced a left proximal humerus fracture and had not been going to dialysis for that reason. The fracture was on the same side as her atrioventricular (AV) fistula and dialysis was causing her pain. She denied fevers, chills, vomiting, and shortness of breath. Vital signs in the emergency department showed temperature 98.4 Fahrenheit, heart rate 78, blood pressure 109/61, and respiratory rate 23. Initial labs showed hemoglobin 8.8, white blood cell (WBC) 7.7, platelets 263, sodium 138, potassium 5.7, and troponin 0.43. She received calcium gluconate, insulin, and Lokelma. An electrocardiogram (EKG) showed normal sinus rhythm with no peaked T waves. On physical exam, the patient was in no acute distress, heart was regular, breath sounds were normal, and the abdomen was soft and non-tender. The patient was admitted with end stage renal disease and missed dialysis. 

The inpatient stay was medically necessary for this patient. Hyperkalemia attributable to missed dialysis in a patient with multiple comorbidities including coronary artery disease is typically treated at the inpatient level of care. While the patient did not have demonstrated acute EKG abnormalities, it is unclear whether the EKG was performed before or after treatments for hyperkalemia were initiated. Acidosis is also a concern in patients that require dialysis and have missed multiple sessions. Overall, these patients require close and active initial monitoring and intervention, and this is provided at the inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a female patient with a history of malignant melanoma to the right arm, Breslow Depth is .95 mm. There is no ulceration or regression.  This is a review for coverage of the DecisionDx-Melanoma assay.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. There is insufficient clinical evidence in the peer-reviewed medical literature to demonstrate improved long term health outcomes.  The DecisionDx-Melanoma testing performed does not need/have final approval from the appropriate regulatory bodies (the Food and Drug Administration [FDA] or National Comprehensive Cancer Network [NCCN]) for this diagnosis [melanoma].
This patient is not a good candidate for the DecisionDx-Melanoma testing performed, and it is not considered to be the best available treatment for this patient at this time.
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.  Furthermore, the clinical practice guidelines from the National Comprehensive Cancer Network (NCCN) recommend against routine prognostic testing for low versus high metastatic risk outside of a clinical trial.  
It is a melanoma's histopathological features, not the DecisionDx-Melanoma gene profiling assay that is recognized by healthcare organizations and specialists to be proven and appropriate information to properly stage and initially treat a malignant melanoma.  Per Boland & Gershenwald (2016), "Although now commonplace in contemporary cancer care, the systematic approach to classification of disease-specific cancers into a formalized staging system is a relatively modern concept.  Overall, the goals of cancer staging are to characterize the status of cancer at a specific moment in time, risk stratify, facilitate prognostication, and inform clinical decision-making.  

Therefore, 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 DecisionDx-Melanoma assay is not likely to be more beneficial than any standard treatment available for the patient.

The carrier's denial of coverage for the DecisionDx-Melanoma testing performed should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

According to the documentation submitted, this patient is a female with a history of cutaneous melanoma.  A right posterior lateral arm biopsy performed showed malignant melanoma with a Breslow depth of 0.95 mm and Clark's level lV without ulceration.  The dermatologist ordered the DecisionDx-Melanoma test for the patient.  Per the Final Report the results were Class 1, Sub-class 1A, which is associated with the lowest risk of recurrence within five years. 

The insurer has denied coverage for the DecisionDx-Melanoma testing.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.  The DecisionDx-Melanoma testing performed does not have final approval from the appropriate regulatory bodies for this diagnosis.  The patient is not a good candidate, as this test has not been approved by the appropriate regulatory bodies for this diagnosis.  The DecisionDx-Melanoma testing performed is not the best treatment for this patient at this time.     

The DecisionDx-Melanoma assay was not known to be effective at the time it was performed, based on a lack of scientific evidence showing that the results will accurately guide patient care and health outcomes.  According to Trotter, S. C., 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."  Furthermore, per Cirenajwis, H., et al. (2015), "Cutaneous malignant melanoma (CMM) is the most lethal form of skin cancer and its incidence has increased faster than that of any other cancer, rendering it a major public health problem worldwide.  In order to provide clinicians and patients with accurate prognostic information about the disease, a correct staging system is fundamental.  Since 1998, the American Joint Committee on Cancer (AJCC) melanoma staging system has served as a foundation for clinical classification and it was recently updated to the 7th edition after adding more tumor intrinsic factors with prognostic significance."

In this case, the DecisionDx-Melanoma assay was not known to be effective on the date of reading, based on a lack of scientific evidence showing that the results would accurately guide patient care and health outcomes, and the use of this testing was not supported by scientifically based guidelines of national medical research or governmental agencies.  Therefore, the DecisionDx-Melanoma assay is not likely to be more beneficial than any standard treatment/procedures for this patient.                                                    

The carrier's denial of coverage for the DecisionDx-Melanoma testing performed should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

This patient is a male (body mass index [BMI] 36 kilograms per meter squared [kg/m2]) who sought surgical evaluation and follow up for the symptoms of recurrent heartburn.  The records indicate that the patient previously underwent the LINX procedure for gastroesophageal reflux disease (GERD), but had recurrent severe GERD symptoms.  The patient underwent surgery that consisted for robotic removal of the LINX device, repair of a hiatal hernia, placement of mesh, and a Hill fundoplication procedure.  The operative dictation is included with the review material.  The operative dictation describes the components of the procedure that was performed without adverse incident.  The anesthesia records documents hemodynamic stability during the procedure.  The patient was monitored overnight and was considered to be stable for discharge home on the first post-surgical day.

No, the inpatient admission from was not medically necessary for this patient.

The care and treatment provided to this patient did not require inpatient admission.  Operative intervention, perioperative care, provision of pain medication and antiemetic medications, post-surgical monitoring and care, and diet progression can occur at a lower level of care..  An inpatient level of care is not required or medically necessary given the pre-surgical diagnosis of recurrent gastroesophageal reflux disease (GERD) and the operative intervention performed.

This patient has symptomatic recurrent  gastroesophageal reflux disease (GERD).  He completed evaluation and underwent surgical treatment.  The records support that the care and treatment provided did not require inpatient admission. An inpatient level of care was not required based on the submitted documentation and pre-surgical diagnosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bi-temporal epilepsy of unknown etiology.

Treatment: The medication Pregabalin capsules, up to 800 mg [milligrams] daily.

The insurer denied coverage for the medication Pregabalin capsules, up to 800 mg [milligrams] daily.

The denial is overturned. 

This is a female patient with a past medical history of bi-temporal epilepsy of unknown etiology.  The Letter of Medical Necessity states that the patient had been taking 300 milligrams (mg) of pregabalin twice a day for focal epilepsy.  The patient experienced breakthrough seizures and her dose was increased to 300 mg in the morning and 400 mg in the evening.  The patient had been seizure-free since that time without adverse effects.  The patient previously tried and failed levetiracetam, lacosamide, oxcarbazepine, and eslicarbazepine at maximally tolerated doses.  The provider noted that the patient should continue on the higher dose to maintain her current level of good seizure control.   

Based on the review of the medical record and literature, pregabalin capsules up to 800mg daily is considered medically necessary for this patient. Given multiple prior failed antiepileptic drugs, change to another agent once this patient's seizures are controlled, would risk breakthrough seizure and injury, or unwanted side-effects. Standard of care is to leave antiepileptic medications unchanged once seizures are controlled and side-effects are absent. Pregabalin is an adequate choice for focal seizures as is the case with this patient.
  
The medication, Pregabalin capsules, up to 800 mg daily is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.

The medical necessity for the medication Pregabalin capsules, up to 800 mg [milligrams] daily is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder/Anemia
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay due to the lack of medical necessity. The health plan's determination is upheld.

The patient is a male with a medical history of hypertension, nephrotic syndrome, gout, and benign prostatic hyperplasia. He presented to the emergency department with hematochezia, constipation, dyschezia, fatigue, and unintentional weight loss of 18 pounds over 6 months. Vital signs were notable for tachycardia with heart rate of 117/minute. Physical examination was notable for soft, nontender, nondistended abdomen, and rectal exam negative for external hemorrhoids and melena. Labs showed low hemoglobin of 6.9 and a hematocrit of 22.9%, an elevated platelet count of 630, and an elevated neutrophil fraction of 85%. Stool was trace guaiac positive. A chest x-ray showed no acute cardiac or pulmonary pathology. He was transfused with two units of packed red blood cells. He was discharged with a plan for primary care, gastroenterology, and colorectal surgery follow-up. 

The health plan's determination of medical necessity is upheld, in whole.

No, the medical necessity of the inpatient level of care is not supported. In this case, the patient presented with symptomatic anemia, concerning for gastrointestinal bleeding; however, there was no sustained tachycardia or hypotension, and no significant visible ongoing gastrointestinal bleeding. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset [1-5]. His blood count responded to transfusion and remained stable. Esophagogastroduodenoscopy and colonoscopy were warranted and performed, with confirmation of rectal cancer as a cause for hematochezia and anemia [1-5]. All the measures that were undertaken, including monitoring, blood transfusion, labs, specialist consultations, imaging, esophagogastroduodenoscopy, and colonoscopy, could have been performed without the inpatient level of care, at the observation level of care [2-5].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient hospital 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld.

The patient is a male who initially presented to an urgent care and was found to have hyperglycemia. He was sent to the hospital. His pertinent history included diabetes mellitus, renal cancer with metastases to the lungs and thoracic lymph nodes undergoing active chemotherapy and prednisone use, and chronic kidney disease. Upon arrival the patient was afebrile, hemodynamically stable, and without hypoxia.
His initial examination documented the patient as alert and oriented. Serology was obtained and revealed a serum glucose of 257, Anion gap of 10, creatinine (Cr) was 1.6 (improved from baseline), white blood cell count (WBC) was 15.7, and lactic acid was 2.6. His electrocardiogram (EKG) revealed sinus bradycardia without acute ischemic changes or conduction abnormalities. Multiple tests and labs were done and pertinent for a negative troponin and clear chest radiography. Due to persistent asymptomatic sinus bradycardia of unknown etiology, the plan was to admit to telemetry overnight for further evaluation.
His serum glucose returned at 257. Endocrinology consultation was obtained whom noted a heart rate of 64 and a morning fingerstick glucose of 69. They had an impression of steroid-induced hyperglycemia and recommended subcutaneous insulin. Recommendations were to hold metoprolol and continue telemetry. Cardiology consultation was obtained whom had an impression of sinus bradycardia possibly due to high dose steroids. 
The serum glucose remained in appropriate ranges. Treatment plan remained unchanged.
The attending physician also noted serum glucose control and felt the patient was medically stable for discharge.
At issue is the inpatient stay for medical necessity.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient stay is not medically necessary for this patient.
Based on the clinical documentation provided, evidence-based literature and standards of care, the inpatient level of care was not indicated as medically necessary for the entire admission. Savage et al. note that diabetic ketoacidosis is defined by the biochemical triad of ketonemia, hyperglycemia and acidemia. It remains a life-threatening condition despite improvements in diabetes care. In this particular case, these criteria were not met.
Regarding the bradycardia, Semlka, et al. note that treatment of sick sinus syndrome includes removing extrinsic factors, when possible, and pacemaker placement. Pacemakers do not reduce mortality, but they can decrease symptoms and improve quality of life.[2]
In this particular situation, expert consultation with a cardiologist was obtained whom had an impression of clinically insignificant sinus bradycardia. Thus, pacemaker implantation was not indicated.
Therefore, the requested treatment of inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class III skeletal relationship
Treatment: D8080- Braces, Pre-service
The insurer denied the D8080- Braces, Pre-service.
The denial is upheld. 

The patient is a male. The request is for dental benefits for Orthodontic treatment (Braces).

The Dental Clinical summary states---Patient presents with a class III skeletal relationship--hypoplastic maxilla, mild upper and lower teeth spacing, undersized upper incisors, anterior crossbite with gingival attachment loss.

No, the proposed treatment of orthodontic therapy is not medically necessary.
Although the patient does have a class III skeletal relationship, the protrusion of the lower jaw is not significant enough to cause the upper teeth to fall behind the lower teeth. This produces more of an edge to edge bite--with only the upper right lateral incisor falling ever so slightly behind the corresponding lower tooth.

A significant crossbite is not supported by the photos submitted.

No substantial chewing or speech function is compromised as a result of the positioning of the patient's teeth.

The information submitted does not show a level of severe malocclusion and therefore would not warrant comprehensive orthodontic treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dandy-Walker syndrome, developmental delay,
ventricular shunt, mental retardation, and seizures
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This male has conditions including Dandy-Walker syndrome, developmental delay, ventricular shunt, mental retardation, and seizures.  The patient presented with his mother to the emergency department (ED) because the mother was unable to care for him after breaking her leg.  He had no medical complaints.  

The patient's vital signs (VS) were as follows: temperature 97.7, pulse 93, respiratory rate 18, nlood pressure 124/71. and oxygen saturation 97%.  Exam was remarkable for nonverbal and does not follow commands.   Complete blood count (CBC) was unremarkable.  Comprehensive metabolic panel (CMP) was remarkable for sodium (Na) 147 and aspartae aminotransferase (AST) 16.  The patient was admitted for social disposition.  The maximum temperature (Tmax) was 101.5, there was no acute disease (NAD), and no leukocytosis.  Plan was for blood cultures.  Antibiotics were put on hold.  

No, the proposed treatment was not medically necessary.

Medically necessary services are those which are:
safe 
effective
generally accepted national standard of medical practice 
not provided primarily for convenience of the patient or the practitioner 
the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested inpatient admission was not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

Vital signs were stable (VSS); the patient was afebrile.  Chest x-ray (CXR) showed no acute disease (NAD).  Blood cultures were negative.  Urine analysis (U/A) was negative.  Coronavirus (COVID) was negative.  The patient remained hemodynamically stable and afebrile though hospital stay.  Discharge was delayed pending discharge planning.  The patient was discharged.

This is a patient with chronic conditions including Dandy-Walker syndrome, developmental delay, and mental retardation.  The patient was admitted for social disposition after his mother was unable to care for him.  He was hemodynamically stable and in no acute distress.  Labs were unremarkable for acute findings that required an inpatient level of care.  There were no acute conditions identified.  Plan of care was placement.  The patient had one time temperature spike with negative work up.  Otherwise, his hospital stay was unremarkable.  He was not receiving interventions at an acute inpatient level of care.  Discharge was delayed pending placement.  He was discharged after being placed in a nursing home.  Inpatient admission was not medically necessary for this scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vertigo

Treatment: Inpatient admission

The insurer has denied coverage for inpatient admission.

The denial is upheld. 

This female patient has a history of hypertension who presented to the Emergency Department (ED) with complaints of vertigo times 6 hours. The patient reported she felt like the room was spinning, and it was worse when sitting up and standing. The patient denied any nausea or vomiting. The patient's vital signs were the following: blood pressure of 131/76, pulse of 85, temperature of 97.8 degrees Fahrenheit, respiratory rate of 20 and oxygen saturation of 100%. The patient's electrocardiogram (EKG) indicated normal sinus rhythm. The patient's lab work was significant for the following: creatine phosphokinase 258, potassium 3.1, lactic acid 3.4 and glucose 174. The patient's magnetic resonance imaging (MRI) of the brain did not show an infarct or hemorrhage.  The treatment plan in the ED included intravenous (IV) fluids, Benadryl, metoclopramide and meclizine.  The patient's symptoms did not improve.  Neurology was consulted, and the recommendation was to continue with metoclopramide and meclizine and to start lorazepam. The patient experienced some relief. The patient was admitted to the Medicine service for further evaluation. The patient's symptoms improved with Ativan, and she was also given potassium due to a low potassium lab level. There was an incidental finding of a possible 1 millimeter (mm) right A1/A2 junction tiny aneurysm, and the recommendation was to consider getting a magnetic resonance angiogram (MRA) as an outpatient for further evaluation. The patient was medically cleared for discharge with outpatient instructions to follow up with her primary care physician.

Based on the review of the medical record and literature, inpatient hospital admission was not medically necessary for this patient. The patient was stable at the time of admission. The patient was not noted to be in distress and she did not have severe neurological findings to support the need for inpatient admission. The patient could have undergone treatment under observation status.

The health plan act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.