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

Diagnosis: Prostate Cancer
 
Treatment: Oncotype DX

The insurer denied the Oncotype DX. The denial was upheld.   

This is a male patient who consulted an urologist for complaints of urinary frequency and slow stream. It was reported that the patient had a rise in his prostate specific antigen (PSA)/prostate nodule; 1.9 to 3.7 over a 2 year period.  A biopsy of his prostate was performed which revealed a Gleason Score 3+3, prostate cancer.  An Oncotpe DX was done to further evaluate the patient's further risk factors.

While National Comprehensive Cancer Network (NCCN) guidelines state that men with low risk or favorable intermediate risk prostate cancer may consider use of the Oncotype DX test, they also note the absence of randomized prospective trials.  The American Urological Association (AUA) guidelines are more negative on this test, stating that "tissue based genomic biomarkers (such as Oncotype DX) have not shown a clear role in active surveillance for localized prostate cancer, and are not necessary for follow up."  The impact of tissue based gene expression tests, such as Oncotype DX, on clinical practice and long term patient outcomes remains to be empirically demonstrated. Prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking.

Based on the above, the medical necessity for the Oncotype DX PCA is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This patient is a female with diagnoses of seizure disorder, cleft lip and palate, ventilator and tracheostomy dependence, feeding difficulty, oxygen dependence, gastrostomy (G)-tube and anteriorly displaced anus. The patient also has severe developmental delays with no social interaction and hypertonia. She was depressed at birth requiring resuscitation. The patient was admitted for acute rehabilitation program.
A letter from the care coordinator at the hospital stated that the patient was on a ketogenic diet and 3 seizure medications. She had an event where she had several episodes of oxygen desaturations and a new onset gallop rhythm in her heart and a wide QRS complex. She was sent to the emergency room (ER) for evaluation. She remained ventilator dependent and required frequent suctioning with intermittent desaturations. She was participating in rehabilitation including physical therapy (PT), occupational therapy (OT), and speech therapy (ST). The facility is awaiting placement in a long term care facility that accepts ventilator dependent children.
The subject under review is the medical necessity for the ongoing inpatient rehab stay.

The health plan's determination is upheld.

The inpatient rehab stay is not medically necessary for this patient.
This patient was on an acute inpatient rehabilitation service receiving PT, OT and ST. However, the patient did not meet standard criteria for acute inpatient rehabilitation including the ability to actively participate in the program, the expectation of functional progress, and actual measurable progress in functional goals. The patient also did not require daily PT, OT or ST with the goals of achieving functional progress.
The patient was not able to actively participate in rehabilitation services. The documentation does not show that the patient made measurable progress in functional goals. The patient did not require daily PT, OT, or ST as functional progress was not likely or expected.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain and swelling
Treatment: Nerve treatment on tooth #9
The Nerve treatment on tooth #9 is medically necessary.

The tooth (#9) has a very deep composite restoration in it, very close to the nerve. The nerve became infected, with a fistula, or lump, above the tooth, as a result of this infection. The treatment needed is a root canal procedure, as requested. The root canal procedure is medically necessary to treat the infection in tooth #9. Without this treatment, the tooth will need to be extracted.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued inpatient admission 

The proposed treatment, continued inpatient admission, was medically necessary for this patient.

The requested benefit of continued inpatient admission could not have been safely or effectively provided at a lower level of care in this case scenario.  The patient in this case was using large quantities of alcohol on a daily continuous basis together with tobacco and cannabis that did warrant inpatient level detoxification and withdrawal management and monitoring.  Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient struggled with withdrawal symptoms (tremor, hallucinations, nausea, anxiety, restlessness and insomnia) in the context of limited insight, impaired judgment and poor control of impulses, as well as active symptoms of the mood and psychotic disorder.

Thus, the adult inpatient stay and detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level setting with structure, supports, and 24-hour monitoring.  The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments (disability) and co-occurring psychiatric disorder do reflect the seriousness of the substance use disorders, does support and the need for a safe and effective detoxification with withdrawal management as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to be attempted at a lower level of care.  Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and, consistent with New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria that requires that the patient default to the higher level of care-referenced below.

The requested benefit of the continued inpatient admission is clinically appropriate, medically necessary and warranted, and is, therefore, a covered benefit in this case scenario.  The substance abuse detoxification and continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above.  Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and NY OASAS LOCADTR Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of hypertension who presented to the hospital with left lower quadrant pain. The patient stated his symptoms started earlier that day. The patient reported the pain was severe and Tylenol had minimal effect. The patient denied fevers and chills, chest pain, and shortness of breath. Past medical history also included lumbar hernia and clavicle fracture. Vital signs showed temperature 100 Fahrenheit, heart rate 108, respiratory rate 20, and blood pressure 116/78. On physical examination, heart was regular, breath sounds were normal, abdomen was soft and nondistended. There was tenderness in the left lower quadrant. Labs showed creatinine 1.3, sodium 138, Calcium 8.1, white blood cell (WBC) 10.9, Hemoglobin 14, and platelets 141. Ultrasound of the groin was negative for testicular masses and torsion. A computed tomography (CT) of the abdomen was negative for acute findings but did show splenomegaly. Chest x-ray was negative. The patient was admitted for suspected acute epididymis. The plan of care included pain management, Urology consult, intravenous (IV) fluids, IV antibiotics, and continue other medications. Temperature later increased to 102 Fahrenheit according to the documentation provided by the hospital. The patient had an improvement with antibiotics and was discharged. The inpatient stay is under review.

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient presented with concerns for sepsis and evidence of hemodynamic instability with elevated temperature and tachycardia. In addition, the etiology of the patient's infection was not immediately clear, and the acute pain complicated the evaluation. It would generally not be appropriate to treat a patient like this with outpatient antibiotics and a more intensive diagnostic evaluation was needed, along with close monitoring because of the risk of worsening sepsis. While epididymitis is typically managed as an outpatient, the high fevers and presence of tachycardia, which suggests an increased risk of both bacteremia and hemodynamic instability, made inpatient care medically necessary in this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #3:

This case involves a male with a history of two left cheek inferior lesions.  The confocal microscopy documentation indicated that lesion #1 (inferior) had been present for less than one year.  The lesion was increasing in size.  Lesion #2 (superior) had been there more than one year and had increased in size.  The confocal evaluation indicated the patient had seborrheic keratosis on examination of lesion #1 and had lentigo: Solar, and evolution to seborrheic keratosis on examination of lesion #2.

Ahlgrimm-Siess, V., Cao, T., Oliviero, M., Laimer, M., Hofmann-Wellenhof, R., Rabinovitz, H. S., & Scope, A. (2013) stated seborrheic keratosis (SK) display a distinct set of RCM criteria despite their variable clinical and dermoscopic appearances".  This was noted to include a limited study sample and a retrospective study design. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes.  The patient is not a good candidate for reflectance confocal microscopy (RCM).  Reflectance confocal microscopy (R centimeters) is not the best available treatment for this patient at this time.  The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for Reflectance confocal microscopy (RCM); codes 96931 and 96934, should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2:

This case involves a male who had a history of cheek lesions. A clinical note indicated the patient had a lesion to the left cheek inferior that was 3x3 mm and left cheek superior that was 11x5 mm. Lesion #1 had been there for less than 1 year and it had increased in size. Lesion #2 had been there more than 1 year and it had increased in size.  The service was performed due to these suspicious lesions.  The evaluation showed imaging with normal honeycomb, a cobblestone pattern, epidermal hyperplasia with polycyclic rete and horn pseudocyst.  The left cheek superior #2 - atypical honeycomb pattern, polycyclic rete, arranged in edged pattern and no atypical cells.

The medical literature notes that reflectance confocal microscopy (RCM) is a novel technology that provides noninvasive, in vivo imaging of the skin at nearly histologic resolution. The combination of RCM imaging with dermoscopy has improved the accuracy of skin cancer diagnosis while reducing the number of biopsies of benign skin lesions.  Due to suspicious lesions found, the reflectance confocal microscopy was appropriate as it had the potential to diagnose skin lesions with high accuracy and without biopsy.  

Reflectance confocal microscopy has the appropriate scientific evidence and peer-reviewed literature to support a result of improvement in health outcome and does have final approval from the appropriate regulatory bodies.  The patient is a good candidate for reflectance confocal microscopy.  The reflectance confocal microscopy was the best available treatment for the patient at that time.  Reflectance confocal microscopy is likely to be more beneficial than any other standard treatment/procedure for the patient.  

The carrier's denial of coverage for Reflectance confocal microscopy (RCM); codes 96931 and 96934, should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Left cheek lesions
 
Treatment: Reflectance Confocal Microscopy

The insurer denied coverage for the reflectance confocal microscopy. The denial was reversed.

Reviewer #1:

The patient has a history of left cheek lesions. The lesion inferior measured 3 millimeters by 3 millimeters had been present for less than 1 year and was increasing in size.  The lesion (superior) measured 11 millimeters by 5 millimeters was present for over a 1 year and was increasing in size.  A Confocal Evaluation was performed which indicated left cheek inferior #1 was seborrheic keratosis, and left cheek superior # 2 was lentigo solar, in evolution to seborrheic keratosis.

There is current peer review literature to support the use of Reflectance Confocal Microscopy as a noninvasive diagnostic procedure for lesions.  The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. The Reflectance confocal microscopy (RCM) does have final approval from the appropriate regulatory bodies for this diagnosis.  This patient is a good candidate for Reflectance confocal microscopy (RCM).  Reflective confocal microscopy has been documented by the medical literature as being an accurate diagnostic method avoiding invasive biopsies.     

Reflectance confocal microscopy (RCM) is the best available treatment for this patient at this time.  The requested test is likely to be more beneficial than any other standard testing/procedure.

The carrier's denial of coverage for Reflectance confocal microscopy (RCM); codes 96931 and 96934 should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inguinal hernia
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient was a male infant at the time of surgery. He underwent right inguinal hernia repair.

The baby underwent right inguinal hernia repair. Criteria for overnight apnea monitoring in a former premature infant (<36 weeks gestation) are for a post-conceptual age of <52-56 weeks (some conflicting literature) according to the anesthesia literature. The baby was born premature. His post-conceptual age was less than 52 weeks. The baby required apnea monitoring in the hospital postoperative. Premature babies are at risk for apnea. Overnight monitoring does not require acute inpatient admission. The necessary level of care can safely be accomplished at a lower level of care.

All of the care that was given could have been done equally at a lower level of care, including overnight stay for apnea monitoring. Not allowing acute inpatient care would not have changed any of the management, and would not reasonably be expected to affect the patient's health adversely.

Apnea monitoring following hernia repairs in a former premature infant can safely be accomplished as an ambulatory procedure with observation level of care. Observation level of care would have been identical to the care which the child received without affecting the health or safety of this child following inguinal hernia repair.

Regarding comments in the appeal letter from the hospital's agent citing monitoring of respiratory status due to prematurity as the criteria for admission, no reason is provided why this same level of monitoring could not have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of intractable pain syndrome on Methadone who is requesting placement of an intrathecal pain pump. The patient has failed medical treatment in the past including injections, surgery, physical therapy and oral medication. The patient has no neurological deficits on neurological examination. The pain includes both hands, the side and back of the neck, right shoulder and bilateral knees.

The health plan's determination is upheld. The Implantable Pump Surgery: Spinal Pain Medicine Pump is not medically necessary for this patient. This is a patient with intractable pain syndrome that has not responded to injections, medications, surgery, and physical therapy. The patient is currently on Methadone and per documentation, not a candidate for surgical intervention. The patient's pain is very broad and includes both hands, sides of back and neck, right shoulder and bilateral knees. The implantable pain pump is not medically necessary as it is not in accordance with generally accepted standards of medical practice. As Burchiel and colleagues point out, the most common use of intrathecal opioids in humans remains nociceptive pain due to cancer. The patient's pain is not due to cancer and involves multiple body parts, including shoulders, hands, neck, back and knees.  The current literature does not support the placement of intrathecal pain in this patient. Despite demonstrated efficacy in animals, evidence that neuropathic pain responds to intrathecal opiates is limited.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Keratoconus
 
Treatment: 92499-50 Unlisted ophthalmological service or procedure

The insurer denied the 92499-50 Unlisted ophthalmological service or procedure. The denial was reversed.    
This is male patient with a history of bilateral cataracts and penetrating keratoplasty due to keratoconus. The patient reported that he had been wearing soft contact lenses to correct his visual impairment however, due to the progression the disease; a distorted corneal surface, this was no longer an option. The only alternative treatment for him was a corneal transplant.
The PROSE device (V2627) is used in the management of ocular surface disease and optical imperfections, along with other ophthalmic conditions, such as moderate to severe dry eye syndrome. Corneal surgery is the standard of care for advanced keratoconus. This documentation indicated the patient has tried all the conservative treatments to increase his vision and therefore, the requested PROSE procedure is considered the most appropriate level of care.  

Based on the above, the medical necessity for the 92499 Unlisted ophthalmological service or procedure is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain in Tooth# 8 and Tooth# 9
 
Treatment: D2751 white glass with metal crown tooth # 8 and tooth #9; D3310 nerve treatment on front tooth, tooth #8 and tooth #9

The insurer denied coverage for D2751 white glass with metal crown tooth # 8 and tooth #9; D3310 nerve treatment on front tooth, tooth #8 and tooth #9. The denial was upheld.
This patient is a female who presented for routine comprehensive dental treatment complaining of issues associated with teeth #'s 8 and 9, specifically pain with hot and cold. The insurer has denied these services, stating that there is no clinical/radiographic evidence provided to support the necessity of these services.  The patient is appealing.

The objective documentation provided for review is periapical, bitewing and panoramic radiographs and the dental chart clinical notes.  It appears that there is no evidence of fracture or other pathology specifically affecting #'s 8 or 9.  There does not appear to be any radiographic evidence of caries.  There is no periapical pathology.  Neither the radiographs nor the clinical notes substantiate the requested dental services as enumerated above. Therefore, they are deemed not medically necessary.

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.  D2751 white glass with metal crown tooth # 8 and tooth # 9; D3310 nerve treatment on front tooth, tooth # 8 and tooth # 9 is not considered medically necessary for this patient.

The carrier's denial of coverage for D2751 white glass with metal crown, Tooth # 8 and Tooth # 9; D3310 nerve treatment on front tooth, Tooth # 8 and Tooth # 9 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right sided weakness and dysarthria
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is a male who presented to the emergency ward with the complaint of right sided weakness and dysarthria for several days.  At presentation, he was noted to have right facial weakness and slurred speech. He was hypertensive. MRI showed a sub-acute left brainstem infarct. 

At the time of presentation, the patient's symptoms were not acute.  The clinical evaluation, diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a medical history of suicidal attempt with methadone overdose, hypertension, hyperlipidemia, gastroesophageal reflux disease, chronic obstructive pulmonary disease (COPD), depression, memory loss, Vitamin D deficiency and wheelchair bound due to bilateral lower extremity contractures. Per the determination of the medical physician, nursing and physical medicine and rehabilitation assessments, it was determined the patient met medical necessity criteria for personal care assistance services Level II, 12 hours per day, 7 days per week; total of 84 hours per week. Due to lower extremity contractures and decreased mobility, the patient requires supervision for falls safety, transfers (bed/wheelchair), dressing, toileting and bathing and grooming. In addition, due to memory loss the patient requires assistance with activities of daily living such as making beds, housework such as dusting/vacuuming/dishwashing and partial assistance with medication administration and prepping meals. Personal care assistance services Level II, 12 hours per day, 7 days per week; total of 84 hours per week is medically necessary for this patient. Per Guidelines for the Provision of Personal Care Services in Medicaid Managed Care, the member is eligible for services that are essential to the maintenance of the enrollee's health and safety in his or her own home. Per the provided clinical information, the patient requires multiple level II services such as; bathing, dressing, grooming toileting, transferring from wheelchair to bed, preparing meals, and administration or prompting of medications. The patient was determined to have a stable medical condition that is not expected to deteriorate suddenly or require frequent medical or nursing care, the patient is self-directing and able to follow commands and make appropriate choices, would require partial help with activities of daily living such as managing medications, grocery shopping, taking transportation (e.g. bus, train) and full assistance with activities such as, house work such as dusting/vacuuming/dishwashing, making beds, laundry, prepping meals, bathing and grooming, dressing, toileting, transfers from bed to wheelchair and locomotion (rolling  wheelchair). The HP determination is overturned in whole.