Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Gastroesophageal Reflux Disease/GERD
Surgical Services  (All)

The patient is a male with body mass index (BMI) 26.8 kg/m2 (based on height 5 feet 11 inches, weight 192 pounds) with long standing gastroesophageal reflux disease (GERD) despite proton pump inhibitor (PPI) use. A 24 hour pH study revealed a significantly elevated DeMeester score consistent with GERD. An upper gastrointestinal (UGI) revealed small hiatal hernia and GERD. Esophageal manometry was normal. Pathology was without dysplasia. The LINX Laparoscopic Surgical Esophageal Sphincter Augmentation Procedure is being requested and is under review.

The health plan's determination is overturned. The LINX Laparoscopic Surgical Esophageal Sphincter Augmentation Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has GERD refractory to medical management. Surgical treatment options that are considered standard today include laparoscopic Nissen fundoplication and LINX procedure. Both of these treatments have been shown in published studies to be more effective than medical management. LINX is comparable for mid-long-term studies to be as effective and durable as laparoscopic Nissen fundoplication with less risk of mortality and major morbidity. It has been recommended based on the available published literature to be a standard surgical treatment for GERD in newly updated nationally published guidelines from the Society for Gastrointestinal and Endoscopic Surgeons. LINX is Food and Drug Administration (FDA) approved treatment for GERD. The only current exclusion is age 18 or less, BMI >35 kg/m2 and history of prior gastric/bariatric surgery which this patient has not had. The requested LINX procedure is likely to be more beneficial and effective than available medical management of GERD and comparable to laparoscopic Nissen fundoplication in efficacy and durability with less mortality and major morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mood Disorder
Treatment: Continued residential mental health treatment 

The continued residential mental health treatment was not medically necessary.

Summary:
The patient is an adopted female with diagnoses of unspecified mood disorder, generalized anxiety disorder, oppositional defiant disorder, cannabis dependence, nicotine dependence, alcohol dependence, and cocaine use. She was admitted due to a recent increase in suicidal ideation, self-cutting, property destruction, and substance use.

The patient's treatment history includes three emergency department visits for aggressive behaviors and threatening to harm herself. In addition, she has had a number of different therapists, psychiatrist, and participation in substance-abuse groups. The patient receives special support in school for anxiety and behavioral issues. She has a history of suspensions for talking back to teachers, aggression toward peers, and vaping on school property, and was expelled for possession of marijuana. She has a strained relationship with her family.

The patient made inconsistent progress in the residential facility. She was caught smoking an electronic cigarette that she claimed to have found. She was frequently verbally, but not physically, aggressive.

The patient's medications including Lamictal 100 mg twice daily, hydroxyzine 20 mg at bedtime, Abilify 2 mg in the morning, and Lexapro 20 mg daily. She tolerated her medications without difficulties. There were no identified medical comorbidities. She had no current suicidal ideation, signs of psychosis, or physically aggressive behavior. Her mood was reported to fluctuate. Her family was described as involved and supportive, despite the fact that the patient stormed out of a recent family session after elbowing her mother.

This patient's clinical picture was primarily consistent with her diagnosis of oppositional defiant disorder. There was no evidence of imminent danger to self or others. There was no evidence of psychosis. While she was verbally aggressive, there was no evidence of any behaviors which would require 24-hour daily supervision and treatment. She tolerated her medications without difficulties. For the dates of services under review, nothing in the documentation reviewed suggests that the patient could not have been treated equally safely and successfully, with confrontation and consequences for her behavior, in a less intensive setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Prostate Cancer
Cancer Screening
This is a male patient with a history of Gleason 6 prostate cancer who underwent an Oncotype DX test. He was found to have Gleason 6 in 8% of one core. His pre-biopsy prostate-specific antigen (PSA) was 6.4 nanograms/milliliter (ng/ml). The subject under review is whether the OncotypeDX is likely to be more beneficial for the patient than any standard treatment.

The health plan's determination is upheld.
The proposed health service (Oncotype DX) is not more likely to be more beneficial than any standard treatment for the patient's Gleason 6 prostate cancer.

The clinical utility/significance of this test has not been established. In a 2014 article the authors state "Although results appear to be encouraging, the biggest challenge about new markers in prostate cancer (PCa) is to validate them in large clinical trials and subsequently implement these markers into clinical practice." In another 2014 article the author (Trock) concludes: "Circulating biomarkers represent a promising approach to identify men with apparently low-risk biopsy pathology, but who harbor potentially aggressive tumors unsuitable for active surveillance. Research is still at an early stage; existing biomarkers need rigorous validation with consistent methodology, and additional biomarkers need to be evaluated. Successful clinical translation would reduce the frequency of surveillance biopsies and may enhance acceptance of active surveillance." The clinical utility of this test in patients has not been fully established. In a 2014 review article the author concludes "while the overall data are promising, there is a need for appropriate clinical guidelines and protocols to ensure a systematic and critical evaluation of each potential test prior to their introduction in patient care." The author also states, "At this time, the usefulness of genetic tests related to PCa screening, detection, and management is unclear because it has not yet been demonstrated that it actually improves outcomes." At this time the scientific evidence does not permit conclusions concerning the effect of Oncotype DX test on health outcomes.
Appeal type: Experimental/Investigational
Decision: Upheld

Prostate Cancer
Cancer Screening

The patient is a male with prostate cancer who had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 6 adenocarcinoma in 1 of 13 cores. The clinical stage was T1c. The prostate-specific antigen (PSA) was less than (<) 10.
The subject under review is whether the OncotypeDX is likely to be more beneficial than any standard treatment for the patient's condition. 

The health plan's determination is upheld.

No. Per American Urological Association (AUA) Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance."
Guideline Statement 32: Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up.
The patient has a low-risk prostate cancer.
Therefore, the proposed OncotypeDx is not likely to be more beneficial than any standard treatment for the patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital

The patient is a man with hypertension, hyperlipidemia, pre-diabetes, gastroesophageal reflux and hypothyroidism. He presented to the emergency room (ER) with chest pain radiating to his back which began while walking up hill. Symptoms lasted 3 hours. There was associated dyspnea and palpitations. Blood pressure (BP) was 138/89 mm HG, pulse 81 and oxygen saturation 98% on room air. Initial troponin was 0.01. An electrocardiogram (EKG) showed no ST or T wave changes.  He was admitted and ruled out for myocardial infarction with negative serial troponins and EKGs. Cardiology consult was obtained. A lexiscan stress nuclear study was done on 6/12 which was negative for ischemia. He was discharged in stable condition. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient admission is not medically necessary. The patient had stable pulse, blood pressure and normal room air oxygenation. He had no diagnostic evidence for an acute coronary syndrome (negative initial cardiac biomarkers and no ST changes on EKG). There were no objective findings to suggest an alternative serious cardiac or pulmonary diagnosis which required hospitalization, such as aortic dissection or pulmonary embolus. Based on Milliman and standard criteria, such as using the HEART score, the inpatient admission is not medically indicated. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension and chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female with a past medical history notable for hypertension, bradycardia, and pacemaker implantation. She presented with high blood pressure and chest pain. Vital signs noted blood pressure 173/96. She was admitted. She ruled out for myocardial infarction. EKG showed dual chamber paced rhythm without ischemic EKG changes. Chest radiography showed no abnormalities including pneumothorax. The pain was noted over the pacemaker insertion site, which was free of infection. The pacemaker was interrogated and found to be functioning normally. She was discharged home for follow-up with her primary care provider. 

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

The patient presented with hypertension and chest pain.  The initial evaluation in the ER was unremarkable, including non-diagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. Observation care would have been appropriate.

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

Diagnosis: Asthma exacerbation

Treatment: inpatient admission 

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female who has history of asthma/chronic obstructive pulmonary disease. She presented to the Emergency Department (ED) with worsening shortness of breath and wheezing. The patient reported recent upper respiratory tract infection (URTI) with sinusitis like symptoms in the preceding week. The patient had been using a lot of Albuterol and complained of some palpitations. As per the patient the Albuterol did not help so she came to Emergency Room (ER). The patient felt dizzy and had a possible transient syncopal episode. The vital signs at presentation were: temperature (T) 98.2 F., heart rate (HR) 54, respiratory rate (RR) 20, blood pressure (BP) 112/75 mm Hg and oxygen (O2) saturations were100% on room air. The patient was in no acute distress.  She was alert and oriented x3.  She was resting comfortably. The lung exam revealed bilateral wheeze.  There was good air entry (AE) in lungs and good effort is noted.

The patient was treated with Duo Nebs and given Prednisone. She also was given intravenous (IV) Magnesium. The patient was admitted for further management as she was still wheezing. As per History & Physical: Temperature  98 F., Heart Rate 62, Respiratory Rate 20, Blood Pressure 125/81 mm Hg and oxygen saturations were 100 % on room air. The white blood cell count was 11K (the patient had been given steroids). The chest x-ray was unremarkable. The echocardiogram was within normal limits.

The patient remained stable and was discharged a few hours later. It appears that this patient did not need acute hospitalization. The patient could have been placed in Observation status while diagnostic studies and treatment initiated. The patient was treated with oral steroids and bronchodilator. The patient remained afebrile and hemodynamically stable. She was tolerating fluids and food orally. The venous blood gas was unremarkable. She was not hypoxic. This patient was stable for discharge after a period in Observation status with close follow-up in an outpatient setting. The prior denial is upheld.

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

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain 

Treatment:  inpatient admission 

The insurer denied coverage for inpatient admission.  The denial was upheld.

This patient is a female with a past medical history notable for sinusitis, pituitary macroadenoma, and toxic shock syndrome.  She presented to the ER with complaints of chest pain and palpitations.  EKG was unremarkable.  Cardiac troponins were negative.  Echocardiography showed normal left ventricular systolic function.  She remained in normal sinus rhythm and was discharged home with instructions for outpatient follow-up with her primary care provider.  

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

The patient presented with chest pain.  The initial evaluation in the ER was unremarkable, including non-diagnostic EKG and cardiac biomarkers.  Inpatient admission was not medically necessary for this patient.  The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.  The acute inpatient level of care was not medically necessary.

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

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female with a past medical history notable for hypertension, hyperlipidemia, diabetes mellitus, and a prior stroke. She presented to the Emergency Room (ER) with complaints of chest pain which radiated to her left side and was associated with left-sided paresthesia. An EKG was unremarkable. A CT of the head showed no acute intracranial pathology. Cardiac troponins were negative. She underwent nuclear stress testing which was normal. Neurology felt that the patient had an anxiety disorder. The patient was admitted with a diagnosis of chest pain with a high risk for a cardiac etiology. She was on aspirin, clonazepam, insulin, nitroglycerin sublingual, albuterol inhaler, simvastatin, docusate sodium, and metoprolol tartrate. An electrocardiogram (EKG) showed normal sinus rhythm. A computed tomography (CT) scan of the head showed no acute intracranial pathology. She was discharged home with instructions for outpatient follow-up with her primary care provider and behavioral health.  

The acute inpatient admission was not medically necessary. The patient presented with chest pain. The initial evaluation in the ER was unremarkable, including a non-diagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted; however, inpatient admission criteria were not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting the acute inpatient level of care.

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 the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral shortened Achilles tendons

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a male child with bilateral shortened Achilles tendons. He was a toe walker. He was brought to hospital for surgical management. He underwent an open Achilles lengthening, z-plasty, posterior capsular release to the right side. He underwent a percutaneous procedure to the left side. He was placed on bilateral long leg casts. His post-surgical course was non-complicated. He received Tylenol and Toradol for pain. Physical Therapy (PT) was provided and a social worker managed the discharge planning. He was discharged to home. He was to be non-weight bearing and was provided with a wheelchair.

The surgical procedures completed were neither complex nor extensive. The open lengthening consisted of direct exposure to tendon with incision. Additional posterior capsulotomy was completed without problem. There was no blood loss, no bone work completed, no placement of hardware nor other procedure to substantiate the admission. The duration of the procedures was limited. The percutaneous procedure likewise is common and without complexity. Application of casts was also provided thus there was no need for PT services. The young child was in a wheelchair which could be provided as outpatient service. The post-surgical course was non-complicated with pain levels treated without narcotic. The medical records denote no problems after completion of the operation. i.e. pain levels, nausea/vomiting status, ability to tolerate oral medications. There were no extenuating circumstances to warrant admission and length of stay. 

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 the inpatient admission status post lengthening or shortening of tendon, leg or ankle is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis of the scalp
Issue under review: Otezla

Determination:
The Otezla is medically necessary.

Because of the location of the psoriasis in the scalp and on the face, phototherapy is not an appropriate treatment option (the UV light cannot reach the scalp because of hair and presence of psoriasis on the face indicates resistance to UV light, which it is exposed to environmentally daily). Cyclosporine is not a sustainable long term treatment option due to side effects. Methotrexate carries serious side effect risk and is not expected to be more effective than the requested medication, Otezla.

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy.  (Celgene, 2015)  Otezla is an oral small molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene, 2016)  

The patient has moderate to severe psoriasis for which therapy with Otezla is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a biopsy proven regressed melanoma to the left back. DecisionDx-melanoma assay was performed and the lesion was designated class 1 (low risk of recurrence within 5 years). The health plan's determination is upheld. The use of the DecisionDx-melanoma assay is not medically necessary for this patient biopsy proven regressed melanoma to the left back. It is not currently in accordance with generally accepted standards of medical practice and not currently considered clinically appropriate. There is no evidence based medical literature to support that a greater benefit is imparted after DecisionDx testing than current standard of care and there are insufficient outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for melanoma.
Standard of care in a melanoma greater than 1 mm (one millimeter) is wide local excision with a sentinel lymph node biopsy. Further testing or work-up is performed by symptoms and results of sentinel lymph node testing. For melanomas less than 1 mm, wide local excision with routine skin and physical exams is standard of care. The requested service has not been approved by the FDA (Food and Drug Administration), and it has not been determined to be more beneficial than current standard of care. The DecisionDx test (Castle Biosciences Inc., Friendswood, TX) is a commercially marketed gene expression profiling test intended for use in assessing metastatic risk in individuals with melanoma, initially studied in uveal melanoma. It consists of a 15-gene polymerase chain reaction (PCR)-based assay that stratifies individuals with uveal melanoma into two classes based on the molecular signature of tumor tissue. The peer-reviewed literature related to the DecisionDx test consists of studies describing the derivation of the gene expression profile and analytical and clinical validation of the technology (Onken, 2010a; Onken, 2010b; Onken, 2012). It has not been extensively studied for cutaneous melanoma. At the current time, the most significant limitation in the peer-reviewed literature concerning the use of gene expression profiling for melanoma is the lack of published data providing direct evidence of the clinical utility of the DecisionDx test in directing treatment plans. The National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for melanoma (V [version] 4. 2014) do not include a recommendation for gene expression profile testing for melanoma at this time. Additional prospective studies are required to determine how this risk stratification test will direct the clinical management and selection of treatment options that would result in an improved prognosis for individuals with melanoma. Because this has primarily been studied in uveal melanoma, it is promising but still remains unproven, especially in cutaneous melanoma.