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

This case involves a female who underwent a biopsy of the left calf.  The pathology report detailed the patient had a malignant melanoma with a maximum tumor thickness of 0.4 mm.  There was no ulceration and the pathologic stage was pT1a.  The patient did undergo the requested DecisionDX testing revealing the patient was a class I, which is associated with the lowest risk of recurrence.  

The DecisionDx-Melanoma, a 31-gene panel assay, is stated to determine the risk of recurrence and metastases of the melanoma.  However, the test is not the standard of care.  The DecisionDx-Melanoma test is not recommended by the panel of expert authors of UpToDate. The following are the guidelines for diagnosis and prognosis of cutaneous melanoma offered by the expert authors in UpToDate: "SUMMARY - A simple, accurate staging and prognostic system provides important insight into the prognosis of patients with cutaneous melanoma, thus facilitating appropriate treatment.  Staging and prognosis are based upon the tumor (T) node (N) metastasis (M) system, which incorporates information about the primary tumor, regional lymphatics, and potential distant metastatic sites."

The patient would not be considered a good candidate for the requested testing and it was not the best available treatment for the patient at the time of testing.  As such, the requested service is not likely to be more beneficial than any other standard treatment or procedure.  

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

Diagnosis: Melanoma
 
Treatment: DecisionDX-Melanoma test

The insurer denied the DecisionDx-Melanoma test. The denial was upheld.

This female patient underwent a skin biopsy of the left calf.  The pathology report indicated melanoma measuring 0.4 mm in thickness.  Tumor staging was pT1a.  Per the Castle Biosciences report, the DecisionDX-Melanoma class is 1 and sub-class is 1A.  The appeal letter notes the patient was diagnosed with cutaneous melanoma and states that the DecisionDX-Melanoma test is a validated prognostic assay for the prediction of metastatic recurrence in early stage melanoma, and has been clinically validated by multiple peer-reviewed published studies.  The letter of medical necessity from the treating provider states the DecisionDX-Melanoma results will help determine the most appropriate management plan for the patient and provide risk-specific surveillance.

The results of the DecisionDX-Melanoma test revealed the patient as 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 patient is not a good candidate for the DecisionDX-Melanoma test. The DecisionDX-Melanoma test is not the best available treatment for this patient at this time.  The DecisionDX-Melanoma test is not likely to be more beneficial than any other existing standard health service. 

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

Diagnosis: COPD
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a male with history of COPD (chronic obstructive pulmonary disease) with worsening shortness of breath. The patient was found to be in COPD exacerbation, and he received Duonebs, IV (intravenous) steroids, and BiPAP (bilevel positive airway pressure) treatment in the emergency room. At the time of admission, the patient remained in respiratory distress and lethargic and continued to receive BiPAP treatment as well as IV steroids, and nebulization. 

The next day, patient was transitioned to oral steroids and was off BiPAP. The patient's respiratory distress had resolved.

Since the patient's condition improved with emergency room care and was transitioned off BiPAP and IV steroids in 24 hours after admission, the acute in hospital level of care is not medically necessary. The patient could have been safely and effectively by treated as an observation level of care followed by outpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder
 
Treatment: Inpatient substance use residential treatment services 

The insurer denied coverage for Inpatient substance use residential treatment services. The denial was reversed.

This male patient was admitted for inpatient substance residential treatment after a three-day hospital stay for hallucinogen-induced psychosis. He was using hallucinogens with his drug of choice being Lysergic acid diethylamide (LSD).  His substance use was interfering with his functioning. He had a family history of death by overdose.  He was using hallucinogens while living with family.  He also had co-morbidities of Attention Deficit Hyperactivity Disorder (ADHD), Asperger's Disorder, and depression.  He had individual, group and family therapy, recovery skills and self-motivation, as well as addiction education.  He was discharged.

The insurer denied coverage for inpatient substance residential treatment as not medically necessary treatment.  They stated that he had a safe recovery environment, did not require residential treatment, and they recommended a less restrictive level of care.

Chart notes provided enough specific evidence to support the patient needed this treatment.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders indicates that residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  Residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse.  In this case this, patient was considered in need of 24-hour residential treatment as he was using serious substances which resulted in psychosis and a hospitalization, which interfered significantly with his functioning.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for substance residential treatment as he continued to use; seriously impairing his functioning, which resulted in a psychiatric hospitalization prior to this residential treatment.   He had inability to stop using and continued to use in his own home.  Without this structured and supervised therapeutic residential treatment, he likely would have relapsed quickly.  

As a result, the inpatient substance residential treatment was medically necessary. The health care plan did not act reasonably, with sound medical judgment or in the best interests of the patient.  

The carrier's denial of coverage for the inpatient hospital services at the substance use residential level of care is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Subtherapeutic INR

Treatment: Inpatient admission

The insurer has denied coverage for. The denial was upheld.

This case involves a male patient with a past medical history of coronary artery disease, hypertension, diabetes mellitus, hyperlipidemia, gastroesophageal reflux disease, and left ventricular (LV) thrombus on Coumadin. The patient presented to the emergency department with a low INR of 1.17.  The patient indicated he had a prior blood clot in his heart and was on Coumadin 6 mg.  Chief complaint was low INR.  The patient's blood pressure was 118/75.  The patient's heart rate was 85.  The patient denied pain.  The patient was saturating (oxygen) at 99% on room air.  The patient was comfortable without complaints.  The patient had gone to his cardiologist and was called about his INR and was told to go to the emergency room.  The patient was unclear about his medical history.  The patient was recently hospitalized with a subtherapeutic INR and was bridged with Lovenox.  A transthoracic echocardiogram (TTE) was done at that hospitalization and did not show thrombus.  

The physical examination was normal on exertion. However, the patient indicated that he had dyspnea on exertion. He was admitted to medicine for a subtherapeutic INR. The treatment plan included aspirin, glucose monitoring, with coverage via sliding scale, Lovenox subcutaneously, furosemide, lisinopril, Metoprolol, warfarin, and INR monitoring. When stabilized, the patient was cleared for discharge and follow-up with cardiologist.

The MCG indicate that admission may be appropriate for patients who have hemodynamic instability with vital sign abnormality not readily corrected by appropriate treatment within 12 to 24 hours, for hypertension requiring inpatient treatment, for cardiac arrhythmias of immediate concern, upper respiratory and abnormalities, for a severe physiologic disorder, or for a severe electrolyte abnormality.  It would also be appropriate for treatment requiring inpatient care such as the need for intravenous anticoagulation or thrombolytics.  The documentation submitted for review indicated the patient was admitted with a low INR. The patient had no other complaints. The records failed to support the patient could not have undergone observational treatment, instead of admission.  The healthcare plan acted reasonably and with sound medical judgment, and in the best interest of the patient.  The inpatient hospital services were not medically necessary for this 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: Lymphadenopathy

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld. 

This patient is a young female who presented to the Emergency Department (ED) with complaints of right sided chest pain for the past few months but had now gotten worse.  The chest pain was reproducible on palpation over her ribs and it was also worse with movement. Her lungs were clear to auscultation. The patient reported some weight loss over the past few months. She denied trauma, fever and or chills. She has a past medical history of Sickle Cell trait. Patient's white blood cell (WBC) count noted to be 3.6. A computerized tomography (CT) scan of the chest and abdomen was done which revealed hilar and mediastinal lymphadenopathy. Oncology consulted and recommended lymph node biopsy to be scheduled as an outpatient to rule out Lymphoma, versus Infectious etiology. She was also seen by Pulmonology; outpatient Fiberoptic Bronchoscopy with Endobronchial Ultrasound Bronchoscopy was recommended. The patient was treated with intravenous (IV) Ketorolac for pain management with resulted improvement. The patient remained stable for discharge.

She improved after pain medications in the Emergency Department (ED) and responded to oral (PO) pain medications.  She was afebrile and hemodynamically stable with stable labs.  Outpatient work-up was recommended for her mediastinal lymphadenopathy.  The patient was stable for discharge after evaluation and treatment in the ED.  If needed, she could have been placed in the Observation level of care for a brief period. 
 
Based on the above, the medical necessity for inpatient hospital services at the acute level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient presents with a Class I, mildly crowded occlusion.  The photographs indicate he has a mild deep bite.  Treatment planned for 18-24 months of orthodontics to correct the malocclusion.  The patient has some mild crowding but a solid Class I occlusal relationship.  The bite is slightly deep, but there is no indication of damage to the incisors or the palate in the photographs, and the cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate.  There is no medical reason to correct this mild crowding with braces.  There are many ways to correct patients with a deep bite and retroclined incisors, and there is strong evidence that one treatment is not better than another.  In addition, deep bites may be corrected in adulthood.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a Class II, division 1 malocclusion with protrusive maxillary incisors.  Tooth number (#) 9 has a history of trauma and has a large restoration.  She is treatment planned for 24 months of orthodontics to correct this malocclusion, but her health plan denied the services as not medically necessary.  The health plan's determination is overturned.
This patient exhibits an Angle's Class II bite.  Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible.  There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma.  Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth.  This is particularly important for this patient since tooth #9 has already been fractured once.  If it is traumatized again, it will likely result in more significant tooth damage.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute Coronary syndrome

Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld. 

This is a middle aged female who presented to the emergency department in mid-2019 with left arm pain that had been present an extended period of time.  She had a history of hypertension and hyperlipidemia.  She had an EKG, which revealed normal sinus rhythm, tall R waves and deep T wave inversions in the lateral leads.  Her chest x-ray revealed stable elevation of the right hemi-diaphragm and new mild right tracheal deviation.  The computed tomography scan of the chest confirmed questionable thyroid hypodensity with trace left pleural effusion, mild left perihilar pulmonary infiltrate, and a 4 mm left lung nodule.  The nuclear stress testing was normal and transthoracic echocardiography revealed normal left ventricular ejection fraction (LVEF 55-60%) and severe concentric left ventricular hypertrophy.  She was evaluated by endocrinology who recommended thyroid ultrasound as an inpatient or outpatient.  The nuclear stress testing on 5/7/19 was normal and transthoracic echocardiography revealed normal left ventricular ejection fraction (LVEF 55-60%) and severe concentric left ventricular hypertrophy.  She was discharged home for further outpatient follow up.

There is no evidence that this patient required an acute inpatient level of care to determine that her left arm pain was not related to acute coronary syndrome. 

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

Diagnosis:  Overjet; overbite
Treatment:  Braces

The braces are not medically necessary. 

The patient does not qualify for braces based upon her having a handicapping index score of less than 25.  Therefore, she does not meet needed criteria.  As such, the medical necessity for braces is not established.
Appeal type: Medical necessity
Decision: Overturned

This is a patient under evaluation and management for Crohn's Disease. The patient is s/p ileocolic resection. The patient's prior treatments included Remicade, steroids and thiopurines. He failed Entyvio as well. The patient has complex perianal fistulous disease
with local abscess formation perhaps a coccygeal osteomyelitis is developing. Treatment has included an EUA along with abscess drainage and seton placement. Currently the patient is maintained on Stelara 90 mg Q 8 weeks. A trough level was ordered but the results are not provided. 

The patient's provider has recommended therapy with Stelara at 90 mg Q 4 weeks. This request was denied by the plan as this is not the FDA approved dose of the medication and therefore not medically necessary. 

The health plan's determination is overturned. This patient has failed anti-TNF and anti-integrin therapy. With respect to treatment options, interleukin inhibitors are the only remaining therapeutic class of biologics available for treatment. The patient has highly aggressive disease with complex perianal disease that is not responding fully to
Stelara Q 8 weeks. If there is progression of his perianal disease he may end up with a permanent colostomy. 

Clinically a significant number of patients medically require dose escalation of Stelara to Q 4 weeks due to suboptimal response with Q 8-week dosing. There is considerable data that steady state drug levels are influenced by dose frequency. For example, in the study by Adedokun, et al, the authors found that the median trough concentration was approximately threefold higher in patients given ustekinumab at 8-week intervals compared with 12-week intervals. Ustekinumab serum concentrations were associated
with rates of clinical remission and endoscopic efficacy endpoints and correlated inversely with the level of C-reactive protein. Trough concentrations of ustekinumab up to 1.4 g/mL or greater were associated with maintenance of clinical remission in a higher proportion of patients than patients with lower trough concentrations. This data provides the rationale to push the dose higher in patients with only a partial response to Q 8-week dosing. Similarly, in the study by Battat, et al. the mean trough concentration of ustekinumab at week 26 was higher in patients with an endoscopic response (4.7 ug/mL) than without (3.8 ug/mL; P = .03). An optimal ustekinumab threshold trough concentration at week 26 or later was found to be 4.5 g/mL. A greater proportion of patients with trough concentrations of ustekinumab above 4.5 g/mL at week 26 or later had an endoscopic response (75.9%) than did patients with trough concentrations below this level (40.7%; P = .008). Patients with trough concentrations of ustekinumab
above 4.5 g/mL at week 26 or later also had a lower mean level of CRP (12.6 mg/L) than did patients with trough concentrations below this level (mean level of CRP, 23.9 mg/L; P = .04).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
 
Treatment: Inpatient admission, diagnostic testing, monitoring

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

The patient was a male with no significant past medical history who presented to the ED with complaints of recurrent chest pain, headache, loss of consciousness, and periorbital numbness.  His vital signs were stable, EKG showed normal sinus rhythm, and his Troponin was normal.  The patient was admitted for chest pain.  Cardiac biomarkers remained negative.  The patient remained clinically and hemodynamically stable during his hospitalization.  Cardiology evaluated the patient.  An Echocardiogram showed preserved left ventricular systolic function and a nuclear stress test was unremarkable for any significant ischemia.  The patient was discharged for follow-up with his primary care provider. 

The patient presented with chest pain, however, the initial evaluation in the ED was unremarkable, including negative cardiac troponin and a nondiagnostic EKG.  In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.  Further evaluation was warranted, however inpatient admission criteria were not met.  Although the patient had new onset symptoms, medical policy criteria were not met for any other additional extenuating circumstances.  There were no other high-risk co-morbidities.  An observational level of care would have been appropriate to meet this patient's needs.

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

This is a case of a patient with no significant past medical history, who presented to the emergency department with abdominal pain. The patient was also approximately 6 weeks pregnant, with some vaginal spotting. Workup in the emergency room revealed an intrauterine pregnancy and the OB/Gyn service ruled out an ectopic pregnancy. The acute care surgery service was consulted to rule out appendicitis. A right lower quadrant ultrasound did not visualize the appendix. After examination and assessment of the clinical picture, the acute care surgery service had low suspicion for acute appendicitis. The patient was admitted to the acute care surgery service. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient's treating team felt that the duration of stay was likely less than a 2 day stay. It is important to recognize that appendicitis in pregnancy has been proven to result in multiple detrimental pregnancy outcomes. Furthermore, diagnosing appendicitis in pregnancy is particularly challenging, as the gravid uterus displaces the appendix and other viscera. Additionally, lab tests are often abnormal in pregnancy and thus often are not helpful in the diagnosis of appendicitis in the pregnant woman. Imaging of the appendix in pregnancy is controversial. Ultrasound is used as a first test, as it is quick and requires no radiation or contrast exposure. However, in the case of this patient, the appendix was not visualized. Had the surgery team had more suspicion of appendicitis, a magnetic resonance imaging (MRI) or possibly even a computed tomography (CT) scan would have been obtained. However, the suspicion was very low. The plan for pain control, intravenous (IV) fluids, and serial exams was appropriate. There are no pain medications ordered in the chart, nor is there any charting that the patient received any while inpatient. Such a plan did not require an acute admission. The fact that the patient was pregnant did not influence the care, as the fetus was previable and also had no heartbeat to monitor, even if monitoring was desired, although not indicated. The patient was hemodynamically stable and had no concerning signs that she needed an inpatient level of care. The patient did not require an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces and follow-up visits

The braces and follow-up visits are medically necessary. 

The patient has a deep impinging overbite with soft tissue damage. This is an "automatic qualifying" condition for orthodontic benefits.
Appeal type: Medical necessity
Decision: Upheld

This patient who presented to the emergency department (ED) with abdominal pain and vomiting was known to have gallstones and was scheduled to undergo cholecystectomy.  The medical history was significant for sleeve gastrectomy, gastroesophageal reflux disease (GERD), thalassemia trait and prior abdominoplasty.  The patient  underwent a laparoscopic cholecystectomy.  The health plan's determination of medical necessity is upheld in whole.  The patient remained hemodynamically stable throughout the perioperative period; there was no documented complication of surgery.  The records include no documentation of a comorbid medical condition that required an inpatient level of care, such as conversion to open procedure, intolerance of diet, complications of procedure, thromboembolic disease, care for comorbidities, advanced age/ or decompensated physiologic status.  This patient's clinical needs could have been satisfied with a lower level of care.