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

Diagnosis: Prostate Cancer. 

Treatment: Genetic testing of prostate tissue with Oncotype DX for prostate cancer.

The insurer denied coverage for genetic testing of prostate tissue with Oncotype DX for prostate cancer. 

The denial is upheld. 

This is a male patient with prostate cancer. His physician ordered an Oncotype DX Prostate Cancer Assay (PCA) test for assistance in determining the appropriate individualized treatment for this patient. The patient's Genomic Prostate Score (GPS) was low-risk. The insurer has denied coverage for the genetic testing with Oncotype DX PCA. The insurer stated there is a lack of any significant randomized trials in medical literature that shows a significant benefit or difference in the outcomes of patients with prostate cancer. 

While current National Comprehensive Cancer Network (NCCN) guidelines state that men with low or favorable intermediate risk prostate cancer and at least a 10-15 year life expectancy may consider the usage of genomic testing to aid in risk stratification, they note the lack of randomized prospective trials. NCCN notes, regarding genetic testing, that while this test can be considered, "future comparative effectiveness research may allow these tests and others like them to gain additional evidence regarding their utility for better risk stratification of men with prostate cancer." As stated in the latest American Society of Clinical Oncology (ASCO) guideline "Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up." Furthermore, ASCO states in their guideline "There are currently commercially available biopsy-based multigene expression classifiers (ie, Decipher, Oncotype Dx Prostate, and Prolaris) and one protein-based biomarker (ProMark). Each seems to independently improve the prognostic accuracy of clinical multivariable models for identifying men with biologically significant disease. The clinical benefit of integrating these classifiers in selecting patients for surveillance has not been prospectively demonstrated." American Urologic Association (AUA) guidelines state that "tissue based genomic biomarker tests, such as Oncotype DX PCA 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 PCA, on clinical practice and long-term patient outcomes remains to be empirically demonstrated. Prospective studies of these types of tests yielding a true clinical benefit when implemented in clinical practice are still lacking, unfortunately.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The medical necessity for genetic testing of prostate tissue with Oncotype DX for prostate cancer is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral occipital neuralgia.
Treatment: Occipital nerve stimulator/pulse generator.
The insurer denied coverage for occipital nerve stimulator/pulse generator.
The denial is overturned. 

This female patient has a history of bilateral occipital neuralgia that causes occipital headaches. The patient's condition has been well-managed with occipital nerve stimulator (ONS), but the stimulator needed replacement due to need of new battery. 

As per Pert Yang, et al (2016), a systematic review of ONS for migraine found that: "Results from the retrospective studies and case series indicated that ONS significantly reduced the pain intensity and the number of days with headache in patients with migraine."

As per Moisset, et al (2020), a systematic review of invasive methods found that: "Invasive occipital nerve stimulation was effective for migraine prevention, with a large effect size but considerable heterogeneity" among the 3 randomized trials analyzed.

Based on the review of the medical record and literature, the removal and replacement of the occipital nerve stimulator/pulse generator is considered medically necessary for this patient. The long duration of efficacy in this patient supports the replacement of the generator and battery.  

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

Based on the above, the medical necessity for occipital nerve stimulator/pulse generator is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Diverticulitis. 
Treatment: Inpatient hospital stay. 

The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination. 

 The patient was seen in the emergency room (ER) for 1 day of right lower quadrant (RLQ) pain. The patient has a history of diverticulitis in the past as well as a percutaneous nephrostomy tube. The patient denied associated nausea vomiting or gastrointestinal (GI) bleeding. No systemic symptoms such as fever or chills. In the ER the patient was much improved with a single dose of morphine. Thereafter appeared in no acute distress. Vitals stable. Abdomen was described as non-tender. On labs she had an elevated white count to 13.4 without a left shift. Normal comprehensive metabolic panel (CMP) and venous lactate. On computed tomography (CT) scan of the abdomen there was fat stranding around a cecal diverticulum. The patient was placed on Cipro and Flagyl. The patient was admitted to the hospital. The following day the patient was without new problems. Endorsed pain in the right upper quadrant (RUQ). A liquid diet was started. The patient was discharged without complications. 

The requested service of inpatient hospital stay was not medically necessary for this patient. The patient had uncomplicated diverticulitis. She was not experiencing any complications which would warrant inpatient care such as perforation, abscess, fistula, or bacteremia/sepsis. Uncomplicated diverticulitis can be managed in a lower level of care such as observation or outpatient setting. All that is needed for patients with uncomplicated diverticulitis is oral pain medication which can range from acetaminophen all the way to an opioid narcotic. Antibiotics likely do not affect the clinical course of diverticulitis but, when given, can be provided orally. In light of the patient's age and underlying diabetes, it was reasonable to keep her for a short stay in a lower level of care setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hydronephrosis
Treatment: Inpatient Hospital Stay. 
The health plan denied the requested inpatient stay. 
The health plan's determination is upheld.

The patient is a male who was admitted for evaluation of left sided colic. Imaging revealed a proximal left ureteral stone, 6 millimeter (mm), with hydronephrosis. His lab studies were essentially normal, he was afebrile, and he tolerated fluids. He was seen in urologic consultation. no emergency procedures or recommendations were made; rather, the subsequent day, he was taken to the operating room (OR) for Extracorporeal Shock Wave Lithotripsy (ESWL).
At issue is the medical necessity of the inpatient stay.

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

No. The patient, upon presentation to the emergency room (ER), was afebrile. His blood pressure, pulse and temperature were normal. His oxygenation was 99%. His pain was described as moderate, he had no relief with outpatient nonsteroidal anti-inflammatory drugs (NSAIDs). He had no significant medical comorbidities. He was admitted for intravenous (IV) fluids and pain control; he underwent uneventful ESWL within 24 hours of admission and was discharged.
ESWL is typically done as an outpatient. The patient did not receive acute inpatient hospital level of care for his stay and should have been managed under observation criteria. The patient may have been safely discharged to home management and returned the subsequent day for treatment or may have been admitted for close observation without admission. No emergent care nor hospital level of care was provided. The patient had stable vitals, controlled pain, and he tolerated orals. Hospital admission did not meet standard of care of necessity; observation would have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted tooth
Treatment: Braces and Periodic Treatment Visits
The insurer denied the Braces and Periodic Treatment Visits.
The denial is overturned.

The patient is a male. The request is for orthodontic benefits.

Yes, the Braces and Periodic Treatment Visits are medically necessary.

The patient has an impacted anterior tooth (#11). The tooth is not to be extracted, but rather brought into alignment with orthodontic treatment. This is an automatic qualifier according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: Comprehensive Orthodontic Treatment (D8080)
The insurer denied the Comprehensive Orthodontic Treatment (D8080).
The denial is overturned. 

The patient is a female requesting orthodontic benefits.

The photos and HLD (Handicapping Labio-Lingual Deviation) index explain the patient's condition.

Yes, the Comprehensive Orthodontic Treatment (D8080) is medically necessary.

The patient has a crossbite of an anterior tooth. Tooth #22 (lower left canine) is outside of tooth #10 (upper left lateral incisor). This is reverse from as it should be.

When there is an anterior crossbite with attachment (gum) loss, it is an "automatic qualifier" according to the handicapping index scale. The case has medical necessity, as this problem needs to be orthodontically corrected.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip pain
Treatment: MRI of any joint of lower extremity without contrast material (73721) 
The insurer denied the MRI of any joint of lower extremity without contrast material (73721) (Pre-Service).
The denial is upheld. 

The patient is a male with worsening right hip pain. The duration of the patient's symptoms was five to six months. He reported groin pain and clicking. He had taken Advil and had no other treatments.

The patient's physical examination was significant for no limp and a BMI (body mass index) of 36. He had decreased motion.

The patient's x-rays showed osteoarthritis (moderate to severe arthrosis). He was diagnosed osteoarthritis, and he was recommended several conservative treatments. THR (total hip replacement) was also discussed with weight loss.

The patient was previously evaluated, and an MRI (magnetic resonance image) ordered for his hip. He had not received conservative treatment. 

No, the MRI (magnetic resonance image) of any joint of lower extremity without contrast material (73721) is not medically necessary.

An MRI (magnetic resonance image) is of benefit if additional information assists in establishing a diagnosis. The scientific literature describes MRI (magnetic resonance image) should be recommended if conservative treatment has not been beneficial. The diagnosis can alter the decision, prognosis and plan of care. The necessity for more invasive procedures (surgical treatment) can be assessed.

The performance of the MRI (magnetic resonance image) should have an impact on a patient's treatment regimen. If diagnostic tests are not clinically useful, they are not medically necessary.

The medical records do not describe treatments provided. He did not receive activity restriction, bracing, medication or physical therapy. He was not a surgical candidate. His physician recommended the MRI (magnetic resonance image) upon initial evaluation.

There were no extenuating circumstances to substantiate necessity of MRI (magnetic resonance image) testing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This male patient has a past medical history significant for coronary artery disease, diabetes mellitus, and hypertension. He presented to the hospital for an elective outpatient cardiac catheterization. This demonstrated severe stenosis of the proximal left anterior descending coronary artery, for which he received angioplasty and a drug-eluting stent, with optical-coherence tomography guidance. He experienced chest pressure after the procedure, and was started on a nitroglycerin infusion. His symptoms abated, and he was monitored overnight. He was treated with antiplatelet agents. He had a headache overnight and was given Tylenol. He did not have evidence of recurrent ischemia, and was discharged home after a period of medical stability. 

Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient procedure. The clinical presentation and peri-procedural course did not require acute inpatient level monitoring. Following the procedure, the patient had chest pain, which was treated with intravenous nitroglycerin. Repeat angiography was not indicated, and there were no diagnostic ischemic electrocardiogram changes necessitating acute evaluation and/or intervention. The patient was ambulatory and tolerating oral intake, without vascular access site complications. There were no other extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and stent placement. 

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

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

Diagnosis:  Total Hip replacement.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case describes a female patient with a complaint of right hip pain. She failed conservative treatment and opted to undergo elective right total hip replacement surgery. The surgery was successful with no documented complications. She progressed well with post-operative physical therapy and was deemed stable for discharge. At issue in this case is the medical necessity of the inpatient hospital admission.

The Inpatient Hospital Admission was not medically necessary for this patient. The rationale for this determination is based upon the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature. The records in this case document that the patient underwent a successful right total hip replacement. There were no documented complications of the operation and the patient had normal vital signs and lab values following the surgery. The progress note from the orthopedic service documented that the patient had no acute events overnight and that the patient's pain was well controlled with the prescribed medication regimen. The patient also participated in supervised physical therapy and was ambulatory out of bed. Therefore, based upon the documentation in the patient's medical records, she could have been safely discharged.
The current, peer-reviewed orthopedic literature, including articles published by Greenky and colleagues in the Journal of Arthroplasty and by Weiser and associates in the Journal of Arthroplasty have established the safety and efficacy of short stay and outpatient total hip replacement surgery. Greenky and his co-authors concluded that "Outpatient and short-stay total hip arthroplasty (THA) appears to be safe in a small subset of Medicare-aged patients. Centers for Medicare and Medicaid Services should allow surgeons flexibility in determining admission status based on each patient's risk profile."
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease
Treatment: Treatment: Sucralfate Suspension
The insurer denied the Sucralfate Suspension.
The denial is overturned. 

The patient is female with gastroesophageal reflux disease (GERD). She has failed treatment with pantoprazole, lansoprazole, rabeprazole, famotidine and Carafate tablets. The attending physician is requesting treatment with Carafate suspension.

Yes, the health plan should cover the Carafate suspension.

Carafate is safe and effective for the treatment of gastroesophageal reflux disease (GERD), and is standard of care when patients with GERD have failed proton pump inhibitors (PPIs). As this patient has failed the plan preferred formulary alternative, Carafate tablets, and is not tolerating it, even in slurry form, the health plan should cover Carafate suspension.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic low back pain and lumbar radiculopathy.
Treatment: Epidural Steroid Injection 01 Unit.
The insurer denied the Epidural Steroid Injection 01 Unit.
The denial is overturned. 

The patient is a female with a history of chronic low back pain and lumbar radiculopathy. She previously underwent an epidural steroid injection. She had over 70% improvement, but she remains with limitations due to pain.

Yes, the Epidural Steroid Injection 01 Unit is medically necessary.

The patient is a female with a history of lumbar radiculopathy/chronic low back pain. She has MRI (magnetic resonance image) evidence of a foraminal disc herniation. She had 75% improvement with the first injection. Her repeat injection is being denied due to her health plan only approving this injection every three months.

There is no literature or pain management association guidelines that restrict a repeat injection to three months. Typically, it is considered standard practice for no more than thee injections in a year, however there is typically no limitation on how quickly these can be performed in succession. Some guidelines, specifically the Spine Intervention Society guidelines, assert that within the "diagnostic" phase, a second injection can be performed in relatively short succession, typically within two to six weeks, provided that the patient has an appropriate response. (3)

This patient had an injection over a month ago, with over 70% improvement in her low-back and leg pain. Her function has improved. Therefore, the patient is still considered in the diagnostic phase, and a repeat injection would be appropriate. Given the above, therefore it is medically necessary to consider repeat injection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bioprosthetic aortic valve failure 
Treatment: Valve-in valve transcatheter Aortic Valve Replacement (TAVR), CPT 33361, And One (1) Day Inpatient Hospital Admission
The insurer denied the Valve-in valve transcatheter Aortic Valve Replacement (TAVR), CPT 33361, And One (1) Day Inpatient Hospital Admission.
The denial is overturned. 

The patient is a male with multiple cardiac surgeries including aortic valve replacement x 2. His bioprosthetic aortic valve has failed, and request to perform TAVR (transcatheter aortic valve replacement), (valve in valve). He has had thoracic aortic root replacement for aortic dissection. He was found to have severe AI (aortic insufficiency). Discussion with family documented options of TAVR (transcatheter aortic valve replacement) vs SAVR (surgical aortic valve replacement) with Bentyl procedure. Following that discussion, TAVR (transcatheter aortic valve replacement) was chosen as the preferred intervention.

Yes, the Valve-in valve transcatheter Aortic Valve Replacement (TAVR), CPT 33361, And  One (1) Day Inpatient Hospital Admission are medically necessary.

With this degree of AI (aortic insufficiency), AoVR (aortic valve replacement) is required. The question is TAVR (transcatheter aortic valve replacement) vs SAVR (surgical aortic valve replacement).

While denial of TAVR (transcatheter aortic valve replacement) may be consistent with standard guidelines, the present generation of TAVR (transcatheter aortic valve replacement) valves have been shown to be at minimum non-inferior, and more likely superior (lower mortality rate).

Per Up-to-Date  "At the present time, data comparing transcatheter valve-in-valve procedures with surgical replacement are limited, but they suggest noninferiority with similar mortality, stroke, and survival rates [22]. An observational study of 69 patients undergoing surgical aortic valve replacement (SAVR) and 22 patients undergoing TViV (transcatheter valveinvalve implantation), used STS (Society of Thoracic Surgeons) risk scores to create 22 matched pairs of SAVR (surgical aortic valve replacement) and TViV (transcatheter valveinvalve implantation) for comparison (STS [Society of Thoracic Surgeons] scores 7.7 and 7.5) [22]. Operative mortality was 4.3 in the SAVR (surgical aortic valve replacement) group and zero for the TViV (transcatheter valveinvalve implantation) group. Mild PVLs (paravalvular leaks) were seen in none of the SAVR (surgical aortic valve replacement) group and in 22 percent of the TViV (transcatheter valveinvalve implantation) group. Postoperative stroke rate was 9 percent for SAVR (surgical aortic valve replacement) and zero for TViV (transcatheter valveinvalve implantation). Actuarial survival at three years was 76.3 percent for SAVR (surgical aortic valve replacement) and 78.7 for TViV (transcatheter valveinvalve implantation)."

The best interests in this patient would be to allow the procedure with lower mortality, less morbidity for a relatively newer technology.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Co-Occurring Anxiety and Depression. 
Treatment: Mental Health: Residential Treatment. 

The health plan denied the residential mental health treatment. The health plan's determination is overturned. 

The patient is a female who was admitted for residential level treatment of co-occurring anxiety and depressive disorders best characterized as generalized anxiety disorder and severe major depressive disorder with worsening symptoms of depression and suicidal behavior. The patient has a history of suicidal behavior and self-harming behavior associated with symptoms of generalized anxiety disorder and major depressive disorder. She had made a suicide attempt cutting her wrist with a butcher knife that had required stitches. She continued to struggle with suicidal thoughts in the context of coping difficulties and tendency towards perfectionism. She presented with limited, but fair insight. She had failed to respond to treatment in the community with therapy and medications including Prozac and Buspar. 

At issue is the Inpatient Residential Treatment Center Services. 

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

The patient remained/remains in residential level treatment with planning for discharge with identification of a clinically appropriate disposition and safe discharge plan. Her family remained supportive, and the patient was actively participating in therapy utilizing cognitive techniques, and the development of better coping skills and relational functioning. There were no complications of treatment reported in this case with regard to safety issues or a recrudescence of high-risk behaviors in the context of 24-hour monitoring and a safety plan though the patient remained at imminent risk for harm and relapse during the residential stay due to persistent irritability and deficient coping with perfectionism and depressive thought content including sad affect and thought blocking. Thus, the step down for continued treatment was being carefully planned to assure a safe and clinically appropriate discharge and disposition with reasonable supports, and recommendations for mental health treatments to include efforts to facilitate normal grief and resolution of family issues.