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

This is a pregnant patient with complaints of abdominal pain and contractions.  She was noted to be 2 centimeters (cm) dilated.  She had no  vaginal bleeding or urinary symptoms. She reported good fetal movements.  She had a prior history of a short cervix and had a pessary in place.  She was noted to be on Procardia every 8 hours orally since her last admission.  She was not complaining of contractions at presentation per the intake information.  She had none on tocolytic (toco) monitoring. There was a reactive and reassuring nonstress test (NST).  She was noted to have a 2 cm external dilated cervix on exam.  She was on Procardia and vaginal progesterone.  She was noted to have a vertex presentation on ultrasound and normal amniotic fluid index (AFI) of 12 cm with a reassuring biophysical profile (BPP) score of 8 of 8.  She had an estimated fetal weight (EFW) of 1123 grams.  This was at the 60th percentile.  She had a normal umbilical artery Doppler.  She had no other complications this pregnancy.  The fetal monitoring was reassuring.  There was no fundal tenderness.  The cervical exam was deferred at admission.  Reassuring and Category I fetal heart tones were noted.  The patient was admitted with a diagnosis of short cervix and preterm uterine contractions.  The health plan's determination is upheld.  The patient had no contractions on monitoring and a pessary was in place.  She was 2 cm externally and closed internally.  There were no other complications of the pregnancy, and the patient was managed on Procardia orally in the outpatient setting.  She had completed steroids. This was an initial appropriate intervention.  There was no indication for magnesium for tocolysis, as there were no contractions on monitoring.  This was not necessary in this case, as there were no contractions.  The standard of care for a short cervix in an asymptomatic patient would include:  1) Course of steroids at this cervical length - 2 doses of celestone given 24 hours apart was completed, 2) Vaginal prometrium 200 mg nightly in the vagina for prevention of preterm birth and this was in place in the outpatient setting, 3) Modified activity and precautions for preterm labor, 4) Serial followup in the outpatient setting, 5) Serial assessment for urinary tract infection, 6) Assessment of gen probe (completed in this case with prenatal care).

Tocolysis would not be recommended chronically - the American College of Obstetricians and Gynecologists (ACOG) states the following: "women with preterm contractions without cervical change, especially those with a cervical dilation of less than 2 cm, generally should not be treated with tocolytics" - This patient should not be tocolyzed. This patient was closed with a pessary in place.

In this case, the acute level of care serviced would not be medically necessary, as the patient had completed steroids and did not have documented cervical change to support preterm labor as recommended by ACOG and the Milliman Care Guidelines (MCG) Care Guideline Preterm Labor, Threatened.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a past medical history of muscle spasms, migraine headaches, bipolar disorder, and fibromyalgia who came to the ER after she developed a severe headache, diffuse muscle spasms, and tremors. This was also associated with a facial droop and left-sided weakness as well as pain on the left side of the body.
The review of systems was negative for syncope, loss of consciousness, chest pain, shortness of breath, and hallucinations.
On the physical exam the patient's temperature was 98.1F, heart rate 87 beats per minute (bpm), respiratory rate 20, blood pressure 145/81, oxygen saturation 98%. The rest of the physical exam was documented as normal. A computed tomography (CT) scan of the head demonstrated no acute intracranial hemorrhage. During the hospital stay the patient underwent a magnetic resonance imaging (MRI) scan of the brain, which did not show any acute abnormalities that could explain the symptoms. According to the discharge summary, the entire workup was negative.

The health plan denied the inpatient stay as not medically necessary. The health plan's determination is upheld. The patient presented with sudden onset of symptoms including headache, muscle spasm, tremors, left-sided weakness, and pain. Those symptoms were nonspecific and could represent several medical conditions. Considering the fact that the patient had a history of migraine headaches, those symptoms could have been definitely related to the migraine. According to the history and physical examination note, the patient had an unremarkable neurological exam. Laboratory studies were unremarkable, and the diagnostic studies that included a CT scan of the head and MRI of the brain did not reveal clinically significant abnormalities. The patient was in stable clinical condition and had no alarming findings on the physical exam, in the diagnostic studies, and on laboratory tests.
The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath, Cellulitis
 
Treatment: Inpatient Admission

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

This is a female patient who presented to the emergency department (ED) with complaints of shortness of breath for one week. She has a history of pulmonary embolism, deep vein thrombosis, hypertension, hyperlipidemia, and diabetes. The patient's vital signs were stable at the time of presentation. Upon physical exam it was noted that the patient had right sided pannus that was warm and red consistent with cellulitis. The patient was started on intravenous (IV) fluids and antibiotics. She was consulted by Infectious Disease, Hematology and Oncology, Pulmonary, Pain and Palliative Services, and Gynecology. She had a chest x-ray that was negative. A computer tomography (CT) was performed which was negative for a pulmonary embolism, but did reveal fractures of her right 9th and left 10th ribs. It was determined that the patient's shortness of breath was secondary to her rib fractures. The patient responded well to the medical treatment of plan and was safely discharged home. 

According to the documentation, the patient presented with shortness of breath and a superficial fungal infection in the groin area. Otherwise, she was afebrile and hemodynamically stable, good oxygen saturation and unremarkable laboratory results including a normal white blood cell count. The imaging studies were negative for infection but showed (2) rib fractures that accounted for her symptoms. There was no evidence of a systemic infection or acute cardio-pulmonary issues that required acute care inpatient admission. The patient was stable for the Observation level of care. 

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

Diagnosis: Bilateral vitreous detachment, arthritis
Treatment: 81415 - Whole exome sequencing
The health plan should cover the 81415 - Whole exome sequencing.

Whole exome sequencing is likely to be more beneficial.

The whole exome sequencing (WES) test analyzes the protein coding portion of the human genome and is offered by a number of CLIA (Clinical Laboratory Improvement Amendments)-certified diagnostic laboratories. WES does not need FDA approval as it is a genetic test based on routine molecular techniques, such as DNA isolation, enrichment, polymerase chain reaction (PCR), and DNA sequencing. The results of the tests will likely identify the underlying genetic causes of this patient's disorder and may offer an opportunity for targeted treatment. Furthermore, WES is in a wide use by clinical geneticists and is current standard of care for patients with similar complex genetic syndromes of unknown causes. Despite extensive genetic clinical and molecular evaluations, no definitive diagnosis was established for this patient. The disease is presumed to have genetic etiology, based on the clinical symptoms.

The WES has the potential to identify a mutation a gene responsible for this patient's disease. Without a specific diagnosis, it is not possible to predict what the best treatment options for this patient is, which is why the WES test is medically appropriate. Once a specific genetic diagnosis is established, the next step in the management of this patient would be to determine what the best treatment options are for her condition.

In conclusion, once a specific genetic diagnosis is established for this patient, then it can be determined what the best treatment options are. Therefore, the request for this patient in this case is medically appropriate and should be covered by the health plan.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Bilateral vitreous detachment, arthritis
Treatment: 81415 - Whole exome sequencing

The health plan should cover the 81415 - Whole exome sequencing.

Whole exome sequencing is not experimental, investigational, or unproven. This testing is performed in CLIA (Clinical Laboratory Improvement Amendments)-approved laboratories by American Board of Medical Genetics Board-Certified Clinical Molecular Geneticists and is supported by peer-reviewed, published medical literature. It is now a standard of care in diagnosis of individuals with undefined and unexplained genetic and/or neurologic syndromes, developmental delay, skeletal dysplasias, malformations, birth defects, dysmorphic features, mental retardation, and autism spectrum disorders. The clinical and medical utility of this testing in delineating and identifying a specific gene mutations that would not be detectable by conventional microarray, targeted gene sequencing, karyotypic, cytogenetic and chromosomal studies, both prenatally and postnatally, is well-proven and documented.  

The whole exome sequencing is likely to be more beneficial. The testing requested is standard of care in this circumstance and could impact not only her diagnosis, but ongoing management decisions. 

The complexity of this patient's clinical presentation meets the ACMG guidelines for exome testing. 

The standard of care evaluation of a patient with a hereditary sensory neuropathy (peripheral neuropathy) is to initially screen for common causes, and then if non-diagnostic, to pursue broader genomic testing, either through exome or genome sequencing (GeneReviews: https://www.ncbi.nlm.nih.gov/books/NBK1358/#cmt._escape__3_Evaluation_Strategies_to). Given that prior testing has screened for the common PMP22 duplication and screened 70 genes known to be causally related to peripheral neuropathies, genomic sequencing would now be standard of care for this diagnosis. 

Both articles referenced by the physician appealing this denial of service support this recommendation within large patient cohorts.

PMID: 25802885  "This study highlights the advantage of using WES for genetic diagnosis in highly heterogeneous diseases such as IPNs and has been particularly powerful in this cohort where genetic diagnosis could not be achieved due to phenotype and mode of inheritance not being previously obvious. However, first tier testing for common genes in clinically well-defined cases remains important and will account for most positive results."
PMID: 28491899  "This study provides evidence that WES has a high diagnostic utility and is cost effective in patients with a peripheral neuropathy. Expanded analysis of WES data significantly improves the diagnostic yield in patients in whom a diagnosis is not found on the initial targeted analysis. This is primarily due to diagnosis of conditions caused by newly discovered genes and the resolution of complex and atypical phenotypes."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident
 
Treatment: Personal Care Aide Services 168 hours per week

The insurer denied personal care aide services at 168 hours per week. The denial was reversed.

The patient has an extensive history including left frontal cerebrovascular accident (CVA). She meets criteria for nursing home level of care; however, the family is committed to keeping her living safely in the community. The patient needs 24 hour continuous care. She is bed bound and dependent on caregiver assistance for all IADLs.  For ADLs, she is totally dependent on caregiver assistance for mobility out of bed, i.e. Hoyer lift for transfers. She is non-ambulatory and cannot self-propel herself in a wheelchair. She needs maximal assistance for bathing, dressing, toilet use/incontinence care and bed mobility (she cannot reposition herself without assistance). She needs limited assistance for personal hygiene (has use of only one hand). The only daily activity she can perform independently with setup help is eating.  The patient has a foley catheter. She has chronic pain attributed to leg spasms. 

There is one informal helper (daughter). It appears that she provides some care (finances, medications), but not routine assistance for daily activities. Informal caregiver assistance is voluntary, as per NYS regulations for personal care services. 

Considering the patient's physical disability and severe restriction of mobility, along with a history of making unsafe decisions, leaving the patient alone at night does not appear to be a safe plan of care. As a result of the patient's severe functional impairments and the need for substantial assistance with all aspects of her daily care, it is medically necessary for the patient to have caregiver assistance available throughout the day and night. 

The carrier's denial of coverage for personal care aide 168 hours per week is reversed.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a male with developmental delay, abnormal muscle tone, epilepsy, and abnormal movements. He is unable to walk, pull to a stand, crawl, or sit unsupported. Thus, he is substantially developmentally delayed. There is no family history of similarly affected individuals. No specific clinical diagnosis has been made despite an extensive diagnostic work up that has included magnetic resonance imaging (MRI), electroencephalogram (EEG), chromosomal microarray, plasma amino acids, urine organic acids, acylcarnitine levels, lactate, pyruvate, creatine kinase (CK), and acylglycine profile. His pediatric neurologist believes that the patient's condition is most likely genetic in origin. In an attempt to identify the genetic basis of his condition, the provider has ordered a whole exome sequencing test. The insurance company has determined that whole exome sequencing is investigational under these circumstances. The issue under review here is whether Whole Exome Sequencing is more likely to be beneficial for this patient than any standard diagnostic testing.

The health plan's determination is upheld.

Whole exome sequencing is a recently-developed laboratory technique that analyzes virtually all of the exons of an individual's deoxyribonucleic acid (DNA) in a single setting. In this process, tens of thousands of genes are analyzed simultaneously. As a result, this technique has the potential to elucidate genetic mutations that underlie a patient's condition.
Whole exome sequencing carries a great deal of promise to become a valuable clinical tool in the future. However, at this time, insufficient information is known to allow the data acquired from the test to be clinically useful for most patients. In particular, the technique may allow gene mutations and polymorphisms to be identified, but the clinical significance of those mutations would remain unknown. In other words, a patient with a neurologic condition, like the patient in this case, may have one or more genetic mutations identifiable by whole exome sequencing, but whether those mutations underlie or contribute to his disease would remain unknown. Furthermore, even if a causative genetic condition is identified by whole exome sequencing, this information is generally useful only for genetic counseling purposes and is almost never valuable for patient management. Thus, for all of these reasons, whole exome sequencing should be considered experimental/investigational at this time. The standard approach to diagnosis is to conduct the tests that have already been done and that were negative. In many cases like this, the ultimate cause of a child's developmental delay remains unknown, but this is the reality of the limitations of modern medicine.
Appeal type: Experimental/Investigational
Decision: Overturned

 Seizures
Genetic Testing

Report # 1
The patient is a male with global developmental delay and a history of seizures treated with anti-epileptic drugs (AEDs). The diagnostic workup, including neuroimaging, electroencephalogram (EEG), and laboratories has been extensive, but unrevealing. There is a paternal family history of a dystrophy, but the father is unaffected. At issue is the request for whole exome sequencing to identify an etiology for the delay and history of seizures. This has been denied by the health plan on the grounds that it is considered investigational for the diagnosis of genetic disorders.

The health plan's determination is overturned.

After years of rigorous peer review, whole exome sequencing (WES) has demonstrated utility in obtaining a diagnosis to more efficaciously provide a directed treatment plans rather than use "watchful waiting" to respond to the evolution of clinical disease in children with global developmental delay and seizure disorders. This is particularly true when developmental delay occurs because of interactions between genes and environment. For example, a recent study of genetic epilepsies demonstrated that WES was 1.9-fold higher than targeted next generation sequencing panels for epilepsy (TNGSP-E) in properly identifying mutations that give rise to epilepsy, including ones that were amenable to specific dietary interventions (Contain et al., 2019). This type of anticipatory guidance on a molecular level represents best medical practice for children with as yet undiagnosed etiologies for global developmental delay. Therefore, WES is likely to be more beneficial than standard treatment for the care and potential treatment of this patient.
Appeal type: Medical necessity
Decision: Overturned

Burns
Inpatient hospital stay

This is a patient who experienced a burn to the right thigh. 11 days after the initial burn, patient was found to have worsening superinfection after failure of outpatient antibiotic therapy. It was determined that the patient had a 2% total body surface area (TBSA) third degree burn. The patient was admitted for intravenous (IV) antibiotics, pain control, wound care, and plans for surgical debridement and likely skin grafting. Patient underwent tangential excision and split thickness skin graft to the thigh. The health plan's determination of medical necessity is overturned in whole. The best interest of this patient is an inpatient admission. The patient had a 3rd degree burn to 2% of his TBSA. This is a burn that started as partial thickness but progressed as an outpatient. According to the International Society for Burn Injury guidelines, any third degree burn necessitates a transfer to a burn center. Besides meeting standard practices for medical necessity, this case also meets McKesson InterQual criteria for acute adult: burns. This case qualifies with 3rd degree burns with 2-5% TBSA and need for complex burn care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructive sleep apnea

Treatment: Obstructive sleep apnea appliance

The insurer denied coverage for obstructive sleep apnea appliance. The denial was upheld.

This patient is a male currently diagnosed with chronic fatigue, deviated nasal septum and obstructive sleep apnea.  The patient underwent a sleep study revealing an apnea-hypopnea index (AHI) was 4.  The patient's respiratory disturbance index (RDI) was 10.  The patient underwent a nasal vestibular stenosis repair, a septoplasty turbinectomy, and sleep endoscopy.  The sleep endoscopy that was performed revealed a severe to complete base of tongue (BOT) collapse, which was significantly improved with the jaw thrust. The patient had poor concentration and memory, chronic fatigue and severe daytime somnolence.  The provider stated the patient was an excellent candidate for a mandibular advancement device. 

The American College of Physicians recommends, "mandibular advancement device (MAD) as an alternative therapy for patients who prefer it or who do not tolerate or comply with CPAP treatment."  The American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine Clinical Practice Guideline recommends, "sleep physicians prescribe oral appliances for treatment of adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy."

The Centers for Medicare and Medicaid Services state that the apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) must be greater than or equal to 15 events per hour with a minimum of 30 events; or, the AHI or RDI must be greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of: excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or hypertension, ischemic heart disease, or history of stroke; or the AHI greater than 30 or the RDI greater than 30 and meets either of the following: the beneficiary is not able to tolerate a positive airway pressure (PAP) device; or the treating physician determines that the use of a PAP device is contraindicated.
The patient had poor concentration and memory, chronic fatigue and severe daytime somnolence. The patient had an AHI of 4 and an RDI of 10.  Although the patient could not utilize CPAP, the literature did not support treatment for patients with an AHI less than 5 or RDI of 10.  Therefore, the healthcare plan acted reasonably, and with sound medical judgment, and in the best interest of the patient.  The obstructive sleep apnea appliance is not considered medically necessary for this patient.

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

This is the case of an otherwise healthy female who presented to the emergency department (ED) with vomiting and diarrhea for the past 2-3 days. She had low-grade fever to 100.2 F. She was seen at the primary medical doctor (PMD) and given Zofran, but symptoms continued despite outpatient use. She was sent to the ED by the PMD due to continued vomiting with oral trial.

Vital signs in the ED were T 35.7 C, heart rate (HR) 154 (while crying), weight 11.7 kilograms (kg). She is described as active with moist mucus membranes, non-toxic appearing and in no distress. The last diaper was 45 minutes prior to ED arrival. The patient was noted to be vomiting in triage. Labs were notable for sodium (Na) 136, chloride (Cl) 96, carbon dioxide (CO2) 14, blood urea nitrogen (BUN) 19, creatinine (Cr) 0.3, blood glucose (BG) 48. Urinalysis (UA) had specific gravity (SG) 1.015 with large ketones and otherwise negative. She received normal saline (NS) bolus x 2 and dextrose 10 % (D10) bolus x 2 for dehydration and hypoglycemia, respectively. The child was taking sips of milk and tolerative cheerios while in the ED. She was admitted to the hospital overnight and was discharged home the next day.

The health plan's determination is upheld.

No, the inpatient admission is not medically necessary. This 18 month old patient was seen in the ED for dehydration and hypoglycemia secondary to gastroenteritis. She received IVF while in the ED and showed improvement of her symptoms, was able to tolerate oral intake while still in the ED. Thus, this patient with stable vital signs and improved clinical condition could have been safely cared for at a lower level of care status.