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

Diagnosis: Chest Pain 
 Treatment: Inpatient Admission 

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

This is a female patient with a history of atrial fibrillation status post ablations, chronic chest pain, asthma, migraines, liver masses, seasonal allergies, status post sleeve gastrectomy, and status post cholecystectomy. She presented to the Emergency Department (ED) with complaints of chest pain. It was reported that she had recently been evaluated by Pain Management and received a trial of gabapentin and cyclobenzaprine. She was admitted and monitored on telemetry. She underwent a computed tomography (CT) scan of the chest that was negative for a pulmonary embolism. Cardiac biomarkers were drawn with negative results. She had an echocardiogram that was unremarkable. Her symptoms improved and she was discharged home. 

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 were 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 health care 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: Dental Problems
Treatment: Dental/Orthodontic Procedure
Denied: braces
Denial: UPHELD in whole

The patient is a female with a Class II occlusion and deep bite. The maxillary arch has spacing due to missing 4 and 13, and the mandibular arch has moderate crowding. She is treatment planned for 24-30 months of orthodontics with extraction of a mandibular incisor to correct her malocclusion. The subject under review is the medical necessity for the treatment.

The health plan's determination is upheld in whole.

The patient has maxillary spacing and mandibular crowding. Her bite is deep but there is no indication of damage to the incisors or the palate, and her cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs there is severe soft tissue damage (or any soft tissue damage) on this patient.

There is no medical reason to correct her malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are many ways to correct patients with a deep bite, and there is strong evidence that one treatment is not better than another.1 Deep bites may be corrected in adulthood, the patient does not lose the ability to correct her malocclusion should she choose to do so as an adult.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension and aortic stenosis

Treatment: inpatient transcatheter aortic valve replacement (TAVR)  

The insurer denied coverage for inpatient transcatheter aortic valve replacement (TAVR). The denial is reversed. 

This patient is a female with a history of hypertension and aortic stenosis. She has severe calcific aortic valve stenosis, with symptoms of syncope. She was found to be low perioperative risk for open heart surgery. She was referred for transcatheter aortic valve replacement (TAVR). She was being followed at a valve center in Canada, and presented for a second opinion office visit with an interventional cardiologist. 
The health care plan did not act reasonably with sound medical judgement in the best interest of the patieny. The current scientific evidence that has shown low-risk patients do better with transcatheter aortic valve replacement compared with surgical aortic valve replacement.

The patient has severe aortic stenosis with low surgical risk. Low risk patients have been shown to have better outcomes with TAVR compared with surgical aortic valve replacement. The medical policy is not current and does not reflect the current state of scientific knowledge in this subset of patients requiring aortic valve replacement. In a study of 1403 patients who had TAVR  Popma, et al. concluded that "In patients with severe aortic stenosis who were at low surgical risk, TAVR with a self-expanding supraannular bioprosthesis was noninferior to surgery with respect to the composite end point of death or disabling stroke at 24 months."

Similarly Mack, et al. in a study of 1000 pts undergoing TAVR the authors concluded that "Among patients with severe aortic stenosis who were at low surgical risk, the rate of the composite of death, stroke, or rehospitalization at 1 year was significantly lower with TAVR than with surgery." 

Based on the data from the references below, the TAVR procedure is appropriate, medically necessary, and should be covered for this patient.

Based on the above, the medical necessity for inpatient transcatheter aortic valve replacement (TAVR) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Abnormal Echocardiogram
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The denial is upheld.

The patient has a history of hypertension, hyperlipidemia and nephrolithiasis. Patient presented to the emergency department complaining of two days of flank pain, was afebrile. Urinalysis showed 4-5 white blood cells per high power field. It was negative for nitrites and leukocyte esterase. The patient's white blood cell count was 12.5.  A computed tomography (CT) scan showed left hydronephrosis and a stone in the distal left ureter. Patient was admitted to the hospital and treated with Rocephin. An echocardiogram was performed for evaluation of a systolic murmur. This showed a 2x2 centimeter (cm) mass on the anterior mitral leaflet with mild to moderate mitral regurgitation. The patient was transferred to another facility for workup of the mitral valve mass. Upon transfer the patient denied pain and had not had any pain medication since recently. Upon admission to the second facility blood pressure was 140/80 millimeters of mercury (mmHg) with a heart rate of 86 beats/minute. Patient was afebrile. A repeat echocardiogram was performed. This showed dynamic left ventricular outflow tract obstruction suggestive of hypertrophic cardiomyopathy. The "mass" was thought to represent thickened mitral valve chordae. The patient underwent cystoscopy and placement of a ureteral stent. The procedure was uncomplicated. 
The reason for the patient's transfer to the second facility and subsequent inpatient admission there was for evaluation of the abnormal echocardiogram. The initial study showed what appeared to be a mass on the mitral valve and was later deemed to be thickened mitral valve chordae. The patient was also diagnosed with hypertrophic cardiomyopathy.  The patient had no cardiac symptoms and was hemodynamically stable and in normal sinus rhythm. There was no evidence of congestive heart failure. While preoperative evaluation was certainly necessary, it did not require a hospital admission. Likewise, from the records provided, it is not evident that inpatient admission was warranted based on the patient's nephrolithiasis. There is no documentation of infection, intractable pain or vomiting, bilateral obstruction or an inability to take oral fluids.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain; Vomiting
Treatment: Inpatient admission

Determination:
The insurer denied Inpatient admission. The health plan's denial is upheld.

The patient is an adult male. He has a history of hypertension and latent TB (tuberculosis). The patient was started on INH (Isoniazid) as treatment six months before this presentation. The patient also had a history of chronic pancreatitis and chronic alcoholism. He presented to the ED of the facility filing the appeal after three days of alcohol use. He noted abdominal pain, nausea and emesis. The pain was severe and radiated to the back. The patient also had a headache. 

The patient was admitted, and he received IV fluids and supportive care. His vital signs were within acceptable limits. His laboratory values as noted did not reflect severe abnormalities. The patient refused alcohol rehabilitation. 

While the treatment provided to the patient was medically appropriate, the level at which this care was delivered was not medically necessary. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain from chronic pancreatitis with acute alcohol ingestion; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level in its entirety.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Blood Disorder 
Treatment: Pharmacy/Prescription Drugs 

This is a female with a right lower extremity popliteal deep vein thrombosis. The patient is stated to be intolerant to Xarelto (headaches) and Eliquis during a trial while being treated for a previous thromboembolic event. She is stated to have an "allergy" to these medications but multiple notes state "no known drug allergies." 

The health plan's determination is upheld. 

The included documentation does not definitively clarify whether the patient has an allergy to Eliquis and Xarelto - nor what the allergies were. One note indicates that the patient could not tolerate Xarelto due to headaches. However, the patient is not stated to have an allergy to warfarin. "...While the factor Xa and thrombin inhibitors are preferred..." by the authors of UpToDate, they support the benefit of warfarin in this clinical scenario and the patient has no contraindications to this agent. They go on to state that "...Because individual patients perceive burdens differently, patient's values and preferences are particularly critical in selecting a long-term agent for anticoagulation in acute deep vein thrombosis (DVT)....". There are a multitude of approved formulary choices, there is no evidence that should the patient take a formulary option she would receive a less effective or more toxic agent.
Appeal type: Medical necessity
Decision: Overturned

Primary Diagnosis: Mental health/Depression 
Primary Treatment: Pharmacy Prescription Drugs 

The patient diagnosed with severe major depressive disorder and a history of treatment refractory depression with treatment failure with multiple medication trials. The patient is diagnosed with psychiatric co-morbidity with an unspecified eating disorder and co-occurring alcohol use disorder in full remission. The patient is receiving medication assisted treatment with Vivitrol. The issue under review is the medical necessity of the medication Spravato. The health plans determination of medical necessity is overturned in whole. 

Yes, the requested health service, Spravato for treatment refractory, major depressive disorder, is medically necessary for this patient. 

The requested service of Spravato is in keeping with prevailing standards of medical practice for the condition under treatment in this case with an evidence-base treatment; and, the requested services/treatment being provided in this case are clinically appropriate, and are backed by credible scientific evidence known to benefit patients with the condition diagnosed in this case. 

The request for Spravato is reasonable and in the best interest of the patient who has failed to benefit from other standard treatments for major depressive disorder. There is no contraindication in this case, including a past history of alcohol use disorder. The FDA approval for Spravato does not reference contraindications for the use of this augmentation strategy to address major depressive disorder. Augmentation strategies are noted in national guidelines for the treatment of refractory major depressive disorder. Per the Food and Drug Administration (FDA): Spravato for Treatment Resistant Depression is Indicated in conjunction with an oral antidepressant for treatment-resistant depression (TRD).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cutaneous melanoma
Treatment: Decision Dx-Melanoma 
The insurer denied the Decision Dx-Melanoma.  The denial us upheld.
The DecisionDx-Melanoma test was not medically necessary.

The patient is a male.  He has been diagnosed with a 0.5 millimeter (mm) melanoma of the left instep.  DecisionDx testing was done. 

Gene expression profile signature (DecisionDx-Melanoma) to predict visceral metastatic risk in patients with stage I and stage II cutaneous melanoma is currently not standard of care in the management of cutaneous melanoma and is considered unproven.

The NCCN Guidelines for Melanoma version 1.2020 (accessed at https://www.nccn.org/professionals/physician_gls/pdf/cutaneous_melanoma.pdf) do not recommend Decision-Dx Melanoma in the work up of any stage of cutaneous melanoma.  Per the guidelines, gene expression profile signature (DecisionDx-Melanoma) to predict visceral metastatic risk in patients with stage I and stage II cutaneous melanoma is currently not standard of care in the management of cutaneous melanoma and is, therefore, not considered medically necessary. 

To date, there is a paucity of evidence in the peer-reviewed published medical literature evaluating the clinical utility of the DecisionDx-Melanoma test.  The National Comprehensive Cancer Network (NCCN, 2014) Clinical Practice Guideline (CPG) in Oncology recommendations for the clinical staging and workup of melanoma (principles of pathology), states:  While there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low- versus high-risk for metastasis, routine (baseline) genetic testing of primary melanomas (before or following sentinel lymph node biopsy [SLNB]) is not recommended outside of a clinical trial. 
 
In summary, there is insufficient evidence to evaluate the clinical validity and clinical utility of the DecisionDx-Melanoma test.  Additional study is required to further validate if gene expression profiling of cutaneous melanoma will accurately identify which individuals are likely to have aggressive disease and how the results of testing would alter treatment plans and improve health outcomes in the surveillance and treatment of high-risk cutaneous melanoma.  At this time, it is considered unproven and not known to improve health outcomes.  The consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, is efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.  Thus, it is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache/blurred vision.  
Treatment: Inpatient stay. 
The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a woman with a history of a herniated cervical disc who presented to the emergency department with a headache and visual disturbance.  She stated that she lost her vision for half an hour on the day prior to presentation.  In addition, she reported vertigo and nausea.  She denied chest pain, shortness of breath, fevers and weakness.  She was admitted to the hospital. 

The inpatient stay was not medically necessary.  The patient presented with a headache and visual disturbance but had negative imaging for an acute stroke and no evidence of seizures or other acute neurologic abnormalities.  She did have evidence of cervical disease, but a head CT was negative, and laboratory studies were unremarkable.  In addition, the second head CT that she underwent after admission was negative.  Because there was no evidence of acute stroke, spinal cord compression, brain mass, sepsis, or other acute diagnosis, the inpatient stay was not necessary for treatment of her condition.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse
Inpatient Hospital Stay

This patient with a past medical history of polysubstance use with alcohol, heroin, marijuana, and benzodiazepines, also on suboxone with last use several days prior, in addition to anxiety,  presented to the emergency department  with alcohol withdrawal after being evicted from friend's house. On presentation to the emergency department, patient was afebrile with blood pressure 135/96, heart rate 67, respiratory rate 18, sat 97% on room air. Exam otherwise noted dilated pupils. Labs showed white blood cell count (WBC) 8.16, Hemoglobin (HGB) 13, Platelets 304, sodium 147, potassium 4, blood urea nitrogen (BUN) 10, creatinine 0.8, aspartate aminotransferase (AST) 43, alanine aminotransferase (ALT) 31, and alcohol level of 281.3. Urine drug screen was positive for tetrahydrocannabinol (THC). Clinical Institute Withdrawal Assessment (CIWA) score was 9 in the emergency department. Patient was seen by psychiatry in the emergency department, given an initial report of suicidal and homicidal ideation and was cleared for discharge. The patient was brought into the hospital with concern for alcohol withdrawal and plans for intravenous (IV) fluids, CIWA protocol, thiamine, folic acid, and laboratory monitoring. 2 days after presentation the patient was noted to have a CIWA score of 15.  was alert and oriented. The patient wanted to leave and was deemed to have capacity to leave against medical advice. The health plan's determination of medical necessity is upheld in whole. The inpatient stay was not medically necessary. This patient presented with mild alcohol withdrawal with a CIWA of 9 in the setting of no known prior history of seizures or delirium tremens during withdrawal. It was reasonable to observe the patient on the medical unit at a lower level of care with CIWA protocol, IV fluids, thiamine and folate, and observation for the development of new symptoms such as changes in mental status. It is noted, however, that the patient remained alert and oriented throughout  hospitalization without ongoing nausea, vomiting, or inability to take oral medications. The maximum CIWA score was 15. Though ongoing observation was recommended on the last day, the patient wanted to leave and was deemed to have the capacity to leave against medical advice. It is unclear why this patient with concerns for mild alcohol withdrawal, CIWA scores of 9-15 with a normal mental status, no reports of ongoing nausea or vomiting, and without any other concurrent medical issue, required care at the inpatient level of care and could not have been safely treated at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/gastrointestinal
Inpatient Hospital

Diagnosis: diverting loop ileostomy
treatment: Inpatient hospital stay. The insurer denied the inpatient stay. 
The denial was overturned. 

This is the case of a male with a history of a Hartmann's procedure with diverting loop ileostomy. He underwent successful closure of his ileostomy. He was admitted as an acute inpatient. His diet was advanced while awaiting return of bowel function. The patient had full return of bowel function and was discharged home. Under review is the inpatient level of care.

The inpatient stay was medically necessary. This patient underwent closure of his enterotomy. This is on the Medicare list of inpatient procedures, under CPT code 44620, repair of bowel. It is standard of care to admit a patient when there is a closure of an enterostomy. Closing an enterostomy entails an anastomosis from one end of the bowel to another. In the postoperative period, it is standard of care to admit these patients to an inpatient setting to observe for possible leaks from the anastomosis and to await return of bowel function. Additionally, the patients often don't tolerate a diet. When closing an enterostomy, there is a connection between the proximal bowel, which is in continuity with the digestive system, and the distal bowel, which has been in discontinuity since the diverting ostomy was created. Oral food intolerance can be an issue, as that bowel than was in discontinuity has not been receiving enteric contents since the time of diversion. Furthermore, in this case, where the diverting ostomy was created to protect the colonic anastamosis downstream, there are now 2 untested anastomoses to protect. This most certainly is a case requiring an inpatient level of care and is not an ambulatory surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations.  Treatment: Inpatient hospital stay.  The insurer denied the inpatient hospital stay.  The health plan's determination is upheld. 

The patient is a man with a known history of chronic cardiomyopathy, class II systolic congestive heart failure (CHF), nonischemic cardiomyopathy ejection fraction (EF) 20 to 30%, nonobstructive coronary artery disease, diabetes, left inguinal hernia, pericarditis, pneumonia, and cardiac catheterization, who showed prior mid left anterior descending (LAD) stent patent, left circumflex mild irregularities less than 30%, and right coronary artery (RCA) mild irregularities.  He presented to the hospital complaining of on-and-off palpitations. 

The inpatient hospital admission was not medically necessary.  The patient has a known history of nonischemic cardiomyopathy, hypertension, hyperlipidemia, diabetes, EF 25 to 30% and presented with benign symptoms of palpitations/near syncope.  There was no loss of consciousness and no acute ischemic changes noted.  There were no signs of volume overload, and he was hemodynamically stable.  The patient underwent an EP study, which showed inducible VT, which was induced with isoproterenol infusion.  He underwent an ICD implantation for primary prevention of sudden cardiac death.  There were no immediate complications noted, and he was subsequently discharged home.  All of the patient's care could have been done at a lower level.