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

Diagnosis: Periodic paralysis
Treatment: Whole exome sequencing 
The health plan should not cover the whole exome sequencing, per below. 

The patient does not have any of the emblematic features of periodic paralysis on diagnostic testing to date. Specifically, there are no findings on muscle biopsy to support the diagnosis. There are no findings on routine laboratory resting during an attack to support the diagnosis. She has had two provocative exercise tests which have been negative. Moreover, there is no family history of this condition and she has undergone screening for known gene mutations related to this condition, which was also negative. Finally, she did not respond to potassium replacement during the attacks either. Overall, there is no evidence to support the underlying diagnosis to date for the genetic testing that has been requested and the exome sequencing would not change management even if it identified a candidate genetic loci.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Periodic paralysis
Treatment: Whole exome sequencing 
The health plan should cover the whole exome sequencing.

The patient clinically has a severe case of periodic paralysis (severe episodic muscle weakness). The standard clinical, biochemical and genetic testing for periodic paralysis did not yield. The patient had all the possible tests for periodic paralysis available including muscle biopsy. Therefore, there are no standard treatments or testing remaining for the patient's condition. Essentially, the patient receives supportive care only. Medical literature documents that there are multiple cases of periodic paralysis syndromes related to mutations that are only detectable by whole exome sequencing. In some of those cases, the specific detection of a mutation provides information leading to improved management (references 1-4). Therefore, in the patient's case, the requested whole exome sequencing is likely to be more beneficial than the remaining treatment options, such as supportive care only.
Appeal type: Medical necessity
Decision: Upheld

Hypertension/High Blood Pressure
Inpatient hospital

The patient is a woman with a recent diagnosis of hypertension who presented with a seven out of 10 headache. She reported throbbing pain that was diffuse and non-radiating. She denied nausea, vomiting, diarrhea, numbness and tingling. Initial blood pressure was 214/138. Review of systems was negative for fevers and chills. Social history was notable for no smoking. Vital signs showed blood pressure 155/92, heart rate 98, and temperature 36.8 Celsius. Labs showed creatinine 1.6, sodium 142, potassium 3.9, calcium 9.5, white blood cell (WBC) 11.9, hemoglobin 13.2, and platelets 279. Head computed tomography (CT) was negative for hemorrhage or other acute findings. She was given intravenous (IV) beta blocker and IV hydralazine in the emergency department. The patient was admitted for hypertensive urgency/emergency. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had significantly elevated blood pressure in the setting of hypertensive urgency, but she had no evidence of cerebral infarct or hemorrhage, no evidence of acute kidney injury related to the hypertension, cardiac ischemia, and no other acute ongoing diagnoses such as sepsis or seizures. Overall, she could have safely and effectively been managed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a male patient with a long history of chronic pancreatitis. He was evaluated at a gastroenterology allergy clinic. The patient was noted to have idiopathic chronic pancreatitis that needed to be further evaluated. Recommendation was made for genetic testing. It was reported that the patient's disease had progressed.  He continued to have chronic abdominal pain but refused to take narcotic medication. The patient underwent DNA sequencing that did not reveal any positive results. 

Based on the review of the medical record, literature support genetic testing as a standard of care for this patient's workup for his longstanding, idiopathic chronic pancreatitis. The literature indicates that hereditary pancreatitis is a genetic condition characterized by recurrent episodes of inflammation of the pancreas. The literature indicates that pancreatic fibrosis leads to the loss of pancreatic function in many affected individuals, such as insulin production, and develop secondary diabetes. Genetic testing is an appropriate option for this patient in an attempt to identify hereditary pancreatitis, and prevent the complications associated with it.  

The genetic testing is likely to be more beneficial than any of the standard treatment/ procedures for this patient. 

The carrier's denial of genetic testing is reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Idiopathic Pancreatitis 

Treatment: Genetic Testing

The insurer denied the genetic testing. The denial was reversed.   

This is a patient with a diagnosis of chronic idiopathic pancreatitis. It was reported that the patient has been experiencing abdominal pain for several years and there has been no identifiable etiology for his chronic pancreatitis.

Up-To-Date has an article titled "Hereditary pancreatitis". The article states that the diagnosis of hereditary pancreatitis is based upon the clinical history and/or genetic testing in patients with recurrent acute or chronic pancreatitis. The article states that patients without a clear family history may initially be thought to have idiopathic pancreatitis and genetic testing becomes the basis of the diagnosis in symptomatic patients. The article states that genetic testing is medically necessary for the evaluation of patients with idiopathic acute or chronic pancreatitis after the major causes such as gallstones, alcohol, duct obstruction and medications have been excluded.

The scientific literature supports the use of genetic testing in chronic idiopathic pancreatitis. The test kits for genetic testing have FDA approval. Since the patient had idiopathic pancreatitis, this patient was a good candidate for this genetic testing. It was an important part of the workup for idiopathic pancreatitis because it was important for the patient to know whether or not the patient had hereditary pancreatitis as this diagnosis carries an increased risk for pancreatic cancer.

The genetic testing is likely to be more beneficial than any of the standard treatment/ procedures for this patient. 

The carrier's denial of genetic testing is reversed.
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 male patient with a history of hypertension, congestive heart failure, hyperlipidemia, transient ischemic attack, sepsis, hypothermia, anxiety, alcohol abuse, and right hip replacement. He presented to the Emergency Department (ED) with complaints of chest pain and high blood pressure. Cardiology consulted on the patient.   It was reported that the patient had walked from another hospital after being discharged. An electrocardiogram was performed that revealed normal sinus rhythm with sinus arrhythmia. Troponin levels were drawn with negative results. The patient was negative for an acute coronary syndrome and was discharged.

This patient presented with chest pain and a history of hypertension.  Utilizing the HEART score, he was considered low risk (3 points).(1)  Utilizing the Thrombosis in Myocardial Infarction (TIMI) risk score, he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1).(2) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al.(2)  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  Ultimately, this patient underwent myocardial perfusion imaging that revealed no evidence of ischemia- confirming the aforementioned low risk stratification.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.  It was reasonable to treat the patient at a lower level of care.  

The health plan acted reasonably, 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

This is a patient with lupus and rheumatoid arthritis (RA). Her lupus and RA is now well controlled and she is having frequent flares in the form of pain involving her hands, knees, back, neck and elbows, as well as hair loss and oral ulcers. Prior treatment included: Plaquenil, prednisone oral methotrexate (MTX), and Fioricet. She has been on by mouth (po) MTX , which has been effective, but it is causing gastrointestinal (GI) side effects. The issue in this case is the medical necessity of Rasuvo (a brand name form of pre-filled subcutaneous (SQ) MTX).
Question(s):
The health plan's determination is upheld.
There is no medical reason why the patient cannot prepare and administer the generic injectable MTX. Per the rheumatology note on , the musculoskeletal (MSK) exam showed edema and tenderness but no loss of function or limited mobility. Although switching to injectable MTX is a reasonable next step in the management of this patient's lupus and RA, there is no reason that she cannot try the generic injectable MTX, which is not inferior to Rasuvo.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection (UTI)

Treatment: Inpatient admission 

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

This patient is a female with history of arrhythmia, irritable bowel syndrome (IBS), Crohn's disease, renal stones, Lyme disease, urinary tract infection (UTI), obesity and history of laparoscopic gastric restrictive procedure. The patient presented to the Emergency Department with complaint of left flank pain for several weeks; the patient also complained of fever and vomiting. The patient was on oral antibiotics for a recently diagnosed urinary tract infection without relief. The CT pelvis two days prior to the ED visit was negative for calculi.  The Emergency Room (ER) triage vital signs were: temperature of 99.10F, heart rate 103, and blood pressure 121/59. The patient was given intravenous (IV) fluids and IV antibiotics, and was prescribed Toradol / Morphine to control her flank pain. The patient was admitted and urology / infectious disease consultations were obtained. The CT scan / Kidney, Ureter, Bladder (KUB) were negative for renal/ureteral stones. The patient was medically stabilized and discharged to home with instructions for outpatient follow-up care. The insurer has denied coverage for the inpatient admission.

Per MCG Health (23rd Edition) Urinary Tract Infection (UTI) RRG, the patient fails to meet clinical indications for admission to inpatient care. The patient also fails to meet clinical indications for admission to inpatient care per MCG Health (23rd Edition) Urologic Disease GRG under subsection "Urologic infection requiring inpatient care."

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered medically necessary for this patient. The insurer's denial of coverage for inpatient admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Abscess/Infection
Dental/Orthodontic Procedures

This patient had an odontoma that was protruding through the mucosa in the maxillary anterior, which was removed with general anesthesia. The patient had a pathologic lesion that required removal. 

The health plan's determination is overturned. Removal of Odontogenic Cyst or Tumor and Anesthesia is medically necessary for this patient.
Odontomas represent the most common type of odontogenic jaw tumors among patients younger than 20 years of age. Clinically, they are often associated with eruption failure of adjacent permanent teeth. Radiographic examination is essential to verify the presence of the tumor and early removal prevents tooth eruption failure and disturbances in a majority of the cases. The decision to use sedation/general anesthesia for a particular dental procedure should only be determined by considering the needs of the patient, the requirements of the operating dentist and the effect on the quality of the dental treatment. The provider has determined that it is needed in this particular case. Removal of the lesion is the standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neuropathic pain

Treatment: Inpatient admission

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

This patient is a female with several medical conditions including breast cancer, leukemia, heart disease and arrhythmia.  She was admitted to the hospital with severe pain in the right leg, radiating.  She was admitted and received steroids, neurology consultation and transfusion.  She required intravenous (IV) Dilaudid.  She was treated for neuropathic pain and required Tacrolimus.  She required ongoing Dilaudid IV.  She received physical therapy (PT), occupation therapy and rehabilitative medicine consultations.  Her pain gradually improved and she was discharged.

The admission was medically necessary for this patient.  The medical record demonstrates several significant factors to substantiate admission and length of stay.  This patient recently had undergone a bone marrow transplant.  She recently was admitted to the hospital for severe pain.  She had a history of AML (leukemia) and breast cancer and was on immunosuppressive therapy (Tacrolimus).  Her condition had not improved since her last stay. 

She reported severe pain requiring Morphine and intravenous Dilaudid.  Due to her immunocompromised condition, it would be essential to define a pain generator.  Her response to normal pain producing stimuli would be abnormal.  She required diagnostic testing and monitoring.  She was found to have anemia which required transfusion.  She was evaluated by several sub specialists with their recommendations.  She required steroids. 

The combination of her underlying morbidities and current clinical condition thus required the admission and length of stay.  The services provided (consultations, IV analgesia, IV steroid, monitoring for immunocompromised condition) could not have been completed on an outpatient basis.  There were several extenuating circumstances to substantiate her admission and course of care. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.  The inpatient hospital admission is considered medically necessary for this patient.

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion 

Treatment: Braces (D8080) and Monthly Visit (D8670)

The insurer denied coverage for Braces (D8080) and Monthly Visit (D8670). The denial was upheld.

This patient is a female who patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, maxillary and mandibular crowding and has recommended orthodontics. The orthodontist has completed the HLD index attaining 23 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements having attained a score of 23 points on the HLD index.

It is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 23 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 23 points on the HLD index (4 overjet, 3 overbite, 10 anterior crowding and 6 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note is in this case, the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies, cited below. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

In this case the patient's own orthodontist completed HLD index total score of 23 points remains below the threshold of 26 points to justify orthodontic care. 

The braces (D8080) and monthly visit (D8670) was not considered medically necessary for this patient. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the Braces (D8080) and Monthly Visit (D8670) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath and lightheadedness
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient is a female with history of COPD (chronic obstructive pulmonary disease). She presented to emergency room with worsening shortness of breath and lightheadedness. 

The patient was found to be in COPD exacerbation. After receiving treatment with nebulization and steroids, the patient was admitted to acute in hospital stay for continued IV steroids and frequent nebulization treatments. The patient also had pre syncope during emergency evaluation and required telemetry and blood pressure monitoring.  The patient left against medical advice (AMA) from the hospital.

Since the patient's condition improved with emergency room care, the acute inpatient level of care does not meet medical necessity. The observation level of care would have been as effective in this case. 

The patient required observation for the pre-syncope episodes on telemetry as well as treatment for COPD exacerbation.  The vitals were stable, and the patient was speaking in full sentences. The blood work was with in normal range.  The patient was tolerating oral diet.  The acute inpatient level of care was not medically necessary.  The observation level of care would have been as safe and effective as acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe left temporal brain hemorrhage

Treatment: Air ambulance transfer 

The insurer denied coverage for Air ambulance transfer. The denial was reversed.

This patient is a woman who suffered a severe left temporal brain hemorrhage while on vacation out of her home state. The hemorrhage was caused by cerebral venous thrombosis, likely related to the patient's use of oral contraceptives, but this was not recognized at the out-of-state hospital, which did not have an MRI, neurologic intensive care unit nor on-site neuroradiology.  The venous sinus thrombosis was recognized and treated with anticoagulation only after she was transferred to a hospital in her home state. The insurance company denied air ambulance transfer.
	
The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient suffered a serious neurologic event while on vacation. This patient was intubated, with recently unstable vital signs and autonomic storming, unresponsive, with external neurosurgical hardware in place.  She clearly met criteria for emergency air transport (Thomas, et al., 2014).

The bigger question is, was it medically necessary that she be transported? The answer is yes.  The insurance company did not provide any closer Neuro ICUs.  The two in-network hospitals in a neighboring state that were suggested do not appear (based on their websites) to have neuro ICUs.  In addition, the husband's contention that she should be transported closer to, not farther from, her home is reasonable.

It was medically necessary to transfer the patient to a neurological ICU.  She was (by report) in a medical ICU at the out-of-state hospital and this did not provide her with adequate care in that a treatable venous sinus thrombosis was not recognized.  She needed both neurologic expertise and technical resources such as the MRI machine that ultimately led to the correct diagnosis. This issue is easy to address: even without the out-of-state hospital's documentation. The later hospital's documentation makes it clear that she required a higher level of care than was available at the out-of-state hospital. This is because the out-of-state hospital lacked necessary equipment (MRI) and expertise (Neurology/Neurosurgery Intensivists and Neuroradiology) to make the correct diagnosis of venous sinus thrombosis.
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the Air ambulance transfer is substantiated.  The insurer's denial is reversed.