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

Diagnosis: Primary Immunodeficiency
Treatment: Genetic Testing (81479)
The insurer denied the Genetic Testing (81479)
The denial is upheld.

This patient is a male child. He has a history of fever and recurrent infections. There is concern for immune deficiency versus periodic fever syndrome.  The patient has required several courses of antibiotics. 

The request is for genetic testing (81479) for primary immunodeficiency (PID).

The proposed genetic testing is not medically necessary.

This is a patient with hypogammaglobulinemia.. 

Per Rohan Ameratunga et al (1), while they advocate that all patients with common variable immunodeficiency disorders (CVID) should be routinely offered diagnostic genetic testing, this has not yet similarly been advocated by the practice guidelines by Bonilla et al (2) for the diagnosis of common variable immunodeficiency. Additionally, the authors do admit limitations in testing including presence of variants of unknown significance (VUS), de novo pathogenic mutations in databases, etc.

While the patient has hypogammaglobulinemia, it is unclear how additional testing would specifically change his treatment course. Therefore, this would not be medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Increased spit-up with poor weight gain - rule out pyloric stenosis. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is a male infant. He was born without complication. The patient presented to the emergency room for concern of increased spit-up with poor weight gain, and a concern for pyloric stenosis. The patient was subsequently admitted for a workup of pyloric stenosis versus gastroesophageal reflux. 

The Inpatient Hospital Admission was not medically necessary. 

The patient did not necessarily need to be admitted for this concern. The patient could have had the ultrasound as well as the electrolyte evaluation done in the emergency room or even an outpatient setting. The patient had demonstrated a good linear growth with poor weight gain. However, with reflux, a patient can have decreased weight gain. There is no assessment of calories per day noted. There is no documentation of urine output. There is no documentation of a patient that is having projectile emesis with continued hunger after said emesis. As there is no sign of clinical deterioration or concern for rapid deterioration, admission was not medically necessary. The work 
up for pyloric stenosis did not require an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department following a fall down 12 stairs. There was a reported transient loss of consciousness. Comorbid health conditions included chronic back pain. His complaint at the time of presentation was that of right low back pain and hip pain. His vital signs were normal at presentation and the Glasgow coma score was 15. An imaging evaluation identified no acute fractures, intracranial, intrathoracic or intra-abdominal injury.
He was admitted to the hospital. Consultations were obtained from neurosurgery and the trauma service. The patient reported pain and tingling in the legs (right greater than [>] left). A magnetic resonance imaging (MRI) scan of the lumbar spine was obtained showing mild disc degeneration with paracentral herniation at lumbar (L) 4-5 with impingement of the right L5 nerve root. The neurosurgical recommendation was for a short course of oral steroids, pain management, and a physical therapy assessment. It was determined that there was no need for surgical intervention per the neurosurgery service. Outpatient neurosurgical follow up was arranged. The patient had normal vital signs. The patient was discharged to an acute rehabilitation facility. At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was not medically necessary for this patient. The care and treatment provided in this case could have been rendered with a lower level of care, which would have permitted the necessary consultations, provision of pain medication and oral steroids, clinical monitoring including overnight stay and physical therapy.
The patient was clinically stable with normal vital signs at the time of presentation. He was tolerating a diet and pain control was provided with oral medications. It was determined that there was no need for acute surgical intervention.
Inpatient admission may be required when there is a newly diagnosed or suspected bone, joint or orthopedic device infection, fracture, dislocation or other musculoskeletal injury that requires inpatient care, severe rheumatologic disease, severe vasculitis, severe crystal arthropathy, rhabdomyolysis, severe myopathy, post-amputation complication, severe pain requiring inpatient management, or other musculoskeletal condition for which emergency and observation care have failed. In this case, none of the above condition existed to justify inpatient admission.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Urothelial Cancer. 
Treatment: FoundationOne CDx and PD-L1 (Programmed death-ligand 1) testing. 

The insurer denied FoundationOne CDx and PD-L1 testing. 
The determination is overturned. 

The patient has urothelial carcinoma, status post cystoprostatectomy, disease invading into the rectum, prostate, seminal vesicles with 14/14 lymph nodes positive for metastatic cancer. Resection margins are positive for invasive carcinoma. The patient did not receive neoadjuvant chemotherapy due to the inability to receive cisplatin based treatment. Foundation One next generation sequencing (NGS)/molecular profiling and Programmed death-ligand 1 (PDL-1) testing was ordered by the treating physician to facilitate adjuvant chemotherapy/immunotherapy and future treatment options for clinically metastatic cancer and is under review. 
Next generation sequencing (NSG) testing (FoundationOne is one of the commercially available tests) and Programmed Death Ligand-1 (PDL-1) testing (Immunohistochemistry [IHC]) is now considered a standard of care practice in management of advanced and metastatic cancers such as bladder (urothelial/transitional cell) cancer. 

The National Comprehensive Cancer Network (NCCN) bladder panel recommends the molecular/genomic testing (NGS) to be conducted early, ideally at the diagnosis of advanced bladder cancer, to facilitate treatment decision making and to prevent delays in administering later lines of therapy. In addition to determining eligibility for Food and Drug Administration (FDA) approved therapies, molecular/genomic testing may be used to screen for clinical trial eligibility. (NCCN guidelines version 1.2022 for bladder cancer). Identification of mutation such as fibroblast growth factor receptor (FGFR), Kirsten rat sarcoma (KRAS), Neurotrophic Tyrosine Kinase (NTRK) genes will allow patients to receive FDA approved therapies targeting particular molecular alterations such as Erdafitinib, Entrectinib, Sotorasib. Micro-satellite instability (MSI) high and tumor mutational burden high (TMB high) tumor can receive FDA approved immunotherapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Urothelial Cancer. 
Treatment: FoundationOne CDx and PD-L1 (Programmed death-ligand 1) testing. 

The insurer denied FoundationOne CDx and PD-L1 testing. 
The determination is upheld. 

The patient was diagnosed with urothelial carcinoma, muscle invasive bladder cancer who underwent cystoprostatectomy and rectal surgery with ostomy. The pathology showed Stage III disease (tumor [T] 4 nodes [N]1 metastasis [M] 0).
The Foundation One CDX assay was ordered. At issue is whether Foundation One CDx Test and PD-L1 testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The proposed health service, Foundation One CDX and Programmed Death Ligand-1 (PD-L1) testing, is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
According to the National Comprehensive Cancer Network (NCCN) guidelines in the adjuvant or neoadjuvant setting, there are no molecular testing recommendations. In cases of metastatic disease then molecular testing can be considered in the choosing of systemic therapy options. Those include: PD-L1, fibroblast growth factor receptor (FGFR) 3, and FGFR2. Any other markers in addition to these are not recommended by the NCCN and are not supported by controlled clinical trials to offer any survival benefit over standard of care therapies based upon those markers as outlined by the National Comprehensive Cancer Network (NCCN). 

Therefore, according to NCCN guidelines, the use of the requested testing in this case is not likely to be more beneficial than any standard treatment(s).
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: human immunodeficiency virus (HIV)
Treatment: Juluca.
The insurer denied Juluca. 
The health plan's determination is upheld. 

The patient is a female with human immunodeficiency virus (HIV) infection, on Truvada and Isentress. The HIV viral load (VL) was < (less than) 20. She delivered baby girl. She had followup visit. The note states she will switch back to Juluca now, post-delivery. She was on Juluca prior to her pregnancy. Per the health plan, Juluca was denied as the patient can take the formulary medications.

A formulary exception is not indicated. Based on the provided records, there is nothing to indicate why this member cannot be treated with the formulary alternatives. She was successfully treated with Juluca prior to her pregnancy, and was changed to Truvada/Isentress during pregnancy, also with good response. She requested to change back to Juluca, but there is nothing to indicate that she had, or will have, any adverse effects, intolerance to, any of the formulary agents, or the formulary alternatives would be less effective or ineffective. There is no mention that she had genotyping or phenotyping in past, or that she had any resistance mutations detected previously that might render any alternative agent ineffective. As well, it appears she has been virally suppressed for a long period of time, therefore allowing for drug changes more easily than if she had no drug resistance mutations.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, hypertension, and dementia
Treatment: Personal care aides for 24 hours/day split shift (two 12-hour shifts), 7 days per week, for a total of 168 hours per week.
The insurer denied coverage for personal care aides 24 hours/day split shift (two 12-hour shifts), 7 days per week, for a total of 168 hours per week.
The denial is overturned.

This is an elderly patient with multiple medical problems including diabetes, hypertension, and dementia. He lives with his wife. The insurer approved Personal Care Aides (PCA) 7 days per week live-in but has provided only PCA 12 hours/day, 7 days/week. The request is for 24 hours/day split shift (two 12-hour shifts), 7 days per week, total of 168 hours per week, which is under review.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times." He is totally dependent for bathing, personal hygiene, dressing, locomotion and toilet transfer/use. He is frequently incontinent of bowel and bladder. Extensive assistance is needed for bed mobility and maximal assistance for eating. The patient has sustained multiple falls. The patient's medical condition: essentially total dependence for instrumental activities of daily living (IADL) and most of his activities of daily living (ADL) tasks are at a level or unpredictable as to require the requested PCA services 24 hours/day, 7 days/week (split shift). Based on the records reviewed, the currently approved 12 hours/day or a live-in PCA is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. In addition, and given his diagnosed progressive supranuclear palsy, the patient is at particularly high risk for additional falls and sustaining multiple fractures. The patient's health and safety are more appropriately provided and maintained at home with the requested PCA services 24 hours/day, 7 days/week split shift.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care aide (PCA) hours 7 days a week 2-12 hours a day split shift (168 hours per week) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Bilateral missing lower molars with supra-eruption of teeth #s 2-4. 
Treatment: Outpatient surgery (21206 x 2).
The insurer denied coverage for outpatient surgery (21206 x 2).
The denial is modified to allow right side segmental osteotomy.  

This patient is missing lower molars bilaterally. The patient is under the care of a dentist and oral and maxillofacial surgery (OMS). The patient has over erupted teeth 2-4. These three teeth are a fixed bridge. The entire bridge has over erupted. The treatment plan includes a segmental osteotomy to impact this segment allowing space for reconstruction of the lower arch with a partial denture. This request for outpatient surgery (21206 x 2) has been denied. 

To properly treat this patient space needs to be available for the reconstruction of the lower arch with a partial denture. in this case the fixed bridge touches the lower ridge. The best option includes the maintenance of these teeth and their impaction superiorly to gain space interocclusally. 

The outpatient surgery (21206 x 2) is not considered medically necessary; however, the outpatient surgery (21206 x 1) is considered medically necessary for this patient. 

The right posterior segment is the only segment that needs to be impacted. This is done from a functional standpoint to improve function by allowing room to place a lower partial. Therefore, the request for outpatient surgery (21206 x 1) is considered medically necessary for this patient. 

Shand, J.M., and Heggie A.A. (2016), "Among the well-established indications for undertaking segmental maxillary surgery are the management of an anterior arch length discrepancy and a narrow maxilla with posterior transverse discrepancy that can be resolved with surgical expansion. As the experience with orthognathic surgery techniques increased, together with the development of orthodontic expertise, segmental procedures were undertaken for specific occlusal or skeletal problems as part of a combined surgical/orthodontic treatment plan. In 1962, Wunderer described a modification of the Wassmund technique with the majority of the procedure being performed via a palatal approach. This helped to improve overall access whilst maintaining a broad buccal pedicle for perfusion. The Wassmund technique maintains more of the buccal and palatal mucosal pedicles, however the access provided results in a technically challenging procedure."        

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for outpatient surgery (21206 x1) services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Back Pain. 
Treatment: Intracept Procedure. 
The insurer denied coverage for codes 64628 x 1, 64629 x 1, Pain injection. 
The denial is upheld. 

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcomes for use of basivertebral nerve (BVN) ablation with the Intracept procedure to treat chronic low back pain. The publications to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. The Spine Society makes no mention of the Intracept procedure or ablation of the basivertebral nerve using radiofrequency. 

This patient is not a good candidate for intraosseous basivertebral nerve ablation. There are other evidence-based treatments available to this patient. This procedure is unlikely to be more beneficial than the standard approaches. The basivertebral nerve ablation procedure with the Intracept device is not the best available treatment for this patient based on the patient having no documented evidence of Modic changes at any level in the magnetic resonance imaging (MRI). Vertebrae were specifically discussed in the MRI report and there were no fracture, cortical destruction, or suspicious osseous lesions noted. 

In summary, the supporting publications to date have been mostly company sponsored, have had methodologic flaws, and were at risk for confirmation bias. UpToDate does not support the use of radiofrequency ablation for low back pain. The Spine Society makes no mention of the Intracept procedure or ablation of the basivertebral nerve using radiofrequency. Despite limited Food and Drug Administration (FDA) approval, there is no current Center for Medicare (CMS) approval for the use of the Intracept procedure. Without any MRI evidence of Modic changes or vertebral body bone marrow changes of any kind at any level, this patient would have been excluded from the INTRACEPT trial and therefore the Intracept procedure is unlikely to be more beneficial than standard treatments/procedures for this patient. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for codes: 64628 x 1, 64629 x 1, Pain Injection services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Lung Disease/COPD (chronic obstructive pulmonary disease)
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission
The health plan's determination is overturned.

The patient is a male with a medical history of hypertension, diabetes mellitus, sleep apnea, and oxygen dependent (2 liters per minute [LPM]) chronic obstructive pulmonary disease (COPD) who was admitted for an acute COPD exacerbation with symptoms of increased shortness of breath, increased sputum production, and wheezing. He was treated with intravenous Solumedrol, albuterol-ipratropium nebulizers, and antibiotics (Levaquin & Ceftriaxone). However, he continued to require more oxygen supplementation than his baseline.

At issue is the medical necessity of the inpatient hospital admission.

The health plan's determination of medical necessity is overturned in whole. The requested health service/treatment of Inpatient Hospital Admission was medically necessary for this patient.

Based upon the severity of illness and intensity of required therapy, the inpatient level of care was medically necessary. This patient with a medical history of hypertension, diabetes mellitus, sleep apnea and oxygen dependent (2 LPM) COPD was admitted for an acute COPD exacerbation with symptoms of increased shortness of breath, increased sputum production, and wheezing. On admission, although the patient was afebrile, hemodynamically stable, and did not have accessory muscle or a respiratory rate of (less than ) < 30 breaths per minute, he required 4 LPM to keep his oxygen saturation (greater than ) > 90 percent (%) and had wheezing bilaterally on auscultation of the chest. He was treated with intravenous Solumedrol, albuterol-ipratropium nebulizers, and antibiotics (Levaquin & Ceftriaxone). He remained afebrile and hemodynamically stable but continued to have bilateral wheezing and was still requiring 3 - 4 LPM of supplemental oxygen. Therefore, due to new/worsened signs and symptoms of COPD from baseline (shortness of breath/increased sputum production/wheezing) and hypoxia requiring an increased oxygen supplementation despite initial care, the admission was medically necessary at an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg Weakness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Overturned

The patient is a male who was admitted to the hospital. He was transferred by ambulance from an outside hospital for a higher level of care. The day prior to admission he noticed leg weakness, numbness and tingling after taking the trash out. He also developed difficulty with urination and defecation. The following morning, he was unable to walk without assistance. He had experienced back pain for the past week. He had not had any recent trauma or infections. His past medical history included asthma and cataract surgery on one eye following a soccer injury. His maternal grandmother had a history of Guillain Barre syndrome, and there was also a family history of Bell's palsy.

Magnetic resonance imaging (MRI) of the thoracic and lumbar spine showed diffuse root enhancement without enlargement of the cauda equina. The patient's strength, and ability to urinate and defecate improved during his hospital stay, and by discharge he was able to walk without assistance. He was to follow up in the neurology clinic within a week. The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is overturned. The requested inpatient hospital admission was medically necessary for this patient.

The patient presented with acute leg weakness, back pain, decreased perineal sensation, and difficulty with urination and defecation. These symptoms are suggestive of either a spinal cord lesion, such as spinal cord compression, transverse myelitis or cauda equina syndrome, or the acute onset of a demyelinating polyneuropathy (Guillain Barre syndrome). Several of these conditions, including spinal cord compression, transverse myelitis and Guillain Barre syndrome, have the potential to cause life-threatening decompensation, mandating inpatient monitoring following acute presentation of weakness. The MRI findings of diffuse root enhancement in the thoracic and lumbar region supported a diagnosis of Guillain Barre syndrome. Zuccoli et al. [1] note that in children "Enhancement of the cauda equina roots represents the neuroradiologic hallmark of Guillain Barre syndrome."

The patient fulfilled Milliman Care Guidelines (MCG) criteria [2] for inpatient admission as he had severe weakness on admission (he required one person assistance for walking). He was a fall risk. He also had difficulty urinating and defecating. He had the potential for life-threatening autonomic cardiorespiratory decompensation, including the need for intubation.