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

Diagnosis: Testicular cancer
Issue under review: PET/CT

Determination:
The PET/CT is not medically necessary.

For a residual mass under 3cm for pure seminoma with normal tumor markers, the NCCN does not recognize the role of PET/CT for disease management.  Per the NCCN, a patient such as this should be placed on surveillance, and there would be no role for PET/CT, as the patient's lymph node disease is all under 3cm.  

The AP's note that, "... given the substantial size of the lymph nodes, a PET scan is warranted to check fluorodeoxyglucose (FDG) activity," is not correct. Per the NCCN, PET/CT should only be performed if a residual mass is over 3cm. Per the NCCN, following completion of chemotherapy CT scans should be performed, and then, if a mass is over 3cm, then PET/CT can be performed. The NCCN does not base the use of PET/CT on the size of the original masses. This patient's residual LN was less than 3cm, and therefore would not support a PET/CT. Therefore, the 78815 - PET CT is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper quadrant pain, hepatocellular carcinoma
Treatment: Inpatient admission 

Summary:
In the hospital, the patient's pain was controlled with IV morphine. He tolerated the diet well and did not have any episode of vomiting. He also remained hemodynamic stable, and did not have episode of hemodynamic instability, no evidence of any infection. He was also seen by General Surgery and as per their opinion, the patient did not have any evidence of cholecystitis and did not require any surgical intervention. Given this clinical scenario, the patient could have been appropriately managed at the lower level of care, and acute level care was not appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stage I adenocarcinoma of the sigmoid colon

Treatment: FoundationOne CDx tumor marker panel

The insurer has denied coverage for FoundationOne CDx tumor marker panel. The denial was upheld.

This case involves a male patient diagnosed with stage I adenocarcinoma of the sigmoid colon.  The patient had a sigmoidectomy several years prior.  The patient was not compliant with his follow-ups for colon cancer surveillance and presented to the physician's office for new concerns in regards to his liver.  The patient's test requisition form did have a diagnosis of colon cancer that was metastatic stage IV. The patient underwent FoundationOne CDx in late 2018.

The medical literature notes that there are over three hundred (300) genes tested with the FoundationOne assay. There are three (3) genes which are included in the panel which have an impact on colon cancer (KRAS, NRAS and BRAF).  The documentation indicated that the patient does have stage 1 adenocarcinoma of the sigmoid colon. The patient underwent FoundationOne CDx tumor marker panel in late 2018. While medical literature notes that patients with metastatic colorectal cancer should have tumor tissue genotyped for RAS (KRAS and NRAS) and BRAF mutation, the need for the entire panel is not supported by literature. This entire panel has not been demonstrated to be in accordance with current standards. Therefore, the requested FoundationOne CDx tumor marker panel performed is not medically necessary and the prior determination is upheld. The insurer acted reasonably, with sound medical judgment, and in the patient's best interest. 

Based on the above, the medical necessity for the FoundationOne CDx tumor marker panel performed is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of hypertension, hyperlipidemia, myocardial infarction, gastroesophageal reflux disease (GERD) and polysubstance abuse who presented to the emergency department (ED) complaining of chest pain after doing several grams of cocaine and drinking alcohol. The patient was admitted for possible pneumonia and alcohol abuse. The patient was treated with alcohol detox protocol and intravenous antibiotics. Patient left the hospital against medical advice on the following day.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient could have been monitored and treated at a lower level of care. This patient was not hemodynamically unstable and did not have any objective measures to indicate a possible myocardial infarction. Other than the chest x-ray findings, there were no indicators of a possible pneumonia. There was also no clinical indication of alcohol withdrawal. There were no clinical indicators that would warrant acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastric ulcers and gastritis

Treatment: Inpatient admission

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

This patient is a female who presented with epigastric pain and vomiting. She had hypertension, but it improved with treatment. There were no peritoneal signs. A CT scan revealed gastric wall thickening. An endoscopy showed gastric ulcers and gastritis. The patient was treated with Protonix. The vomiting resolved with Zofran.

According to Milliman Care Guidelines (MCG), clinical indications for admission for gastritis (M-560) include gastric outlet obstruction, perforation, peritoneal signs, ongoing bleeding, and severe anemia. The patient did not have these conditions. She presented with vomiting, but it improved with Zofran. She also did not have hemodynamic instability, severe dehydration, or severe electrolyte abnormalities.

This patient had gastric ulcers and gastritis. There was no active bleeding or intestinal obstruction. No surgical interventions were needed. The patient could have received proton pump inhibitor (PPI) therapy and antiemetics, and have an endoscopy with observation status. She did not meet the MCG Criteria for admission for gastritis. The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. Inpatient hospital services were not medically necessary.  

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

Diagnosis: Congenital Central Hypoventilation Syndrome
 
Treatment: Medical equipment- Trilogy home ventilator

The insurer denied continued nocturnal home ventilation. The denial was reversed.

The patient was diagnosed with late onset Congenital Central Hypoventilation Syndrome (LO-CHS). This diagnosis was confirmed by genetic testing. He has undergone surgery to remove a retro mediastinal ganglioneuroma and an additional procedure to decompress an Arnold Chiari malformation which was causing compression of the brainstem. He is maintained on daily Keppra for epilepsy. Since his diagnosis he has required nocturnal ventilator support using the Trilogy home ventilator. He is doing well clinically with his current prescribed nocturnal ventilator support, and he does not require ventilator support when awake. 

The patient has a life threatening illness that requires ventilator support whenever he is sleeping. His brainstem central ventilatory control center is not functioning when he sleeps and this condition places him at risk for serious complications whenever he is asleep. His condition is not obstructive sleep apnea, and ventilatory support is not adequately provided with a simple BIPAP machine. The Trilogy ventilator is the optimal home ventilator for his condition and is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructive sleep apnea 
Treatment: E0486 - oral device/appliance
The proposed oral appliance is not medically necessary.  The records do not support the medical necessity of the appliance. There is no documentation from a physician that this patient has OSA. A new appliance was requested by the patient; however, the appliance was only four years old and there is no documentation to show that an attempt by the new dentist was made to repair the old appliance, as many times that is possible. Since this was a new dentist (to the patient), a note from a physician to the dentist stating the patient has OSA should be present. A new appliance is not appropriate without the knowledge, in writing, from the appropriate healthcare professional, that there really is a diagnosis of OSA. This note from a physician is not present.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient admission

The inpatient admission was not medically necessary. 

This is a male with a history of opioid and alcohol abuse who presented to the hospital for assistance with substance abuse detoxification. Intake vitals were afebrile, hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air. Examination was non focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or focal/global neurologic deficits. Laboratory and ECG testing was also within normal limits with no significant abnormalities noted including no evidence of acute end organ damage. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition, where he received supportive care with IV fluids, electrolytes and continued cardiac monitoring. He responded well to the prescribed therapies and was subsequently discharged in stable condition. There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.  Furthermore, based on this patient's vital signs, clinical symptoms and objective findings, he did not meet LOCADTR criteria for this level of care. For these reasons, the proposed treatment of Inpatient admission is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented to the emergency department (ED) with abdominal pain of new onset.  She was known to have gallstones from a prior ultrasound examination.  She had undergone an abdominoplasty several weeks prior.  At the time of presentation, the patient was without a fever and vital signs were normal.  She was tender in the right upper abdomen.  The white blood cell count (WBC) was elevated at 12 thousand (K).  The complete metabolic panel was normal.  An ultrasound showed gallstones and gallbladder wall thickening consistent with acute cholecystitis.  She was initially treated with intravenous (IV) fluid and IV antibiotics.  She underwent a laparoscopic cholecystectomy.  The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy with Jackson-Pratt (JP) drain placement.

The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, and antiemetics.  The immediate post-surgical recovery was uncomplicated.  On post-operative day number (#) 1 following surgery, the patient had stable vital signs.  Her pain was controlled.  Her diet was advanced.  The patient remained clinically stable.  The drain was removed and she was discharged from the inpatient setting.  

The health plan's determination is overturned.  Based on the submitted clinical documentation, an inpatient level of care was medically necessary.  This patient was admitted to the hospital with the diagnosis of acute cholelithiasis/cholecystitis.  Her white blood cell count (WBC) was elevated and an ultrasound which identified acute cholecystitis and gallstones.  She underwent a laparoscopic cholecystectomy procedure.  She required placement of a surgical drain at the time of surgery due to the degree of inflammation.

Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure or for the diagnosis of acute cholecystitis.  In this case, the records support the diagnosis of acute cholecystitis and warrant an inpatient level of care.  Inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein greater than (>) 10, WBC count > 10 K).  Inpatient admission is also indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission.  

In this case, the patient presented with upper abdominal pain, an elevated WBC count (12K), and imaging findings that supported the diagnosis of acute cholecystitis.  She required urgent operative treatment for this condition.  These clinical findings justify an inpatient level of care.  Inpatient level of care was consistent with generally recognized standards of care.
Appeal type: Medical necessity
Decision: Overturned

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient in question is a male with a Class II malocclusion and anterior crossbite of tooth #7. He is treatment planned for 24 months of orthodontics to correct his malocclusion. This is the subject of this review.

The health plan's determination is overturned. Braces, monthly visit (x 12), retainer are medically necessary for this patient. The patient has significant maxillary anterior crowding with tooth #7 in crossbite. This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Tooth #26 already has slight recession, and further movement of #26 will likely lead to the need for future for periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mild cognitive impairment, anxiety, depression
Treatment: PCA Level II: 24 hours per day, live-in per diem, seven days per week 

The proposed treatment of PCA Level II: 24 hours per day, live-in per diem, seven days per week is not deemed medically necessary. 

The patient is a female with a history of mild cognitive impairment, anxiety and depression. She requires some assistance for completion of her ADLs. She has requested an increase in her PCA Level II coverage to 24 hours per day, live-in per diem, seven days per week to help alleviate her anxiety and phobia of living alone. However, a recent face to face clinical assessment utilizing the New York State Department of Health's Uniform Assessment System Tool revealed no significant changes in the patient's functional abilities to complete her ADLs when compared to her prior assessment. Both assessments concluded that the patient's current approved plan of seven hours per day, seven days a week for a total of 49 hours per week is adequate to meet her needs. For these reasons, the proposed treatment of PCA Level II: 24 hours per day, live-in per diem, seven days per week is not deemed medically necessary
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal - Tendon Problem
Inpatient Hospital

The patient sustained a fall in her garage resulting in right leg pain and inability to bear weight. She was evaluated in the Emergency Department (ED) and her examination was suspicious for a partial quadriceps' tendon tear. The patient was subsequently admitted to the hospital for further work up which included a magnetic resonance imaging (MRI) scan of the right knee which confirmed a quad tear in the right knee. The patient underwent operative repair of the quad tendon injury. The patient was eventually discharged to a rehab center.

The health plan's determination of medical necessity in this case is upheld in whole. 

The rationale for this determination is based upon the provided medical records and the current, peer-reviewed orthopedic literature. The health plan, in its determination of medical necessity, acted reasonably, with sound medical judgment and in the best interest of the patient in this case. The rationale for this determination is based on the provided medical records which document that this patient had an examination suspicious for a quadriceps tendon tear. There is no documentation in the medical records as to why the patient could not have been discharged from the ED in a knee immobilizer and had outpatient orthopedic follow up after this injury. The requested health service/treatment of inpatient stay was not medically necessary for this patient. The rationale for this determination is based on the provided medical records which do not provide justification for the inpatient stay for a suspected quad injury after a fall. The records state that x-rays of the femur and knee revealed no fractures. The patient could have been discharged from the emergency department in a knee immobilizer and had a further diagnostic work up, including a right knee MRI scan and operative quadriceps repair done as an outpatient. Outpatient quadriceps repair is safe and effective and is supported by the current, peer-reviewed literature as documented by Lee and colleagues in the Journal of Knee Surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis and abscess
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a female whose inpatient admission is under review. The patient has a history of morbid obesity, ETOH (alcohol) abuse, tobacco abuse, hypothyroidism, and MI (myocardial infarction). She presented to ER with three days of rash. The patient noted a pimple under her armpit three days prior. She went to her PMD, who started the patient on Augmentin.  Worsening rash (spread down arm) was noted.

In the ER the patient's vitals were as follows: T (temperature) - 99.0, BP (blood pressure) -125/78, P (pulse) - 69, RR (respiration rate) - 16, BMI (body mass index) - 41.71. On general examination, the patient was noted to be NAD (no acute distress). Examination of her chest, CVS (cardiovascular system), and abdomen were normal. Examination of her skin revealed left axilla two-centimeter (cm) by two-cm fluctuant mass with streaking. Another exam revealed erythema, tenderness, and warmth. The erythema extends from axilla to elbow.

The patient's labs and investigations were as follows: WBC (white blood count) - 11.4 (high), Hg (hemoglobin) - 13.2, Hct (hematocrit) - 41.1, Plt (platelets) - 166, Na (sodium) - 139, K (potassium) - 4.2, Cl (chloride) - 108, CO2 (carbon dioxide) - 23, BUN (blood urea nitrogen) - 13, Cr (creatinine) - 0.68, Glu (glucose) - 97

U/S (ultrasound) revealed left axilla with three-cm by three-cm fluid.

The patient was admitted with cellulitis with abscess. She was started on IV vancomycin. The patient was treated with IV vancomycin for several days. She underwent I&D (incision and drainage). She improved, and was sent home on PO (oral) doxycycline. 

The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America (1), as she failed outpatient therapy. Thus, this admission was warranted, supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cellulitis

Treatment:  Acute inpatient hospital admission

The insurer denied coverage for acute inpatient hospital admission.  The denial is upheld.

This patient is a female with past medical history significant for breast cancer, status post mastectomy and lymph node dissection, chronic right upper extremity lymphedema, and depression/anxiety who presented to the Emergency Department with complaints of right arm pain and swelling.  Vitals on presentation included: Temperature-99.3 F, Blood Pressure-127/74, Pulse-100, Respiratory Rate-18, and Oxygen saturation-98%.  Laboratory values were notable for the following: White blood cell (WBC) count-10.75, hemoglobin (Hgb)-14.3, hematocrit (Hct)-43.8, creatinine-0.7, glucose-88, ESR-22, and CRP-2.5.

The patient was admitted for possible right upper extremity cellulitis and started empirically on intravenous antibiotics (vancomycin and aztreonam).  Doppler exam was negative for deep vein thrombosis (DVT).  Infectious Diseases was consulted.  She developed some loose stools, and C difficile testing was negative.  The patient remained afebrile and hemodynamically stable.  She was discharged on a course of oral antibiotics (clindamycin).

According to medical documentation, patient presented with right upper extremity erythema and pain.  She has history chronic lymphedema of the affected arm.  Otherwise, she was afebrile and hemodynamically stable.  Laboratory results similarly were unremarkable including a normal WBC.  There was no evidence of a systemic infection, and no surgical intervention was required.  Moreover, patient had not failed an outpatient course of antibiotics.  Based on above findings, patient met criteria for observation level of care.  Criteria for acute inpatient admission were not met.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the acute inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient was diagnosed with a melanoma, 0.4 mm in greatest depth, stage T1a.  The requested test is DecisionDx. DecisionDx is not beneficial for the patient's diagnosis.  For stage 1 melanoma there is no additional testing that needs to be done.  The risk of metastasis for this thin melanoma is small. The National Comprehensive Cancer Network (NCCN) guidelines and American Academy of Dermatology (AAD) guidelines do not recommend any additional workup for T1 melanomas, outside of an excision with 1 cm margins. 

DecisionDx is a gene expression profile test that is used to stratify risk of metastasis in patients with melanoma.  Gene expression profiling (GEP) like that undertaken by this provider has not yet been accepted as standard of care in treating cutaneous melanoma patients.  The American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) guidelines for clinical decision making and follow up for patients with cutaneous melanoma do not currently incorporate gene expression profiling. The 2019 melanoma guidelines from the American Academy of Dermatology state that information gleaned from the assay itself should not affect the treatment or follow up approach for cutaneous melanoma. The limited data on gene expression profile (GEP) for melanoma have not yet been extensively vetted and validated by the dermatology or oncology research community.     

The DecisionDX-Melanoma test is not the best available treatment for this patient at this time.  For a stage 1 melanoma, the best available treatment is an excision. The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for DecisionDX-Melanoma testing should be upheld.