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

Immunologic Disorder
Pharmacy/Prescription Drugs
Diagnosis: psoriatic arthritis 
Treatment: Acthar 80 Unit/mL Vial 
The insurer denied Acthar 80 Unit/mL Vial. The health plan's determination is upheld. 

The patient is a female with psoriatic arthritis (PsA). The health plan denied HP Acthar gel 80 units/ML SQ twice a week x 12 weeks as not medically necessary. Prior tx (treatment): The patient has tried and failed Prednisone, Cosentyx, Xeljanz, Remicade, Stelara, Rituxan, Orencia, Otrexup, Cellcept, Rasuvo, Mtx, Imuran, Acitretin, Othovisc, Leflunomide, Norco, Indomethacin, Otezla, Humira, Ssz, Ibuprofen, Tramadol, Lidoderm, Clobetasol 0.05% and Diclofenac 1%. Per review of the chart, she is on prednisone 6 milligrams (mg) daily and has experienced weight gain, 'Cushionoid changes' as well as poor response.

The Acthar 80 Unit/mL Vial is not medically necessary for this patient. While the patient has tried and failed many standard therapies, she has not tried Simponi, Taltz Or Cimzia, which are all approved medications for the treatment of her PsA and are considered to be steroid sparing agents.
While the patient has tried and failed many standard therapies, she has not tried Simponi, Taltz or Cimzia, which are all approved medications for the treatment of her PsA. HP acthar gel 80 units/ML SQ twice a week x 12 weeks is not the standard of care for the treatment of PsA. According to UpToDate, treatment for PsA includes disease modifying anti-rheumatic drug (DMARD) (such as methotrexate (MTX)), Otezla, anti- tumor necrosis factor (TNF) agents (such as Simponi or Cimzia), Il-17 antagonists (such as Taltz), Stelara, Orencia or Xeljanz.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Swelling on left side of face
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with hypertension who presented to the hospital with swelling of the lips and face for 5 hours due to angioedema, after having been initiated on enalapril 12 days prior.  The patient was afebrile with a blood pressure 116/79 and pulse 72.  Labs were notable for a white blood cell count 4.7, potassium 4.5, BUN (blood urea nitrogen) 31, and creatinine 1.5.  The chest x-ray showed no acute process and the electrocardiogram showed no acute ischemic changes.  The patient was alert and oriented without evidence of stridor and with clear lungs.  

In the emergency department intravenous Benadryl, steroids, and epinephrine were administered.  A soft tissue x-ray of the neck demonstrated no acute finding.  The patient was monitored in the intensive care unit on prednisone, Benadryl, and Pepcid.  Intravenous fluids were provided.  The creatinine dropped to 1.13.  The patient remained stable during the hospitalization and was discharged the day after admission.

No, the proposed Inpatient Admission is not medically necessary.

The patient had angioedema but did not have evidence of stridor, airway compromise, no inability to handle secretions, anaphylactic shock, or acute respiratory compromise.  The patient remained alert and oriented without neurologic compromise.  The chest x-ray and soft tissue x-ray of the neck demonstrated no acute findings.  Laboratory indices were notable for only a mild decrement in renal function; renal function improved with hydration.  Symptoms resolved completely and promptly with only conservative treatment.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: inpatient admission
The insurer denied coverage for inpatient admission. The denial is upheld.

This patient is a female with lupus retinitis (blind in her right eye), iron deficiency anemia and obesity, who presented to the Emergency Department (ED) with complaints of worsening chest pain that had been present for the past week. The chest pain began a week prior, after a night of drinking where she had 3 cups of alcohol. The patient denied any episodes of vomiting. The patient reported the pain was 3-4/10 in intensity and intermittent for the past week until the day prior to ED arrival when it suddenly jumped to 7/10 in intensity and progressed to 10/10.  The patient described the pain as an ache in the substernal region, non-radiating and worse with inspiration. The patient also reported some exertional shortness of breath. The patient was given Cellcept 1000 mg in the morning and 500 mg in the evening. Arrangements were made for her to follow up with rheumatology clinic as an outpatient. Because of her iron deficiency anemia, the patient was started on iron pills at the time of discharge.

Current ESC guidelines for the diagnosis of myocardial infarction consider a rise and/or fall of cardiac biomarkers. However, whether rising or falling patterns of high-sensitivity cardiac troponin T (hs-cTnT) improve the discrimination of ST-elevation myocardial infarction (non-STEMI) from non-acute coronary syndromes (ACS) has not been evaluated yet. Investigators compared protocols of rising and falling absolute and relative hs-cTnT changes in an unselected emergency department population. These investigators concluded that detection of rising but not falling hs-cTnT values improves discrimination of non-STEMI from non-ACS in an unselected emergency department population. (2)

This patient presented to the Emergency Department (ED) with a history of chest pain that had been present for a week. In spite of this long history, the patient's troponin was minimally elevated on admission and then fell to 0.00 and 0.01. The literature review indicates that this troponin pattern along with an electrocardiogram (EKG) that showed no ST abnormalities makes acute coronary syndrome (ACS) very unlikely. There was no evidence of pericarditis or pulmonary embolus. This patient was placed in a telemetry unit, which was not medically necessary. The literature also recognizes the use of an observation unit for this type of patient. Based on the literature review, this patient's care could have been provided at a less intensive level of care, such as Observation. Thus, inpatient admission was not medically necessary.

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

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a child with medical history significant for prematurity (birth weight 1030 grams) and asthma that awoke from sleep with difficulty breathing, wheezing, and accessory muscle use and was transported to the ED via EMS for further evaluation. He had been seen earlier in the day for asthma exacerbation. While en route via EMS, he was given two DuoNeb treatments. His mother reported no URI (upper respiratory infection) symptoms prior. Vital signs included temperature 37.9, heart rate 165, respiratory rate 54, and 94% oxygen saturation in room air. Examination was significant for wheezing and non-focal neurologic exam. 

Laboratory evaluation was significant for WBC (white blood count) count 15.6K with left shift (90.5% neutrophils), mildly decreased CO2 (carbon dioxide) (20), and hyperglycemia (glucose 149). Rapid RSV (respiratory syncytial virus) testing was negative. Chest x-ray was unremarkable. He was treated with normal saline bolus, magnesium, prednisolone, terbutaline, and continuous DuoNebs, and subsequently admitted because of persistent tachypnea secondary to status asthmaticus. 

Yes, the proposed inpatient admission is medically necessary.

In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.

This young child with history of significant prematurity, neonatal intubation, prolonged NICU (neonatal intensive care unit) stay, and asthma presented with signs and symptoms consistent with status asthmaticus. He had been seen in the ED within 24 hours prior, treated, and discharged home, only to return again symptomatic with significant respiratory distress. He was treated aggressively in the ED with bronchodilators, systemic corticosteroids, terbutaline, magnesium, and IV fluids. Despite the fact that he had no oxygen requirement, he was in sufficient distress, having failed outpatient management twice, to support need for acute inpatient admission. He could not have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Root canal with crown.
Treatment: D3310 - Nerve treatment on front tooth, Tooth 26 and D2751 - White glass with metal crown, Tooth 26.
The insurer denied the D3310 - Nerve treatment on front tooth, Tooth 26 and D2751 - White glass with metal crown, Tooth 26.
The denial is upheld. 

The patient is a senior male requesting dental benefit for a root canal procedure and crown on tooth #26.

No, the D3310 - Nerve treatment on front tooth, tooth 26 and D2751 - white glass with metal crown, tooth 26, are not medically necessary. 

The tooth (#26) has decay down along the root below the level of the bone. This is not a restorable situation as there will be the need to remove bone to place the crown, and if this is done, the tooth will become very loose. This tooth cannot be restored and needs to be removed. The tooth is not salvageable so therefore the requested treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Abdominal pain
Inpatient stay

The patient presented to the emergency department complaining of 10 days of lower abdominal/pelvic pain, nausea and urinary frequency. Patient had already been to another facility several days before and felt they were  misdiagnosed. Patient had been taking Tylenol and Ibuprofen at home without relief.  The patient had a report from the outside facility of an ultrasound  which suggested a possible hemorrhagic cyst.  The exam was unremarkable, but the patient stated  severe pain. The blood pressure (BP) was 109/75,  temperature of 36.3 degrees Celsius, and a pulse of 65. The exam reported that there was no distress, and only mild abdominal tenderness. A computed tomography (CT) scan was performed to rule out appendicitis--it was negative. A pelvic US was also completed which revealed a small left ovarian cyst, possibly hemorrhagic or endometrioma. A small amount of free fluid was also noted. Gynecology was consulted and found the same things. No rebound tenderness, no distress, no cervical motion tenderness, and no pelvic mass. Patient was admitted to Inpatient at approximately 22:28 for serial exams to rule out intermittent ovarian torsion or a bleeding hemorrhagic cyst. The patient was discharged home to follow up as an outpatient. The health plan's determination is upheld. While it was reasonable to perform serial exams and labs, it could have been done at a lower level of care. Appendicitis had been ruled out in the ED (negative CT scan, normal WBC, no fever, benign exam) and if an ovarian torsion or bleeding from a hemorrhagic cyst occurred, both of these could have been addressed at a lower level of care.The patient reported continuous pain for 10 days. This patient was in the hospital less than 24 hours, including  ER time. Patient was tolerating by mouth (PO), had normal vital signs and labs, and a benign exam. There were no objective signs of extreme pain such as an elevated heart rate or distress noted. The patient did not require any additional pain medications after leaving the ED and was discharged home a few hours after admission.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cutaneous Melanoma
Treatment: DecisionDx Genetic Testing
The health plan should not cover the 84999 - DecisionDx Genetic testing.
The 84999 - DecisionDx Genetic testing is not likely to be more beneficial.

There is no evidence that this testing is of clinical benefit.  There is no evidence that this testing can be used to guide therapy or surveillance strategies in patients with cutaneous melanoma.  At this time, the NCCN does not support the routine use of this testing in patients with melanoma.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cutaneous Melanoma
Treatment: DecisionDx Genetic Testing
The health plan should not cover the 84999 - DecisionDx Genetic testing.
the 84999 - DecisionDx Genetic testing  is not likely to be more beneficial.

There is no evidence-based medical literature to support that a greater benefit is imparted after DecisionDx testing than current standard of care. There are insufficient outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for melanoma.

Standard of care in a melanoma greater than 1 mm (one millimeter) is wide local excision with a sentinel lymph node biopsy. Further testing or work-up is performed by symptoms and results of sentinel lymph node testing.  For melanomas less than 1 mm, wide local excision with routine skin and physical exams is standard of care.

The requested service has not been approved by the FDA (Food and Drug Administration), and it has not been determined to be more beneficial than current standard of care. 
The National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for melanoma (V [version] 4. 2014) do not include a recommendation for gene expression profile testing for melanoma at this time. Additional prospective studies are required to determine how this risk stratification test will direct the clinical management and selection of treatment options that would result in an improved prognosis for individuals with melanoma. Because this has primarily been studied in uveal melanoma, it is promising but still remains unproven, especially in cutaneous melanoma. 

The 2015 review by March et al states: "although there is great promise, these newer RNA-based methods (such as DecisionDx Melanoma) have not been studied in enough detail to make any current recommendations for their use.  Long-term prospective trials using molecular techniques to guide excision and staging decisions are necessary to determine the utility of down-staging particular lesions.  If viable in such use, molecular studies have the significant potential to limit cost and morbidity of additional laboratory work-up and treatment.  In conclusion, these tests have significant potential to affect clinical practice in the management of melanocytic lesions; however, such applications will require additional validation by clinical trials with extensive numbers of lesions and long term clinical follow-up."

The 2018 NCCN guidelines for cutaneous melanoma state that the evidence for use of DecisionDx-Melanoma and/or other forms of gene expression or genetic biomarker testing is inconclusive or unsubstantiated at this time.  The 2018 guidelines recommend use of the Breslow depth and presence or absence of ulceration as the only determining factors for undergoing a sentinel lymph node biopsy.
Therefore, based on review of the current peer-reviewed medical literature, the technology would not be medically appropriate for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Chronic Sinusitis
Issue under review:  C2625 Stent, noncoronary, temporary, with delivery system (Propel drug-eluting stent for postoperative treatment following endoscopic sinus surgery)

Determination:  The health plan should cover the C2625 Stent, noncoronary, temporary, with delivery system (Propel drug-eluting stent for postoperative treatment following endoscopic sinus surgery).

The patient is an adult female with a history of reported chronic sinusitis.  She had undergone previous ESS (endoscopic sinus surgery).  Recently, the patient underwent revision ESS including surgery on the ethmoid, sphenoid and maxillary sinuses.  Scarring and polypoid tissue was reported.  The provider placed Propel steroid eluting implants (C2625) at the end of the procedure. 

The implants placed are steroid eluting implants that have support in the scientific literature for reducing the amount of polyps, adhesions and middle turbinate lateralization for patients undergoing ESS.  This reduces the need for additional surgery and oral steroids.  Therefore, based on the information provided, the health plan should cover the proposed treatment, as the requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Chronic Sinusitis
Issue under review:  C2625 Stent, noncoronary, temporary, with delivery system (Propel drug-eluting stent for postoperative treatment following endoscopic sinus surgery)

Determination:  The health plan should cover the C2625 Stent, noncoronary, temporary, with delivery system (Propel drug-eluting stent for postoperative treatment following endoscopic sinus surgery).

The patient is an adult female with chronic sinusitis.  She underwent endoscopic sinus surgery.  In the course of the surgery, propel steroid eluting stents were placed in the sphenoid sinus ostia.  

Topical steroid had been used as an adjunct to sinus surgery in a variety of topical applications to reduce the potential for scarring after surgery over decades.  Propel steroid eluting stents are a standardized preparation to deliver steroid to healing spaces in the sinuses in the early postoperative period.  The stents usually dissolve over a period of 30 days.  This provides stenting and delivery of steroid during this critical period.

Propel steroid eluting stents are a standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Chronic Sinusitis
Issue under review:  C2625 Stent, noncoronary, temporary, with delivery system (Propel drug-eluting stent for postoperative treatment following endoscopic sinus surgery)

Determination:  The health plan should cover the C2625 Stent, noncoronary, temporary, with delivery system (Propel drug-eluting stent for postoperative treatment following endoscopic sinus surgery).

The patient is an adult female.  She had sinus surgery to treat a deviated nasal septum and disease in the sphenoid, maxillary, and ethmoid sinuses.  She did fairly well until recently, when she started having more sinus infections that did not clear with numerous antibiotics, nasal steroid sprays, and nasal saline rinses.  A CT scan noted mucosal thickening greater than 3 mm in the affected sinuses with scar tissue in the affected areas.  She was then taken back to surgery, where the sinuses were again opened up, scar tissue and polypoid tissue was removed.  In an attempt to prevent further scar tissue and polyps developing, propelled steroid eluding splints were used in the ethmoid cavities.

This treatment has been used for over eight years now and has been shown to be effective and safe in the prevention of recurrent scaring and polypoid tissue formation. It is not experimental.  Numerous articles demonstrate this, including those listed below.

The Medical Definition of Standard of care, in legal terms, is the level at which the average, prudent provider in a given community would practice.  It is how similarly qualified practitioners would have managed the patient's care under the same or similar circumstances.  The use of drug-eluting nasal implants is the standard of care in the treatment of patients with recurrent chronic rhinosinusitis.

The treatment is, in fact, the standard treatment for recurrent rhinosinusitis requiring surgery.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung cancer
 
Treatment: Diagnostic Testing

The insurer denied coverage for Diagnostic Testing. The denial is upheld. 

This patient is a male with a history of lung cancer who had Guardant360 cDNA (Liquid Biopsy) done. The diagnostic testing performed is considered not medically necessary for this patient.

National Comprehensive Cancer Network (NCCN) does not yet accept cDNA in lieu of tissue diagnosis. Liquid biopsies can be performed when a tissue biopsy is inaccessible or unavailable. While the current focus is dominated by DNA, additional components of a liquid biopsy include ribonucleic acids (RNA), circulating tumor cells (CTCs), extracellular vesicles (EVs), and tumor educated platelets (TEPs). The latter components are mainly of research interest. As more translational research is performed, these additional components of a liquid biopsy may have increasing clinical use in the future. Methods that are currently used to detect or measure ctDNA can broadly be divided into two categories: polymerase chain reaction (PCR) based and next-generation sequencing (NGS) based. NGS is broader and has greater promise. Although liquid biopsy may be an attractive tool for cancer screening in asymptomatic patients, such applications will need to be carefully and thoughtfully considered to avoid excessive patient suffering due to false-positive results. In the short term, liquid biopsies may be more helpful to confirm malignancy in patients with already clinically or radiographically apparent lesions.

Currently, Guardant360 is sold in 30 countries, including in the U.S. as a laboratory-developed test. It is not yet approved by the Food and Drug Administration (FDA). The FDA has so far only approved one blood-based cancer test, FoundationOne, which detects mutations in the EGFR gene in non-small cell lung cancer patients. Recently NCCN added the following to the non-small cell lung cancer (NSCLC) guidelines: "...The use of cell-free/circulating tumor DNA testing can be considered in specific clinical circumstances, most notably: 1) If a patient is medically unfit for invasive tissue sampling (This had not been specified in the record) 2) In the initial diagnostic setting, if following pathologic confirmation of a NSCLC diagnosis there is insufficient material for molecular analysis, cell-free/circulating tumor DNA should be used only if follow-up tissue-based analysis is planned for all patients in which an oncogenic driver is not identified."
The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.      

Based on the above, the medical necessity for the Diagnostic Testing performed is not substantiated.  The insurer's denial is upheld.