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

Diagnosis: MUTYH-associated polyposis

Treatment: Molecular pathology procedure analysis testing (code 81406)

The insurer denied coverage for molecular pathology procedure analysis testing (code 81406)

The denial is upheld

An Invitae MUTYH 9 (mutY DNA glycosylase)- Associated Polyposis Syndrome Test was performed for the patient. The patient's results showed that the patient is a carrier, and that he has one pathogenic variant identified in MUTYH, which is associated with autosomal recessive MUTYH-associated polyposis. 

Though the documentation provided testing results, it does not support that the patient has a personal history of 20 or more cumulative adenomas; nor a personal history indicating 10 or more adenomas, 5 or more serrated lesions/polyps proximal to the rectum above the size of 10 millimeter (mm), or more than 20 serrated polyps of any size throughout the colon. There is also no documentation indicating any known MUYTH mutation in the patient's family.

This test analyzes the MUTYH gene. Individuals who have pathogenic variants in both copies of this gene can develop MUTYH-associated polyposis syndrome (MAP), a colorectal cancer predisposition syndrome. A clinical summary had not been provided. 

Per Syngal, S., et al. (2014), "Individuals who have a personal history of >10 cumulative colorectal adenomas, a family history of one of the adenomatous polyposis syndromes, or a history of adenomas and familial adenomatous polyposis (FAP)-type extracolonic manifestations (duodenal/ampullary adenomas, desmoid tumors (abdominal>peripheral), papillary thyroid cancer, congenital hypertrophy of the retinal pigment epithelium ((CHRPE), epidermal cysts, osteomas) should undergo assessment for the adenomatous polyposis syndromes. Genetic testing of patients with suspected adenomatous polyposis syndromes should include APC (adenomatous polyposis coli) and MUTYH gene mutation analysis."

Information regarding the presence or absence of these features is not provided. Thus, it appears that the criteria are not met. As such, medical necessity cannot be established.

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 molecular pathology procedure analysis testing (code 81406) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arthritis, hearing loss, obstructive sleep apnea
Treatment: Consumer Direct Personal Aide Service (CDPAS) 5 days a week, 12 hours a day, for a total of 60 hours per week
The insurer denied coverage for Consumer Direct Personal Aide Service (CDPAS) 5 days a week, 12 hours a day, for a total of 60 hours per week
The denial is upheld

According to the documentation submitted, this is a patient with a history of arthritis, hearing loss and obstructive sleep apnea. According to the most recent Uniform Assessment System (UAS), via interactive video teleconference the patient was alert and oriented (A&O) x (times) 3. She could self-direct care and make needs known. The patient is forgetful at times. She requires maximal assistance for meal preparation and ordinary housework. Extensive assistance is required for bathing, dressing upper body, dressing lower body, and toilet use. The patient experiences occasional urinary incontinence. No falls were reported in the last 90 days. The patient's physician is requesting an increase in Consumer Direct Personal Aide Service (CDPAS), due to deteriorating health.

The submitted records show the patient lives with her daughter. She has no reported deterioration of a medical condition. The level of function has not deteriorated as per the recent report by the nurse. Her levels of independence were not significantly different. The reported decrease to range of motion, pain and inability to put shoes on do not substantiate an indication for the increased level of service. 

No additional information was provided to support the claim.

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 Consumer Direct Personal Aide Service, (CDPAS) 5 days a week, 12 hours a day, for a total of 60 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission 
The denial is overturned
 
This is an adult patient that presented to the hospital complaining of chest pain, dizziness and weakness. Past medical history was significant for systolic congestive heart failure and recent discharge from an outside hospital after presenting with similar symptoms. Upon arrival to the hospital, blood pressure was borderline at 93/63 and pulse was 48. No significant findings were noted on physical examination. While being evaluated the patient was noted to be hypotensive and was effectively treated with intravenous fluids.

A 12-lead electrocardiogram (ECG) revealed atrial fibrillation with controlled ventricular rate and flat T waves (interval on an ECG) in all leads. Serum blood testing revealed hyperkalemia (6.0), serum creatinine of 1.7 and an elevated B type natriuretic peptide of (224). No elevation in troponin levels (0.02) was noted. A Computed tomography (CT) of the chest excluded pulmonary embolism and acute aortic pathology. The patient was admitted to the hospital for further treatment and testing. An echocardiogram revealed a left ventricular (LV) ejection fraction of 21-25% with segmental wall motion abnormalities. Cardiac catheterization demonstrated non obstructive coronary artery disease. The patient was treated with oral anticoagulant therapy, guideline directed medical therapy for systolic congestive heart failure and scheduled for outpatient cardioversion.

This patient presented with chest pain, lightheadedness, atrial fibrillation and systolic heart failure. Electrocardiogram (ECG) on admission revealed atrial fibrillation (AF) which may have resulted in periods of rapid ventricular rates and symptoms of chest pain.  An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic atrial fibrillation. In addition to AF, this patient had chest pain and a high pretest probability of significant coronary artery disease. This patient had an elevated HEART (cardiac risk assessment) score and appropriately underwent cardiac catheterization prior to discharge. In conclusion, an acute inpatient admission was medically necessary in this case.

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 hospital inpatient services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain without radiculopathy
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female with a 1 month history of low back and left leg pain who presented to the emergency room (ER). She also had issues with urinary incontinence. Her pain medications did not relieve her pain. The neurologic exam showed 4 out of 5 for left dorsiflexion. Her lumbar magnetic resonance imaging (MRI) showed a herniated disc at lumbar (L) 4-5 on the left. The provider recommended a lumbar discectomy that was performed. The patient was discharged the day after surgery.

The inpatient stay for the patient was not medically necessary. The patient developed severe left leg pain and a mild foot drop. It would have been appropriate to admit the patient to an alternate level of care and to schedule the surgical procedure on the following day. The patient could have had surgery and discharged that same day. A lumbar discectomy is generally an outpatient procedure, and there were no factors that would have necessitated the patient staying post-operatively overnight.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chest Pain and Pancreatitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is partially overturned.

The patient is an adult female with a history of alcohol abuse. She presented to the ER (emergency room) with upper abdominal pain and chest pain. There was some vomiting.
The patient was hemodynamically stable. Lipase was elevated at 297. She was admitted with a diagnosis of pancreatitis. She was hydrated and placed on IV (intravenous) PPI (proton pump inhibitor) and Zofran. By the next day her pain was noted to be improving, and she tolerated a clear liquid diet. The following day, her pain was improved, and she was noted to be tolerating a diet. She was discharged on day #3.

The Inpatient Hospital Admission was medically necessary, in part. The proposed acute inpatient hospital stay for the first day was medically necessary, and the acute inpatient hospital stay for the remainder of the hospital stay was not medically necessary. 

The patient presented with upper abdominal pain and had a lipase greater than 3 times normal. As the patient met 2 out of 3 criteria for acute pancreatitis requiring inpatient admission, the acute inpatient admission was medically necessary. By the next day, the patient's abdominal pain was noted to be improved. As she was hemodynamically stable, tolerating a clear liquid diet, and had no intractable vomiting, need for prolonged NPO (nothing by mouth), obstruction, GI (gastrointestinal) bleeding, or signs of worsening acute pancreatitis, she was medically stable for discharge. Therefore, the proposed acute inpatient hospital stay for the first day was medically necessary, and the acute inpatient hospital stay for the remainder of the hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Iron deficiency anemia

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

The patient is an adult with a history of anemia who presented to the emergency room (ER). Her hemoglobin (Hgb) was 6.8. She was sent by her primary care provider (PCP) for a blood transfusion. She was not noted to be bleeding. Labs confirmed iron deficiency anemia. Her labs showed an elevated platelet count of 625 and creatinine of 1.53. She had 1 unit of packed red blood cells (PRBC) and left against medical advice (AMA). This patient was hemodynamically stable and could have been managed and treated in a lower level of care without acute inpatient hospitalization. 

"Generally, a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018)

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 the hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Occlusion. 
Treatment: Braces. 

The insurer denied: Braces. 
The denial is overturned. 

The patient is a male with a Class I occlusion with appropriate overbite and overjet. He has maxillary and mandibular spacing. He has treatment planned for orthodontics to correct his malocclusion but his insurance company rejected the claim on the basis that treatment is not medically necessary. The subject under review is the medical necessity for braces. 

The health plan's determination is overturned. 

If left untreated the damage that will likely occur to the patient's teeth will be more time consuming and complicated to correct than the patient's existing orthodontic problem. Studies show that odontomas can lead to damage to the adjacent permanent teeth that could lead to them needing extraction. If the permanent tooth is not damaged by the odontoma or its removal, the potential for that tooth to require combined orthodontic/surgical treatment to assist its eruption is very high. (2) Therefore it is reasonable and customary to apply orthodontic traction to the blocked-out tooth at the time of the surgical removal of the odontoma. For these reasons, treatment is deemed medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Pain Management-Intracept procedure.
The health plan denied the Intracept procedure as experimental/investigational. 
The reviewer has upheld in whole the health plans determination.

The patient is an adult female with complaints of low back pain, neck, and rib pain. Patient has trialed many injections, medications, as well as physical therapy. A magnetic resonance imaging (MRI) scan of the lumbar spine reported diffuse multilevel disc desiccation, as well as history of spinal fusion from lumbar (L)1-sacral (S)1. There is a request for the Intracept procedure.
The proposed health service or treatment Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This patient has complaints of low back pain.
There is a request for intraosseous basivertebral nerve ablation. This procedure is not recommended despite promising early reports, further trials with longer-term outcomes and less risk of bias are required. A Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the proposed health service or treatment Intracept procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Pain Management-Intracept procedure.
The health plan denied the Intracept procedure as experimental/investigational. 
The reviewer has upheld in whole the health plans determination.

The patient is an adult female with a history of low back pain secondary to degenerative disc disease. The patient has been treated with oxycodone, trigger point injections, sacroiliac joint injections, physical therapy and intrathecal pain pump. Her treating provider recommended an Intracept procedure.
At issue is whether the Intracept procedure is likely to be more beneficial than standard treatment or treatments for this patient.
In this case the proposed treatment of the Intracept procedure is not supported by the literature to offer long term relief and the treating provider does not offer any specific rationale in the records submitted for review on how this intervention would offer any long-term relief for this patient.
Intracept is a minimally invasive procedure that targets the basivertebral nerve for the relief of chronic vertebrogenic low back pain. However, the evidence is insufficient to determine that the technology results in an improvement in the net health outcome. While a recent study has shown promising results the limitation of most of the studies performed include unavailable long-term comparative data, lack of a sham controls and short duration of follow-up.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stage 4 breast cancer with lung metastasis.
Treatment: Consumer directed personal assistant services 24 hours/day live-in services.
The insurer denied: Consumer directed personal assistant services 24 hours/day live-in services.
The denial is: Overturned.

The patient is a female with medical history notable for recent hospitalization due to fall and intracerebral hemorrhage, stage 4 breast cancer, chronic obstructive pulmonary disease (COPD), arthritis, congestive heart failure, and dementia. The patient is currently approved for 63 hours per week of consumer directed personal care services. The patient and her care team requested an increase to 24 hours per day live-in, 7 days per week, and this request was denied by the insurance company. This denial is the subject under review.
A letter of medical necessity for this appeal was provided by the patient's physician. The letter states that the patient had had a rapid deterioration in her physical and cognitive status. She lives alone. She recently had a fall and developed a cerebral hemorrhage and cervical spine fracture. She is now in a rigid neck brace. Her COPD has worsened due to lung metastasis, and she is now on oxygen. She was placed on home hospice at the recommendation of her oncologist. She can no longer independently perform any activities of daily living. The physician feels that it is medically necessary to have 24 hour help available to provide her with the necessary assistance.

The health plan's determination is overturned. 

The requested health service of Consumer directed personal assistant services 24 hours/day live-in services is medically necessary for this patient. The patient is reliant on others for all activities of daily living. She has had a marked functional decline following a fall which was complicated by cervical vertebral fracture and intracerebral hemorrhage. In the setting of her advanced age and stage 4 cancer diagnosis, she would not be expected to have meaningful improvement in her ability to perform activities of daily living. She will continue to require hands on assistance for all tasks. Given her needs for toileting and managing incontinence, a task tool is not able to accurately assess her true need. She will have unscheduled health care needs throughout the day and night which will require assistance. The patient's physicians have attested to and agree to the medical necessity of continuous 24 hour care to meet her functional needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hereditary hemorrhagic telangiectasia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient in this case is an adult male with hereditary hemorrhagic telangiectasia. He is noted to have a history of chronic iron deficiency anemia due to bleeding. An outpatient CBC (complete blood count) revealed a hemoglobin of 6.9 g/dl (grams per deciliter). He reported chest pressure, shortness of breath, rapid heartbeat and dizziness. He was seen in the emergency department. The patient's vital signs and physical exam were unremarkable. ECG (electrocardiogram) was done and did not reveal any ischemic changes. Given his symptoms, the patient was admitted to the hospital and treated with transfusion.
On day #2 the patient's hemoglobin was increased to 7.5 g/dl (grams per deciliter). He was seen by hematology/oncology and treated with intravenous tranexamic acid. Given ongoing bleeding, additional transfusion was recommended. He was feeling a little better than he did at the time of admission. It was noted that he had ongoing melena, but no bright blood per rectum.
On day #3 the patient was feeling better. Hemoglobin was up to 8.8 g/dl (grams per deciliter). Port placement was planned for the next day in anticipation of regularly scheduled outpatient transfusions.
The next day the patient had stable atelectasis and stable melena. He felt well. Hemoglobin was 8.6 g/dl (grams per deciliter). He was discharged to home.

The Inpatient Hospital Admission was not medically necessary.

This patient was noted to have chronic anemia due to ongoing bleeding related to hereditary hemorrhagic telangiectasia. When he was admitted, his hemoglobin was 6.9 g/dl (grams per deciliter). He was not hemodynamically unstable. He did not have any signs of acute coronary ischemia. ECG (electrocardiogram) was done and did not reveal changes of acute ischemia. While he clearly required transfusion, given the lack of hemodynamic instability, acutely worsening bleeding or active coronary ischemia, this treatment did not require acute care inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic kidney disease (CKD).

Treatment is an inpatient admission. 

The insurer denied coverage for an inpatient admission. 
 
The denial is upheld.

The patient was admitted for shortness of breath and volume overload, she was treated with hemodialysis and blood transfusion on admission.
Her condition responded to daily dialysis, she did not have persistent severe hyperkalemia, no signs of severe volume overload or hypoxia, no documentation of severe uremia such as encephalopathy or uremic bleeding, she had established dialysis access and did not require emergent vascular intervention.
Her condition could have been treated safely under lower level of care.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the 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 inpatient hospital admission is not substantiated.