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

This case describes a patient with a complaint of left knee pain. The physician prescribed Mobic as an oral anti-inflammatory and administered a cortisone injection. The provider has requested proceeding with a Hyaluronan, Gel-One injection for this patient's left knee.The health plans determination of medical necessity is upheld in whole. the requested Hyaluronan, Gel One injection is not medically necessary.
The rationale for this determination is based upon the provided medical records and the current, peer-reviewed orthopedic literature on the topic of visco-supplementation for the treatment of knee osteoarthritis.

One article published by Tammachote and colleagues in the Journal of Bone and Joint Surgery was a prospective, randomized study which compared a Hylan injection to a corticosteroid injection. The authors concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week."

A second article published by Jevsevar and associates in the Journal of Bone and Joint Surgery concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of Hyaluronic Acid (HA) treatment over placebo." The current, peer-reviewed literature has not established the efficacy of visco-supplementation injections performed for knee osteoarthritis. Thus, the medical necessity of the requested gel-one injection for this patient is not established in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Obesity
Treatment:  Sleeve gastrectomy

Summary:
This patient is a woman under consideration for bariatric surgery.  She has a body mass index (BMI) of 38.8 kg/m2.  Her obesity related comorbid conditions include sleep apnea for which she is prescribed CPAP, joint pain and GERD (gastroesophageal reflux disease).  The patient has a long history of prior weight loss efforts that have not been successful.  While she has attempted to lose weight with conventional programs, she has remained with medically complicated morbid obesity.  

Sleeve gastrectomy will be more beneficial than any alternative non-surgical weight loss program for the treatment of this patient's medically complicated obesity.  There are numerous published reports in the peer-reviewed literature describing outcomes in patients after sleeve gastrectomy.  There is > 5-year follow up data that is available to support the safety and efficacy of the sleeve gastrectomy procedure.  The reports describe surgical treatment of patients with preoperative body mass index ranging from 35 to 69 kg/m2 and excess weight loss ranging from 33% to 83%.

The health plan rationale for denial was based on the contention that the patient must have a BMI of at least 40 kg/m2 or a BMI between 35-39.9 kg/m2 with weight related comorbidity.  The requirement that a patient have weight related comorbid illnesses of a certain arbitrary severity is not consistent with nationally recognized standards.  This patient has significant weight related illness (sleep apnea) that will respond favorably to the weight loss anticipated with sleeve gastrectomy.

The proposed sleeve gastrectomy is medically necessary for her and is consistent with the standard of care.
Appeal type: Formulary Exception
Decision: Overturned

This is a patient who is requesting for Dupixent for asthma and nasal polyps. She has tried Xolair and Nucala. She has been non-compliant with the use of fluticasone and Xolair. The patient is on Symbicort. There is mention that the patient has used budesonide suspension. She has tried Xhance, fluticasone and steroid sprays and has had polyp surgery. The health plan's determination is overturned.
The patient is requesting Dupixent for the treatment of chronic rhinosinusitis with nasal polypsis, for which Nucala is not Food and Drug Administration (FDA) approved for and would not be as effective as Dupixent. The patient has tried budesonide rinses.
Dupixent is FDA approved for CRS (chronic rhinosinusitis) with NP (nasal polyps). The current standard of care for the treatment of CRSwNP includes the use of systemic corticosteroids as  needed for acute symptom management and maintenance therapy with intransasal corticosteroids Sinus surgery to remove nasal polyps is another treatment option that can be considered when  pharmacologic therapies have failed. Relapse after surgery is common, however, and revision  surgery is often required. In the trials for Dupixent that led to its approval for CRSwNP, the co-primary efficacy endpoints were the change from baseline in the nasal polyps score (NPS) and  the nasal congestion/obstruction (NC) score. The 22-item sino-nasal outcome test (SNOT-22) includes 22 items assessing symptoms and  symptom  impact associated with CRSwNP with each item scored from 0 (no problem) to 5 (problem as bad as it can be) with a global score ranging from 0 to 110.
In this case, the patient has tried and failed first line therapies for CRS with NP. Thus, Dupixent is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male who was admitted for a diagnosis of seizures.
The patient has a history of seizures for the past 35 years, treated with Keppra (levetiracetam). He reportedly had a generalized seizure at home and was taken to the hospital. He had a second seizure in the emergency department, followed by transient confusion and right side weakness, all attributed to the seizure.
In the emergency department seizures and deficits resolved spontaneously. He also had a rapid ventricular rate associated with his chronic atrial fibrillation, which resolved in the emergency department with Cardizem.
The patient was observed for 24 hours and discharged with addition of Vimpat for seizure control.
The subject under review is the medial necessity of the inpatient stay.

The health plan's determination is upheld.

The patient has a history of chronic seizures, and presented with two self-limited seizures, associated with post ictal symptoms that also resolved spontaneously.
He was reported to have an unremarkable clinical and neurological examination except for rapid ventricular rate, resolved while in the emergency department with Cardizem.
No evidence of acute stroke was identified. The patient had no difficulties caring for himself, and no evidence of any impending neurological event that would immediately imperil the patient's health. The current standard of care for seizure control in known epileptics, in cases without status epilepticus, is monitoring until patient has recovered baseline neurological status and discharge with or without medication changes. There is no documented evidence of status epilepticus in this patient.
There were also no reported hemodynamic instability, fever, uncontrolled infection, new, or worsening neurological deficits, uncontrolled cardiac arrhythmias (Cardizem controlled the tachycardia), uncontrolled hemorrhage, or any other acute changes requiring an immediate intervention.
No interventions occurred in the hospital after the Cardizem, other than additional testing and addition of an oral medication.
There is no evidence to support such additional testing and addition of Vimpat could not have safely been done at a lower level of care status once initial evaluation ruled out an acute stroke.
 In summary, there is no evidence to support that the patient could not have been safely managed at a lower level of care status until the tachycardia and post ictal status had resolved, and then discharged home. 
There is no reported evidence to support need for inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inpatient admission
Treatment: Inpatient admission
The proposed inpatient admission was not medically necessary.  

The medical literature states that in the case of blunt trauma to the abdomen, immediate adverse outcomes are limited to patients in which a period of uterine contractions with frequency of greater than every two to three minutes in the first four hours is observed.  Therefore, if this frequency of uterine contractions or greater is not observed in the first four hours, then further observation in the hospital is not necessary.  This patient only was documented to have irregular contractions and never to this frequency and there were no other clinical or laboratory signs of preterm labor, abruptio placentae, vaginal bleeding, or abnormal fetal heart rate tracing that would warrant consideration for prolonged monitoring.  Therefore the admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Abdominal /Stomach Pain
Inpatient hospital stay

This is a patient with a history of hypertension, chronic obstructive pulmonary disease, asthma and gastroesophageal reflux disease who presented to the emergency department at the Hospital with abdominal pain, nausea and vomiting.  A computed tomography (CT) abdomen/pelvis revealed chronic pancreatitis and 10 centimeter (cm) pancreatic pseudocyst and hepatic steatosis. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration, antiemetic therapy and pain control. Gastroenterology services were consulted and recommended commencing therapy with Creon. They did not feel percutaneous drainage of the pseudocyst was necessary as this was not causing the patient's diffuse pain. The patient was hemodynamically stable without fever, tachycardia or hypotension. Bloodwork revealed no evidence of anemia, leukocytosis or significant electrolyte derangements. The patient did not require endoscopic or surgical intervention for further management of the pseudocyst. The health Plan determination of medical necessity is upheld in whole. 
Generally accepted standards of medical practice as supported by nationally-recognized peer reviewed literature and guidelines support the inpatient stay was not medically necessary. Based on the Milliman Care Guidelines , the patient did not have peritoneal signs, hemodynamic instability, severe pain requiring inpatient management, absent bowel sounds, intestinal obstruction, toxic megacolon, severe electrolyte abnormalities, high fever, or require parenteral nutrition, percutaneous drainage or surgery.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with metastatic cervical cancer.  The patient was hospitalized at New York Presbyterian (NYP) Lawrence Hospital with sepsis and a small bowel obstruction.  The family elected for hospice, and the patient was transferred to Calvary Hospital for end of life care, the medical necessity of which is the subject under review. The health plan's determination is upheld.

The transfer to Calvary Hospital for end of life care is not medically necessary for this patient.

Hospice care is a model and philosophy of care that focuses on providing palliative care to patients with life-limiting illness, focusing on palliating patients' pain and other symptoms, attending to their and their family's emotional and spiritual needs, and providing support for their caregivers.  It is not location-dependent.  This patient was seen for a palliative care consultation while hospitalized at New York Presbyterian Lawrence Hospital; there is a paucity of evidence that this patient would have an inferior outcome at New York Presbyterian Lawrence relative to Calvary Hospital.  It is also not clear that there are services that would improve this patient's quality of life at Calvary Hospital relative to NYP-Lawrence.  Neither the National Comprehensive Cancer Network (NCCN), the peer-reviewed literature, nor the authors of UpToDate specifically recommend patients be cared for in a hospice hospital.  For these reasons, medical necessity has not been established.
Appeal type: Medical necessity
Decision: Overturned

The patient is a male with an unspecified bipolar disorder with most recent episode depressed and posttraumatic stress disorder (PTSD) with persistent symptoms of depression associated with substantial functional impairments with respect to social, occupational and daily functions.  The patient is forgetful with limited functioning related to the mental health and general medical issues that include diet controlled hypertension.  The patient does provide self-care with bathing, feeding, dressing, ambulation, and toileting, but he requires assistance with general housework, including laundry, shopping, and meals.  He needs some assistance with nutritional needs and with medications with regard to compliance and with use of transportation.  There is a history of substance use disorder.

Following an episode of severe depression, the patient was referred for Day Treatment with a frequency of three days per week.  The program allows for core services focusing on general health and mental health with nutritional supports, mental health programming, nursing support, and attention to socialization and social services.  The Day Treatment Program does not provide occupational or physical therapy but does provide modest assistance with daily activities and does provide individual, group and educational sessions focusing on illness recovery, as well as activity therapies on each of the days of participation.

The health plan's determination of medical necessity is overturned.

The requested health service/treatment of adult day health care program medical day care, at a frequency of three days per week is medically necessary for this patient.  The requested adult day health care program, medical day care at a frequency of three days per week, is clinically appropriate and necessary with regard to the scope, intensity, frequency and duration of treatment for the dates of service requested.  The patient is receiving active treatment together with peer support and medication management. Compliance and medication adherence are supported, as well as the benefit of psychosocial interventions and active treatment of the mood and trauma related disorders.  The treatment provided could not be effectively provided with lower level services or with more usual senior citizen services not designed to provide mental health care and individualized treatment, as the patient is receiving.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3:

The patient was a male who had a diagnosis of malignant neoplasm of the prostate and a history of hyperlipidemia.  The patient had an initial prostate biopsy 2 years ago and a repeat biopsy one year ago.  According to the Genomic Prostate Score report, his National Comprehensive Cancer Network (NCCN) Risk Group was intermediate, Gleason Score 3+3, Prostate Specific Antigen (PSA) (nanograms per milliliter) 4.5, clinical stage T1c, number of cores collected 12, and number of cores positive 1.

The test under consideration has not been shown to affect treatment outcome or patient survival. The Oncotype DX Genomic Prostate Score testing does not have final approval from the appropriate regulatory bodies for this diagnosis and is not considered standard of care.  It has not been shown to affect treatment outcome or patient survival.     
As mentioned above, the test has not been shown to have any effect on treatment outcome or patient survival. It is but one of a host of proprietary laboratory exercises that have been proposed to accurately predict disease progression, but has not been shown to successfully accomplish this objective. It has not been approved for use in the United States by the Food and Drug Administration (FDA). It is not likely to be more beneficial than any standard treatment/procedures for this patient.

The carrier's denial of coverage for the Oncotype DX Genomic Prostate Score testing should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

This is a male with a past medical history of prostate cancer and hyperlipidemia who had a prostate biopsy and an Oncotype DX test.  The patient had one biopsy core positive for Gleason 3+3 prostate cancer.

While the Oncotype DX test does provide an additional measure of risk stratification, the respected professional organizations which issue management guidelines regarding prostate cancer do not uniformly endorse the usage of this test.  For example, the National Comprehensive Cancer Network (NCCN) Guidelines on Prostate Cancer state that men with low risk or favorable intermediate risk disease may consider usage of the Oncotype DX test; however, they also note the absence of randomized, prospective trials.   The American Urological Association (AUA) Guidelines are more negative about the usage of the Oncotype DX test, stating "tissue based genomic biomarkers have not shown a clear role in Active Surveillance for localized prostate cancer, and are not necessary for follow-up."  This statement is in regard to management of localized prostate cancer.  Overall, the impact of tissue based gene expression tests such as Oncotype DX on clinical practice and long term patient outcomes remains to be empirically demonstrated.  Prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking.  Scientific evidence in peer reviewed literature does not support an improvement in health outcomes by usage of this test.  The Oncotype DX test is Medicare reimbursed, but there is no long term data confirming its clinical utility.  The Oncotype DX test is not the best available treatment for the patient at this time, and is not likely to be more beneficial than any of the standard treatment/procedures for this patient.  

The carrier's denial of coverage for the Oncotype DX Genomic Prostate Score testing should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate cancer

Treatment: Oncotype DX Genomic Prostate score test

The insurer denied coverage for Oncotype DX Genomic Prostate score test. The denial was upheld.

Reviewer #1

This case involves a male diagnosed with malignant neoplasm of the prostate.  The patient underwent a biopsy.  The patient had a prostate specific antigen (PSA) of less than 10 with a PSA density of greater than or equal to 0.15.  The patient had a Gleason score of 3+3 grade group 1.  The total number of cores obtained at biopsy was 12 with one positive core with no greater than 50% cancer in any positive core.  The patient had a T stage of T1c.  The patient had a life expectancy of 10 to 20 years. The Oncotype DX Genomic Prostate Score was ordered to identify the patient's specific risk of aggressive prostate cancer in order to make a more informed decision between active surveillance and immediate intervention.

According to literature, the role of the requested testing at the time of testing was uncertain.  Based on review of evidence, there was no clinical indication for the technology.  The National Comprehensive Cancer Network (NCCN) very recently altered the recommendation for the requested testing indicating men with a low or favorable intermediate risk disease may consider the use of the requested testing.  This was updated in version 01/2019.  The patient underwent this testing prior to that date; therefore, it was not the best available treatment for the patient at that time. The scientific evidence did not support a result of improvement in health outcome in peer-reviewed literature and the testing did not have final approval from the appropriate regulatory bodies at the time of testing.  At the time of testing, the patient was not a good candidate for the Oncotype DX Genomic Prostate Score test, and it was not likely to be more beneficial than any other standard treatment/procedure for the patient.  

The carrier's denial of coverage for the Oncotype DX Genomic Prostate Score testing should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism
 
Treatment: Inpatient Hospital Admission

The insurer denied the Inpatient Hospital Admission. The denial was upheld.    

This is a male patient who presented to the emergency department (ED) with complaints of cough, right sided flank pain, and chronic right lower extremity swelling. He has a history of hypertension, antiphospholipid syndrome, pulmonary embolism, and deep vein thrombosis, on Coumadin. The patient had a computerized tomography (CT) of his chest that revealed multiple non occlusive segmental and sub segmental pulmonary embolism and bronchiectasis. He had a chest x-ray that revealed atelectasis over pneumonia. Rheumatology was consulted and suggested outpatient follow up. Hematology was also consulted and recommended adding oral aspirin to his current anticoagulant regimen.  The patient remained afebrile and hemodynamically stable and was discharged home.
The patient did not need acute inpatient hospitalization. He could have been placed in Observation status while having diagnostic testing, treatment, and consultations.
The patient remained stable after admission. He could have been discharged after a period of observation with close follow up in the outpatient setting.

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

Patient has a past medical history significant for recurrent pilonidal cyst infections requiring incision and drainage.  Patient had 3 days of left buttock pain and swelling.  On exam, patient had a warm and fluctuant left upper buttock abscess, and the white blood cell count was elevated.  Patient was taken to the operating room the following day for excision of recurrent pilonidal cyst.  Patient was discharged home later the same day.  The health plan's determination of medical necessity is upheld in whole.  The inpatient admission was not medically necessary.  The patient is young and without significant comorbidities.  The care provided (e.g. pain control, intravenous antibiotics, surgical procedure) could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath, coughing
Treatment: Inpatient stay

Summary:
The patient is a  male child. He has a medical history significant for asthma. He presented to the ED with two day history of coughing and shortness of breath, as well as decreased appetite, some right upper quadrant pain, and one episode of vomiting. He denied abdominal pain in the ED. 

This young male child presented to the ED with URI (upper respiratory infection) symptoms and asthma exacerbation. He was given multiple bronchodilator treatments in the ED, along with systemic corticosteroids with some improvement, but he had persistent wheezing and poor appetite. Following admission, his condition improved with routine bronchodilator treatments and systemic corticosteroids, with resolution of symptoms. While it was not unreasonable to continue to treat this patient in this hospital for persistent bronchospasm, he was overall hemodynamically stable, with no oxygen requirement, no signs or symptoms of impending respiratory failure, no ongoing vomiting/diarrhea/fever, and no concerning underlying chronic medical conditions. He did not require acute inpatient admission. He could have been safely managed at a lower level of care.