Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: OncotypeDx Prostate Cancer Assay (0047U). 

The insurer denied the OncotypeDx Prostate Cancer Assay (0047U). 
The denial is upheld. 

The patient in this case was diagnosed with early stage prostate cancer. The Gleason Sum was 3+3=6.  Three of 16 cores were involved, all less than 50%.  The prostate specific antigen (PSA) at diagnosis was five. 

No, the health plan should not cover the proposed OncotypeDx Prostate Cancer Assay (0047U). 

OncotypeDX Prostate Cancer is a gene expression assay performed to assess the likelihood of finding high-risk pathology at the time of radical prostatectomy.  There is no evidence showing that this test can improve health outcomes in men diagnosed with early stage prostate cancer.  It is not currently considered a routine standard of care test in men diagnosed with early stage prostate cancer based on the National Comprehensive Cancer Network (NCCN) or the American Society of Clinical Oncologists (ASCO) guidelines.  While there is some evidence showing that this test can provide prognostic information beyond that obtainable by clinical assessment, there is no evidence that using this test actually improves health outcomes. 

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Prostate Cancer. 
Treatment: OncotypeDx Prostate Cancer Assay (0047U). 

The insurer denied the OncotypeDx Prostate Cancer Assay (0047U). 
The denial is upheld. 

This male with prostate cancer had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in three of 16 cores. The clinical stage was T1c. The prostate specific antigen (PSA) was less than (<) ten. 

No, the health plan should not cover the proposed OncotypeDx Prostate Cancer Assay (0047U). 

Regarding this testing, the Policy states "Due to insufficient evidence of efficacy, molecular profiling using gene expression profiling, Chromosome Microarray multi-gene cancer panels are unproven and not medically necessary for all other indications." 

No, the requested health service or treatment is not more beneficial than any standard treatment for the insured's condition or disease. 

Per the American Urologic Association (AUA) Guidelines: 
"14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)" 
Guideline Statement 32: Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion) 

The patient has a low-risk prostate cancer. 

Although results are promising, further validation is necessary to understand fully the potential clinical utility of this test. The National Comprehensive Cancer Netowrk (NCCN) Guidelines state that "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclear." "[A]ny of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elevated Blood Pressure and Painless Hematuria.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with chronic kidney disease in the setting of polycystic kidney disease and hypertension. She presented to the hospital with hematuria in the setting of medication non-compliance and uncontrolled hypertension.

Patient was admitted and started on fluid and antibiotics. Urine culture was significant for Citrobacter, and the patient was transitioned to oral antibiotics.

The health plan denied coverage of the inpatient admission, as there was no documentation that the patient could not have been safely and effectively managed at a lower level of care. The decision is being appealed.

No, the Inpatient admission was not medically necessary.
The inpatient admission was not consistent with generally accepted national standards of medical practice. It cannot be established that it was not  provided primarily for the convenience of the patient or the practitioner, or that it was the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Based on the available data, inpatient level of care was not medically necessary, as there was no documentation regarding Hemodynamic instability, Vomiting that was severe or persistent, Altered mental status that was severe or persistent, Persistence or worsening of clinical findings despite observation care treatment, Parenteral antibiotics needed beyond observation care treatment, Pregnancy of 24 weeks' gestation or beyond,  Immunocompromised state, New coagulopathy, Urinary system finding that required invasive procedure, or placed patient at increased risk for systemic illness or delayed recovery, Acute renal failure or need for IV (intravenous) hydration support or Other condition, treatment, or monitoring requiring inpatient admission. Based on available data these criteria are not met. Therefore the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Food Allergy Reaction.
Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.
The denial is overturned.

This case involves a male who was brought to the emergency department with facial swelling and generalized body itching.  He does have a history of food allergies and a prior allergic reaction.  The submitted documentation indicated prior to arrival he was given 10 mL (milliliters) of Benadryl.  On physical examination, there was evidence of swollen lower lip and a swollen uvula.  There is also swelling to the right eye.  The pulmonary effort was normal and there was no evidence of respiratory distress.  Oxygen saturation was 99% (percent).  The documentation indicated the patient was observed for greater than 2 hours however he continued to have swelling to the tongue with a bulky uvula.  There was no wheezing evident and no respiratory distress.  He also did tolerate small sips of water.  It was recommended he receive IV (intravenous) Solu-Medrol and Pepcid and be admitted for continued steroids and H2 (reduce acid produced by cells in stomach) blockers.  The documentation detailed he continued with treatment and was able to advance to regular diet.  Given these symptoms did improve he was discharged the following day.

According to the referenced literature, the patient may be admitted when there is evidence of hemodynamic instability, or when there is a need for treatment requiring inpatient care.  The submitted documentation indicated this patient presented to the emergency department with facial swelling and itching.  He does have a history of food allergies and it was noted that he did consume chocolate that had a nut in it.  He was monitored however despite treatment and follow-up observation he continued to have swelling to his tongue in addition to a bulky uvula.  While there was no sign of respiratory distress it was recommended, he be admitted for further IV medication given ongoing symptoms.  Given the continued presence of swelling, the inpatient admission was needed to continue frequent monitoring in addition to allow administration of IV medications.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Distal myopathies/muscular dystrophy

Treatment in-network coverage for an out of plan referral for genetic testing: distal myopathy advanced sequencing evaluation, 81404, 81405, 81406, 81407, 81408 (molecular pathology procedure), and 81479 because of weakness in both hands

The insurer denied coverage for in-network coverage for an out of plan referral for genetic testing: distal myopathy advanced sequencing evaluation, 81404, 81405, 81406, 81407, 81408, and 81479 because of weakness in both hands

The denial is upheld

This case involves a male who has been recommended to undergo genetic testing for distal myopathies/muscular dystrophy. The documentation indicated while there is currently no therapy that directly treatment needed the tested disorders to address muscle weakness, many of the disorders are associated with other systemic involvement, most concerning the pulmonary cardiac involvement. The physician indicated it was important to know the patient's exact diagnosis so that he may be treated for any underlying condition. He was seen for a routine follow-up complaining of hand weakness. He has previously undergone genetic testing for type I myotonic dystrophy which was negative. He has reported no change in the degree of weakness. Per physical examination motor strength is 4/5 bilaterally to the upper extremities. The lower extremities were 5/5 with the exception of foot dorsiflexion. The sensory examination was intact and there was a normal gait. The physician indicated there was continued concern for a myopathy process such as a very distal myopathy. It was recommended he therefore undergo a genetic panel.

According to referenced literature the utilization of the recommended genetic screening is not appropriate as there are no known treatments for the muscular dystrophies identified on the requested testing. Typically, a patient's symptoms can be treated as they arise. Therefore, given the above, the requested denial should remain upheld.

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient. 

The insurer's denial of coverage for the in-network coverage for an out of plan referral for genetic testing: distal myopathy advanced sequencing evaluation, 81404, 81405, 81406, 81407, 81408, and 81479 because of weakness in both hands is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis

Treatment: Opzelura 1.5% topical cream

The insurer denied coverage for Opzelura 1.5% topical cream

The denial is upheld. 

The patient is a female with a diagnosis of atopic dermatitis of the hands with secondary lichenification. The patient has failed topical steroids. The request is for Opzelura 1.5% (percent) topical cream. The health plan is requiring tacrolimus ointment prior to approval of Opzelura cream. The request is for Opzelura cream.

Based on the submitted documentation the use of Opzelura cream is not medically necessary. The patient has failed topical steroid therapy; however, there is no documentation of a failure or contraindication to tacrolimus ointment. The health plan has approved the use of tacrolimus 0.1% ointment. Tacrolimus ointment is approved for use in atopic dermatitis and is a reasonable non-steroidal next step alternative in the treatment of the patient's disease. The request is denied based on the submitted documentation.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Opzelura 1.5% EX (external) CREA (cream) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic sarcoma

Treatment: continued home health aide (HHA) services

The insurer denied coverage for continued HHA services

The denial is upheld
 
The patient is a female with metastatic sarcoma who is status post-surgery and currently being treated with chemotherapy. Two home health notes are included. At the start of services, she needed intermittent assistance in the shower, transfers required minimal assistance, set-up assistance for oral hygiene, walked independently with use of assistive device, set-up for lying to sitting on edge of bed, set-up for sit to stand, set-up with transfers, and set-up for mobility including steps. No recent function was provided. She is going to chemotherapy every other week. A recent note states she is homebound due to weakness.

A home health aide provides personal care services such as assistance with bathing, toileting, and dressing. The physician's letter of medical necessity provides specific medical details about the patient such as the dizziness, weakness, loss of vision, and shortness of breath to justify the patient's homebound status. However, the physician's letter is not specific enough regarding the personal care services that would be needed by this patient. In addition, the most recent home health note provides insufficient information to justify the patient's need for continued personal care services. A telemedicine note provides no data regarding her ability to function with regard to activities of daily living (ADL) or instrumental activities of daily living (IADLS). It details her cancer status and does note a negative review of systems. Another note contains a fall assessment, and all aspects are noted as "no" including any weakness or changes in how she walks, she noted no need for help in ambulating or getting in a chair. The justification for continued HHA is not supported. 

For the continued HHA services, specific details regarding the patient's current function and need for a HHA are required. As the documentation does not provide sufficient information regarding the patient's current function, a continued HHA would not be considered clinically appropriate or in accordance with generally accepted standards of medical practice. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for continued home health aide (HHA) services is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Alopecia universalis.

Treatment: Xeljanz 10 milligram (mg).

The insurer denied coverage for Xeljanz 10 milligram (mg).

The denial is overturned.

The patient is a female with a diagnosis of alopecia universalis. The patient has tried and failed topical, intralesional, and oral steroids without success. The patient is currently on Xeljanz 10 milligram (mg) twice a day (BID) and has noted 80% hair regrowth. The request is for continuation of Xeljanz.

The literature and scientific data support an improvement in alopecia universalis with Xeljanz treatment. Xeljanz does not have Food and Drug Administration (FDA) approval for use in alopecia universalis. No FDA approved treatments are available for alopecia universalis. The patient is a good candidate for Xeljanz therapy and has responded favorably to treatment thus far. Xeljanz is the best available therapy for this patient at this time. The adverse risks associated with Xeljanz are increased compared to topical and some oral therapies; however, the risks are not significant, and the medication has been well tolerated with routine lab monitoring according to the documentation provided. Xeljanz is more likely to be beneficial for this patient than any of the standard available therapies for treatment of alopecia universalis.

The carrier's denial of Xeljanz 10 milligrams (mg) to treat alopecia areata/alopecia universalis is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right hip pain

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is overturned.

This is a female with a history of cardiomyopathy, atrial fibrillation, pulmonary embolism, deep vein thrombosis (DVT), hyperthyroidism, lupus, and morbid obesity. She presented to the hospital for a scheduled right total hip arthroplasty. The patient lost 1.5 liters of blood and needed a blood transfusion. She required vasopressors during surgery. A fluid bolus was given. A chest x-ray (CXR) did not reveal fluid overload. On postoperative day 1 vital signs improved. Hemoglobin (hgb) dropped, and another unit of red blood cells was transfused. Pain was well controlled with medication. The patient did not need any additional transfusions on postoperative day 2. The patient worked with physical therapy and occupational therapy (PT and OT). Pain medication was given as needed (PRN). The patient was discharged after a period of hemodynamic stability. 

The medical record denotes several underlying medical conditions which significantly increased risk of post-surgical complications. The patient required close monitoring and could not be treated in any other setting than an acute admission. The records showed abnormal vital signs. She was found to have a respiratory rate of 20, she had tachycardia, and was febrile. The post-surgical temperature was reported to be 100. 
She had a previous history of bilateral PE (pulmonary embolism) and had atrial fibrillation. She had post-surgical anemia requiring transfusions. Her Cardiologist recommended an additional ECG (electrocardiogram) and medication changes. She had a BMI (body mass index) of greater than 50 which would be an additional factor which supported her level of care. She was at great risk for recurrent VTE (venous thromboembolism) recent surgery, immobilization, venous stasis, previous PE.

There would be no alternative to level of service based upon her unique clinical condition. 

The inpatient stay is considered medically necessary for this patient.
DENIAL OVERTURNED

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient stay is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class I, Class II canines, maxillary and mandibular crowding, deep bite, moderate maxillary and mandibular incisor protrusion and severely excessive overjet). 

Treatment: D8080 braces and D8670 periodic treatments visits.

The insurer denied coverage for D8080 braces and D8670 periodic treatments visits.

The denial is upheld. 

This patient is a child who presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to skeletal Class I, Class II canines, maxillary and mandibular crowding, deep bite, moderate maxillary and mandibular incisor protrusion and severely excessive overjet. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the Handicapping Labio-Lingual Deviation (HLD) index attaining only 19 points on review by their internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating Orthodontist does not submit an HLD index but presumably claims an automatic qualifying condition of excessive overjet. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care. This reviewer concurs with the findings of the insurer of attaining 19 points on the HLD index (7 points overjet, 5 points overbite, 5 points anterior crowding, 2 points labiolingual spread).

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies.
 
Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient.
 
The insurer's denial of coverage for D8080 braces and D8670 periodic treatments visits is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied an inpatient stay. 
The denial is overturned.  

The patient is a male, with cardiomyopathy, on chronic aspirin who presented to the emergency department (ED) with weakness, fatigue, and rectal bleeding for three days. The rectal blood was described as bright red, painless, and persistent. He was also noted to be pale and dizzy. The patient has a history of gastric bypass surgery and small bowel resection in the past. The patient was admitted to the hospital with acute blood loss, anemia, and hypovolemic shock due to gastrointestinal (GI) bleed. He was started on aggressive intravenous (IV) fluids, typed and screened, and transfused two units of packed red blood cells. Gastroenterology was consulted, and aspirin was placed on hold. The patient's elevated troponin was due to demand ischemia, secondary to severe anemia. In addition, the patient was suffering from acute kidney injury and metabolic acidosis, which the medical team hoped to correct with IV fluids. The vital signs appeared relatively stable, with a heart rate of 80 and blood pressure 139/82. The esophagogastroduodenoscopy (EGD) showed a normal esophagus and jejunum, a healthy-looking Roux-en-Y bypass, but was biopsied. Colonoscopy revealed a few non-bleeding diverticula of the left colon. The patient's diet was advanced, and the patient was cleared for discharge, with plans for outpatient capsule endoscopy. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned.

Based on the provided documentation, the inpatient stay was medically necessary for this patient. This is a patient who presented to the hospital with hemorrhagic shock due to an undifferentiated GI bleed, hemoglobin less than seven, and requiring multiple blood transfusions for stabilization. There is evidence of lactic acidosis, acute kidney injury, and demand ischemia in a patient with known hypertrophic obstructive cardiomyopathy. Physical exam revealed positive guaiac stool, concerning for acute severe GI bleed. The standard of care is to admit this type of presentation to inpatient. The patient walked into the emergency department, with blood pressures in the 70s, which would not have been appropriate for management at a lower level of care status. The clinical literature clearly supports the decision to follow an inpatient level of a care plan.