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

Diagnosis: Melanoma
Issue under review: DecisionDX-Melanoma test

Determination:
The health plan should not cover teh DecisionDX-Melanoma Test

Guidelines from the National Comprehensive Cancer Network [NCCN] are clear: "While there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas (before or following SLNB) is not recommended outside of a clinical study (trial)" [NCCN]. In other words, the NCCN considers gene expression profile assays experimental or investigational. 
Moreover, studies have been inconsistent, consequently demonstrating that genetic expression profile assays have limited clinical utility -- "the difficulty of embracing gene expression profiling as an independent predictor of outcome is illustrated by the inconsistency of results across studies aimed at defining the most predictive gene sets for melanoma." [NCCN, Germani, Nsengimana, Winnepennick, Brunner, Timar.]

According national guidelines and peer-reviewed literature, gene expression profile assays for cutaneous melanoma, including DecisionDX-Melanoma, are experimental or investigational. The health plan acted in accordance with national guidelines and peer-reviewed literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleep apnea
Treatment: Attended polysomnography

The attended polysomnography was not medically necessary.

The patient had no significant comorbid condition which would make a home-based sleep study a contraindication.  Based on the guidelines published by the American Academy of Sleep Medicine, a laboratory based sleep study was not medically necessary in this case as the clinical history did not document high pretest probability of moderate to severe obstructive sleep apnea in this case and there were not any significant comorbid medical or sleep conditions which would make a home-based sleep study a contraindication.  

The high pretest probability of moderate to severe obstructive sleep apnea requires documentation of all four of the following but it is not restricted to these major four symptoms, these include:
- witnessed apnea
- presence of excessive daytime sleepiness as recorded by Epworth Sleepiness Scale of more than 10/24
- presence of unexplained hypertension
- BMI of more than 35.

Presence of all of the above confer a high pretest probability of moderate to severe obstructive sleep apnea in the presence of significant comorbid medical condition or sleep conditions such as:
- presence of severe congestive heart failure
- presence of pulmonary disease requiring oxygen
- recent stroke or heart attack
- concern for obesity hypoventilation syndrome
- concern for narcolepsy
- concern for central sleep apnea
- concern for periodic limb movement (PLMD) or parasomnias
- craniofacial anatomy defects.

The laboratory based sleep study would be medically indicated in the presence of high pretest probability as recorded by the four symptoms above with presence of significant comorbid/sleep conditions.  The laboratory based sleep study would not be medically necessary under those circumstances in which a home-based sleep study is appropriate and there is an absence of significant comorbid medical or sleep conditions as mentioned above. As the clinical history provided in this case did not meet the criteria for a laboratory based sleep study since it could have been done as a home-based sleep study, the laboratory based sleep study was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

The patient with past medical history significant for hypertension, kidney transplant, hyperkalemia, cholecystectomy, and hernia repairs, presented to the emergency department with chief complaints of nausea, vomiting and abdominal pain for the last day. Patient reported passing flatus and did not note any difficulties with bowel movements. Patient denied fevers, chills, chest pain, urinary symptoms, or other complaints. On presentation to the hospital, patient was noted to have vital signs within normal limits. Exam was otherwise remarkable for mild right sided tenderness.EKG did not show changes concerning for acute ischemia or arrhythmia. CT of the abdomen and pelvis showed dilated loops without transition point concerning for early small bowel obstruction versus ileus.Surgery was consulted. The patient was given intravenous fluids, IV anti-emetics and pain medications, and was subsequently admitted to the hospital for ileus versus early small bowel obstruction. HP determination is upheld, inpatient hospitalization was not medically necessary. It would be expected on presentation that patient would potentially improve  quickly given patient was continuing to pass flatus and was not having difficulty with bowel movements or ongoing vomiting, and in this setting it is reasonable to have expected less than two midnights hospitalization being required. The presentation was consistent with one of ileus more likely than early small bowel obstruction. Patient did not have hypomagnesemia, hypokalemia or other process such as immediate postoperative state expected to contribute to prolonged ileus requiring several days of treatment. Inpatient level of care was not medically necessary, and a lower level of care was more appropriate.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of R thalamic cerebrovascular accident (CVA), coronary artery disease (CAD) 
status/post (s/p) stent, hypertension (HTN), and hyperlipidemia and presented to the emergency department (ED) 
on 6/5/2018 due to leg cramping. He was discharged home with outpatient followup.

The health plan's determination is upheld. The inpatient stay is not medically necessary. The record shows the patient had acute kidney injury and an elevated troponin. Acute coronary syndrome was ruled out and his acute kidney injury resolved with IV fluid administration. There was no serious underlying condition requiring inpatient management. Inpatient care is more care than needed for this condition. The patient had no hemodynamic instability or serious electrolyte abnormalities. The record shows the patient had acute kidney failure with a serum creatinine of 1.25, above his baseline of 1.0. This resolved overnight with the administration of IV fluid. The patient had no ongoing fluid losses requiring continued IV fluid replacement. The troponin elevation was felt to be related to acute kidney injury and hypertension, and the labetolol dose was increased. Acute coronary syndrome was ruled out and the cardiac ECHO did not show any serious condition. The brain imaging showed no acute infarct. The patient had no condition that could only be safely managed at the inpatient level of care. This patient's condition could have been safely and appropriately managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of a heart murmur who presented with difficulty breathing, who was well until 2 days prior to presentation when he developed a cough and difficulty breathing. During that night and into the early morning he had 2 episodes of post-tussive emesis. He continued to worsen throughout the following day, when his mother noted that he continued to have respiratory symptoms as well as a fever. He was brought in for evaluation and was diagnosed with croup. The health plan's determination of medical necessity is overturned.  The patient had worsening symptoms despite appropriate therapy as an outpatient, and continued to have stridor and increased work of breathing after receiving appropriate and intensive treatment in the emergency department. He required several doses of racemic epinephrine, as well as intravenous fluids to maintain his hydration status in the setting of multiple episodes of posttussive emesis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee swelling
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
Knee pain is an extremely common complaint in children, one of the most prevalent musculoskeletal complaints in pediatric practice. There are age associated disease and injury patterns, and making an accurate diagnosis requires understanding of these differences as well as anatomy. Skilled examination is essential, and diagnosis may ultimately require advanced imaging.
This young girl was referred to the ED for left knee pain and swelling. X-rays and lab studies were unremarkable, and she had no constitutional symptoms. She was given an initial dose of antibiotic for possible cellulitis, but antibiotics were not continued. She was ultimately diagnosed with left knee pain and viral syndrome (she also had cold symptoms). While it was not unreasonable to monitor her for progression or regression of pain and swelling, she was overall hemodynamically stable, with no significant constitutional symptoms, no significant need for pain management, and no underlying illness. She did not require acute inpatient care and could have been managed safely at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse 

Treatment:Inpatient admission 

Summary:
The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received supportive care with IV fluids, electrolyte repletion, prn (as needed) benzodiazepines for withdrawal and continued cardiac monitoring. She responded well to the prescribed therapies and was subsequently discharged in stable condition.  There is no evidence of intensification of services throughout the course of this patient's hospital stay. Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation 
Treatment: Inpatient Stay

Summary:
There is no documentation for hemodynamic instability, peritoneal signs, suspected bowel obstruction, suspected ischemia or colitis, other signs or symptoms of acute abdominal disease. Therefore, the requested Acute inpatient Hospital stay is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sensitivity/Cracked Tooth Syndrome and Failing Restoration on #5, as well as #2.
 
Treatment: Resin-based Composite -two surfaces, Posterior (D2392), for Tooth #2; Porcelain Crown (D2740), for Tooth #5; Core buildup including pins (D2950), for Tooth # 5

The insurer denied the Resin-based Composite -two surfaces, Posterior (D2392), for Tooth #2; Porcelain Crown (D2740), for Tooth #5; Core buildup including pins (D2950), for Tooth # 5.  The denial was reversed.    

This is a male patient who has a crack on the distal of the tooth, as well as fractures on the lingual, and an amalgam that was leaking. Upon review of the submitted documentation, which includes copies of bitewing and periapical radiograph, intraoral clinical images, dental treatment notes, as well as insurer correspondence, it appears that the patient exhibited sensitivity/cracked tooth syndrome and failing restoration on #5, as well as #2. Based on these clinical findings, the treating dentist recommended placement of a full coverage crown on this tooth (with core buildup) and a direct placement resin restoration #2. 

Upon review of the documentation, the existing metallic restoration placed on #5 appears to be failing.  The margins are open and cracks in the tooth are noted clinically and radiographically. Given this clinical circumstance, placement of a full coverage crown is indicated (and associated core buildup as necessary) and is a conservative restorative option which would represent a standard of care for this clinical circumstance in general dental practice.  A direct placement composite restoration for #2 is also a standard of care.  As such, these services as noted above, which are also covered services for this individual, are deemed medically necessary.

The carrier's denial of coverage for Resin-based composite -two surfaces, posterior (D2392) for tooth #2; Porcelain Crown (D2740) for tooth #5, Core buildup including pins (D2950) for tooth # 5 is reversed.  The medical necessity is substantiated
Appeal type: Formulary Exception
Decision: Overturned

The patient has severe ulcerative colitis, and has an incomplete response to Entyvio and needs treatment of steroids to control a flare. The preferred formulary alternatives (dexamethasone; hydrocortisone; methylprednisolone; prednisolone; prednisone) are potent glucocorticoids, that have side effects that are much more severe than Uceris, and therefore, they are all contraindicated in this patient with avascular necrosis. The patient already has avascular necrosis of both femoral heads due to steroid use. As Uceris does not worsen osteoporosis and derogates bones, such as the preferred formulary alternatives do, it is medically necessary in this patient.  Therefore, the health plan should cover Uceris 9 mg tablets.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Brochiolitis, viral syndrome

Treatment: Inpatient admission, diagnostic testing, medication management

The insurer denied inpatient admission. That denial was upheld.
This presented to the ED with history of fevers for 1 week, 2-3 days of cough, diarrhea (unspecified amount per day), decreased activity and decreased appetite. The child was seen by the Pediatrician the day prior to ED presentation and diagnosed with bronchiolitis and was started on Albuterol nebs of which she had received 3 treatments in the interim prior to the ED (In one documentation, it is said to have helped, in another it was reported as not helping). The patient's father reported that child was brought in due to concerns for her not eating her usual and concern for dehydration, the father was noted to have denied any vomiting episodes while in the ED triage. Serial ED vital signs were stable, Physical exam was unremarkable (described as active and playful, clear chest and good breath sounds, good capillary refill). No significant electrolyte derangement was noted (Bicarb was 13 initially, corrected to 25 after intravenous (IV) fluids in the ED at 4:56 am.  White blood cell (WBC) was 5.86K (Normal range for this institution 6-17.5). She received IVF and Zofran IV in the ED. 

It is mentioned, at least 2 times, in the notes that the admission was for "observation." 

The medical records provided and reviewed do not show any severe problems as noted by MCG 23rd edition criteria, for example Severe Fluid or Blood Loss (there is no documentation of the number of stools or consistency. There was a discrepancy in the mother's description of stool and what was observed by the nurse while on the unit on. Criteria for full hospital admission were not met.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse

Treatment: Inpatient detoxification

The insurer denied inpatient admission for detoxification. That denial was reversed.

This patient was admitted to inpatient alcohol detoxification treatment. She was drinking 1 liter to 1/2 gallon of alcohol per day and had an 18 year history of use and also was using Xanax 1-2 mg a few times per week. She reportedly had alcohol withdrawal symptoms including moderate tremors, sweats, nausea and vomiting, and anxiety. She had a CIWA of 17. She was put on an Ativan taper. She had a past inpatient detoxification for alcohol withdrawal. She lacked sober supports and had limited family supports. It was reported that she needed to build better coping skills, identify triggers and stressors.

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) she did require 24 hour treatment as she continued to drink alcohol despite past inpatient substance detoxification treatment, could not safely and effectively be treated for detoxification in a less restrictive setting as she needed detoxification medication (Ativan)  to modify withdrawal from alcohol , and she needed 24 hour treatment then as she was at risk for worsened withdrawal symptoms if not in this 24 hour setting then, including possible life threatening withdrawal such as delirium tremens which can occur 4 days after cessation of alcohol use. She had lacked sober supports and had limited family supports. It was reported that she needed to build better coping skills, identify triggers and stressors. Inpatient hospital detoxification treatment was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the hospital for an elective cardiac catheterization for exertional chest pain and dyspnea of 1-2 weeks duration. 

The health plan's determination is upheld. The inpatient admission was not medically necessary. There is no medical necessity in the medical documentation to explain the need for full admission. The patient had some diaphoresis and lightheadedness which responded to fluids. This could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: G6PD deficiency and a history of hemolytic crises requiring transfusions who presented with recent fever, jaundice, worsening anemia, hyperbilirubinemia, elevated ferritin, elevated reticulocytes, and decreased platelets.

Treatment: Inpatient admission, and monitoring.

The insurer denied inpatient admission. That denial was reversed.

This patient with the above noted blood disorder was described as feeling weak. Vitals signs were significant for tachycardia. Of note, in the Emergency Department triage, the mother highlighted the patient's history of always needing a transfusion when he gets sick.
 
Patients with G6PD deficiency have variable severity of disease. As such, when determining the appropriate management for this patient, one must consider this patient's medical history of frequent severe hemolytic crises requiring transfusion. This fact was highlighted by the mother and the Pediatric Hematologist fellow and must be taken into consideration in this tachycardic patient with worsening jaundice and labs consistent with ongoing hemolysis. In fact, the subsequent hemoglobin had a significant drop of over 1 gm.
 
As noted in the references, prolonged monitoring for ongoing hemolysis, need for transfusion support, and concern for renal dysfunction was within standard of care. The admission was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroparesis, history of hypertension

Treatment: Inpatient admission, diagnostic testing, and medication management

The insurer denied inpatient admission. That denial was upheld

The patient presented with epigastric pain, nausea and vomiting. He had morbid obesity. There was an initial blood pressure of 184/125. There was no abdominal rebound or guarding. A CAT scan was negative for obstruction. The patient was started on Reglan for gastroparesis. The hypertension was treated. An endoscopy was consistent with gastroparesis. 

MCG guidelines for Gastroenterology (MG-GAS) list the clinical criteria for admission. Gastroparesis is an indication for admission if there is a complicating factor. This condition can be severe dehydration, severe electrolyte abnormalities, acute renal failure, or severe vomiting that is not responsive to anti-emetic treatment. Acute renal failure is defined as a 3-fold rise in serum creatinine. In this case, the creatinine was 1.6. The patient did not meet these criteria.

This patient had gastroparesis. He required intravenous hydration and potassium replacement. This could have been done with observation status. The treatment with Reglan and the endoscopy could also have been done on an outpatient basis. 

This patient did not meet MCG criteria for admission for gastroparesis. The healthcare plan acted reasonably and with sound medical judgment. Inpatient services were not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Mole
Treatment: 96931 - Reflectance confocal microscopy for cellular and sub-cellular imaging of skin
The health plan should cover 96931 - reflectance confocal microscopy for cellular and sub-cellular imaging of skin.
96931 - Reflectance confocal microscopy for cellular and sub-cellular imaging of skin is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.
Biopsy and histologic evaluation have been the gold standard to diagnose skin tumors. Reflectance confocal microcopy (RCM) is a noninvasive, innovative diagnostic technique that enables visualization of different skin layers at an almost histologic resolution. RCM has been proven beneficial in management of various cutaneous lesions.  This prevents unnecessary biopsies.  Current literature supports use of RCM.  
A recent review compared dermoscopy and confocal microscopy.  Eight published studies were included in the analysis, involving 1141 skin lesions, which reported a per-lesion analysis of dermoscopy and RCM. Within the same patient group and at the per-lesion level, RCM significantly increased the detection rate of malignant skin tumors by 7.7% (95% CI 0.01-0.14). 
RCM imaging combined with dermoscopic examination is guiding the triage of lesions into those that appear benign, which are being spared from biopsy, against those that appear suspicious, which are then biopsied.  Current evidence supports that RCM prevents unnecessary biopsies.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Mole
Treatment: 96931 - Reflectance confocal microscopy for cellular and sub-cellular imaging of skin
The health plan should not cover 96931 - reflectance confocal microscopy for cellular and sub-cellular imaging of skin.
96931 - reflectance confocal microscopy for cellular and sub-cellular imaging of skin is not likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.
Reflectance confocal microscopy for cellular and sub-cellular imaging of skin is the subject of multiple ongoing phase I, II or III clinical trial (https://clinicaltrials.gov/ct2/results?cond=&term=Reflectance+confocal+microscopy+skin&cntry=&state=&city=&dist=&Search=Search).
Reflectance confocal microscopy (RCM) is a novel tool for noninvasive in vivo diagnosis of nonmelanoma skin cancer at high resolution. Multiple studies have evaluated the use of RCM in melanoma and nonmelanoma skin cancer and have demonstrated high sensitivity and specificity rates. However, it is still being evaluated in clinical trials against the use of biopsy for diagnosis, which is the current standard of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Mole
Treatment: 96931 - Reflectance confocal microscopy for cellular and sub-cellular imaging of skin
The health plan should not cover the 96931 - reflectance confocal microscopy for cellular and sub-cellular imaging of skin.
As stated in the Borsari reference "Reflectance confocal microscopy is a useful tool for the diagnosis of challenging lesions suspicious for malignant abnormalities".  
There is no documentation that the lesion was clinically suspicious or challenging.  
96931 - reflectance confocal microscopy for cellular and sub-cellular imaging of skin is not likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.
As stated in reference #2, RCM is an add-on imaging tool but not a treatment for a suspicious lesion. If the lesion were clinically suspicious, standard treatment would be to remove the lesion.