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

The patient is a male who presented to the emergency department as a level 1 trauma for a gunshot wound (GSW) to the right upper quadrant. The patient's vitals were stable and exploration at the bedside revealed penetration of the anterior abdominal fascia by the bullet and possible penetration of the posterior fascia. The patient underwent computed tomography (CT) scan showing likely pneumoperitoneum, as there was air tracking near the mediastinum, and a bullet just anterior to the liver. The patient also had a small right pleural effusion. Because the patient did not have evidence of an injury requiring immediate surgical intervention, the patient was admitted as an inpatient for non-operative management. The patient was admitted for serial abdominal examinations, pain control, repeat chest x ray, and serial hematocrits. The following day the patient was tolerating a regular diet, his pain was controlled, and the patient was deemed stable for discharge. He was discharged to home.

The health plan's determination is overturned.

This patient was admitted with penetrating abdominal trauma. Traditionally, all gunshot wounds to the abdomen warranted an immediate exploratory laparotomy. It is only in recent times that surgeons have selectively managed a small portion of patients with abdominal GSWs non-operatively. Non-operative management can only be applied to a very carefully selected group of patients with abdominal GSWs. Even with selective non-operative management, there are still many patients who ultimately require an exploratory laparotomy for injuries that were not obvious at presentation. It is very hard to predict who will fail. This is noted in a systematic review of the subject by Lamb and Garner, "Objective predictors of failure of SNOM (Selective non-operative management) seem to be surprisingly difficult to identify in a prospective and timely fashion." In an article on the subject in UptoDate, the authors state, "Usually, patients managed nonoperatively are admitted and undergo serial abdominal examinations, even if all initial studies are negative." Most surgeons admit such patients to the hospital. The patient was appropriate for an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower lip / facial swelling
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient had HTN, asthma and had history of angioedema requiring treatment just three days before.  His symptoms were not resolving and were worsening after ER treatment.  ICU admission was reasonable. The patient presented with facial swelling.  The patient was noted to not respond to treatment with continued swelling of lips.  Biphasic reactions can occur and should be monitored for.

The patient failed to sufficiently improve status-post treatment in the emergency department (ED) as demonstrated by the following pertinent positives during this admission: "Lip: diffuse, nonpitting, tense swelling of the dermis and subcutaneous tissue. CLASS 1 MALLAMPATI." In addition, the patient already failed to improve as demonstrated by his prior emergency department (ED) visit to Brookdale Hospital just three days prior to this admission. Therefore, the patient was not safe for discharge home from the emergency department (ED)/observation unit.

The management was according to clinical standards of care.  This patient is older and has a history of HTN in addition to other cardiac risk factors.  The patient had HTN, asthma and had history of angioedema requiring treatment just three days before.  His symptoms were not resolving and were worsening after ER treatment.  ICU admission was reasonable. He presented with facial swelling.  The patient was noted to not respond to treatment with continued swelling of lips.  Biphasic reactions can occur and should be monitored for.
Appeal type: Medical necessity
Decision: Overturned

This patient complains of a 27-year history of leg swelling and pain, despite wearing compression garments for 8 hours a day.  The legs fatigue quickly, the patient feels tender lumps under the leg skin, the legs bruise easily, the patient has trouble maintaining balance and the pain starts after standing for 15 minutes or waking for 8 minutes.  In the first half of 2019, the patient fell twice sustaining a wrist sprain and a dislocated toe.  The patient saw a vascular surgeon, who after ultrasound examination was the first to tell the patient that she had lipo-lymphedema.  Photos show type 3 stage 1 lipedema of the legs with a sharp line of demarcation at the ankles more significant on the right leg, slight valgus deformity of the right knee, trace valgus deformity of the left knee, wide inter-foot distance stance, excess supraumbilical abdominal skin and fat with effacement of the umbilicus on standing but no upper or lower abdominal pannus, bilateral folds of excess skin and fat below the bra strap line posteriorly.  Lymphatic-Sparing Liposuction: Suction Lipectomy of Thighs with Anesthesia was denied by the health plan and is under review. 

The health plan's determination is overturned.  The requested Lymphatic-Sparing Liposuction: Suction Lipectomy of Thighs with Anesthesia is medically necessary for this patient.  The symptom-based therapy of lipedema consists of conservative (compression, complex decongestive physiotherapy, manual lymphatic drainage, exercise) and surgical treatments (liposuction) but there is no cure.  Studies have shown improvement in spontaneous pain, sensitivity to pressure, edema, bruising and restriction of movement persisted in lipedema patients up to 8 years following liposuction surgery.  Another cohort study also showed improved quality of life and decreased need for conservative therapy up to 37 months following liposuction.  Therefore, liposuction for lipedema is safe and effective and medically necessary to prevent ongoing functional impairment and joint damage due to lipedema.  Lipedema is characterized by being almost exclusively in women, it can be inherited, it occurs independent of weight (but Obesity is an important risk factor for its severity and prognosis), it is symmetric bilaterally with visible sharp demarcations of fat accumulation vs. non-accumulation at the ankles, elbows and or waist, it does not diminish with limb elevation, it cannot be diminished by diet or exercise due the high fat concentrating abilities of hyperplastic fat deposits, and it spares the feet and hands.  It is clear that untreated lipedema progresses and results in valgus knee deformities and knee joint damage, as well as valgus ankle with increased inter-foot distance on standing or gait.
Therefore, liposuction for lipedema is safe and effective and medically necessary to prevent ongoing functional impairment and joint damage due to lipedema.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a skeletal Class I molar occlusion with an overjet of 9 millimeters (mm), 20% overbite. She has unerupted maxillary cuspids with retained URE (Upper right E or tooth #A), LLE (Lower left E or tooth #K), UC's (Upper cuspids or teeth #C and #H)and mild upper spacing and moderate lower crowding. The proposed treatment is braces for 24 months. The health plan's determination is upheld. The malocclusion in question does not meet the criteria used in most programs to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 19 with no auto qualifiers. Most programs using these evaluation methods require a score of 26 or more for treatment to be considered medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a female patient who was diagnosed with malignant melanoma who had a Decision X-Melanoma testing performed.
As reported by the authors Sondak, V. K., & Messina, J. L. (2016), "A similar (but genetically unrelated) gene expression profile test is now commercially available for cutaneous melanoma (DecisionDx-Melanoma; Castle Biosciences).  This test has not yet been evaluated in the kind of prospective clinical study that demonstrated the value of the uveal melanoma profile, nor is the scientific basis for including the component genes as well characterized.  The clinical value of this test remains unclear, and the National Comprehensive Cancer Network (NCCN) Guidelines for Melanoma state 'while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate 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)."'      

The carrier's denial of coverage for the DecisionDx-Melanoma Testing performed should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a female patient who was diagnosed with malignant melanoma with a shave biopsy.  She underwent a biopsy of her right arm, which was indicative of malignant melanoma.  Her physician ordered the Decision DX-Melanoma Assay.
The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.  The DecisionDx genetic testing has not been shown to improve the net health outcome of patients with cutaneous melanoma.  This testing has not been shown to be beneficial in patients with uveal melanoma or in patients with cutaneous melanoma. 

DecisionDx-Melanoma Testing does not have final approval from the appropriate regulatory bodies for this diagnosis.  This patient is not a good candidate for DecisionDx-Melanoma Testing.  There is no clinically significant benefit arising from the DecisionDx testing. The DecisionDx-Melanoma Testing is not the best available treatment for this patient at this time. 

The carrier's denial of coverage for the DecisionDx-Melanoma Testing performed should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Malignant Melanoma
 
Treatment:  DecisionDx-Melanoma Testing

The insurer denied the DecisionDx-Melanoma Testing.  The denial was upheld.

This is a female patient with a history of malignant melanoma.  She underwent a biopsy of her right arm which revealed malignant melanoma.  The specimen was sent for Decision DX Melanoma assay.   

The DecisionDx-Melanoma test is not recommended by the panel of expert authors of UpToDate.  The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.  DecisionDx-Melanoma testing does not need final approval from the appropriate regulatory body for this diagnosis as the facility is overseen by Clinical Laboratory Improvement Amendments (CLIA) and does not need to be Food and Drug Administration (FDA) approved.  The patient is not a good candidate for DecisionDx-Melanoma testing.  DecisionDx-Melanoma testing is not the best available treatment for the patient at this time, as the literature recommended that an annual routine physical examination, including a full skin assessment and palpation of the regional lymph nodes, would be appropriate for patients at risk.  More frequent visits would be appropriate for patients with stage III or stage IV disease.  

The carrier's denial of coverage for the DecisionDx-Melanoma Testing performed should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Colonoscopy
Issue under review: Anesthesia

Determination:
The Anesthesia was not medically necessary.

Patients may undergo GI (gastrointestinal) endoscopic procedures without sedation, analgesia, or both.  The majority of patients however receive some level of sedation and analgesia to relieve patient anxiety and discomfort and improve the outcome of the examination. 

The level of sedation and analgesia required to perform endoscopic procedures varies. Patient age, health status, concurrent medications, pre-procedural anxiety and expectation, as well as pain tolerance influence the level of sedation required to achieve the desired result, as do procedural variables such as the degree of invasiveness and the duration of the procedure. Patients like this patient are generally informed of and agree to the administration of sedation and analgesia with endoscopic procedures, including a discussion of the benefits, risks, limitations, and possible alternatives.  By definition: "Monitored anesthesia care may include varying levels of sedation, analgesia and anxiolysis as necessary. Monitored anesthesia care is a physician service provided to an individual patient." (1)  

Many factors may contribute to the decision to have anesthesiologist-directed sedation for endoscopic procedures. "MAC is indicated for some patients based on the nature of the procedure they are to undergo, their medical condition, or the potential need to covert to general anesthesia during the procedure. MAC differs from moderate sedation in that it is provided by an anesthesiologist or certified registered nurse anesthetist who makes an assessment in advance of the actual or potential medical problems that may occur during the procedure." (2)  

There are theoretical advantages with MAC, versus benzodiazepines and narcotics, for patients with risk factors for sedation-related complications and for patients undergoing prolonged procedures.  However, MAC carries substantial risk. With MAC, Wernli et al. did not demonstrate any increased cardiopulmonary risks such as hypotension or myocardial infarction, but did suggest an increase in stroke occurrence, as well as an increase in endoscopic perforation and hemorrhage. This study used 30-day administrative claims data to study complications. A study of similar design using the SEER database further identified aspiration as a risk factor associated with propofol anesthesia. 

Available records, however, in this patient's case do not support that the risk factors warranting MAC were present, nor were the risk factors associated with MAC justifiable - In the patient's case, for example: anticipated prolonged procedure time, advanced ASA classification, dysmorphia, history of or anticipated trouble with conscious sedatives.  As such, the patient's request for Plan coverage of MAC, based on available records, fails to meet the community-accepted indications for MAC and the conventional definition of "medical necessity."  

Denial of service is upheld given the lack of provided documentation that in the patient's case, MAC was necessary in lieu of conscious sedation.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male.  There is documentation that this individual has a diagnosis of a T12 incomplete paraplegia secondary to a fall.  There is documentation that this individual uses a standing frame.  There is documentation indicating that this individual has completed over 1000 lower extremity functional electrical stimulation (FES) cycling sessions and has been continuing cycling at home as part of his home rehabilitation program.

On a report it is noted that this individual primarily uses a manual wheelchair for long distances; however, he stands often in his bilateral KAFOs (knee-ankle-foot orthosis) while at work and is efficient with short distances while using bilateral Lofstrand crutches.  This indicates that he performs standing on a daily basis.

The functional electrical stimulation (FES) does have final approval from the appropriate regulatory bodies for this diagnosis.  This device is Food and Drug Administration (FDA) approved.  This patient is not a good candidate for functional electrical stimulation (FES).  There is reasonable evidence to support the use of this device in those with complete spinal cord injury, but there is a lack of adequate data to support the use of this device in those with incomplete spinal cord injury.  The literature does not support that this is the best available treatment or that this treatment is efficacious in this individual's condition.     

The use of FES cycle would not be considered the most appropriate treatment for this individual with an incomplete spinal cord injury due to the lack of high quality published medical literature to substantiate the efficacy of this device in this patient population.  The literature does not support that the requested service is likely to be more beneficial than standard treatments for this patient.  The ongoing performance of a home exercise program including incorporating the use of his individual standing frame would be considered appropriate.

"Functional electrical stimulation (FES) has clinical evidence in the rehabilitation of patients with spinal cord injury as indicated by several studies.  Both inpatients and outpatients benefit from the therapeutic effect of the FES.  The application areas are multifaceted and can be customized on the need for patients.  This is represented by the individuality of the programmability of the stimulators and the variety of stimulation schedules that are based on the knowledge about the effects of FES on structural and functional level.  Nevertheless, looking into daily clinical practice, the use of FES is rather poor.  Expenditure of time, complexity of technical equipment, and compliance and acceptance of therapists and patients should be taken into account as limiting factors." (Bersch I, Tesini S, Bersch U, Frotzler A. 2015).

The carrier's denial of coverage for the functional electrical stimulation (FES) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a male who sustained a spinal cord injury.  He developed T12 incomplete paraplegia with limited motor function below T12 in his lower extremities.  
The requested Functional Electrical Stimulator (FES) Cycle Ergometer is an FDA cleared class 2 medical device.  This device is intended for patients with spinal cord injury with minimal to no voluntary arm or leg movement.  The requested durable medical equipment (DME) is not merely "a type of exercise device."  Proposed beneficial effects are improving cardiopulmonary function, increasing muscle mass, decreasing spasticity and increasing bone density.  
The accumulated peer reviewed medical literature supports a result of improvement in health outcome.  The long term beneficial effects of this device evaluated in the peer reviewed (randomized controlled) published medical literature are also promising
According to the clinical records, the patient has completed a total of 1,063 lower extremity FES cycling sessions as part of his inpatient rehabilitation therapy and continued via a home rehabilitation program.  Based on the patient's diagnosis, positive response to this device and lack of alternative beneficial treatments, the proposed treatment should be approved.  The requested Functional Electrical Stimulator is likely to be more beneficial than any of the standard treatments/procedures for this patient.
From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, regarding coverage for the Functional Electrical Stimulator (FES):  
		
The scientific evidence in the peer-reviewed medical literature supports a result of improvement in health outcome. The Functional Electrical Stimulator (FES) has final approval from the appropriate regulatory bodies for this diagnosis. The patient is a good candidate for the Functional Electrical Stimulator (FES). The Functional Electrical Stimulator (FES) is the best available treatment for this patient at this time and is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for the functional electrical stimulation (FES) should be reversed.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  T12 incomplete paraplegia

Treatment:  Functional electrical stimulation (FES)

The insurer denied coverage functional electrical stimulation (FES. The denial was upheld.

This patient is a male who per a letter of medical necessity had T12 incomplete paraplegia as a result of a fall accident.  Prior to the injury, the patient was an active individual.  The patient now had loss of volitional motor function below T12 in the bilateral lower extremities.  The patient's light touch sensation and proprioception was absent below the T12 level bilaterally.  The patient utilized a standing frame weekly to maintain leg and trunk flexibility.  The provider noted that the patient needed to undertake an alternative form of activity, since he had lost the ability to do this volitionally.  The patient had been evaluated on the RT 300 and had an excellent response while trialing it.  With electrical stimulation, the patient was able to achieve strong, coordinated muscle contractions in his legs and gluteal muscles.  This positive lower extremity response to electrical stimulation indicated that the RT 300 was appropriate for the patient at home. 
 
The published scientific evidence does not support the RT 300 FES cycle as effective in improving health outcomes when compared with standard medical care.  Functional electrical stimulation has not been shown to be superior in neurological outcomes compared with conservative therapy including physical therapy.  The published scientific evidence does not support that the RT300 FES cycle ergometer is effective in improving health outcomes when compared with standard medical care.  Functional electrical stimulation has not been shown to result in superior outcomes compared with conservative physical therapy. Functional electrical stimulation (FAS) has final approval from the appropriate regulatory bodies and for this diagnosis.  The patient is not a good candidate for functional electrical stimulation (FES), and it is not the best available treatment for this patient at this time.  The requested service is not likely to be more beneficial than any standard treatments/procedures for this patient, including physical therapy.  There was no evidence that functional electrical stimulation utilizing the RT300 cycle therapy improves outcomes including improvements in activities of daily living, the ability to transfer or the ability to ambulate. Therefore, the requested service is not considered to be more beneficial for this patient's diagnosis. 

The carrier's denial of coverage for the functional electrical stimulation (FES) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic obstructive pulmonary disease
Treatment:  Inpatient admission 

The patient is a gentleman who was admitted to the hospital for acute COPD (chronic obstructive pulmonary disease) exacerbation.

Based on the hospital records provided, the patient was not in acute respiratory distress as defined by - tachypnea with respiratory rate more than 30 per minute, hypoxic respiratory failure, use of accessory muscles, with the without altered mental status, acute hypercarbic respiratory failure as determined by blood gases, requirement of invasive ventilation versus noninvasive ventilation, with without hemodynamic compromise, presence of comorbid severe pneumonia, presence of hemodynamic instability requiring ICU monitor.  The patient usually is on 4 L oxygen at home and has chronic severe COPD and chronic dyspnea on exertion. At two days history of cough, normal chest x-ray did not show any pneumonia, and laboratory data was unremarkable.  He was cooperative and calm.  His respiratory rate was less than 22 breaths per minute, and he did not require more oxygen than his baseline, which was 4 L.  Based on this data, and based on the severity of his presentation, the patient did not require acute inpatient hospital admission.  The patient could have been easily managed at a lower level of care, such as observation.