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

The patient has a history of Malignant Melanoma of the right mid-back that was biopsied.  The Melanoma was read out as having a Breslow depth of 0.3 millimeter (mm), no ulceration, and with less than one mitotic figure per square millimeter field.

The health plan's determination is upheld.  The DecisionDx-Melanoma (5) test is not likely to be more beneficial than standard histologic criteria used for the staging and treatment-making decisions for malignant melanoma.  The test is not in accordance with generally accepted standards of medical practice in the United States, is not clinically appropriate for this patient's clinical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a cutaneous melanoma to the back, 0.3 millimeter (mm) in depth with absent ulceration.  The DecisionDx-melanoma assay designated the tumor class 1 (low risk of recurrence within 5 years).

The health plan's determination is upheld.  The DecisionDx-melanoma is not likely to be more beneficial than any standard treatment or treatments for the insured's condition. There is no evidence based medical literature to support that a greater benefit is imparted after DecisionDx testing than current standard of care and there are insufficient outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for melanoma.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, COPD, atrial fibrillation, anemia, obesity, major depressive disorder, schizophrenia, and long term use of anticoagulants
 
Treatment: Home health care

The insurer denied the Skilled Nursing Care. The denial was reversed

The patient has an extensive medical history. He lives at home with a roommate and was noted as being homebound in the 4/15/19 visiting nurse assessment. The patient apparently was able to go to clinic last year, but it is not clear whether his condition has deteriorated since then, or if he is still able to go to occasional medical appointments with assistance.

It is apparent from the nursing assessment that the patient's cardiopulmonary status is significantly compromised and has a substantial impact on his functional capacity. The patient is oxygen dependent (4 L nasal cannula [NC] continuous) and uses a BiPAP at night. He has dyspnea with exertion, including with daily activities such as dressing, using the commode and walking short distances. He needs some degree of assistance for all ADLs. In addition to his cardiopulmonary disease, other medical conditions likely contribute to his functional impairments, including: arthritis, back pain, obesity, peripheral neuropathy, and orthostatic hypotension. An important factor that affects his ability for self-care is memory impairment. It is noted that he is forgetful and could not remember events within the previous 24 hours. 

For older patients, the risk of acute adverse health events increases with the increasing number of comorbidities and medications. The patient has significant sequelae from his cardiopulmonary disease, with other medical conditions causing symptoms such as pain and dizziness, which also contribute to functional decline. The patient takes approximately 15 medications per day, which increases the risk for adverse drug effects and the potential for medication errors, even with prefilled pill containers. For a patient with memory impairment and a history of mental illness (schizophrenia), the potential for poor compliance with various aspects of care must be recognized (e.g. medications, oxygen, BiPAP, fluid intake). 

The patient is at high risk for acute critical illness due to extensive cardiac and pulmonary disease; therefore, intermittent skilled nursing assessment is a medically necessary component of the patient's plan of care by identifying changes in clinical status, informing the physician, and monitoring patient compliance. These interventions can help the patient and the physician manage changes in the patient's condition in a more timely manner, with the goal of decreasing episodes of acute cardiopulmonary events and Emergency Department and hospital admissions. 

Approval is given for the additional 6 skilled nursing visits.
Appeal type: Medical necessity
Decision: Overturned

The patient in question has impacted teeth #11 and #21 due to premature loss of tooth H and S and presents with a skeletal Class I malocclusion and significant crowding.

The health plan's determination is overturned. Braces are medically necessary for this patient. Yes, Braces are medically necessary for this patient. If left untreated the damage that can occur to the patient's teeth will be more time consuming and difficult to correct than the patient's existing orthodontic problem. Complications of impacted canines include potential root resorption and devitalization of the adjacent lateral incisor.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck and Right Arm Pain 
Treatment: 63650x2 Implanted Electrical Stimulator of Spinal Cord
The proposed spinal cord stimulator (SCS) trial is medically necessary.
The patient has exhausted all conservative measures; she has also met national standard criteria including indication of post-cervical laminectomy syndrome, chronic neuropathic pain secondary to cervical radiculopathy; she has failed conservative measures as stated above and it was also recommended to proceed with the SCS trial after Neuropsychological evaluation.
The medical necessity guidelines for spinal cord/dorsal column stimulation insertion in line with general clinical practice as written under the 2018 Interqual procedures criteria for spinal cord stimulator insertion and in line with national recommendations which state that spinal cord stimulators be reserved for patients who have failed conventional treatments and met the following medical necessity criteria:
Electrical nerve stimulation:
Neuromodulation with electrical stimulus:
	Spinal cord stimulation: Spinal cord stimulation may be used in the multimodal treatment of persistent radicular pain in patients who have not responded to other therapies.
	Spinal cord stimulation may also be considered for other selected patients (e.g., complex regional pain syndrome [CRPS], peripheral neuropathic pain, peripheral vascular disease, and post-herpetic neuralgia).
	Shared decision making regarding spinal cord stimulation should include a specific discussion of potential complications associated with spinal cord stimulator placement.
	A spinal cord stimulation trial should be performed before considering permanent implantation of a stimulation device.
In this instance, the patient has neck pain with radicular pain to the right arm, is post-cervical laminectomy syndrome and has failed several conservative measures documented in the medical records reviewed. In addition, she had a neuropsychological assessment that concluded that she is a good candidate for the SCS trial.
The patient has exhausted all conservative measures and she has also met national standard criteria including indication of post-cervical laminectomy syndrome and chronic neuropathic pain secondary to cervical radiculopathy.  The patient has failed conservative measures as stated above and also received recommendation to proceed with the SCS trial after Neuropsychological evaluation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Issue under review: inpatient admission

Determination:
The inpatient admission was medically necessary.

The detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level detoxification setting and monitoring. The patient's history of substance abuse (frequency and quantity) together with the drug-infested social environment and negative influence of peers and severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management; the patient was at high risk for treatment failure if detoxification and withdrawal management were to have been attempted at a lower level of care. The patient had deficient coping skills, significant withdrawal symptoms, and clearly could not have completed or sustained a detoxification treatment episode at a lower level of care, especially in view of no past treatment history. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and with New York State instruction for medical necessity reviews including the application of the NY OASAS LOCADTR 3.0 Tool (referenced below) that requires the patient in this scenario default to the higher level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient hash buccal (reverse) crossbites on teeth #5 and #12, and a deep bite. The patient presents with a skeletal Class I malocclusion and maxillary and mandibular spacing. The patient is treatment planned for 18-24 months of orthodontics.

The health plan's determination is overturned. Comprehensive Orthodontic Treatment and Periodic Orthodontic Treatment Visit: Braces and Related Adjustments to Braces is medically necessary. Teeth 5 and 12 are in buccal crossbite, they have no antagonists. As a result, it is extremely likely that these teeth will over-erupt. Once this overeruption occurs, it is very difficult to treat. If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Possible Viral Syndrome
 
Treatment:  Inpatient admission, evaluation, and medication management. 

The insurer denied the coverage. The denial was upheld.

This female patient with past medical history significant for breast cancer status post mastectomy and chemotherapy who presented to the emergency department with complaints of fever and flu-like symptoms.  Vitals on presentation included: Temperature 39.4C (102.9F), Blood Pressure 130/80, Pulse 85, Respiratory Rate 18, oxygen saturation was 97% on room air.  Laboratory values were notable for the following:  WBC-8.2, Hgb-13, Hct-40.9, glucose-107, creatinine-1.06; lactate-1.4 to 2.7, influenza A (+).  The patient was admitted for possible viral syndrome.  Rapid viral testing was positive for influenza A.  She was started on oral Tamiflu for influenza.  All other cultures were negative.  The patient improved clinically and was discharged on oral anti-viral medications to follow-up as an outpatient.

The patient had unremarkable laboratory results including normal WBC.  Initial lactate was elevated, but was repeated while in the emergency department (ED) and was normal.  Additionally, the patient was not immunosuppressed, the chest x-ray was negative, and she was able to tolerate oral intake.  Based on above findings, patient meets criteria for observation level of care for uncomplicated influenza infection.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department on complaining of abdominal pain. The patient underwent an extensive evaluation, with a computed tomography (CT) showing that the intrauterine device (IUD) was in the patient's abdomen. The patient was admitted with a plan for surgery. The health plan's determination is upheld.

The inpatient stay requested is not medically necessary. Outpatient laparoscopic removal of an intraabdominal IUD is the standard of care for this situation. Vital signs were normal, and pain was described as managed. The patient tolerated a regular diet. No blood products or extra fluids were administered. There is no documentation in the multiple physician notes of any complications or unexpected events during the stay. Blood pressure and other vitals were normal the day after surgery. Diagnostic laparoscopy and lysis of adhesions (essentially what this procedure was) does not require inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient hospital admission with appendectomy
The inpatient hospital admission was not medically necessary.  
The submitted medical records do not support that an inpatient level of care was medically necessary for this patient and the date of service under review.  The care and treatment provided could have reasonably been provided at a lower level of care.
This patient presented with lower quadrant pain.  The evaluation with examination, lab data and computed tomography (CT) scan supported the diagnosis of appendicitis. The patient was treated with nothing by mouth (NPO) status, intravenous (IV) antibiotics, and laparoscopic appendectomy.  She was admitted to an inpatient level of care and was discharged from the hospital following surgery.  
There is no clinical documentation to support the need for inpatient admission.  The patient remained hemodynamically stable throughout the period of care. There was no fever or documented complication of surgery.  This patient's clinical needs could have been satisfied with a lower level of care. This level of care would have provided for surgical assessment including monitoring.  IV antibiotics could have also been provided with this lower level of care.  
A lower level of care would have provided for provided for ED evaluation, surgical assessment, operative care, pain management and IV antibiotics including monitoring (if needed).
Appeal type: Medical necessity
Decision: Upheld

This is an infant patient with no significant past medical history (PMH) presenting with an upper respiratory infection (URI), rhinorrhea for 2 days. Maximum temperature (Tm) was 100 degrees Fahrenheit at home. The patient's sibling had a group A strep infection. The health plan's determination of medical necessity is upheld. There was no significant leukocytosis, the complete blood count (CBC) was showing a value of 13.1 and the platelets were normal. There was no major lab perturbation such as bicarbonate level less than 14. The patient was also had no hypoxia noted on room air. The patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bladder mass, hematuria, decreased appetite

Treatment: Inpatient admission, evaluation, and medication management

The insurer denied the inpatient admission. The denial was upheld.


This child presented with gross hematuria that started as 2-3 bloody drops at the end of voiding.  However, the hematuria acutely worsened to dark red with clots, for which parents brought the patient to the Methodist emergency department (ED). Ultrasound showed a vascular bladder mass, and patient was referred for further evaluation. The parents reported that the gross hematuria had been improving prior to admission, but the patient had been getting tired more quickly over prior 2 weeks and had a decreased appetite (ie. He had constitutional symptoms).  The bladder ultrasound was interpreted to be consistent with a neoplasm.  The patient was admitted and received IV hydration and underwent further imaging to evaluate for other neoplasms or metastatic disease.

As noted in Ref. 1, "Macroscopic hematuria requires prompt evaluation to exclude potentially life-threatening causes."  It was within standard of care to provide IV hydration in a monitored inpatient setting for this child with recent clots in his urine.  Clots in the urine can result in blockage of the urinary tract, and hydration to dilute the urine and maintain adequate urine output is within standard of care.  After a period of observation with no clots in the urine and decreasing darkness of the urine, discharge for further ambulatory evaluation was appropriate.

Furthermore, this patient had a known bladder mass concerning for malignancy.  Given the challenges to coordinate multiple imaging studies for a 4 year old in a timely manner, it is within standard of care to hospitalize children with suspected new diagnosis of cancer in order to facilitate initial evaluations.  Given his constitutional symptoms of fatigue and decreased appetite, it was reasonable to suspect metastatic disease. The need to complete further imaging as soon as possible justifies hospitalization. 

In conclusion, hospitalization was within standard of care for both (1) IV hydration and management of gross hematuria and (2) facilitation or imaging to rule out further neoplastic disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Profound hearing loss, chronic vertigo, poor visual acuity secondary cataracts and glaucoma and oropharyngeal dysphagia

Treatment: Increase in PCA services 

Summary:
The proposed treatment of an increase in PCA (personal care assistance)  services from 35 to 68 hours per week is deemed medically necessary. This is a patient with multiple comorbid conditions including profound hearing loss, chronic vertigo, poor visual acuity secondary cataracts and glaucoma and oropharyngeal dysphagia. For these reasons, she requires increased PCA services to better assist for all of her ADLs (activities of daily living). including ambulation/fall prevention, meal prep, feeding supervision, bathing and toileting. For these reasons, the proposed treatment of an Increase in PCA services from 35 to 68 hours per week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Comprehensive Orthodontic Treatment (D8080)
The comprehensive orthodontic treatment (D8080) is medically necessary.  
The patient has a Class III bite. This is a "reverse" bite in that his lower teeth are in front of his upper teeth. He also has an anterior open bite. This means that his front teeth do not touch together. Both of these issues will cause problems over time. The open bite and reverse bite will mean that the front teeth will not mesh together at all like they are supposed to, and this will cause increase pressure and trauma to the back teeth. Over time, they can fracture or loosen. This improper bite can also lead to temporomandibular joint (TMJ) problems, as the joints will become overloaded and pain and degeneration can develop.  This case needs orthodontic treatment to correct the severe malocclusion this patient has.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department with complaints of right face and arm numbness. A head computed tomography (CT) scan performed on presentation revealed no acute changes. The patient was evaluated by neurology at the time of presentation. Laboratory workup was negative. The health plan's determination of medical necessity is upheld. An acute stroke required exclusion but could have been ruled out in the emergency department or at a lower level of care utilizing a brain magnetic resonance imaging (MRI) scan. The patient did not require admission for a brain MRI. Once an acute stroke was ruled out, the patient could have been discharged with plans for further workup of symptoms as an outpatient and provided with evidence-based stroke prophylaxis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission

The insurer denied inpatient admission. The denial was upheld.

This case involves a patient who presented to the emergency department with a chief complaint of abdominal pain, epigastric/right upper quadrant pain starting 4 days prior, worsening the previous night. The pain had been continuous, rated 9/10 not relieved by anything and included nausea and vomiting.  The physician documented the patient had a past medical history of breast cancer.  Upon examination the patient had right upper quadrant tenderness to palpation.  The patient had a gallbladder ultrasound performed that revealed a markedly distended gallbladder with multiple stones, large amount of intraluminal sludge and diffuse wall thickening.  The constellation of findings is compatible with acute calculus cholecystitis.  The treatment plan was to take the patient to the operating room (OR) for laparoscopic cholecystectomy.  The patient was taken to the OR for surgical intervention at 1653. The physician gave a rationale for keeping the patient overnight based on the severity of inflammation seen in the gallbladder, bleeding seen during surgery and to ensure the patient would not develop a bile leak.  There is documentation the patient was seen the next morning with no evidence of bile leak and was discharged to home.

The MCG state that goal length of stay after cholecystectomy is ambulatory outpatient procedure.  The guidelines further indicate that a minimal stay of a few hours to one day may be needed for observation.  An inpatient stay may be needed for conversion to open procedure, systemic infection, antibiotics and ongoing monitoring, complex conditions such as pancreatitis, heart failure or renal failure may require continued inpatient care.  An expected brief stay extension may be indicated for intraoperative or postoperative bleeding.  

While there is documentation that the patient needed to be observed overnight, the documentation did not support a rationale for an inpatient admission per guideline criteria.  The overnight stay could have taken place as an observation patient rather than a full admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission, diagnostic evaluation, and medication management.

The insurer denied inpatient admission. That denial was upheld

The patient presented to the Emergency Room (ER) on 1/19/19 with complaints of chest pain, lightheadedness, and dizziness. She also complained of palpitations. EKG showed sinus rhythm with premature ventricular contractions and bigeminy. She was admitted to the hospital with the diagnosis of atypical chest pain. She ruled out for myocardial infarction with serial negative cardiac biomarkers. An echocardiogram showed a left ventricular ejection fraction of 55%. She remained clinically and hemodynamically stable throughout her brief hospital stay. She was discharged home to follow-up with cardiology as an outpatient. 

The initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Further evaluation was warranted. However inpatient admission criteria was not met.  Although the patient had new onset symptoms, criteria were not met for any other additional extenuating circumstances. There were no other high-risk co-morbidities.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who is being treated for bilateral foot pain. Her foot pain is secondary to a severe collapsing flatfoot. The provider has requested custom foot orthotics. The health plan's determination is overturned. The requested foot inserts are medically necessary for this patient. They would be part of the initial treatment for symptomatic pediatric flatfoot which includes activity modification, orthoses, non-steroidal anti-inflammatory medication and stretching in cases where an equinus deformity is also present.