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

The patient has a history of pigmented lesion that was excised and determined to be desmoplastic melanoma. The physician ordered the DecisionDx-Melanoma gene expression test. The test was used to predict the patient's risk for metastasis and death. The use of the DecisionDx test is under review.

The health plan's determination is overturned. The Decision Dx Melanoma Test is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Studies prior to 11/2018 support DecisionDx testing. Berger et al 2016 found that the molecular risk classification by gene expression profiling has clinical impact and influences physicians to direct clinical management of CM patients. The vast majority of the changes implemented after the receipt of test results were reflective of the low or high recurrence risk associated with the patient's molecular classification. In addition, other studies, (Farberg et al 2017, Mirsky et al 2018), showed the gene expression profiling positively influenced clinical management and patient care when clinicians incorporated the additional data to modify their clinical recommendations in a risk-appropriate manner and it also appeared to significantly impact management decisions made by providers in dermatology in determination of imaging, and follow-up for patients with cutaneous melanoma.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has a diagnosis of malignant desmoplastic melanoma involving her right arm for which she underwent wide excision and sentinel lymph node biopsy. The final pathology showed malignant desmoplastic melanoma measuring 4.9 millimeter (mm) in Breslow depth, not ulcerated, with < 1 mitosis/mm2. Two right axillary sentinel lymph nodes were negative for metastatic disease. The tumor was sent for the DecisionDX Melanoma gene expression profile test.

The health plan's determination is upheld. The DecisionDX Melanoma gene expression assay is not likely to be more beneficial than any standard treatment for this patient's melanoma. In order for this test to be incorporated into our staging and risk stratification schema for melanoma patients, there will need to be evidence to show that specific interventions for patients with class II results provide a clinical benefit. At the present time, it is not clear that the results of this test provide clinically meaningful information for patients. The argument has been made that patients with a high-risk result could benefit from more intensive clinical surveillance, imaging surveillance and/or administration of adjuvant therapy. There is currently no evidence showing that more intensive clinical surveillance provides a benefit to patients with melanoma. Even for patients known to be at high risk for recurrence/metastasis as defined by our current criteria, the use of routine surveillance imaging is controversial because of its low yield and the significant incidence of indeterminate findings unrelated to melanoma.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic Short Stature
 
Treatment: Nutropin AQ Nuspin

The insurer denied Nutropin AQ Nuspin. The denial was reversed.

This is a male diagnosed with Idiopathic Short Stature (ISS). He started Growth Hormone (GH) therapy 1 year ago.  His GH stimulation test peaked at 21. His mother's height is 162.56 cm and father's height is 175.26 cm; mid-parental height is 175.41 cm (-0.20 SDS). His height velocity on therapy is reported to be 10.10 cm/year. His height velocity over 2.2 years-old f 4.1 cm/ yr, -1.6SD. His height on therapy date was 133.1 cm (-1.71 SDS).  His bone age was 2 years 5 months less than his chronological age (CA). His testes are 2 cc bilaterally; pubic hair is at tanner 1. His IGF1 was 96 and IGFBP3 was 3390.

Classic GH deficiency is based on auxological, biochemical and sometimes radiological findings. Auxological criteria are: severe short stature, defined as a height more than 3 sd below the mean; height more than 1.5 sd below the midparental height; height more than 2 sd below the mean and a height velocity over 1 year more than 1 sd below the mean for chronological age, or a decrease in height sd of more than 0.5 over 1 year in
children over 2 years of age; in the absence of short stature, a height velocity more than 2 sd below the mean over 1 years or more than 1.5 sd sustained over 2 years. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml. The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10. 

Growth hormone in the treatment of ISS is supported by randomized controlled trials and consensus guidelines.(4-9) FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."  The patient had a pretreatment height less than or equal to -2.25 SD. The height velocity is poor and would not allow him to reach an adult height in the normal range. The patient therefore met ISS criteria. 

The request meets nationally accepted criteria for use of growth hormone. The request is therefore medically necessary. 

The carrier's denial of coverage for Nutropin AQ Nuspin is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malignant melanoma
 
Treatment: DecisionDx-Melanoma test

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

According to the patient's medical chart, this is a female with a history of malignant melanoma. She underwent a biopsy of the right chest and the pathology report was indicative of malignant melanoma. The results of a DecisionDx-Melanoma test revealed the patient as class 1A. 

The DecisionDx-Melanoma assay that was performed was not medically necessary in this case. The results of the DecisionDx-Melanoma test revealed the patient as class 1A, which suggests a very low risk of metastatic potential. 

The initial evaluation for risk of metastasis in patients with cutaneous melanoma uses the American Joint Committee on Cancer (AJCC) staging criteria, which includes Sentinel Lymph Node status.  The DecisionDx-Melanoma assay was not known to be effective on the date of the reading based on a lack of scientific evidence showing that the results would accurately guide patient care and health outcomes. Additionally, the use of this testing was not supported by scientifically based guidelines of national medical research or governmental agencies. Furthermore, based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this patient. 
     
Based on the above, the medical necessity for the DecisionDx-Melanoma assay is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Incomplete root canal fill, periodontal defect and tooth fracture
 
Treatment: Dental implants

The insurer denied the dental implants treatment. The denial was upheld.

This is a male patient has a history of lung cancer that is currently undergoing therapy. Dental x-ray showed incomplete fill of the root canal for tooth 15 with a severe periodontal defect of one of the roots of 15. The tooth was fractured and the distal abutment of a four unit bridge. The dentist's treatment planned for the patient to have tooth 15 removed. The treatment also included the replacement of 13-15 with a three unit two implant supported bridge. This was denied by the insurance company in the place of a partial denture. The treating provider sent a letter stating that the quality of this patient's bone would not be good for a partial but dental implants would be appropriate with this quality of bone.

Tooth 15 clearly required removal. With the tooth 15 missing, there would be missing teeth 13-15. The concerns are what other cancer treatments the patient will have to undergo, and is there any bone involvement. This may affect bone metabolism which would affect the treatment plan. If there is bony involvement of the cancer, certain chemotherapeutic medications will directly impact bone healing and thus implant placement. Further, the treating provider mentions that he is concerned about the quality of the bone in regards to the partial denture. Implants need good quality bone to integrate and survive long term.  Without further information from the patient's hematologist/oncologist about current and future treatments for this patient's cancer, including staging, as well as the treating provider's comments that the bone is in question, medical necessity cannot be supported. 

Based on the above, the medical necessity for (D6010) Implant placement, Tooth 13; (D6010) Implant placement, Tooth 15, (D6057) Custom abutment, Tooth 13; (D6057) Custom abutment, Tooth 15, (D7953) Bone replacement graft for ridge preservation- per site, upper left quadrant is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Developmental delay, spastic quadriplegia, Activities of Daily Living (ADL) dependence
 
Treatment:  Personal Care Services Non-Shared Aide

The insurer denied continued coverage for non-shared aide.  The denial was upheld.

This patient is a monozygotic twin with a past medical history notable for global developmental delay, spastic quadriplegia, hypotonia, chromosomal abnormalities and autism.  She is non-verbal and non-ambulatory.  She is totally dependent for activities of daily living and medication administration.  She has been receiving Personal Care Services Home attendant 6 hours per day 5 days per week (M-F, 2:30 PM -8:30PM non-shared aide) and 11 hours per day M-F shared aid (8:30PM - 7:30AM).  She also receives 12 hours x 2 shifts for weekends, holidays and non-school days (non-shared in AM and shared in PM).  The child receives all nutrition orally.  She has no recent history of aspiration pneumonias, hospitalizations, seizures or dehydration episodes.
The insurer is denying coverage for current services for lack of necessity and is offering 17 hours per day, 5 days per week shared aide and 12 hours x 2 shifts shared aide over weekends, holidays and non-school days.  The issue for consideration is the reduced coverage to a shared aide for both sisters without a reduction in total hours of coverage.  This patient's stable overall condition and described care needs do not meet standards for multiple home health aides.  There was no indication of any significant finding to support the need for an individual aide for each individual patient.  The services could be completed by a mutual attendant/aide.  
The carrier's denial of coverage for Personal Care Services Home attendant Level ll (T1019) 6 hours per day x 5 days per week (Mon-Fri, 2:30pm-8:30pm non-shared aide), and 12 hours x 2 shifts for weekends, holidays and non-school days (non-shared aide during the morning) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic migraines
Treatment:  Botox
The requested Botox is not medically necessary.

There are no high quality clinical trials or standard of care guidelines supporting the safety and efficacy of a CGRP agent, such as Emgality, used as an adjuvant to Botox for the treatment of migraine headache disorder.  The clinical trial leading to the Food and Drug Administration (FDA) approval of Emgality excluded persons treated with Botox. Therefore the safety and efficacy of the combination of Botox with Emgality remains undetermined.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bladder tumor
 
Treatment: Outpatient hospital procedure/surgery and monitoring

The insurer denied the outpatient procedure/surgery. The denial was reversed.

This is a female with past medical history of elevated cholesterol, thyroid nodule, gastroesophageal reflux disease (GERD), osteopenia, hematuria, sleep apnea and recent discovery of a bladder tumor. She presented for scheduled cystoscopy/transurethral resection of bladder tumor (TURBT) procedure. Her preoperative vitals were stable. The procedure was performed under general anesthesia and there were no complications. She was monitored in the Post Anesthesia Care Unit (PACU) post-operatively, and remained stable. The patient was discharged home after three hours of monitoring.  

Per MCG Health Bladder: Transurethral Destruction of Lesion, the goal length of stay (LOS) is ambulatory, but the guideline does not specify the location of the procedure. 

The Operating Room note indicates numerous papillary lesions were resected on the bladder neck (with a resectoscope) and fulgurated and a reddish area within the bladder was biopsied / fulgurated. Given the nature of this surgery, most urologists would have performed this procedure in the Hospital Outpatient Department, not an Ambulatory Surgery Center (ASC), given the potential for post-operative bleeding requiring continuous bladder irrigation (CBI), monitoring for clearing of urine, etc.  The Cystoscopy procedures involving minimal biopsy/resection or fulguration are appropriate for performance in an Ambulatory Surgery Center (ASC), but resection of multiple tumors with fulguration is more appropriately performed in the outpatient hospital department. 

The carrier's denial of coverage for the hospital outpatient procedure/surgery for CPT code 88305 and all associated codes is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient is a pregnant female. The patient was referred from clinic with complaints of low back pain. On evaluation in L&D (Labor and Delivery) triage, the patient was noted to have temperature of 100.3 F. Blood pressure was 124 / 85; respiratory rate was 18 and oxygen saturation was 99 %. Influenza Type A testing was positive. The white blood cell (WBC) were 5.9; neutrophils were elevated at 80.6 %; coagulation work - up was normal. No evidence of PPROM (Preterm premature rupture of the membranes) was noted. The amniotic fluid index (AFI) was 17.5 centimeter (cm); cervix was closed. Fetal heart monitoring was category II with fetal tachycardia. The patient was admitted for continuous monitoring, received Tylenol as needed, intravenous (IV) hydration and was started on Tamiflu.

The health plan's determination is overturned. The inpatient stay is medically necessary. Considering the patient's prior very poor obstetrical history ( IUFD at 27 weeks ) and in the setting of acute Influenza type A infection, the admission to acute inpatient level of care was consistent with available literature, generally accepted standards of practice and was medically necessary with respect to type and extent of intervention.
Influenza in pregnancy is associate with significant adverse fetal / maternal outcomes, including fetal mortality as well as significantly higher maternal mortality, as compared to the non - pregnant state.
While most cases of influenza can and should be managed as outpatient, this does not apply to patients with abnormal fetal heart rate tracings.
Given the history of IUFD at 27 weeks and considering fetal tachycardia and category II fetal heart rate tracing, hospitalization for continuous fetal monitoring and initiation of IV therapy, antipyretics and Tamiflu could not be done at a lower level of care and, therefore, the inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient has sleep apnea. The apnea hypopnea index (AHI) was greater than 20. Low oxygen level was 60%. The patient underwent a tonsillectomy and adenoidectomy and was admitted to the Pediatric Intensive Care Unit (PICU). In the PICU, there was a brief desaturation episode that resolved with supplemental oxygen. Under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient could have been managed at a lower level of care which allows for an overnight admission. The patient had severe sleep apnea. It is considered standard of care to observe children overnight who undergo tonsillectomy and adenoidectomy who have severe sleep apnea. Based on the clinical documentation there were no operative or peri-operative complications in this case. There was a brief episode of oxygen desaturation which required supplemental oxygen. Supplemental oxygen is a service that can be rendered at a lower level, thus an intensive care unit is not needed. Otherwise the child had no bleeding, had stable vital signs, and was tolerating oral intake.
It is not considered standard of care to admit children to an intensive care unit after a tonsillectomy if the only risk factor is severe sleep apnea.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department with complaints of bilateral lower extremity edema and associated cough for 2 days.  Past medical history includes multiple medical problems, including chronic obstructive pulmonary disease (COPD), diabetes, peripheral vascular disease, alcohol abuse with chronic pancreatitis.  The patient reported lower extremity pain, unrelieved with pain medication and subjective fevers at home, chest tightness, and shortness of breath that did not get better with inhalers.  The patient is on multiple respiratory medications at home including Spiriva inhalers.  The patient is an ongoing smoker of 10 cigarettes/day.  Vital signs were normal, and the patient is described as resting in bed in no acute distress with occasional coughing.  Her lung exam reveals bilateral expiratory wheezes, coarse breath sounds bilaterally.  There was trace edema in the right lower extremity around the ankle area.  Laboratory studies were normal.  Tests for Influenza A and B were negative.  A chest x-ray was performed, which shows increased interstitial markings, reflecting mild pulmonary edema or an atypical pneumonia.
The patient was admitted started on intravenous (IV) Solu-Medrol 40 mg every 8 hours, duo nebs, azithromycin 500 mg, was placed on sliding scale insulin, due to concurrent diabetes.  Primary admission diagnosis was COPD exacerbation.  Treatment was continued with corticosteroids, azithromycin, and was to transition from Solu-Medrol to oral prednisone.
On day 2 of admission the patient's blood glucose was elevated to 399; however, the vital signs remained normal.  Oxygen saturation was 95%, though it does not state whether this is with oxygen supplementation or not.  On exam, bilateral expiratory wheezes and coarse breath sounds are noted bilaterally.  There was trace edema in the lower extremities. Lower extremity duplex was negative for deep vein thrombosis (DVT) on admission.  White blood cell count remained normal at 8.4, electrolytes and renal function were stable.  The medical team that was evaluating the patient, reports that symptomatology is more consistent with upper respiratory infection than with a pneumonia.  On day 3 the respiratory symptoms are better, still with cough but walking without difficulty.  The exam describes mild expiratory wheeze with good air exchange. Steroids were converted to prednisone the day before.  The patient was deemed stable for discharge with follow-up primary care provider (PCP) as outpatient.  The inpatient hospital stay is not medically necessary for this patient.  The patient does not have the high-risk features of COPD with respiratory failure, that would warrant an inpatient hospitalization.  Based on the provided documentation, the patient has an upper respiratory infection that is causing wheezing, without hypoxemia, hypercarbia or respiratory distress.  It did take longer than 24 hours to resolve the wheezing, but this is not an indication for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure
 
Treatment: Inpatient admission, medication, monitoring

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

The patient was a male with a past medical history notable for hypertension, liver failure, and hyperlipidemia. He presented to the emergency room (ER) with complaints of shortness of breath for the past 6 months. He'd been treated recently for pneumonia. He was sent to the ER by his primary care provider for abnormal liver and kidney testing. The chest radiography showed opacities. There was no focal consolidation. The Brain Natriuretic Peptide (BNP) level was 1029. The patient had orthopnea and dyspnea on exertion. The vital signs were stable. The Troponins were negative x 3. The electrocardiogram (EKG) showed left bundle branch block. He was treated with intravenous Lasix and discharged home to follow-up with cardiology.

The patient was admitted with congestive heart failure; however, care could have been rendered under observational status. There was clinical congestive heart failure with objective findings supporting necessity of observational care, as inpatient admission criteria was not met due to lack of severity of disease or comorbidities. There was no myocardial ischemia, hemodynamic instability, no electrolyte abnormalities, hypoxemia, or other indications for acute inpatient admission status during the stay. Per MCG 22nd Edition Guideline Heart Failure: Observation Care OCG: OC-024 (ISC), the patient's care should have been provided under observational level of care. 

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

This patient was admitted for acute inpatient care due to a low potassium. This patient who presented to the hospital with  a chief complaint of hypokalemia of unknown etiology.The patient was admitted to labor and delivery for electronic fetal monitoring and regular diet. The patient  was to have routine admission labs and  start on normal saline with 40 mEq of potassium and the patient  was also given have oral potassium 40 mEq given. The health plan's determination of medical necessity is upheld in whole. Based upon a review of the medical records in concert with the national utilization guidelines by Milliman Care Guidelines (MCG), there would be no medical necessity for acute inpatient level of care in this case.  The member was asymptomatic with hypokalemia that was known.The hospitalization was provided for IV fluids with potassium and oral potassium with completion of labs for evaluation of the causation of the  hypokalemia. The testing provided in this case did not require inpatient admission. The repletion of K and monitoring can be completed at a lower level of care.