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

Diagnosis: Osteopenia.
Treatment: Genetic Testing (collagen cross links, any method (82523).

The insurer denied the Genetic Testing (collagen cross links, any method (82523).  The denial is overturned.

The patient is a female who is post-menopausal. She has a history of breast cancer and is on Anastrozole. She has been treated with hypercalciuria. BTM (bone turnover marker) testing was recommended to assess "her potential for bone loss".

The values were elevated, and Prolia was then prescribed.

Yes, the health plan should cover the Collagen crosslink testing.

The scientific literature has recommended use of BTM (bone turnover marker) testing. Recent literature (see references) denote use supportive in conditions where there is high bone turnover. The Clinical Practice Guidelines/Endocrine Practice supports its use. The Criteria submitted by insurer last reference was from several years ago. The reference of Clinical Practice Guidelines was from five years ago. Most recent literature considers the test useful for selective circumstances.

The fact is that the patient is at high risk of fracture. She has a history of malignancy and is taking a medication which significantly affects bone turnover. It would be important to assess the loss. Treatment decisions for additional management would be influenced by the above. Her physician has reported this in his letter of appeal. There is credence, and the health plan should, therefore, cover the Collagen crosslink testing.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Osteopenia.
Treatment: Genetic Testing (collagen cross links, any method (82523).

The insurer denied the Genetic Testing (collagen cross links, any method
(82523).  The denial is upheld.

The patient is a female with osteopenia. She has breast cancer and is on anastrozole. Collagen crosslink testing is under review.

No, the health plan should not cover the Collagen crosslink testing.

Collagen cross links testing is one of multiple available bone turnover markers. While the use of biochemical bone turnover markers in clinical trials has been helpful in understanding the mechanism of action of therapeutic agents for the treatment of osteoporosis, their role in the care of individual patients is not well-established. They are not widely used in clinical practice because of high biological variability that makes interpretation challenging. The Endocrine Society guidelines do not recommend their use over standard bone density testing, as outlined below. Therefore, the health plan should not cover the Collagen cross links testing.

The Endocrine Society guidelines on the management of osteoporosis [1] indicate that monitoring bone turnover markers may be an alternative way of identifying poor response or non-adherence to therapy in place of monitoring the bone mineral density by dual energy X-ray absorptiometry at the spine and hip every 1 to 3 years to assess the response to treatment. The guidelines do not indicate that bone turnover markers like collagen cross link testing have been shown to be additive or superior to monitoring bone mineral density. Bone turnover markers are not used for diagnosis of osteoporosis and do not improve prediction of bone loss or fracture within an individual [2].  Therefore, no, the requested collagen cross link testing is not more beneficial than any standard evaluation for the insured's condition or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aortic stenosis, severe and symptomatic.
Treatment: Transcatheter aortic valve replacement (TAVR) and Inpatient Hospital Admission, Pre-service.
The insurer denied the transcatheter aortic valve replacement (TAVR) and Inpatient Hospital Admission.
The denial is overturned.

The patient is an adult male with severe symptomatic aortic stenosis.  He is being considered for TAVR (transcatheter aortic valve replacement).

Yes, the transcatheter aortic valve replacement and full hospital admission are medically necessary.

The patient needs an aortic valve replacement.  Aortic valve replacement is best done by TAVR (transcatheter aortic valve replacement).  It has the same success as open surgery, and with decreased morbidity and mortality.  In low-risk patients, TAVR (transcatheter aortic valve replacement) is currently considered a standard procedure, due to the decreased mortality and morbidity associated with the procedure.  As such, transcatheter aortic valve replacement and inpatient hospital admission is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gross Hematuria

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is an adult male with history of nephrolithiasis status post right percutaneous nephrolithotomy (PCNL). The stent was removed. The patient then presented to the Emergency Department (ED) with complaints of gross hematuria and clots in the urine. Positive right costovertebral angle (CVA) tenderness was noted on exam in the ED. The patient was admitted with diagnosis of gross hematuria. An x-ray of the kidneys, ureter, and bladder (KUB) was done and was negative for a retained stent. Computed tomography (CT) scan was negative for clots in the bladder. The patient improved, he was tolerating regular diet and oral medications as well as voiding freely and ambulating independently. The patient was stable for discharge home after a period of medical stability. 

Per Milliman Care Guideline (MCG) Health (24th) Urologic Disease, General Recovery Care (GRG), the patient fails to meet clinical indications for admission to inpatient care, under subsection "gross hematuria requiring inpatient care". There is no evidence of renal obstruction, clot retention after urinary catheterization and irrigation, severe anemia, and systemic cause (Goodpasture syndrome) needing inpatient care. 

CT scan revealed a small area of bleeding in the right renal upper pole, some small right lower pole stones, and small calculi within the bladder. The patient did not require transfusion. His urine cleared fairly quickly, and the patient was comfortable throughout and was hemodynamically stable.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The inpatient admission was not considered medically necessary for this patient. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Idiopathic thrombocytopenic purpura.
Treatment: Inpatient admission.

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

This male patient has no significant past medical history.

Given the patient's three-day history of dizziness and severe thrombocytopenia (platelet count 12), hospitalization to monitor within a protective environment was within standard of care and supported by current guidelines, especially given the precipitous drop from a platelet count from 38 the day before. It was reasonable and within standard of care for the team to discharge the patient home with a platelet count of 20 after 1 day of hospitalization since the patient was asymptomatic and without evidence of bleeding. Continued hospitalization for further improvement of platelet count was no longer deemed necessary.

As such, hospitalization for monitoring and a protective environment was within standard of care and appropriate. However, after 1 day of observation and denial of any symptoms and follow-up platelet count of 20, it would have been reasonable and within guidelines to then discharge this patient for further ambulatory management. 

The health plan did act reasonably, in part, with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is modified.  The medical necessity is not, in part, substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic deep vein thrombosis (DVT) and pulmonary embolism (PE)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient in this case is a male who presented to the emergency department with a two day history of right groin pain. It is reported that he had been diagnosed with acute on chronic deep vein thrombosis (DVT) and pulmonary embolism (PE). He was to have started fondaparinux, but had not been able to start it due to insurance issues. He had been admitted to an outside hospital and discharged with a two day supply of fondaparinux. The patient had no hemodynamic instability or significant hypoxia or respiratory compromise. Ultrasound did reveal deep vein thrombosis (DVT). It is reported that he had been seen in the emergency department (ED) multiple times with this issue asking for pain medication. The patient was admitted and left against medical advice the following day.

No, the proposed inpatient admission was not medically necessary.

This patient had been previously diagnosed with deep vein thrombosis (DVT) and pulmonary embolism (PE). He had already been prescribed fondaparinux. He had no hemodynamic instability and no active bleeding or significant hypoxia or respiratory compromise. Deep vein thrombosis and pulmonary embolism only require inpatient hospitalization in selected patients, such as those with respiratory compromise, massive/submassive pulmonary embolism or circulatory compromise in the lower extremity. He had none of these findings. He did not require acute care inpatient treatment. He had already been prescribed fondaparinux and had made no effort to secure an outpatient supply. The acute care admission in this case was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.
Treatment: Saxenda - dosage 3mg (Pre-service).
The insurer denied the Saxenda - dosage 3mg (Pre-service).
The denial is overturned.

This is a female patient diagnosed with obesity. Her body mass index (BMI) was reported to be 42.8. This request is for Saxenda. As reported; the patient started taking Saxenda and four months later she lost 30 pounds.  Due to the pandemic and winter weather she only lost five pounds between fall and spring. She tried exercising. She is unable to take a stimulant weight loss medication. The patient's weight was 222 pounds; body mass index (BMI) was 36.9 in the spring. In the fall patient's weight was 227 pounds.

Yes, the proposed treatment is medically necessary.
Saxenda is a glucagon-like peptide-one (GLP1) agonist that is used in the treatment of obesity [1-4]. 

This patient has previously used the requested medication and has lost more than five percent of her body weight suggesting that she has benefited from the requested medication. During COVID, the patient gained some weight and is requesting to restart the requested medication. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Colitis, Irritable Bowel Syndrome (IBS)

Treatment: current procedural terminology code (CPT) 87507, stool panel

The insurer denied coverage for current procedural terminology code (CPT) 87507, stool panel.

The denial is overturned.

The patient is an adult female with a past medical history of colitis, irritable bowel syndrome, autoimmune hepatitis, hypothyroidism, and celiac disease. The patient was having 3 bowel movements a day and other days just 2 daily. The stool was soft, sometimes watery, and a lot of times it was like an explosion. The physical examination was normal.  The impression was celiac disease stable with gluten-free diet which may have triggered hepatitis.  The provider recommended a stool for fecal calprotectin, C.
[clostridium] difficile toxin, culture and sensitivity, fat, and ova and parasite (O&P) comprehensive. The patient underwent testing.

The appeal letter by the provider noted that the apolipoprotein a-1 laboratory work was ordered as part of the NASH [nonalcoholic steatohepatitis] FibroSure. The patient had a history of autoimmune hepatitis and steatosis. Steatosis was seen on the abdominal ultrasound. It was determined a NASH FibroSure lab test should be completed to evaluate severity of the disease.

Multiplex molecular panels have the advantage of avoiding multiple tests which may include a colonoscopy with biopsies. There is data to support that these tests reduce healthcare utilization.

There may be possible positive results for multiple pathogens and this needs to be interpreted with clinical information.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. 

Current procedural terminology code (CPT) 87507, stool panel performed does have final approval from the appropriate regulatory bodies for this diagnosis.

This patient a is good candidate for the stool panel performed.

The stool panel performed is the best available treatment for this patient at this time and is likely to be more beneficial than any standard testing and the adverse risk is not increased over other treatments/procedures

The carrier's denial of the current procedural terminology code (CPT) 87507, stool panel performed should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Colitis, Irritable Bowel Syndrome (IBS)

Treatment: current procedural terminology code (CPT) 87507, stool panel

The insurer denied coverage for current procedural terminology code (CPT) 87507, stool panel.

The denial is overturned.

This case involves an adult female who has previously been diagnosed with colitis as well as irritable bowel syndrome, celiac disease, and hypothyroidism. The documentation indicated she underwent a laboratory panel. The documentation detailed the laboratory testing was ordered to investigate the cause of the patient's chronic diarrhea. Given her history and complaints of multiple bowel movements per day associated with abdominal pain, it was recommended she undergo the panel in question.

The test is a recognized tool in the algorithm recommended by the America Society of Microbiology (ASM) for diagnosis of Clostridium difficile. It is Food and Drug Administration (FDA)-approved. It specifically investigates for gastrointestinal pathogen (e.g., Clostridium difficile, E. coli [Escherichia Coli], Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets.

The patient had an unremarkable abdominal ultrasound performed. Laboratory studies were ordered to see if her symptoms were caused by an infection or an inflammation within the colon. The physician indicated the laboratory studies were ordered and medically necessary to determine a treatment plan for her condition. She was seen where she detailed, she was having 3 bowel movements a day. There was no blood in her stool or black stools. There is sometimes soft and sometimes watery. There are no significant findings on physical examination and the physician indicated she has celiac disease which was stable. She also has colitis and remains limited on food she can eat. She was recommended to follow-up in months and undergo multiple laboratory studies. The documentation indicated she underwent a stool panel with the CPT code 87507.

There are no adverse risks associated with this test. The test will divine more specifically the etiology of the patient's diarrhea. There was sufficient evidence to support that the stool panel performed and was likely to be more beneficial than any standard testing and the adverse risks of the testing are not increased over standard testing.

The carrier's denial of the current procedural terminology code (CPT) 87507, stool panel performed should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Colitis, Irritable Bowel Syndrome (IBS)

Treatment: current procedural terminology code (CPT) 87507, stool panel

The insurer denied coverage for current procedural terminology code (CPT) 87507, stool panel.

The denial is upheld.

This is an adult female with a history of colitis, irritable bowel syndrome (IBS), hypothyroidism, and celiac disease. She presented to the gastroenterologist's office for evaluation of diarrhea. The physician recommended obtaining stool cultures. The patient had a stool panel performed.

Up-To-Date has an article titled, "Approach to the adult with acute diarrhea in resource- rich settings." Stool cultures are advised as part of the workup. The article also reviews multipathogen molecular panels. It states that a high degree of clinical correlation is necessary when interpreting results of molecular testing, since these assays detect genetic material, which does not always indicate infection with a viable organism and identification of more than one pathogen is not uncommon. Any specimen that tests positive for a bacterial pathogen on a multiplex molecular panel should be submitted for confirmatory culture.

Up-To-Date also has an article titled, "Approach to the adult with chronic diarrhea in resource-rich settings." Various stool testing is advised including clostridium (C.) difficile and parasite testing. There is no recommendation that a stool panel test be obtained.

This patient had a history of colitis, celiac disease and autoimmune hepatitis. She was also on budesonide for colitis. She continued to have diarrhea. The physician ordered a gastroenterology (GI) stool panel to look for the cause of the diarrhea. Stool for cultures, C. difficile toxin and fecal leukocytes are advised tests. The stool panel is a Clinical Laboratory Improvement Amendments (CLIA)-approved test. The stool panel tests have not been shown to improve health outcomes over the advised tests.

The patient is not a good candidate because stool testing for culture parasites and leukocytes are more appropriate, especially in a patient with long-standing diarrhea. The stool panel is not the best available treatment. There are no adverse risks, to obtaining the panel. The stool panel is not likely to be more beneficial as compared to routine stool testing. 

The carrier's denial of the current procedural terminology code (CPT) 87507, stool panel performed should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male diabetic with hypertension. He presented to the emergency room with  fifth digit pain.  He had several days of pain and discomfort. He had used some over-the-counter bandaging, and he began noticing redness and pus, and so he presented to the emergency room.

The patient was admitted and put on IV (intravenous) antibiotics.  An MRI (magnetic resonance imaging) was ordered, which showed osteomyelitis.  As the patient clinically improved, the decision was made by the podiatry team to discharge the patient on antibiotics. The wound culture obtained showed methicillin-sensitive Staphylococcus aureus.

Yes, the Inpatient admission was medically necessary.
Admission for diabetic foot infection that is worsening is in keeping with standard of good care.  In this case, the MRI (magnetic resonance imaging) did confirm osteomyelitis, and the patient was only discharged because the team felt that he was improving on IV (intravenous) antibiotics.  The entirety of the treatment was medically necessary, appropriate, and in keeping with good standard of care.

As stated above, admission to a hospital setting for this problem is in keeping with standard of care.  This required monitoring of vital signs, monitoring of wound, the involvement of all the medical teams, urgent advanced imaging and intravenous antibiotics.  Failure to do all of this in a timely manner could have resulted in sepsis, death, or amputation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left through-the-knee amputation

Treatment artificial leg that includes a computerized knee

The insurer denied coverage for artificial leg that includes a computerized knee.

The denial is overturned.

The patient is a left above knee amputee.  He is physically active and has a full-time job.  He worked with an exercise trainer and can swim laps.  Under review is the medical necessity of requested artificial leg that included a computerized knee.

The requested prosthesis has a microprocessor (computerized) controlled hydraulic stance and swing phase prosthetic knee system.  The electrical mechanical precision of this prosthesis provides improved feedback to the patient with resultant greater stability, balance, and functional mobility.  The requested prosthesis is able to monitor the complete gait cycle and can make virtually simultaneous corrections while ambulating.  Additional advantages of the requested microprocessor prosthesis include increased swing/stance phase responsiveness and decreased cardio-vascular effort required with routine use.  In this particular case, the patient has a full-time job, is physically active and at least a K3 (potential or ability to ambulate) ambulator.  The requested prostheses is a reasonable choice and will be appropriately used for ascending/descending stairs, varying cadence, walking over uneven terrain, activities of daily living (ADL) tasks as well as athletic physical activities.  

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations.  All decisions are evidence-based).   

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested artificial leg that includes a computerized knee is medically necessary for this patient.

The insurer's denial of coverage for an artificial leg that includes a computerized knee is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Loss of consciousness
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

The patient is a female with a history of hypertension. She presented after an episode of loss of consciousness.

At presentation, the patient's neurological examination was normal, and her CT (computed tomography) brain did not show any acute changes. CT (computed tomography) cervical spine was negative for acute changes.

The patient was admitted to the acute inpatient service. Subsequent diagnostic studies included EEG (electroencephalogram), which was normal, and MRI (magnetic resonance imaging) brain, which was normal. She was discharged home.

No, the Inpatient admission was not medically necessary.
At presentation, the patient had a normal neurological examination and normal diagnostic studies.  She was suspected of having a syncopal event. There were no recurrent episodes. The diagnostic studies, clinical evaluation, monitoring and treatment could have been safely and effectively completed at a lower level of care.

Therefore, given the above the Inpatient admission was not medically necessary.