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

Diagnosis: Transient Ischemic Attack 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is a female patient who presented to the Emergency Department (ED) with complaints of sharp right sided chest pain that radiated to her jaw and scapula region with right sided weakness. She has a history of cerebral vascular accident (CVA) without residual effects, obesity, and asthma. The patient was given nitro spray for her chest pain; relief was noted.  She had an electrocardiogram and a chest x- ray which were both negative. She had a transthoracic echocardiogram (TEE) which revealed normal left ejection fraction. Neurology was called to evaluate the patient; she was ruled out for a CVA. A magnetic resonance imaging (MRI) was requested however; due to the patient's size it could not be performed. The patient regained movement in her right leg and was medically stabilized. She was discharged home the same day.


The documentation indicated that the patient did have complaints of chest pain. The patient's chest pain was improved by the use of nitro spray. The patient had no findings of a stroke on imaging. There was no indication the patient had hemodynamic instability, respiratory distress, chest pain indicative of a serious diagnosis, focal neurological signs or symptoms that persisted or recur, stroke diagnosed, altered mental status, cardiac arrhythmia immediate concern or clinically significant cardiac disorder identified that required inpatient care.

According to the American Heart Association/American College of Cardiology (AHA/ACC) guidelines, the patient's condition was appropriate for the observational level of care rather than inpatient level 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

Diagnosis: Dizziness
Treatment: Inpatient admission
The proposed inpatient admission was not medically necessary.
The patient presented for evaluation of chronic dizziness and lightheadedness. His glucose was found to be low, and he was treated with juice. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated CHF, malignant arrhythmia or hemodynamic instability. CVA or intracranial bleeding was ruled out by CT scan in the ED. Echocardiography was negative for structural cardiac disease and the Carotid Doppler revealed no carotid stenosis. There was no need for vasoactive drips, pressors or pacemaker placement. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a female patient with a history of malignant melanoma on her left back. Dermpath Diagnostics reported the specimen from her back was specific for atypical proliferation of melanocytes, intraepidermal, ulcer, scar granulation tissue secondary to the previous procedure.

The Decision DX-Melanoma assay was not known to be effective at the time it was performed, based on a lack of scientific evidence showing that the results will accurately guide patient care and health outcomes.  However, more recent studies are showing promise for the usefulness and prognostic values for treating certain populations of melanoma patients.  In this case, the testing would not have been considered effective or useful in treatment planning.

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. Per Trotter, S. C.,et al., (2013), "The stage at presentation of melanoma has a significant impact on the course of the disease.  Most melanoma patients present with localized disease 82 to 85 percent of the time, followed by regional involvement 10 to 13 percent of the time, and distant metastatic disease 2 to 5 percent of the time.  The staging of melanoma holds prognostic value and dictates the recommendation in treatment.  Staging is determined by the tumor, node, and metastasis (TMN) system developed by the American Joint Committee on Cancer (AJCC) (Table 1).  Criteria include microstaging of the primary melanoma and pathologic information about the regional lymph nodes after partial or complete lymphadenectomy as well as a new emphasis on dermal mitotic index (measured in mm2) for T1 melanoma (=1 mm). Survival and recurrence rates for melanoma follow the pathologic stages set forth by the AJCC (Table 2) and are used to guide follow-up recommendations."

The Decision DX-Melanoma assay was not known to be effective on the date of reading on January 31, 2019 based on a lack of scientific evidence showing that the results would accurately guide patient care and health outcomes. 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. 

The carrier's denial of coverage for CPT code 81599 [Unlisted multianalyte assay with algorithmic analysis] Decision DX-Melanoma test assay should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a female who underwent biopsies of three melanoma lesions on her right deltoid, the base of her neck, and her left scapulae. The patient underwent Decision DX testing of the tumor on the base of her neck. 

The Decision DX-Melanoma is a gene expression profile test that is used to stratify risk of metastasis in patients with melanoma.  Gene expression profiling like that undertaken by this provider has not yet been accepted as standard of care in treating cutaneous melanoma patients.  The American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) guidelines for clinical decision making and follow-up for patients with cutaneous melanoma do not currently incorporate gene expression profiling.  In fact, at the NCCN Guidelines for Melanoma V.1.2018 Panel Meeting on 6/28/17, 22/22 dermatologists voted no to include Decision DX in the NCCN guidelines.

These assays are not recommended in clinical guidelines, and the data pertaining to this assay's use is not yet accepted.  The 2019 Melanoma Guidelines from the American Academy of Dermatology state that information gleaned from the assay itself should not affect the treatment or follow up approach for cutaneous melanoma. 
The carrier's denial of coverage for CPT code 81599 [Unlisted multianalyte assay with algorithmic analysis] Decision DX-Melanoma test assay should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cutaneous Melanoma
 
Treatment: 81599 [Unlisted multianalyte assay with algorithmic analysis] Decision DX-Melanoma Test

The insurer denied the 81599 [Unlisted multianalyte assay with algorithmic analysis] Decision DX-Melanoma Test. The denial was upheld. 

The patient is a female with a medical history of cutaneous melanoma, Breslow Depth 0.7mm.

The genetic laboratory test Decision DX-Melanoma is a 31 gene assay for predicting future recurrence of melanoma. This tool cannot be covered as a standard of care treatment for melanoma as to date, results remain inconclusive regarding the efficacy of this tool for improving health outcomes on a large scale. Additionally, this tool is not for treating an active disease nor would any of its prognostics change the plan of care for this patient.  

This tool currently lacks Food and Drug Administration (FDA) approval for predicting the future recurrence of cutaneous melanoma.   As this assay is not a standard of care treatment, the patient would not be a good candidate for CPT code 81599 [Unlisted multianalyte assay with algorithmic analysis] Decision DX-Melanoma test assay.  Additionally, this test is not the best available treatment and is not likely to be more beneficial than any of the standard treatments/procedures, as this test is not validated and is not proven to show benefit in treatment decisions.  

The carrier's denial of coverage for CPT code 81599 [Unlisted multianalyte assay with algorithmic analysis] Decision DX-Melanoma test assay should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces (D8080) 
The braces are medically necessary.

The patient has a "deep, impinging overbite with severe soft tissue damage" to the roof of her mouth. This is an "automatic qualifying" condition on the handicapping index. The patient needs orthodontic treatment to correct her malocclusion.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath, ischemic cardiomyopathy
Treatment: LifeVest

Summary:

The patient had shortness of breath and was diagnosed with ischemic cardiomyopathy and severely depressed LV (left ventricle) ejection fraction (25%). Surface electrocardiogram revealed a prolonged corrected QT interval.  These findings are consistent with an elevated risk of sudden cardiac death. Guideline statements from the Heart Rhythm Society/American Heart Association and the American College of Cardiology specify that external LifeVest defibrillator therapy should be utilized during periods when patients are at risk of sudden cardiac death and require further cardiac workup/treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Intractable back pain
 
Treatment:  Lumbar fusion and decompression surgery

The insurer denied the lumbar fusion and decompression surgery. The denial was reversed.

This patient presented with long-standing low back pain, and numbness and tingling in the right leg (right groin). She is status post lumbar decompression and fusion.  She was having extreme difficulty getting out of bed despite taking 5 Percocet and 4 Norco per day.  She was also on gabapentin, cyclobenzaprine, diclofenac, Mobic, and tizanidine.  Her primary care physician felt that physical therapy was inappropriate for her.  Her neurological examination was unremarkable.  She saw physical therapy (PT) once, who stated that due to high disability and current poor quality of life she would likely benefit from surgical intervention.  An MRI of the lumbar spine showed mild-to-moderate spinal canal stenosis at L2-L3 with mild left inferior foraminal narrowing.  Degenerative changes were stable to mildly increased compared to the prior study.  At L3-L4, there was a disc/posterior osteophyte complex.  There was mild-to-moderate bilateral neuroforaminal narrowing.  The provider recommended a lumbar interbody fusion with pedicle screw fixation at L2-L3 and L3-L4 with removal of prior hardware.   

The patient has severe, intractable back and radicular symptoms.  She was determined not to be a candidate for PT.  She was on multiple medications and was completely incapacitated due to her lumbar condition.  She had significant stenosis at L2-L3 and L4-L5, which can account for her symptoms.  A fusion and decompression was recommended as she had adjacent level degeneration next to a prior fused level (L4-L5).  A simple decompression would lead to iatrogenic instability.  A decompression and fusion is warranted; it would not be prudent to perform a decompression alone in this circumstance.  The requested procedures are appropriate and medically necessary in this circumstance. No further conservative care is indicated.     

The carrier's denial of coverage for 22633; 22634; 22842; 22853; 20930; and 20936 is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral knee osteoarthritis 
 
Treatment: Euflexxa injections

The insurer denied the Euflexxa injections. The denial was upheld.

This is a female with bilateral knee osteoarthritis. She received Euflexxa injections to her knees for several years.  Her physician has recommended additional injections to both knees. He reported the injections provided benefit.

The recommendations for use of Viscosupplementation have changed. A review of the Clinical Practice Guideline by American Academy of Orthopaedic Surgeons (AAOS) reveals the 2013 OA knee treatment CPG contains one significant recommendation change from the 2008 CPG, and this is with regard to the issue of viscosupplementation. The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG.  The second edition CPG recommendation reads, "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria. The CPG's best evidence synthesis does not support the efficacy of viscosupplementation. The Orthopedic group reports "strongly do not recommend use."

The bilateral knee Euflexxa injections are not considered medically necessary for this patient.  The carrier's denial of coverage for bilateral knee Euflexxa injections using codes J7323 RT x3 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose and J7323 LT x3, is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient stay 

Summary:
The patient is a female with a chief complaint of heavy vaginal bleeding and shortness of breath. She was tachycardic. Her hematocrit was 12.41. She received four units of PRBCs (packed red blood cells) and was given oral progesterone. 

This patient was admitted and transfused. Because of her symptoms, she was observed closely. Except for receiving 4 units of PRBCs (packed red blood cells) and monitoring, nothing was done in the hospital. Ideally, this patient could have been transfused in the ED, monitored for a few hours; her CBC (complete blood count) repeated and then discharged home with a follow up with her primary physician or gynecologist. Nothing was done in the hospital that could not be done as an outpatient.

Milliman care guidelines list the clinical indication for inpatient care for patients with anemia. These include active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. Following, the transfusion, the patient had none of the above.

Based on all of the above, admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I Malocclusion, Crowding and Deep Impinging Overbite 

Treatment: Braces (D 8080-comprehensive orthodontic treatment)

The insurer denied the Braces (D 8080-comprehensive orthodontic treatment). The denial was reversed.                 

This is a young female patient who consulted an orthodontist for orthodontic care. A comprehensive exam was performed including a Handicapping Labio-Lingual Deviation (HLD) exam. It was concluded that the patient had Skeletal Class I Malocclusion, Crowding and Deep Impinging Overbite. 
Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies.

Based on the above, the medical necessity for the Braces (D8080-Comprehensive Orthodontic Treatment) is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melanoma
 
Treatment: Decision DX- Melanoma test

The insurer denied the Decision DX- Melanoma test. The denial was upheld.

The patient is a male who underwent a biopsy of a 1.1 mm thick melanoma on his left temple. The requested test is for the Decision DX- Melanoma.

The Decision DX Melanoma is a gene expression profile test that is used to stratify risk of metastasis in patients with melanoma. Gene expression profiling like that undertaken by this provider has not yet been accepted as standard of care in treating cutaneous melanoma patients. The American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) guidelines for clinical decision making and follow-up for patients with cutaneous melanoma do not currently incorporate gene expression profiling. The limited data on Gene Expression Profile (GEP) for melanoma have not yet been extensively vetted and validated by the dermatology or oncology research community. The consensus in the dermatology community is that using gene expression profile (GEP) assays to inform clinical decision making is not yet accepted.      

Given that these assays are not recommended in clinical guidelines, and the data pertaining to this assay's use is not yet accepted, the information gleaned from the assay itself would not materially or appropriately affect the treatment or follow-up approach of most practicing dermatologists.
                                                  
Based on the above, the medical necessity for Decision DX Melanoma testing is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion, overbite, maxillary and mandibular crowding
 
Treatment: Orthodontic treatment

The insurer denied the orthodontic treatment. The denial was upheld.

This patient presented for evaluation for orthodontic care. The orthodontist identified clinical findings including overjet, overbite, Class III malocclusion, maxillary and mandibular crowding and recommended orthodontics. The orthodontist completed the Handicapping Labiolingual Deviation (HLD) index, attaining 26 total points to support orthodontic care. The insurer denied coverage for orthodontic treatment as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements, having attained a score of 17 points on the HLD index. 

It is evident that the patient exhibits a malocclusion.  To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of the Handicapping Labio-Lingual Deviation Index Report. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of the initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index, arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer, attaining a total of 17 points on the HLD index (4 overjet, 5 overbite, 5 anterior crowding, 3 labiolingual spread), which is below the threshold of 26 points to support orthodontic care. The Handicapping Labiolingual Index has been shown to be a valid and reliable determinant of need for orthodontic care.  

The clinical circumstance as presented does not meet the accepted criteria for approval. Based on the above, the medical necessity for Braces (D8080) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer
 
Treatment: Oncotype DX test for Prostate Cancer

The insurer denied the Oncotype DX test for Prostate Cancer. The denial was upheld.

This is a male with prostate cancer. The cancer was diagnosed initially by a transrectal prostate biopsy due to an elevated Prostate Specific Antigen (PSA). The patient then underwent a Magnetic Resonance Imaging (MRI) guided biopsy revealing Gleason 3+4 prostate adenocarcinoma in 2/12 cores. The patient had an Oncotype DX test performed for further risk stratification. 

While the Oncotype DX test does provide additional risk stratification for patients with prostate cancer, the usefulness of the test is not uniformly supported by the organizations which issue prostate cancer management guidelines. For example, the National Comprehensive Cancer Network (NCCN) guidelines state that while men with low risk or favorable intermediate risk prostate cancer may consider the usage of the Oncotype DX test, they also note the absence of randomized prospective trials. The American Urological Association (AUA) guideline statement (2018) regarding management of localized prostate cancer states: "tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer, and are not necessary for follow-up." The impact of tissue based gene expression tests such as Oncotype DX on clinical practice and long-term patient outcomes remains to be empirically demonstrated. Prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking.

The Oncotype DX test for prostate cancer is not medically necessary for this patient.

Based on the above, the medical necessity for Oncotype DX for Prostate Cancer is not substantiated.  The insurer's denial is upheld.