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

The patient presented to an outside hospital with abdominal pain. His evaluation identified a distal pancreatic mass and he was transferred to the admitting hospital for further evaluation. His comorbid health conditions included morbid obesity, sleep apnea, and hypertension. His lab data was normal. He underwent evaluation with a computed tomography (CT) scan of the chest and endoscopic ultrasound with biopsy of the pancreatic mass. He remained stable throughout and following the endoscopic procedure.

The pathology showed atypical cells of the pancreas. Outpatient chemotherapy for acinar cell carcinoma was subsequently planned. He was started on a diet following the procedure. The next day, the patient had a fever to 39.3 C with a heart rate of 108. A sepsis protocol was initiated. The fever resolved without intervention and he was discharged from the inpatient setting the following day. The health plan denied the inpatient admission as not medically necessary.

The health plan's determination is upheld. An inpatient level of care was not medically necessary. This patient was admitted to the hospital with the diagnosis of a pancreatic mass. Vital signs and lab data were normal at the time of presentation. He underwent diagnostic evaluation that included endoscopic ultrasound. The early post-procedure course was notable for an isolated fever, but was otherwise uncomplicated. The submitted medical records support that this patient's care and evaluation could have reasonably been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Low back pain and spinal stenosis
 
Treatment:  Inpatient admission, monitoring, medication

The insurer denied the inpatient admission. The denial was upheld.
This patient had a past medical history of atrial fibrillation, back pain, episodic cannabis use and hypertension.  The patient had previously undergone an atrial fibrillation ablation.  The patient had subjective complaints of low back pain and sciatica for a few years secondary to lumbar stenosis.  He presented to the hospital for an elective L3-S1 micro laminectomy/discectomy for diagnoses of low back pain and spinal stenosis.   Postoperatively, the patient reported minimal postoperative pain, but complained of "numbness and weakness in the right greater than left lower extremity especially when lying flat."  The patient was voiding spontaneously.  Due to his symptoms, he was admitted for intravenous steroids and serial neurological checks.  To assess that the symptoms were related to inflammation and to rule out a hematoma, the patient underwent a needle aspiration x2 near the superior and inferior aspect of the incision.  No collection was aspirated.  The patient had full range of motion. The patient was discharged to home the following day.

Milliman Care Guideline (MCG) indicates that the surgery that was performed is generally performed for a goal length of stay of ambulatory or 1 day postoperative.  Ambulatory surgical intervention is appropriate for minimally invasive procedures.  The surgical intervention was minimally invasive.  The patient was admitted for intravenous steroids and serial neurological checks.  The records failed to support that the patient was not appropriate for observation instead of a full admission.  The treatment could have been performed during observation.  

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Melanoma
Issue under review: DecisionDX-Melanoma test

Determination:
The health plan should not cover the DecisionDX-Melanoma test.

The requested service is not medically appropriate. It is not required to diagnose or treat the illness. Though DecisionDx has been shown to be a valid indicator of metastasis risk for malignant melanoma and may lead to increased patient surveillance, there is no definitive data to date that show how this procedure has led to overall improved patient outcome and survival.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Melanoma
Issue under review: DecisionDX-Melanoma test

Determination:
The health plan should not cover the DecisionDX-Melanoma test.

There is no evidence-based medical literature to support that a greater benefit is imparted after DecisionDx testing than current standard of care. There are insufficient outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate its safety and effectiveness for melanoma.

Standard of care in a melanoma greater than 1 mm (one millimeter) is wide local excision with a sentinel lymph node biopsy. Further testing or work-up is performed by symptoms and results of sentinel lymph node testing.  For melanomas less than 1 mm, wide local excision with routine skin and physical exams is standard of care.

At the current time, the most significant limitation in the peer-reviewed literature concerning the use of gene expression profiling for melanoma is the lack of published data providing direct evidence of the clinical utility of the DecisionDx test in directing treatment plans. The National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology for melanoma do not include a recommendation for gene expression profile testing for melanoma at this time. Additional prospective studies are required to determine how this risk stratification test will direct the clinical management and selection of treatment options that would result in an improved prognosis for individuals with melanoma. Because this has primarily been studied in uveal melanoma, it is promising but still remains unproven, especially in cutaneous melanoma. 

The 2018 NCCN guidelines for cutaneous melanoma state that the evidence for use of DecisionDx-melanoma and/or other forms of gene expression or genetic biomarker testing is inconclusive or unsubstantiated at this time.  The 2018 guidelines recommend use of the Breslow depth and presence or absence of ulceration as the only determining factors for undergoing a sentinel lymph node biopsy.

Therefore, based on review of the current peer-reviewed medical literature, the technology would not be medically appropriate for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Melanoma
Issue under review: DecisionDX-Melanoma test

Determination:
The health plan should not cover the DecisionDX-Melanoma test.

The NCCN Guidelines for Melanoma version 2.2019 (accessed 07/19/2019 at 4:30 pm at https://www.nccn.org/professionals/physician_gls/pdf/cutaneous_melanoma.pdf) do not recommend Decision-Dx Melanoma in the work up of any stage of cutaneous melanoma. Per the guidelines, "While there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low- versus high-risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas (before or following SLNB) is not recommended outside of a clinical study (trial)." Gene expression profile signature (DecisionDx-Melanoma) to predict visceral metastatic risk in patients with stage I and stage II cutaneous melanoma is currently not standard of care in the management of cutaneous melanoma, and it is therefore not considered to be medically appropriate. 

To date, there is a paucity of evidence in the peer-reviewed published medical literature evaluating the clinical utility of the DecisionDx-Melanoma test. The National Comprehensive Cancer Network (NCCN, 2014) Clinical Practice Guideline (CPG) in Oncology recommendations for the clinical staging and workup of melanoma (principles of pathology), states: While there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low- versus high-risk for metastasis, routine (baseline) genetic testing of primary melanomas (before or following sentinel lymph node biopsy [SLNB]) is not recommended outside of a clinical trial. A Cochrane report addressing the primary treatment of cutaneous melanoma (Sladden, 2009) states: standard treatment is surgical excision with a safety margin some distance from the borders of the primary tumour. The purpose of the safety margin is to remove both the complete primary tumour and any melanoma cells that might have spread into the surrounding skin. 

In summary, there is insufficient evidence to evaluate the clinical validity and clinical utility of the DecisionDx-Melanoma test. Additional study is required to further validate if gene expression profiling of cutaneous melanoma will accurately identify which individuals are likely to have aggressive disease and how the results of testing would alter treatment plans and improve health outcomes in the surveillance and treatment of high-risk cutaneous melanoma. At this time, it is considered experimental/investigational/unproven and not known to improve health outcomes. The consensus of opinion among experts regarding the test is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lupus
Issue under review: Mycophenolic Acid 360MG Tablet DR

Determination:
Mycophenolic Acid 360MG Tablet DR is not medically necessary.

Per attached documentation, this patient with SLE and FMS has a history of transverse myelitis, treated with Cytoxan in 2013.  Symptoms of transverse myelitis are presently quiescent.  She was recently noted to have positive anti-aquaporin 4 antibodies, concerning for neuromyelitis optica (NMO), but there was no evidence of optic neuritis or ongoing myelitis, and both MRI and cerebrospinal fluid studies were normal on 02/07/2019.  Her main symptoms were documented as joint pain, joint stiffness/swelling and fatigue.  She was felt to have "serologic SLE," but many of her symptoms were felt to be on the basis of fibromyalgia, or medically unexplained.  There is no documentation of severe, active organ-threatening SLE.  The patient was unable to tolerate an increased dose of CellCept due to GI symptoms. She had been previously offered treatment with the Plan-preferred agents methotrexate and azathioprine, or Benlysta.  

Based upon this patient's constitutional symptoms of joint pain and fatigue, with no clear evidence of severe, active organ-threatening disease, it would be clinically appropriate and in accordance with standard of care in the rheumatology community to offer this patient a more conventional treatment with methotrexate or azathioprine in lieu of the requested Myfortic acid.  Withholding Myfortic acid in lieu of a more conventional DMARD (disease modifying antirheumatic drug) for the treatment of this patient's SLE would not be anticipated to cause harm to the patient.  Therefore, the proposed Myfortic acid for the treatment of SLE in this patient is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Gastroenteritis

Treatment:  Inpatient Admission

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

This is a young male patient who presented to the emergency department with complaints of abdominal pain radiating to his back, fever, and diarrhea.  It was noted that his abdominal tenderness was without rebound.  He had a surgical history of appendectomy, hernia repair, tonsillectomy, and lap band surgery.  A computer axial tomography scan was performed, which revealed enteritis and colitis.  His stool test was positive for campylobacter; he was treated with antibiotics.  The patient was able to tolerate a clear liquid diet.  He was discharged home. 

MCG clinical indications for admission for Gastroenteritis (M-170) include a suspected severe infection such as bloody diarrhea, severe abdominal tenderness, toxic mega colon, hemodynamic instability, severe vomiting, and an inability to maintain oral hydration.  The patient did not exhibit these conditions.

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

Diagnosis: Substance Abuse
 
Treatment: Inpatient substance rehabilitation 

The insurer denied the coverage for inpatient substance rehabilitation. The denial was reversed.

This male patient was admitted to this inpatient substance rehabilitation treatment after an inpatient substance detoxification treatment He was drinking six 24 ounce beers per day and using illicit benzodiazepines. He had prior legal problems, including driving under the influence (DUI). He had prior inpatient substance detoxification treatments. He had relapsed while in recent outpatient substance treatment. He had a history of depressive and anxiety symptoms, including suicidal ideation and a prior psychiatric hospitalization He was unemployed. He took Zoloft, Gabapentin, Zyprexa, Depakote, Naltrexone, and Disulfiram. It was reported that he was discharged. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he met criteria for inpatient substance rehabilitation treatment as he continued to use alcohol and benzodiazepines despite multiple past inpatient substance treatments and a recent outpatient substance treatment in which he was unable to remain abstinent and relapsed. Also, he continued to use despite negative consequences due to alcohol and substance use, including prior legal issues in the form of a DUI. He also had comorbid depressive and anxiety symptoms, including a prior psychiatric hospitalization. He lacked coping skills, needed to better identify relapse triggers, and needed to learn relapse prevention skills. He was also unemployed. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance setting. Without this structured and supervised therapeutic treatment, he likely would have relapsed quickly.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient has a diagnosis of occipital neuralgia since 2011.  The patient has tried and failed conservative care for years, consisting of pain management with medications and occipital nerve blocks.  Occipital nerve blocks have not been helpful (office note early 2019).  The magnetic resonance imaging (MRI) revealed the following:  no significant neurovascular compression, and C5-6 disc herniation with some indentation of the C6 nerve root.  There is no neurologic deficit.  The physician is requesting Occipital Nerve Stimulation.  Occipital nerve stimulation is likely to be more beneficial than most alternate therapies, all of which have a low success rate.  Occipital nerve stimulation is minimally invasive and has a low rate of complication.  The patient has failed prolonged multimodal conservative treatment, and occipital nerve stimulation is documented to be effective for the treatment occipital neuralgia.  The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. 

Per Keifer OP Jr. et al. (2017), "Despite complications, the results suggest, overall, that occipital nerve stimulation is a safe and effective procedure for refractory occipital neuralgia and should be in the neurosurgical repertoire for occipital neuralgia treatment."

The patient's pain was refractory to greater occipital nerve blocks and medications.  Therefore, ONS would be appropriate in this patient's clinical scenario.  Occipital nerve stimulation is the best available treatment for this patient at this time.  Given that the patient has failed prolong multimodal conservative treatment and occipital nerve stimulation is documented to be effective for the treatment occipital neuralgia, occipital nerve stimulation is likely to be more beneficial than any other standard treatment/procedure.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient had experienced several work-related accidents between 2011 and 2017.  The patient complained of severe pain with psychomotor retardation and other symptomatic responses.  The patient was alert and oriented x3 with a depressed mood secondary to pain.  The patient's overall cognitive skills were not seen to be adversely affected.  It was determined there were no significant psychosocial factors that predicted there would be a poor response to installation of a spinal cord stimulator.  The physician submitted a letter of medical necessity indicating the patient has left-sided facial pain and occipital neuralgia as well as headaches.  The patient had exhausted standard treatment.  

Occipital nerve stimulation continues to be investigated for the treatment of refractory chronic migraine.  Results from case series and from prospective controlled clinical trials remain inconclusive regarding the efficacy of occipital nerve stimulation for migraine treatment.  Safety and implantation techniques require improvements since rates of lead migration, infection, and persistent stimulator-related pain continue to be high.  The literature at this time does not support a result of improvement in health outcomes.  Therefore, the requested occipital nerve stimulation would not be considered the best available treatment for this patient, and the procedure is not likely to be more beneficial, than any other standard treatments/procedures.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Neuropathy
Treatment:Occipital nerve stimulation
The health plan denied occipital nerve stimulation. That denial was reversed as two out of three panelists determined occipital nerve stimulation was likely to be more beneficial than any other standard testing/procedures.

The patient had an injury in 2011 when a skylight assembly fell on his head during a fire.  He had additional injuries that year, as well as in 2014, 2015 and 2017 that included injury to the head.  A facial nerve conduction velocity (NCV) test showed left sided facial nerve neuropathy.  He was seen in early 2019.  His primary complaint was pain in the left side of his head and face.  He had severe pain in the left occipital region and the entire left side of the face into all three divisions of the trigeminal nerve.   

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.  There are many small studies that show it is a safe and effective treatment.  While they are considered to be in a Level III category, there is enough conclusive evidence for consideration of treatment for a particular set of patients. According to clinical criteria by Medicare/Medicaid, he would meet all criteria.  He has failed multiple conservative treatments and is not a surgical candidate.  He has proven neuropathy due to multiple injuries.

Occipital nerve stimulation is the best available treatment for this patient at this time.  The patient has tried multiple conservative treatments with no long standing relief.  He has severe pain and a loss of quality of life.  A trial of percutaneous electrical nerve (PENS) would be the best available treatment to determine pain relief and consideration of a permanent placement.

The requested trial and possible permanent placement of PENS for this patient who has intractable pain despite treatment would be likely to be more beneficial than any other standard treatment for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a male with daytime sleepiness.  He has undergone coronary artery bypass surgery after stent placement for coronary artery disease.  He had a loop recorder placed and then removed.  He is obese with a body mass index of 31.9 kg/m2.  He has moderate sleep apnea based on a sleep study that showed an apnea hypopnea index of 24.6 events/hour with desaturations as low as 83%.  He has atrial fibrillation recorded during his sleep study. He did not have frequent or disruptive periodic limb movement sequences of sleep.  He underwent endoscopy that showed absence of concentric collapse.  He reports attempting continuous positive airway pressure (CPAP) usage with several different masks over a period of about two years without success because of frequent sinus infections and removing the mask. He reports that his quality of sleep was not improved with CPAP usage.  There is no documentation about CPAP titration efficacy, physician visits to work on techniques to improve CPAP adherence or compliance downloads. He reports attempts at weight loss.  This request is for coverage of placement of an Inspire hypoglossal nerve stimulator.

Standard treatments include CPAP, weight reduction and oral appliance therapy, all of which are more beneficial than the proposed hypoglossal nerve stimulator.  Weight reduction has additional health benefits above and beyond the reduction in severity of sleep apnea. His letter of appeal states that he has worked on weight reduction but there is no documentation that he has worked with a nutritionist, worked with a personal trainer and has diligently engaged in behaviors that would be expected to result in resolution of obesity. Oral appliance therapy is efficacious for mild to moderate sleep apnea with an effect size that is similar to CPAP and with better adherence to treatment than CPAP.  Records provided do not indicate that he has attempted and failed oral appliance therapy.
The carrier's denial of coverage for CPT code 64568-Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator and 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including 
connection to pulse generator should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

This case involves a male patient currently diagnosed with obstructive sleep apnea.  The patient's sleep study of revealed the patient had an apnea-hypopnea index (AHI) of 24.6.  The patient's Body Mass Index (BMI) was 31.9 kg/m2. The patient had a lack of central apnea and had a favorable pattern of palatal collapse during a drug-induced sleep endoscopy.  CPT code 64568-incision for implantation of cranial nerve (e.g., vagus nerve) Neurostimulator electrode array and pulse generator and 0466T insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator has the final approval from the appropriate regulatory bodies for this diagnosis.  The patient is a good candidate for CPT code 64568-incision for implantation of cranial nerve (e.g., vagus nerve) Neurostimulator electrode array and pulse generator and 0466T insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. 64568-incision for implantation of cranial nerve (e.g., vagus nerve), Neurostimulator electrode array and pulse generator and 0466T insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is the best available treatment for this patient at this time, as he has failed standard, first-line treatment.

The carrier's denial of coverage for CPT code 64568-Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator and 0466T Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator should be reversed.