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

Diagnosis: Prostate Cancer
 
Treatment: Oncotype DX Prostate Cancer Assay
The insurer denied the Oncotype DX Prostate Cancer Assay. The denial was upheld.   
This is a male patient who was diagnosed with prostate cancer based on a PSA value of 6-7 in late 2018. The patient had negative prostate biopsy one-to-two years prior, and no family history of prostate cancer.  The patient was found to have positive biopsy cores for prostate adenocarcinoma, both Gleason 3+3.  The patient's urologist ordered a Oncotype DX PCA test that was performed in early 2019.  The GPS score was 44, indicating unfavorable intermediate risk of prostate cancer, with a 46% risk of Gleason 4+3 disease (adverse pathology).  
The National Comprehensive Cancer Network (NCCN) guidelines do state that molecular testing, including the Oncotype DX GPS assay, be considered for  men with NCCN low or favorable intermediate risk prostate cancer, and a >10 year life expectancy.  However, they also note the absence of randomized, prospective trials.  

American Urological Association (AUA) guidelines 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 carrier's denial of coverage for the Oncotype DX Prostate Cancer Assay for date of service is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rehabilitation for an Edentulous Space in the Right Maxilla, #4 

Treatment: Endosteal Implant (D6010) for tooth #4

The insurer denied the Endosteal Implant (D6010) for tooth #4. 
The denial was upheld.   

This is a middle aged female who presented for dental evaluation, and treatment/discussion regarding prosthetic rehabilitation for an edentulous space in the right maxilla, #4 area.  The treating doctor recommended an endosteal implant to be placed at the site after discussion of treatment plan.

Although implants are an acceptable treatment to restore edentulous spaces, as in this patient, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include a removable partial denture or a fixed bridge.  As partial and fixed dentures (bridge) remain standards of care in general dental practice, the alternate benefits provision of the insureds contract is valid and therefore the endosteal implants are considered elective and not medically necessary.  

Based on the above, the medical necessity for surgical placement of implant body: endosteal implant (D6010) for tooth #4 is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Pregnancy
Treatment:  Genetic testing
The prenatal genetic testing was partially medically necessary and partially not medically necessary.  The portion of the testing panel related to spinal muscular atrophy, CPT 81401, is medically necessary.  No other portion of the complete Ashkenazi screening panel is medically necessary.

The American College of Obstetricians and Gynecologists recommends that patients who do not have a family history of a specific genetic disorder or a history of Ashkenazi Jewish ancestry be offered maternal carrier screening for cystic fibrosis and spinal muscular atrophy.  It is not recommended that such patients receive testing for the Ashkenazi-specific conditions for carrier screening because there is not clear evidence of any increased benefit to them or their pregnancies from this expanded screening.  Because this patient falls into this category, it is not medically necessary for her to receive the entire Ashkenazi panel, which in addition to a number of Ashkenazi-specific diseases also includes screening for cystic fibrosis and spinal muscular atrophy.  According to the information reviewed, no evidence was presented that she had previously been screened for spinal muscular atrophy, although the patient previously had carrier screening for cystic fibrosis.  Carrier screening testing needs to be performed only once per lifetime for any given condition because these characteristics are inherited at birth, so repeat testing for cystic fibrosis is also not medically necessary.  

However, if screening for spinal muscular atrophy has not previously been performed, then the portion of the testing panel related to spinal muscular atrophy, CPT 81401, is medically necessary.  There are no records describing that this patient has been tested for spinal muscular atrophy; therefore, this aspect of the test is medically necessary.  No other portion of the complete Ashkenazi screening panel is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Asthma
Treatment:  Inpatient admission

The inpatient admission was not medically necessary.

Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production.  Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention.  Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1)  Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough.  "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients ... our review findings support the importance of controlling persistent asthma ... early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)
 
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression.  This is achieved with supplemental oxygen, bronchodilators, and steroids.  Fluid hydration may also be necessary.  For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.

While in the ED, this child with history of reactive airways disease received albuterol every hour as well as enteral corticosteroids and magnesium.  She remained symptomatic, so was admitted for further nebulized bronchodilator treatment.  She was able to wean rapidly, and was stable for discharge the day after admission.  While it was reasonable and appropriate to monitor her in the hospital while providing comprehensive asthma care, she was overall hemodynamically stable with no oxygen requirement and able to tolerate a regular diet.  She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient admission
The inpatient admission was not medically necessary for this patient.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The inpatient treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and use of cocaine and cannabis. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient had received detoxification treatment recently with knowledge of substance use disorder treatment protocols, as noted in the clinical summary. The patient had fair insight and control of impulses, and a working knowledge of substance use disorder treatment with a past history of multiple treatment episodes, as noted. Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario.
This answer is consistent with New York State LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.
In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and stimulants/cocaine and cannabis. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe symptoms of withdrawal or biomedical issues in this case. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario, as the health plan asserts. NY State OASAS LOCADTR 3.0 Criteria/Guidelines are not met for the inpatient level of care, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Laparoscopic Cholecystectomy	
 
Treatment: Inpatient Admission

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

This is a middle aged male who presented to the Emergency Department complaining of abdominal pain, nausea and vomiting.  The pain and tenderness was located in the right upper abdomen with no radiation. He has medical history of a urethral stricture with hypertension. It was recommended that the patient undergo laboratory and diagnostic studies.  He was treated with medications to include ondansetron and morphine.  The laboratory studies revealed a white blood cell count of 13.5 and a CT revealed that there was a minimally dilated and fluid-filled appendiceal tip without significant surrounding inflammatory changes.  An ultrasound of the abdomen also revealed cholelithiasis with no sonographic Murphy's sign.  It was recommended that the patient be admitted to undergo a laparoscopic cholecystectomy.  The patient underwent surgical intervention without any complications.

According to current literature, a patient may be admitted to undergo a laparoscopic cholecystectomy when there are the appropriate indications for the procedure. This procedure is typically performed on an ambulatory basis.  A patient may need an extended stay when there is a conversion to an open procedure, systemic infection, care as needed for active comorbidities, or there are other complications noted.  Within the documentation, the above was not present.  The patient did not have any complications and there were no comorbidities noted that would require extensive 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: Coronary Artery Disease 

Treatment: Inpatient Admission

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

This patient is a male who presented to the hospital with complaints of intermittent chest discomfort lasting 30 to 60 seconds. He had a history of hyperlipidemia and coronary artery disease with anterior wall myocardial infarct several years ago and  then coronary artery stents in the proximal left anterior descending (LAD) and distal mid and proximal right coronary artery (RCA) a year after. A treadmill nuclear stress testing in early 2019 revealed a small to moderate fixed mid to distal anterior and apical defect and a small to moderate partially reversible myocardial perfusion defect in the septal region with mild peri-infarct ischemia and a LVEF of 37%. He was scheduled for elective coronary angiography and possible intervention. The procedure was performed using a right radial artery approach with three stents placed. The patient was monitored after the procedure and discharged when deemed medically stable.

There is no evidence that this patient required an acute inpatient level of care for percutaneous coronary artery intervention. 
Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unstable Angina
 
Treatment: Inpatient Admission

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

This is a male patient who presented to the emergency room (ER) in early 2019 with left-sided chest pain, which began 20 minutes prior to arrival, and was associated with shortness of breath. He has a past medical history notable for coronary artery disease, multiple coronary stents, hypertension, hyperlipidemia, atrial fibrillation, myocardial infarction, and congestive heart failure. He had undergone recent coronary intervention to his ostial right coronary artery for in-stent restenosis. His vital signs and physical examination in the ER were unremarkable. Troponin was negative, and electrocardiogram (EKG) was non-diagnostic. He underwent coronary angiography; however, he left that same day against medical advice. 

The patient presented with chest pain, however the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic EKG, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing prior to discharge. Further evaluation was warranted, however inpatient admission criteria was not met.  Although the patient had new onset symptoms, medical criteria were not met for any other additional extenuating circumstances. There were no other high-risk co-morbidities. 

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: Upheld

Diagnosis: Weakness, fever, nausea
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient was an otherwise young patient with no immune deficiency. She had a fever and tachycardia, which was likely viral in origin. She was treated with PO Augmentin (for strep throat), and the team did not suspect severe sepsis or septic shock (no IV antibiotics). Given the proposed treatment and amount of concern, the patient could have been placed in observation overnight, given the PO antibiotics, and re-evaluated in the morning. She was at low risk given her qSOFA score of one (1). Given all of these factors, she could have safely been placed in observation.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with a melanoma to the right back, Breslow .9 mm. There is no ulceration, no regression, the mitotic index is 0. This is a review for coverage of the decision DX melanoma assay.  The requested service is not more likely to be beneficial than any standard treatment.

There is insufficient evidence to determine how gene expression profiling may be used to guide clinical decisions related to the diagnosis and treatment of cutaneous melanoma. Specifically, it is not known how or whether decisions concerning treatment and surveillance are improved over the current standard of care, and it is unknown whether health outcomes are improved as a result of those decisions. Further, the clinical practice guidelines from the NCCN recommend against routine prognostic testing for low versus high metastatic risk outside of a clinical trial. The standard prognostic indicators for melanoma include age, gender, Breslow thickness, ulceration, and mitotic rate. Gene expression profiling has not been shown to have independent prognostic value within the context of the other known prognostic factors for melanoma. It's independent prognostic value has not been confirmed in a large population of patients with average to low risk disease. Therefore the use of decision DX melanoma gene expression profile test is considered investigational/experimental. The health plan determination is upheld in whole.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with a malignant melanoma on the right mid-upper back that was 0.9 millimeter (mm) in depth and without ulceration. DecisionDx gene expression testing is recommended. There is much interest within the medical community regarding the DecisionDxTM -Melanoma assay, with hope that it may be helpful in the ultimate treatment of melanoma, but currently this has not been established with randomized controlled trials of sufficient size. In 2017 Dr. Eddy Hsueh presented an interim analysis of the 5-year Study to Track Clinical Application of DecisionDxTM-Melanoma Gene Expression Profile Assay Results (INTEGRATE and EXPAND cohorts). One issue with this analysis is whether this is superior to standard practice (clinical follow-up). While the preliminary data suggests that the test may have some ability to differentiate a more aggressive melanoma from a less aggressive melanoma, there is still uncertainty whether the test can perform better than simply monitoring the patient clinically for signs and symptoms of advancing disease. It is, therefore, considered experimental/investigational.

The National Comprehensive Cancer Network (NCCN) guidelines, which provide recommendations for the treatment of malignant melanoma of the skin, do not currently support DecisionDxTM testing for cutaneous melanoma. As noted in the current NCCN guidelines for the treatment of melanoma (v2.2018) "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 melanoma (before or following sentinel lymph node biopsy) is not recommended outside of a clinical trial." Because the test is not yet known to be effective in the evaluation and treatment and follow-up of malignant melanoma of the skin, and consistent with recognized professional standards of care, the DecisionDxTM-Melanoma assay is considered experimental/investigational and is not known to be more beneficial than standard clinical monitoring and medical treatments. The health plan determination is upheld in its entirety.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a history of Malignant Melanoma of the right mid-upper back that was biopsied. The Melanoma was read  as having a Breslow depth of 0.9 millimeter (mm), no ulceration, and with no mitotic figures per square millimeter field. No regression, perineural or lymphovascular invasion, or microsatellitosis were observed on histologic examination. The tumor was staged as pT1b.
A DecisionDx-Melanoma Gene Expression Assay was reported as having a result of Class 1, Sub-class 1A, consistent with a low risk of near-term metastatic disease. The DecisionDx-Melanoma (5) test is experimental/investigational. It is not in accordance with generally accepted standards of medical practice in the United States, is not clinically appropriate for this patient's clinical condition. The medically-accepted and standard treatment is observation and followup based on the tumor's histologic features.

No modern dermatology textbook (1,2) even mention this requested gene expression assay as part of the staging of a melanoma to determine if a specific test or work-up is indicated.

The National Comprehensive Cancer Network (NCCN) 2018 guidelines does mention the DecisionDx-Melanoma and/or any other form of gene expression or genetic biomarker testing exists, and that this test is meant to determine whether a sentinel lymph node biopsy (SNLB) is indicated (4), but describes evidence for using this test to help determine proper melanoma treatment as being inconclusive and unsubstantiated at this time. The DecisionDx-Melanoma is entirely experimental/investigational, and not medically necessary for this patient. The only consensus that exists for this test is that more studies need to occur in modern evidence-based and peer-reviewed literature. The HP determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with history of dyslexia that presented to the emergency department (ED) with two-day history of right-sided abdominal pain, three- to four-day history of hematuria, and one-day history of low-grade temperature (to 100.1). Pain was rated 7/10 at its worst. The patient acknowledged history of constipation, with stool every four days or so. He also had sustained a concussion two weeks prior and was currently treated for sinusitis with amoxicillin.

Examination was significant for no acute distress, tachycardia, clear lungs, normal bowel sounds, and non-focal neurologic exam. Computed tomography (CT) of the abdomen was obtained revealing right perinephric fluid, mild thickening of the urinary bladder wall, and decreased attenuation in the medial cortex of the upper pole of the right kidney. Laboratory evaluation revealed leukocytosis with white blood cell (WBC) count of 17.5 thousand (K), 80% neutrophils, elevated C-reactive protein (CRP) 4.3, normal lipase, normal lactate 1.1, and urinalysis with large leukocyte, 3+ occult blood, white blood cells (WBCs) 180, and WBC clumps. He was treated with a normal saline bolus followed by maintenance intravenous (IV) fluids, Tylenol, and ceftriaxone. He was subsequently admitted for further care of pyelonephritis. Admitting orders included IV fluids and ceftriaxone. He did well, remaining afebrile, with pain well-controlled, passing two stools Urine culture returned positive for Escherichia (E.) coli pan-sensitive. Urology was contacted, with outpatient follow-up recommended. He was subsequently deemed stable for discharge to complete a course of Bactrim.

The health plan's determination is upheld, in whole. 

This patient presented with several days of blood in the urine, right sided abdominal pain, and low-grade fever. Testing revealed right pyelonephritis. While it was not inappropriate to initiate treatment with parenteral antibiotics in the hospital setting (male gender, no history of UTI, family history of renal abnormalities), he was overall hemodynamically stable, with no vomiting or significant fever, and no signs or symptoms of sepsis. He did not require acute inpatient management and could have been safely managed at a lower level of care.