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

Diagnosis: Retained intrauterine device (IUD)

Treatment: Current Procedural Terminology Code (CPT) 58558 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C) and the associated codes at the outpatient hospital surgery department

The insurer denied coverage for Current Procedural Terminology Code (CPT) 58558 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C) and the associated codes at the outpatient hospital surgery department. The denial was reversed.

This patient is a female who presented to a hospital for a scheduled diagnostic hysteroscopy and dilatation and curettage for a retained intrauterine device (IUD) in the anterior myometrium as seen on ultrasound. The procedure was performed under monitored anesthesia care (MAC). There was no evidence of a retained IUD in the endometrial cavity. The patient was transferred to the post-anesthesia care unit (PACU) after surgery.  Her vital signs remained stable and her pain was controlled. The patient was discharged to home later.

In women in whom the IUD strings cannot be identified and if the ultrasound evaluation reveals an IUD embedded in the uterine wall, hysteroscopic evaluation and removal can be necessary, either in an office or outpatient surgical setting. After appropriate cervical anesthesia and dilation, or under MAC anesthesia the operative hysteroscope is passed through the cervix and gently advanced into the uterus until the IUD or strings are visualized. Once visualized, the hysteroscopic grasper is used to grasp the strings (preferable if they are seen) or the device, and the IUD, grasper, and hysteroscope can all be withdrawn concurrently from the cervix.

This patient had a retained IUD which was documented by ultrasound to be present in the uterus. The next step is to perform a hysteroscopy to visualize the IUD and remove it. This was performed in an outpatient hospital surgery department. The requested procedure is consistent with standard of care and was medically necessary.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The Current Procedural Terminology Code (CPT) 58558 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C) and the associated codes at the outpatient hospital surgery department are considered medically necessary for this patient. 

Based on the above, the medical necessity for Current Procedural Terminology Code (CPT) 58558 (Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C) and the associated codes at the outpatient hospital surgery department is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diffuse lumbar degenerative changes; foraminal stenosis

Treatment: Posterior lumbar decompression and fusion scoliosis surgery with a two day inpatient confinement

The insurer denied coverage for posterior lumbar decompression and fusion scoliosis surgery with a two day inpatient confinement. The denial upheld.

This patient is a female who has a history of Sjogren's syndrome as well as peripheral neuritis.  She was previously diagnosed with diffuse lumbar degenerative changes and foraminal stenosis as well as L5-S1 radiculopathy. The documentation indicated the patient was initially examined after presenting with mid to low back pain.  She also had complaints of cramping to the right buttocks, as well as leg weakness, and pain with walking and standing. She has had treatment with physical therapy, chiropractic care and acupuncture sessions over the course of many years. Based on physical examination as well as imaging and her subjective complaints, she was diagnosed with diffuse lumbar degenerative changes and foraminal stenosis at L5-S1 with radiculopathy.  It was recommended she undergo a T10 to pelvis posterior lumbar fusion with instrumentation.  The submitted documentation does include x-rays revealing a mild thoracolumbar curve with multi-level degenerative disc disease most severely affecting the L5-S1 motion segment.  There is also an x-ray of the chest showing severe multilevel degenerative disc disease in the lumbar spine with facet joint arthrosis.  There was a loss of upper thoracic kyphosis and lower cervical lordosis.  A CT scan was also submitted revealing L4-L5 anterolisthesis noted to be 2mm.  There is a disc bulge yielding mild central canal stenosis.  There is mild to moderate right and mild left facet arthropathy and moderate neural foraminal stenosis with bony impingement at the L5-S1 level.

The health plan was appropriate in denying the surgery as there is no indication on history and imaging to warrant such a long segment instrumentation and fusion. The posterior lumbar decompression and fusion scoliosis surgery with a 2-day inpatient confinement is not considered medically necessary for this patient. There is no indication on history and imaging to warrant such a long segment instrumentation and fusion.  There was no indication of severe deformity or listhesis at all levels warranting such a long segment fusion.  Jette, et al., noted "Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153)."  

Therefore, the above is absolutely not indicated based on records provided. The carrier's denial of coverage for the posterior lumbar decompression and fusion scoliosis surgery with a two day inpatient confinement is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer # 3:

This is an elderly female patient with a history of adenocarcinoma. Her oncologist ordered the Guardant 360 blood test.

Without question, the use of genetic marker receptor testing for adenocarcinoma of the lung is now the standard of care for every patient at diagnosis (1-2). It is used also to guide future therapies that have shown efficacy in those patients on receptor treatments that have progressed.

Standard receptors that would be evaluated include E6FR, T790M, ALK, ROS1 and others such as MET, BRAF, HER-2 neu, NTRK etc. these treatments have clearly improved survival, Q.L, PFS over use of the chemotherapy. Biopsy of tissue or liquid biopsies have been used to determine the type of receptor the patient has and thus institute specific targeted treatment.

This patient never had a tissue diagnosis to even establish a lung cancer. It was sent off with a presumed diagnosis of adenocarcinoma based on a relatively stable lung nodule over approximately a significant period of time on a Tarceva like drug.

The study identified no somatic mutation. Because the test was sent off without a cancer diagnosis/biopsy, it was not warranted. The Guardant 360 test was not the best available testing/procedure for this patient. This test is not likely to be more beneficial than any other standard treatments/procedures. 

The carrier's denial of Genetic Testing 81201, 81272, 81173, 81321, 81210, 81275, 81310, 81120, 81235, 81276, 81311, 81121, 81270, 81293, 81314, 81400, 81401, 81402, 81403, 81404, 81405, 81406 and 81407 (Guardant 360 blood test) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient Admission

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

This is a male patient with a history of hypertension and pre-diabetes. He presented to the Emergency Room (ER) with complaints of intermittent chest pain. Cardiology consulted on the patient. An electrocardiogram (EKG) was performed revealing normal sinus rhythm with T-wave inversions. Serial troponin levels were drawn and a chest x-ray performed; both tests had negative results. A nuclear stress test and echocardiogram were done with normal findings. The patient was medically stabilized and discharged home.

Based on the review of the literature guidelines for inpatient care, inpatient admission was not medically necessary to treat this patient's medical condition. The patient presented to the Emergency Room (ER) with chest pain. However, the initial ER evaluation for acute coronary syndrome was unremarkable with a non-diagnostic electrocardiogram and negative cardiac biomarkers. The cardiac workup and care that the patient received as an inpatient status could have been safely provided in the observational setting that allows for additional diagnostic testing such as echocardiogram and cardiology consultation. The patient did not exhibit hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

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

The carrier denial of coverage for the inpatient hospital services at the acute level of care is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer
Treatment: Radiation therapy
The Radiation therapy for Primary CNS neoplasms is medically necessary.

The patient is a male with a diagnosis of high grade anaplastic ependymoma s/p (status post) resection.  Adjuvant radiation therapy was recommended, and proton beam radiation therapy was requested. 

Proton beam radiation therapy is a type of very precise external radiation treatment in which protons are used to treat cancer and other conditions.  Compared to photon, a proton beam that is delivered with sufficient energy has a low "entrance dose." A proton beam also has a high-dose "Bragg peak" region, which is designed to cover the entire tumor and there is no "exit dose" beyond the tumor involved in proton radiation therapy.  Because of this unique property, proton beam therapy is highly successful in minimizing damage to normal tissue and surrounding organs, resulting in fewer side effects.  Proton beam radiation therapy is an FDA approved procedure and is not subject to IRB (institutional review board) review.

Proton beam radiation therapy has been shown to be safe and effective for any CNS lesions that are adjacent to critical structures such as optic nerve, base of skull, brain stem or spinal cord, and is considered medically necessary per most insurance policy guideline.  

This patient is a male with a diagnosis of high grade anaplastic ependymoma s/p resection.  Adjuvant radiation therapy was recommended and proton beam radiation therapy was requested.  Proton beam radiation therapy has been shown to be safe and effective for the treatment of CNS tumors.  Studies have also shown that there is a potential reduction of the incidence of radiation induced secondary cancer by using proton beam radiation.  A recent 2018 multi-institution trial performed an analysis of the National Cancer Data Base comparing proton (PBT) vs. photon (XRT) radiation therapy for primary gliomas.  A total of 49,405 patients were treated with XRT and 170 patients treated with PBT.  After PS weighting, all patients treated with PBT were found to have superior median and 5 year survival than patients treated with XRT: 45.9 vs. 29.7 months (p = 0.009) and 46.1 vs. 35.5% (p = 0.0160), respectively. The authors concluded that "proton therapy is associated with improved outcomes which support ongoing prospective, randomized clinical trials comparing the two modalities in patients with gliomas."    

In this case, a proton therapy vs. photon IMRT (intensity modulated radiation therapy) comparison plan was done.  The brainstem Dmax was 61.4Gy with IMRT(which exceeded the tolerance) and 59.4Gy with PBT.  The brain V20 was 14.6% with IMRT and 11.6% with PBT.  The spinal cord Dmax was 54.0Gy with IMRT (which exceeded tolerance) and  49.8Gy with proton therapy (within tolerance).  Because of the special "Bragg peak" characteristic, proton beam radiation therapy (PBT) was able to adequately spare the brain stem, brain and cervical spine, whereas the photon IMRT was not.  The requested proton therapy, therefore, the most appropriate treatment option for this patient at this time.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/Gastrointestinal
Inpatient Hospital
The patient  presented to the hospital emergency department (ED)with complaints of epigastric pain and nausea and vomiting. The patient had been seen at the hospital several days prior to this presentation for the condition of pharyngitis. 
At the time of presentation, the patient was not able to tolerate oral intake, though vital signs were normal. The heart rate was 60 beats per minute (bpm) and there was no fever; electrolytes were normal. The patient was tender in the right upper quadrant. Lab data showed an elevated white blood cell count (WBC) count of 13.8 K - 16.5 K; aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were elevated. An abdominal ultrasound showed gallstones. The patient was admitted to the hospital and was treated with intravenous (IV) fluids, pain medication and a surgical consultation. The patient was treated with a laparoscopic cholecystectomy. The operative dictation describes acute inflammation of the gallbladder. The diet was advanced following surgery. The patient was tolerating a diet. Pain was controlled with oral medications. The patient was discharged from the hospital.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of an inpatient stay was medically necessary for this patient based on the clinical findings of right upper abdominal pain and tenderness, an elevated WBC count, ultrasound findings that identified gallstones, gallbladder wall thickening and pericholecystic fluid, and an elevated liver transaminases.
This patient presented to the hospital with acute right upper abdominal pain and tenderness. The patient was unable to tolerate oral intake and had nausea and vomiting. There was an elevated WBC count and elevated serum transaminases. An abdominal ultrasound showed gallstones. The patient was initially treated with IV fluids, antiemetics and pain medications and underwent surgery at which time the patient was found to have acute cholecystitis.
Per Milliman Care Guidelines (MCG), Gall Bladder or Bile Duct Inflammation or Stone, an inpatient level of care is indicated when there is right upper quadrant pain, AND systemic signs of inflammation (fever, C-reactive protein > 10, WBC count > 10 K). In this case there was right upper abdominal pain and tenderness identified on physical exam, there was an elevated WBC count > 10 K and there were elevated serum transaminases. The care and treatment provided in this case was most reasonably rendered at an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe coronary artery disease

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is upheld.

This patient is a male with a past medical history of Cerebral Vascular Accident (CVA), hypertension, hyperlipidemia, Transient Ischemic Attack (TIA), and tobacco use. He presented for an elective cardiac catheterization. He had undergone an abnormal stress test as an outpatient and therefore had a planned cardiac catheterization. This revealed severe coronary artery disease, for which he underwent placement of a drug-eluting stent to the right coronary artery. There were no procedural complications, and the patient was then admitted for further monitoring. The patient remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no vascular access complications. The patient was subsequently discharged home after an uneventful, brief overnight hospital stay. 

The health plan acted reasonably with sound medical judgment and in the best interest of the patient. The inpatient admission status is not medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), this procedure is an outpatient one. The clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and attempted angioplasty. The patient could have received Aggrastat infusion while admitted under Observational level of care. 

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

Cellulitis
Inpatient hospital

The patient was a male with a past medical history significant for hypertension who presented to the emergency department with complaints of severe cellulitis in the lower extremity that started on the day of admission. At the time of the initial evaluation, the patient complained of high fever. He noted that his left lower extremity was red.
In the emergency department, the patient underwent a computed tomography (CT) scan of the leg that demonstrated no fracture or dislocation. The visualized osseous structures were unremarkable. There was no evidence of focal soft tissue lesions or fluid collection. The review of systems was obtained on admission and was positive for fever, left lower extremity pain. The rest of the review of systems was unremarkable.

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient had a sudden onset of rapidly progressive lower extremity cellulitis, which was associated with high fever and sepsis syndrome. The patient was properly admitted to the hospital and started on broad-spectrum intravenous antibiotics. Even though the sepsis syndrome resolved relatively quickly, the patient still had a low-grade fever for several days.
Most importantly, he continued to have pretty significant cellulitis in the left lower extremities that required continuation of care with broad-spectrum intravenous antibiotics, as well as close monitoring for clinical response and signs of drug toxicity. This kind of care is the most appropriate at the acute inpatient level. When the left lower extremity cellulitis improved to the point that the patient was able to be switched to oral antibiotics, he was transitioned to oral antibiotics and discharged home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical dysplasia

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services. The denial was upheld.

This patient is a female who was admitted because she was diagnosed with cervical dysplasia, which was detected on an antepartum Pap smear and colposcopy. She underwent a loop electrosurgical excision procedure (LEEP) of the cervix under general anesthesia. She was discharged later that day with instructions to follow up with her gynecologist.

The loop electrosurgical excision procedure (LEEP), also called large loop excision of the transformation zone (LLETZ), utilizes a very thin wire in the shape of a loop and modern electrosurgical generators that allow accurate and selective blending of the current. The loops are available in a variety of sizes, allowing individualization and avoidance of excessive excision. They are insulated along the shaft and crossbar to prevent injury to the patient and thermal damage to the ectocervical portion of the cone. A plastic or insulated speculum must also be used. A speculum that will connect to suction is helpful. The LEEP procedure is usually performed in an office setting or in an ambulatory surgical center. Inpatient hospital is not required for this simple procedure. This was a young healthy patient with no history of medical issues that would require inpatient management.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Based on the above information, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Knee Problem/Pain
Surgical Services  (All)

The patient is a college student who was evaluated for knee pain and found to have a large osteochondral lesion of his lateral femoral condyle. He underwent an initial arthroscopy for removal of a loose body, but continued to have pain and significant functional limitations. He underwent a second surgery which involved using an autograft (cadaver bone and cartilage) to replace the injured area of bone and cartilage. At issue is whether this procedure is medically necessary.

The health plan's determination is overturned. The Osteochondral Knee Allograft is medically necessary for this patient. Large areas of osteochondral injury such as this patient had (greater than 50% of the articular surface of the lateral condyle) are not effectively treated by lesser procedures such as marrow stimulation or allograft from the intercondylar notch area. While it is not clear that this procedure will allow return to activity at the highest level for the majority of patients, it is considered more likely to improve symptoms in the short term and to delay the progression to degenerative arthritis in the long term. It was medically necessary for this patient.