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

This is a patient who came to the emergency room (ER) with a complaint of 1 week of abdominal pain. The pain was described as intermittent, crampy and has come and gone over the past week. It had initially improved but worsened 2 days prior to presentation. He also had intermittent diarrhea (3-4 times (x)/day at most) and emesis (2-3x/day at most, most days without emesis).  He had decreased through mouth (per orem), by mouth, or oral nutrition (PO) intake but was drinking well. In the ER he continued to have crampy lower abdominal pain. He had 2 separate right lower quadrant (RLQ) ultrasounds which were inconclusive regarding his appendix. A follow up CT scan of the abdomen, however, showed a normal appendix and mild terminal ileitis and colitis of sigmoid colon. The health plan's determination of medical necessity is upheld. A CT scan ruled out appendicitis. There were no signs of significant dehydration on exam. Vital signs were stable. He had a mildly elevated WBC but was nontoxic appearing and without fevers. The patient did not have any further emesis after admission to the hospital. His laboratory and radiological findings were consistent with an acute gastroenteritis. The patient's clinical findings described in the chart along with his laboratory findings do not support a diagnosis of dehydration. He did not appear to have a surgical abdomen at the outset nor did he show signs of impending deterioration.
Appeal type: Medical necessity
Decision: Upheld

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient. An inpatient level of care was not medically necessary. 

This patient with a history of anxiety and panic attacks presented to the emergency department complaining of three days of chest pressure and facial numbness. Blood pressure was 114/64 mmHg with a heart rate of 106 beats/minute. Room air oxygen saturation was 100%. Cardiovascular exam was unremarkable. Serum troponin level was normal. An electrocardiogram showed nondiagnostic anterior T wave changes and a prolonged QT interval. The patient was treated with aspirin and admitted to the hospital to rule out acute coronary syndrome. Repeat troponin level was normal. The patient was evaluated for a rash that was thought to be due to arthropod bites. The patient left the hospital against medical advice.

The patient presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. On the other hand, the patient was hemodynamically stable, with normal cardiac biomarkers, and no diagnostic electrocardiographic changes. The patient did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level. This approach has been shown to be both safe and effective and is in accordance with the 2010 American Heart Association (AHA) recommendations on the management of patients who present to the emergency department with acute chest pain and who, like this patient, are at low risk for acute coronary syndrome. It is also supported by the 2014 AHA/ American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain, nausea, vomiting
Treatment:  Inpatient hospital admission
The inpatient hospital admission was not medically necessary.

The submitted medical records do not support that an inpatient level of care was medically necessary for this patient.  The care and treatment provided could have reasonable been provided with an observation level of care.

This patient presented with lower quadrant pain.  The evaluation with examination, lab data and CT scan supported the diagnosis of appendicitis.  The patient was treated with NPO (nothing by mouth) status, IV antibiotics, and laparoscopic appendectomy.  He was admitted to an inpatient level of care and was discharged from the hospital following an uncomplicated overnight stay.  

There is no clinical documentation to support the need for inpatient admission.  The patient remained hemodynamically stable throughout the period of care.  There was no fever or documented complication of surgery.  This patient's clinical needs could have been satisfied with an observational level of care.  This level of care would have provided for surgical assessment, including overnight observation.  IV antibiotics also could have been provided with this lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a male patient with a diagnosis of cutaneous melanoma. The patient underwent a punch biopsy of his left upper arm that was indicative of malignant melanoma. The specimen was sent for Decision DX= Melanoma testing. 

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.

An analysis of this test in UptoDate states: "A commercial gene expression profile test (DecisionDX-Melanoma) has been developed in patients with local (stage I and II) or locoregional (stage III) cutaneous melanoma [33]. However, there are no definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. (Tumor node metastasis (TNM) staging system and other prognostic factors in cutaneous melanoma)

The Decision DX-Melanoma assay is under the regulation of Clinical Laboratory Improvement Amendments [CLIA], but this does not mean that it is approved as a standard of care.  This article also mentions current tests that positively affect patient outcomes, but did not mention the test in question as one of them.

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


This is a male who is status post excision of a left upper arm melanoma. The specimen was sent for Decision DX Melanoma testing.

According to Boland, G. M., & Gershenwald, J. E. (2016), "The revisions to the American Joint Committee on Cancer (AJCC) melanoma staging system over time reflect changes in our understanding of the biology of the disease.  Since the 1st edition, where tumor thickness was defined anatomically by its relationship to the reticular or papillary dermis (Clark level) as well as tumor thickness (Breslow thickness), there have been significant strides in our use of clinicopathological variables to stratify low- versus high-risk patients.  Management of the regional nodal basin has also changed dramatically over time, impacted by techniques such as lymphatic mapping and sentinel lymph node biopsy (SLNB) and changes in pathological evaluation of the regional lymph nodes.  

Additionally, stratification of distant metastases has evolved as survival outcomes have been shown to vary based upon anatomic site of metastases and serum lactate dehydrogenase levels.  The variables in use in the current (7th edition) AJCC staging system are surrogate markers of biology with validated impact of survival outcomes."

The Decision DX-Melanoma assay is not Food and Drug Administration (FDA) approved for melanoma risk determination.     

The carrier's denial of coverage for CPT code 81599 Unlisted multianalyte assay with algorithmic analysis (Decision DX-melanoma test) 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.   

This is a male patient with a history of Melanoma.

The genetic laboratory test Decision DX-Melanoma is a 31 gene assay for predicting future recurrence of melanoma. It is still in the funding stages and not yet FDA approved.  Lacking FDA approval, this tool cannot be covered as a standard of care treatment for melanoma. 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. 

The patient is diagnosed with malignant melanoma.  The American Joint Committee on Cancer (AJCC) divides melanoma into four stages, which takes into account tumor thickness and anatomical level of involvement (localized cutaneous disease) for stages I and II. Stage III involves local regional lymph nodes and stage IV includes distant metastasis (skin, subcutaneous tissue, nodal, visceral, and skeletal or central nervous system [CNS]) (National Comprehensive Cancer Network, 2017).
 
As stated by Weiss, S., et al. (2015)., "Recently, Castle Biosciences released the DecisionDx Melanoma gene panel which predicts the risk (high (69%) or low (3%)) of distant metastasis at 5 years for stage I-III patients.  This panel may be used in clinical practice, however it is not currently recommended by any standard treatment guidelines, including the National Comprehensive Cancer Network (NCCN).  Definitive assessment of the sensitivity and specificity of this test should be conducted in prospective analyses of patients who are representative of the general primary melanoma patient population.  Moreover, guidance on interpretation of DecisionDx results is of critical importance.  Clinicians may suggest that patients predicted by this test to be at high risk for metastasis undergo more frequent clinical evaluations and surveillance imaging, particularly in patients who have negative sentinel lymph node biopsies.  However, in settings in which adjuvant therapies are either contraindicated or not available, this categorization may increase patient anxiety without real benefit to the patient."

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

Diagnosis: Crohn's Disease

Treatment: Anser ADA test to measure serum adalimumab (ADA) levels and antibodies to adalimumab (ATA)

The insurer denied the Anser ADA test to measure serum adalimumab (ADA) levels and antibodies to adalimumab (ATA). The denial was reversed.       

This is a male patient who has a long history of Crohn's disease. He has developed antibodies for his previous treatment. The current medical treatment is to potentially decrease the current drug dosage by monitoring his antibody levels.

Papamichael, and Cheifetz, et al. conclude that a consensus was achieved towards the utility of therapeutic drug monitoring of biologics in inflammatory bowel disease (IBD).  This is particularly the case with anti-TNF therapies.
This patient is on Adalimumab which is an anti-TNF agent.  Based on the comprehensive literature review reported in the Clinical Gastroenterology and Hepatology article it has been shown that there is a consensus opinion that therapeutic drug monitoring is useful if the patient is on an anti-TNF drug.  

The carrier's denial of coverage for Anser ADA test to measure serum adalimumab (ADA) levels and antibodies to adalimumab (ATA) is reversed.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia
Treatment: Per Oral Endoscopic Myotomy (POEM)
The health plan should cover the POEM.

The requested POEM is likely to be more beneficial than any standard treatment(s) for the patient's condition of disease.

Achalasia is a rare motility disorder of the esophagus characterized by the absence of peristalsis and a defective relaxation of the lower esophageal sphincter (LES) resulting in an impaired bolus transport and stasis of food in the esophagus. [Boeckxstaens, 2005] Because its exact etiology still is unknown, current treatment options of achalasia are directed only at relieving the functional obstruction at the level of the LES. Three manometric subtypes are identified based on the residual esophageal wave pattern: type I, in which the esophageal body shows minimal contractility; type II, in which there is no peristalsis but intermittent periods of compartmentalized esophageal pressurization; and type III, in which there are spastic contractions in the distal esophagus. (1)
...
Similar conclusions relative to efficacy of POEM versus the gold-standard LHM, show similar post-operative GERD, but favor the shorter length of stay and reduced post-operative narcotic requirements of POEM for the patients indication. (7,8)  Most recently, best practice advice from the American Gastroenterological Association concluded: "if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes." (9)
...
As such, POEM is not investigational for the patient's indication. In this patient's case, POEM is medically appropriate (with greater likelihood of benefit than available standard approaches) for treatment of the patient's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia
Treatment: Per Oral Endoscopic Myotomy (POEM)
The health plan should cover the POEM.

The POEM is likely to be more beneficial than any standard treatment(s) for the patient's condition or disease.

Medical literature supports that POEM is safe and effective treatment for achalasia, and has a positive effect on health outcomes. 

Per Inoue, H., et al. (2015), "Per-oral endoscopic myotomy was successfully completed in all cases, even when extended indications (extremes of age, previous interventions, or sigmoid esophagus) were used. Adverse events were rare (3.2%), and there were no mortalities. Significant improvements in Eckardt scores and LES pressures were seen at 2 months, 1 year, and 3 years post-POEM. Based on our large series, POEM is a safe and effective treatment for achalasia; there are relatively few contraindications, and the procedure may be used as either first- or second-line therapy." 

Per Patel, K., et al. (2016), "In conclusion, POEM is a safe and effective treatment for achalasia, showing significant improvements in objective metrics and achalasia-related symptoms. Randomized comparative studies of LHM and POEM are required to determine the most effective treatment modality, with additional investigation of more novel metrics such as EndoFLIP and objective measures of reflux (e.g. impedance studies) pre- and post-treatment." 

Lastly, per Zaninotto, G., et al. (2018), "Recommendations: we conditionally recommend POEM as an effective therapy (control of symptoms) for achalasia both in short- and medium-term follow-up with results comparable to Heller myotomy for symptom improvement." 

As POEM is safe and effective treatment for achalasia, and is less invasive than Heller myotomy, and as it has a positive effect on health outcomes, it is not investigational and is medically appropriate in this patient.
Appeal type: Medical necessity
Decision: Upheld

The patient began chiropractic treatment for low back pain, Visual Analog Scale (VAS) 6-8/10. The initial diagnosis, which was unchanged, was lumbar subluxation and radiculopathy. The initial examination noted spasm, subluxation, reduced ranges of motion, and positive straight leg raise (SLR), Kemp, Goldthwaite, Gaenslen and Yeoman. Treatment, which was unaltered during treatment, included spinal manipulation, ultrasound and mechanical traction. Goals included reducing pain and improving functional capacity. Chiropractic care is under review. 

The health plan's determination is upheld. The chiropractic services in question are not medically necessary. While the treating doctor noted that the patient's pain is itself a reason for medical necessity, the lack of ongoing clinical improvement indicates a lack of medical necessity. If there is no demonstrated clinical improvement, then maximum therapeutic benefit has been reached, and no further treatment is indicated. There was a lack of ongoing objective clinical improvement, and the details on reported exacerbations were lacking any detail. It is also noted that the notes do not indicate what, if any, non-supervised home rehabilitation program was in place to bring the patient greater pain relief and increased functional capacity. As such, the services in question were not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented to the hospital with a fever to 100.5 degrees Fahrenheit at home, abdominal pain, headache, leg pain, vomiting and diarrhea in the setting of active treatment for high-risk B-cell acute lymphoblastic leukemia (she had just completed the consolidation phase of therapy). On arrival to the hospital, she had a heart rate of 134 and temperature of 37.8 degrees Centigrade (C). She had lab results that showed a white blood cell (WBC) count of 0.6 and an absolute neutrophil count of 14. She was admitted for treatment of high-risk neutropenia and Cefepime and vancomycin were started after blood cultures were obtained. She was given intravenous (IV) fluids at a maintenance rate and her labs were closely followed. The health plan's determination of medical necessity is overturned.
This patient presented with fever and profound neutropenia with associated symptoms of abdominal pain and diarrhea. The child had been undergoing treatment for acute lymphoblastic leukemia and required treatment with multiple IV antibiotics. With the documentation of neutropenia with an absolute neutrophil count (ANC) of nearly 0, the fever, and the symptoms which could have been consistent with typhlitis, the patient was not considered safe to be managed in the outpatient or observation setting. The treatment provided to the patient with close inpatient monitoring and IV cefepime and vancomycin was consistent with the current standards of care in the field.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Breast Infection
 
Treatment: Inpatient Hospital Admission

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

This female patient had an infected wound following breast reduction surgery.  She presented to the hospital and was admitted.  She was not septic.  She required wound care, but did not have surgical debridement or any other procedures in the hospital.  The records document that her primary treatments were pain management, antibiotics and wound care.  She could have received all of these treatments at a lower level of care.  Hospitalization in an acute care setting was not required for wound care, antibiotics and pain management.  According to the MCG, 22nd Edition, "General Admission Criteria", admission is indicated for hemodynamic instability, severe pain requiring acute inpatient management, high fever or other high-risk infection situation, inpatient monitoring needed, e.g.: vital signs, neurologic signs, or vascular checks more frequently than every 4 hours, emergency procedures needed, or treatment requiring inpatient care.

This patient did not have any of these conditions.  She had pain from her infection, but was hemodynamically stable and was not septic.  Her pain was controlled with analgesics.  She did not have any significant physiologic complications following the procedure.  She could have been managed at an observation level of care for wound care, pain management and antibiotics.

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted to the hospital with a flare of Crohn's disease. The patient has had multiple previous admissions for similar presentations. The patient has had interrupted insurance coverage and is only on 6-MP having failed Humira in the past. Prior to admission, the patient developed progressive abdominal pain which rose to 10/10. Along with this the patient had anorexia, nausea, and blood tinged diarrhea. On admission, the patient underwent a computed tomography (CT) scan which demonstrated an entero-enteric fistula and evidence of ileitis with segmental colitis involving the transverse colon. On admission, vitals were stable, no fever, and on the labs there is evidence of microcytic anemia and hypokalemia. The patient was started on intravenous steroids along with cipro/Flagyl for initial management. The patient was not interested in surgical management. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had a mild flare of known underlying Crohn's disease. The patient has a stable entero-enteric fistula as well as known ileo-colonic disease. The patient was clinically stable on admission without fever, severe abdominal pain, or intractable vomiting. All of the therapy given to her including steroids, antibiotics and analgesics could have been provided in PO form. The patient did need observation for repletion of potassium and IV hydration. This could have been done at a lower level of care. It was clear the patient did not have a serious infection or complication from Crohn's that would require ongoing inpatient management.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history significant for sickle cell disease, acute chest syndrome, and status/post (s/p) cholecystectomy. The patient presented to the emergency department (ED) complaining of severe low back and right shoulder pain for 3 days that was unrelieved with her home regimen of oxycodone. The pain was consistent with past pain crises. The patient also complained of a productive cough and nausea and denied having any dyspnea, chest pain, or fever. The patient was started on aggressive hydration as well as IV Dilaudid and continued with pain despite IV Dilaudid 3 milligrams (mg) every 4 hours. The hemoglobin dropped to 5.9 and was transfused 1 unit of PBCs (packed blood cells). Given pregnancy, OB/Gyn was consulted and followed along. The patient pain ultimately improved, blood work and vital signs were stable, and was discharged home on 5/2/19 with plan for follow up in the high risk OB clinic. The inpatient stay is under review.

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient continued to have pain beyond what would be considered an observation period of time. Also, the pregnancy put the patient at higher risk given she required large amounts of narcotics to control the pain. This patient met Milliman Care Guidelines as an inpatient for Sickle Cell Disease given her pain was insufficiently responsive to observation care treatment and required treatment in an inpatient setting given she required frequent parenteral narcotics of every 4 hours.