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

Cardiac/Circulatory Problems 
Inpatient Hospital 

Diagnosis: Dyspnea 
Treatment: Inpatient Hospital stay. The insurer denied the inpatient hospital stay. The health plan's determination is upheld. 

This is a male patient who presented to the emergency department (ED) with dyspnea and worsening distention of his abdomen and lower extremity (LE) edema. The patient has history of heart failure, chronic kidney disease, hypertension, drug abuse, obesity and hepatitis C. The patient has a history of cocaine and heroin abuse and he is an everyday smoker. 

The inpatient stay was not medically necessary for this patient. The patient presented with congestive heart failure exacerbation. His left ventricular (LV) systolic dysfunction was diagnosed previously. There were no new diagnostic tests were done. He was treated with IV Lasix and responded well with improvement of his dyspnea and weight loss. His congestive heart failure (CHF) exacerbation was mild. His BNP was elevated, but that probably was chronic with high baseline BNP. He was comfortable upon presentation and did not have evidence of severe respiratory distress. Based on his CHF presentation, a lower level of care was more appropriate than inpatient admission.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Elevated PRA
Treatment: 4K Score testing

The health plan should cover the 4K Score testing performed.

The patient is a male with elevated PSA (prostate specific antigen).  His AP performed 4K testing. 

The 4K Score testing performed is likely to be more beneficial.

The National Comprehensive Cancer Network (NCCN) states that 4K testing can be used to risk stratify patients with elevated PSA and can be used prior to prostate biopsy to help evaluate the probability of prostate cancer prior to undergoing a prostate biopsy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Elevated PRA
Treatment: 4K Score testing

The health plan should not cover the 4K Score testing performed.

The patient is a male without a prior negative prostate biopsy. He had a 4K score assay performed. The PSA (prostate specific antigen) was 5.77.

The 4K Score testing performed is not likely to be more beneficial.  While alternatives such as PCA3 and Select MDx are available, these tests have similar limitations.  

The 4Kscore Test is a blood test that generates a risk score for the probability for finding high-grade prostate cancer (defined as a Gleason score greater than or equal to [>=] seven) if a prostate biopsy were performed. The intended use of the test is to aid in the decision of whether to proceed with a prostate biopsy. 

The test algorithm combines the measurement of four prostate-specific kallikreins (total prostate specific antigen [tPSA], free PSA [fPSA], intact PSA [iPSA], and human kallikrein 2 [hK2]), which are combined in an algorithm with patient age, digital rectal exam (DRE) (nodules or no nodules), and whether the patient has had a prior negative prostate biopsy.

In general, the evidence for genetic tests related to prostate cancer diagnosis addresses preliminary clinical associations between high-grade prostate cancer genetic tests and disease states. There is no direct evidence that this test will improve subsequent outcomes, such as mortality, morbidity, or quality of life.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Elevated PRA
Treatment: 4K Score testing
The insurer denied the 4K Score testing.  The denial is overturned.

The health plan should cover the 4K Score testing performed.

The patient is a male with history of enlarged prostate on Flomax and finasteride with history of elevated PSA (prostate specific antigen)... The patient had an MRI, which did not demonstrate any suspicious lesions. 

Cystoscopy for hematuria workup demonstrated enlarged prostate and bladder stones; MRI revealed a prostate greater than (>) 140gm. The patient underwent 4K testing with result of 4K score 26% likelihood of having Gleason-7 prostate cancer, suspicious value with recommendation to repeat PSA in three months.

This patient has a history of BPH (benign prostatic hyperplasia) with worsening symptoms and gross hematuria. He has had an elevated PSA for multiple years. His most recent PSA was 5.77. Although the PSA is stable, the percent free PSA decreased from 26% to 17%.  His MRI did not demonstrate any suspicious lesions, and his prostate was noted to be > 140gm. The 4k score was obtained to assist with clinical decision making to determine the need to biopsy in this male with a very large prostate. A PSA on finasteride for which the provider notes has not decreased much on finasteride (typically PSA will decrease by 50% on finasteride), and an MRI which did not demonstrate a lesion. The request for 4k score is consistent with the National Comprehensive Cancer Network (NCCN) guidelines on early detection of prostate cancer, which notes "the panel consensus is that the 4k score can be considered for patients prior to biopsy." A systematic review supports the ability of 4k score to detect high grade prostate cancer.

For high-grade PCa (prostate cancer) detection, the pooled sensitivity was 0.93 and 0.87 for PHI (Prostate Health Index) and 4K panel, respectively, whereas the pooled specificity was 0.34 and 0.61 for PHI and 4K panel, respectively. The derived AUC (area under the curve) from the HSROC (hierarchical summary receiver operating characteristic) showed an accuracy of 0.82 and 0.81 for PHI and 4K panel, respectively. Both PHI and the 4K panel provided good diagnostic accuracy in detecting overall and high-grade PCa (1).

The 4K Score testing performed is likely to be more beneficial. The requested service is being used to determine the need for prostate biopsy for detection of clinically significant prostate cancer, i.e., Gleason-7 or higher.  The patient has had a PSA and % free PSA as well as an MRI. Alternatives include either a different biomarker (i.e., PHI) or prostate biopsy, which has a greater risk of adverse effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nuchal translucency 

Treatment: Current Procedural Terminology (CPT) 76817-Ultrasound, a special kind of picture of the baby

The insurer denied coverage for Current Procedural Terminology (CPT) 76817-Ultrasound, a special kind of picture of the baby. The denial is upheld

The patient is a female gravida 2 para 0010. The patient's second ultrasound evaluated for nuchal translucency. Ultrasound showed increased nuchal translucency. The ultrasound was quoted as CPT 76817. The report states "a basic transvaginal anatomy survey was performed and findings are indicated above". The indications listed for the studies performed were screen for aneuploidy and fetal FRP which includes nuchal translucency. Also noted is a plan for f/u transvaginal anatomy scan between specified weeks. Assessment of cervical length is not noted as an indication for the study.

According to clinical guidelines and standard of care, the recommendation is to perform one nuchal translucency scan (CPT 76813) and one fetal anatomic scan (CPT76805) per pregnancy at the appropriate time frame as the only routine ultrasounds in a low risk pregnancy. Additional fetal ultrasounds might be appropriate if there is a documented medical necessity indication. 

According to the American College of Obstetricians and Gynecologists (ACOG), first trimester ultrasound is indicated for the following: to confirm the presence of an intrauterine pregnancy; to evaluate a suspected ectopic pregnancy; to evaluate vaginal bleeding; to evaluate pelvic pain; to estimate gestational age; to diagnose or evaluate multiple gestations; to confirm cardiac activity.

Based on ACOG's recommendation, this patient's ultrasound performed was medically necessary to estimate gestational age.  The ultrasound done on another date was also medically necessary to evaluate for nuchal translucency but should have been billed as 76813.

CPT Code 76817 may be billed alone or with other ultrasound services at the same session. CPT code 76817 is "Ultrasound, pregnant uterus, real time with image documentation, transvaginal;" If a transvaginal ultrasound for cervical screening is performed on the same date of service as a transabdominal ultrasound performed for other clinical indications, both ultrasound procedures would be billed. The Current Procedural Terminology (CPT) 76817-Ultrasound, a special kind of picture of the baby is not considered medically necessary for this patient.

Note that there was no medical indication for a cervical screening for this patient. As such, CPT code 76817 was not medically necessary. The health care plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for Current Procedural Terminology (CPT) 76817-Ultrasound, a special kind of picture of the baby is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Cardiac: other
Inpatient hospital

The patient is a man with a history of human immunodeficiency virus (HIV) infection and paroxysmal atrial fibrillation. He presented to the emergency department complaining of palpitations. He reported recent alcohol consumption. His blood pressure was 122/75 mmHg with a heart rate of 84 beats/minute. His oxygen saturation was 96% on room air. His physical exam was notable for a rapid. irregular heart rate and was otherwise unremarkable. He was admitted to the hospital. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient could have been cared for at a lower level of care.
This patient presented with atrial fibrillation (AF). He was hemodynamically stable, there was no evidence of ischemia, he was not in heart failure, had no evidence of structural heart disease and was not at high risk for thromboembolism. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization. Likewise, Conti et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations." Vinson et al, based on a smaller study and a review of the literature, agreed with this approach and stated, "The short-term home observation management approach for atrial fibrillation/flutter patients who present early in their symptomatic course has been mentioned in the literature (sometimes called the "wait and watch" method), but it has not been well described. In our sample, 11 of 16 patients (69%) managed with this approach spontaneously cardioverted to normal sinus rhythm within 48 h of symptom onset. Our findings are consistent with previous studies, which have reported that up to two-thirds of selected patients with presumed recent-onset atrial fibrillation spontaneously convert to normal sinus rhythm within 2-3 days."
In addition, per the MCG, this patient did not meet criteria for an inpatient level of care. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous system /Other  
Treatment: Physical therapy 
The insurer denied  Physical Therapy Outpatient Services- 16 visits.
The denial is upheld .

The patient  who suffered a stroke with residual left spastic hemiparesis and noted diagnosis of left shoulder impingement. The patient  was initially evaluated for outpatient physical therapy . The patient  has been actively participating in therapy. The patient's BERG score was 52 and was no longer a fall risk. the patient's  timed up and go test had improved from 50.06 on left  to 22.54 seconds and now without an assistive device and without an ankle-foot orthosis (AFO).The patient  was also able to negotiate "2 FOS with U HR using a reciprocal pattern for ascending and step to pattern for descending with DS."
The patient  was also able to ambulate greater than 300 feet on even surfaces without an assistive device and without an AFO. Therefore, while the patient still had goals related to the  diagnosis of stroke, the patient  was now functional, excelling and could continue with a home therapy regimen. 
There was no upper extremity strength/range of motion testing nor goals associated with the left upper extremity. This reviewer was able to find documentation of the patient reporting 5/10 left shoulder and left deltoid/triceps pain and not mentioned again in the documentation provided. Therefore, as there was no documentation clearly noting the actual functional impairments that the patient had from this diagnosis (and with no examination findings for the left upper extremity) additional outpatient physical therapy is not medically necessary or supported. Standard of care would be to discharge the patient at her currently functional level for continued improvement with a home based program.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bright red blood per rectum
Treatment: Inpatient admission
The insurer denied the Inpatient admission.
The denial is upheld.

The patient is an adult male. The patient had presented to the emergency department of the facility filing the appeal with the report of bright red blood per rectum (BRBPR). The patient also had abdominal pain, diarrhea, weakness as well as tingling of the extremities. The patient had a history of CVAs (cerebrovascular accidents), TIAs (transient ischemic attacks), anxiety, chronic low back pain, headache, COPD (chronic obstructive pulmonary disease) and hyperlipidemia. The patient was using Fioricet, Pepcid, Aspirin, Alprazolam, Lipitor, Plavix, Tramadol, Vitamin D2, and vitamins. The patient also was receiving Ventolin and Symbicort inhalers. The patient was an active smoker. 

The patient's presenting vital signs showed hypertension. The white count was 12.75. The patient noted his baseline weakness on the left side from his CVA had worsened. The rectal examination showed melanotic stool, which was guaiac positive. 

The patient was admitted due to bleeding while on anticoagulation. A neurological evaluation showed no acute changes.  Once deemed stable, the patient was discharged with outpatient follow-up. The patient did not receive blood products. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had evidenced rectal bleeding; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. The patient did not undergo any endoscopy nor did the patient receive any transfusions. As such, the patient's care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rotated teeth; Crossbite
Treatment: Braces; Monthly visits
The insurer denied Braces; Monthly visits.
The denial is overturned.

The patient is a male child. The patient has teeth #s 9 and 10 rotated approximately 90 degrees. They are hitting the lower teeth cockeyed. Also, when the patient bites down, tooth #10 is behind the tooth below it. Being behind the tooth is called a "crossbite." When teeth are in crossbite, they are more susceptible to chipping and fracturing. In order to prevent breaking these rotated teeth and/or the teeth below them, orthodontic treatment is medically necessary to correct this severe problem. The monthly visits are also medically necessary to monitor the treatment progress.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-ischemic systolic heart failure with a reduced left ventricular ejection fraction (LVEF), history of polysubstance abuse
Treatment: K0606 - Wearable automatic external defibrillator
The insurer denied the K0606 - Wearable automatic external defibrillator. 
The denial is overturned. 

The patient is a female. She presented to the hospital after being found unresponsive at home.  

The patient's work up revealed polysubstance abuse and non-ischemic systolic heart failure with a reduced left ventricular ejection fraction (LVEF) of 15%.  Cardiac catheterization revealed normal coronary arteries without obstruction and a severely reduced cardiac index of 1.9.  ECG (electrocardiogram) revealed sinus rhythm with mild QT interval prolongation 478msec, diffuse T wave changes were noted, and troponin levels were elevated. The patient was treated in the ICU, and ultimately, she was discharged with an external LifeVest defibrillator. 

External LifeVest defibrillator for a patient presenting with newly diagnosed systolic congestive heart failure with severely reduced LVEF (15%) and a prolonged QT interval is considered medically necessary.  Such therapy is both safe and efficacious. 

The SCD HFT trial clearly demonstrated that such patients have a significant risk of sudden cardiac death and benefit from ICD (implantable cardioverter defibrillator) therapy (Reference 1).  Prior to implanting an ICD, patients must be treated with guideline directed medical therapy for at least three months in an attempt to allow for ventricular remodeling and improve LVEF.  If medical therapy is effective, then patients often do not require device implantation (Reference 2).  During this period of treatment, patients are at risk for sudden cardiac death and must be protected.  External LifeVest defibrillator therapy provides such protection. 

Guideline statements from the Heart Rhythm Society/American Heart Association and the American College of Cardiology specify that external LifeVest defibrillator therapy should be utilized during periods when patients are at risk of sudden cardiac death and require further cardiac workup/treatment (References 3-5).  A real-world study of patients treated with external LifeVest defibrillators, almost 5% of subjects received lifesaving therapy (Reference 6). 

In conclusion, wearable LifeVest defibrillator therapy is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Eating Disorders
Mental Health: Residential

Diagnosis: anorexia nervosa
Treatment: Residential Mental Health Services 
The insurer denied the Residential Mental Health Services. The health plan's determination is overturned. 

The case involves an adult female with history of an eating disorder best characterized as severe anorexia nervosa, restricting type and comorbidity with generalized anxiety disorder, major depressive disorder and elements of persisting parent-child relational problems. The patient presented with a relapse and worsening symptoms of her anorexia nervosa together with symptoms of anxiety and depression in the context of the eating disorder that included body image disturbance with disordered eating and restricted caloric intake and compulsive exercising.

The requested services are clinically appropriate, medically necessary, and consistent with prevailing standards of professional practice and consistent with the scientific literature, referenced below.
Specifically, the patient's complicated clinical issues did require a treatment setting to facilitate the development of improved coping skills and life skills together with the development of improved insight and motivation, as well as family intensive work and evidence based therapy combined with medication management. She did need the admission and continued structure and monitoring of a residential setting in order to safely continue mental health treatment and services. There are psychiatric complications related to the family functioning, and severe psychiatric symptoms and disordered eating that required residential level services, structure and monitoring. The case is complicated by high risk eating disorder behaviors and affective instability. Thus, the requested Residential Mental Health Services are clinically appropriate, medically necessary, and consistent with prevailing standards of professional practice and consistent with the scientific literature.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal
Inpatient stay

Diagnosis: Abdominal pain/Colitis
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with a medical history of depression. She presented to the emergency department with one day of cramping mid-abdominal pain, chills, and watery diarrhea with hematochezia. Labs showed hemoglobin of 12.3 g/dL and hematocrit of 36.0%. Computed tomography scan of the abdomen and pelvis showed inflammatory changes around the descending colon suggesting underlying nonspecific colitis, and incompetent left gonadal vein with pelvic varicosities. She was treated with intravenous fluids, Maalox, famotidine, ciprofloxacin, metronidazole, and Toradol. 

The inpatient level of care is not medically necessary for this patient. The admission is not medically necessary at the acute inpatient level of care. The patient had symptoms including abdominal pain and hematochezia, as well as imaging findings, consistent with colitis. The standard of care for the treatment of colitis and the evaluation of diarrhea was appropriately performed, including intravenous fluids, empiric antibiotics, and supportive care, and her symptoms improved and diet was advanced. There was no suspected or established complication such as gastrointestinal perforation, pancreatitis, intra-abdominal abscess, toxic megacolon, bowel obstruction, peritonitis, sepsis, or other complications warranting inpatient level of care. The standard of care which was undertaken, including observation, monitoring, labs, antibiotic administration, and intravenous fluid administration, could have been performed at a lower level of care.