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

Diagnosis:  Left lower extremity (LLE) cellulitis

Treatment:  inpatient hospital admission

The insurer denied coverage inpatient hospital admission.  The denial was upheld.

This patient is a female with past medical history significant for hypertension, diabetes mellitus, asthma, and cellulitis, who presented to the Emergency Department with complaints of left lower extremity pain, swelling, and erythema.  The vital signs on presentation included:  Temperature 98.5 F., Blood Pressure 121/84, Pulse 65, Respiratory Rate 20, and oxygen saturation 99%.  The laboratory values were notable for the following:  White blood cell (WBC) count 10.5 K, hemoglobin (Hgb) 12.5, hematocrit (Hct) 38.6, creatinine 0.7, and glucose 89.

Hospital course:  The patient was admitted for evaluation of left lower leg swelling and pain. She was empirically started on intravenous antibiotics (Clindamycin in the Emergency Department followed by Vancomycin).  The blood cultures were negative.  The left tibia/ankle x-ray showed bi-malleolar soft tissue changes and edema.  The lower extremity ultrasound was negative for deep vein thrombosis (DVT).  The patient remained afebrile, hemodynamically and clinically stable.  She was discharged to continue oral antibiotics (Clindamycin) as an outpatient.  

The patient presented with swelling and erythema of her left lower leg.  According to medical records, the patient was afebrile and hemodynamically stable.  The laboratory results showed a borderline white blood cell count (WBC), otherwise it was unremarkable.  There was no evidence of a systemic infection, and no surgical intervention was required.  Although the patient was treated with outpatient antibiotics (Keflex) prior to admission, "failure" of outpatient intervention by itself does not fulfill criteria for acute inpatient admission in an otherwise stable patient, as described above, capable of tolerating oral intake.  Based on the above findings, the patient met criteria for observation level of care.  The MCG Care Guidelines 23rd Edition Cellulitis ORG: M-70 (ISC) criteria for acute inpatient admission were not met. 

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

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

Diagnosis: Chronic Pain
Treatment: Lyrica 75 mg

Summary:
The patient is a female with chronic pain due to a tethered cord/spina bifida who has been prescribed Lyrica 75 mg.  This is a continuation of therapy, as the patient has been on this medication for a number of years, according to the letter of Medical Necessity.  However, the basis to the denial is that the patient has not failed a generic formulation for 30 days.  Lyrica is now available in a generic formulation, pregabalin.  There is no documented advantage of brand name versus generic. Therefore, it is not unreasonable to consider the generic formulation of this medication.  Given the above, the requested Lyrica is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pancreatic cyst 

Treatment:  Genetic testing

The insurer denied coverage for genetic testing PancraGen PathFinder TG, code 81479). The denial is reversed. 

This patient is a female who has a prior history of a pancreatic cystic lesion.  The patient underwent an endoscopic fine needle aspiration with ultrasound guidance for collection of pancreatic cyst fluid and decompression of the 1.8cm cyst.  The specimen was sent to a lab for a Pancreatic Uncinate Cyst Fluid that included: AccuCEA and Amylase with reflex testing to PancraGen (CEA) and GNAS add-on.  The results were reported with an AccuCEA of 4.2 ng/mL and Amylase of 28,404 u/L.  The test automatically reflexed to PancraGen molecular testing because the carcinoembryonic antigen (CEA) value met or exceeded the client specific limit of 0.0/ng./ml. the GNAS point mutation test results were revealed with no mutation detected (no detection of the GNAS oncogene).  The PancraGen test results were benign.  The diagnosis of the pancreatic cyst was consistent with a likely pseudocyst.  It was recommended that the patient continue with repeat imaging in approximately one year.  The testing in question was completed.  The results of the test indicated the biological behavior of the patient's lesion fell in the category of benign.

Kowalski, et al., looked into the utility of using DNA molecular pathology in managing the surveillance of pancreatic cysts. The conclusion was that adjunct use of this technology can provide evidence for relaxed surveillance of patients with benign cysts. This analysis can give confidence that further observation of the cyst is safe, allowing  longer surveillance intervals.  Arner et al. presented the results of EUS-FNA (Endoscopic ultrasound with fine-needle aspiration) of pancreatic cysts both with and without DNA molecular analysis to 2 different surgeons to determine whether molecular testing altered their decision regarding management.  Even when all other variables including CEA values were taken into account, the molecular data altered the decision regarding the need for surgery. 

The American College of Gastroenterology [ACG] notes that pancreatic cysts are being increasingly found due to increased imaging and since they have the potential to become malignant, there is cause for concern. With regard to the use of molecular markers, they state "Molecular markers can help identify IPMNs (intraductal papillary mucinous neoplasms) or MCNs (mucinous cystic neoplasms).  Their use may be considered in cases in which the diagnosis is unclear and the results are likely to change management."

Genetic testing (PancraGen Pathfinder TG, code 81479) performed was considered medically necessary for this patient.

Based on the above, the medical necessity for the genetic testing (PancraGen PathFinder TG, code 81479) performed is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention deficit hyperactivity disorder
Treatment: Vyvanse 40mg, two capsules per day

The Vyvanse 40mg, two capsules per day, is medically necessary.  

The patient has been compliant with treatment and has been tried on Adderall and Vyvanse at 70 milligrams (mg) by mouth (PO) daily.  This was ineffective for her symptoms.  She was taking Vyvanse 80mg PO daily with a very good response and tolerability.  The patient has a psychiatric condition that was not responsive to other treatments.  She has been effectively treated with Vyvanse 80mg PO daily.  She is treated by a board-certified psychiatrist who explicitly notes that treatment is medically necessary. Therefore treatment should be covered by the health plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia 

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay. The denial was reversed.

This patient is a female with a past medical history significant for hypertension who presented to the emergency department with complaints of fever, malaise, and poor appetite.

Vitals on presentation included: Temperature max 100.4 F, blood pressure 121/82, pulse 103, respiratory rate 20, oxygen saturation 97% on room air. Laboratory values were notable for the following: WBC-6.0, Hgb-9.7, Hct-30.1, creatinine-4.38, glucose-91, and urinalysis >300 proteinuria; EKG showed first degree atrioventricular block.

The patient was started in intravenous fluids and antibiotics (ceftriaxone and azithromycin) for possible pneumonia. Chest x-ray showed patchy and linear lingular opacity. Renal ultrasound showed increased cortical echogenicity consistent with intrinsic medical renal disease. Chest CT scan showed bilateral lower lobe and left upper lobe scarring and atelectasis, as well as a 9 mm thyroid nodule. Infectious Diseases consulted. The patient was stabilized and discharged to continue outpatient management.  

According to medical records, patient presented with fever (100.4 F), tachycardia (103 bpm), and multiple abnormalities including renal failure (creatinine 4.38), anemia (hgb-9.7) and proteinuria (>300). Chest x-ray and EKG findings also showed abnormalities. The patient was described as "ill appearing." Based on the complexity of these findings and unclear source of these presenting symptoms, hospital admission was medically necessary for intravenous fluid (IVF), empiric antibiotics and additional diagnostic testing.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the inpatient hospital stay is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient hospital admission

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

This patient is a male with a past medical history notable for CVA, pre-diabetes, dyslipidemia, benign prostrate hypertrophy BPH, and post-traumatic left shoulder surgery. He presented to the ER with passing out associated with chest pain, shortness of breath, and diaphoresis. The vital signs and physical examination were stable. The serial Troponins were all negative. The electrocardiogram (EKG) showed no acute findings. Per the(ED) physician provider notes, the patient also complained of weakness in his left leg since the night before and swelling of his knee. Initially recorded vital signs were blood pressure 113/77, respiratory rate 20, temperature 97.6 F., pulse rate 69, and oxygen saturation on pulse oximetry 98%. He was admitted to the telemetry unit for syncope where he had diagnostic imaging that did not show significant abnormalities. The possibility for an acute coronary syndrome (ACS) was ruled out Patient was discharged after a brief overnight stay for outpatient cardiology follow-up. 

The patient presented with chest pain and syncope. The initial evaluation in the ER was unremarkable, including a non-diagnostic electrocardiogram (EKG). The inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Further evaluation was warranted, however inpatient admission criteria InterQual Guidelines for Acute Coronary Syndrome or Milliman Care Guidelines (MCG Neurology GRG) criteria was not met. There was no evidence of other medical conditions warranting inpatient level of admission.

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

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: Upheld

Diagnosis:Alcohol and Drug Abuse
Treatment: Inpatient admission 

The Inpatient admission was not medically necessary.

Summary:
This patient with a history of opioid abuse presented for detox after using heroin.  Urine toxicology showed polysubstance abuse.  Initial evaluation showed the patient to have signs of overdose, which resolved after IV Narcan.  At the time of admission, the patient was awake and alert. His physical exam did not identify signs of early opioid withdrawal:  Agitation; Anxiety; Muscle aches; Increased tearing; Insomnia; Runny nose; Sweating; and Yawning.  His labs and EKG were unremarkable.  There were no significant clinical findings during hospital stay.  The patient was awaiting rehab placement.

The patient's symptoms were very uncomfortable, but they were not life threatening.  Withdrawal can be managed at home or detox treatment facilities.  Inpatient hospital stay is indicated for severe symptoms.  This patient did not have severe symptoms of opioid withdrawal.  Therefore, the requested Inpatient admission was not consistent with generally accepted national standard of medical practice.
Appeal type: Medical necessity
Decision: Overturned in Part

Abdominal/Stomach Pain
Inpatient Hospital

The patient is a male with history of thoracic aortic aneurysm status/post (s/p) repair, metallic aortic valve placement on home anticoagulation, and current marijuana abuse who presented to the emergency department (ED) with episodes of bright red blood per rectum associated with abdominal pain. Hemodynamics were stable. The international normalized ratio (INR) was 2.1 while on coumadin. He was admitted to inpatient level of care for ongoing work up and management of his presenting complaint with hemodynamically stable lower gastrointestinal (GI) bleed. 

The health plan's determination is overturned in part. The inpatient health services are medically necessary with the patient's baseline comorbidities including psychiatric illness, aortic valve replacement and need for anticoagulation and presenting complaint of lower GI bleed with broad differential diagnosis. Initially infectious colitis was suspected based on the CT abdomen requiring IV antibiotics and then ischemic colitis was seen based on the colonoscopy. This required careful serial abdominal exams, reinitiating of diet and anticoagulation with Lovenox bridging with monitoring for further bleeding and serial complete blood count (CBC).
However, the patient could have been discharged on the 4th day after all the necessary procedures, and consults were done. The patient was stable hemodynamically with no further bleeding in the prior three days.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This patient presented with atypical chest pain. She had no significant past medical history. Her pretest probability of coronary artery disease is low (Reference 1).  Utilizing the HEART (History, EKG, Age, Risk factors, initial Troponin) score, she was considered low risk (3 points- age/family history/nonspecific ECG findings) (Reference 2).  Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  

In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal bleeding
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

This patient presented with anemia (hemoglobin 8.6) and vaginal bleeding. The suspicion was that of a bleeding vaginal laceration. 

Ideally, the first step in managing this patient is to stabilize her condition by finding the source of the bleeding and stopping it. An examination under anesthesia does not require admission. In addition, this patient does not fulfill the transfusion guidelines for use of blood components: her hemoglobin was more than 8g/dl and she was asymptomatic. 

Note that in this day and age, transfusions are done routinely in outpatient settings (oncology clinics, infusion centers even at home). So the need for transfusion is not a reason for admission.

Ideally, this patient could have been examined under anesthesia on presentation and once the provider ascertained that there was no life-threatening hemorrhage, she could have been sent home to be followed up as an outpatient.

According to the standard of care, indications for inpatient care for patients with bleeding are: active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. This patient did not have any of these. 

Based on all of the above, the admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung cancer
Treatment: Proton Beam Thearpy

Summary:
In this case, the patient is a male with a diagnosis of stage IV lung cancer with extensive metastasis involving bone, adrenal gland, liver and brain. He was found to have leptomeningeal spread.  Craniospinal radiation therapy was recommended, and proton beam radiation therapy was requested.  However, based upon and in conclusion of the review above, the proposed treatment is not considered to be medically necessary for this individual under these unique circumstances.

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.
	
Although proton beam radiation therapy has been shown to be safe and effective for the treatment of intracranial lesions, there is insufficient clinical data in the medical literature to show that proton is equivalent or superior to other treatment options such as photon IMRT (intensity modulated radiation therapy) for leptomeningeal metastasis or for craniospinal radiation.  There are ongoing trials evaluating the role of proton therapy for adult primary brain tumors and or craniospinal radiation.  

In this case, a proton/photon comparison plan was done.  It is unknown if IMRT technique (which would be the preferable technique) was utilized for the photon plan.  The proton plan was able to reduce dose to the esophagus, heart, kidneys, lens and liver.  However, the doses to those organs were all with tolerance for both plans per RTOG guideline and Quantec limits.  Proton beam radiation therapy, therefore, is not considered medically necessary due to insufficient peer-reviewed data in well-conducted randomized trial supporting its use over photon IMRT.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizures
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

Febrile seizures are not an uncommon event, occurring in 2-5% of children ages six months to five years. The peak occurrence is between 18 months and three years, with markedly decreased incidence in children after four years of age, and rarely occurring after seven years of age. Febrile seizures are more common in Asian and Indian populations. Males have a higher incidence than females, and there are two seasonal peaks (November-January, June-August) associated with prevalence of common viral illnesses (respiratory and gastrointestinal, respectively). Most febrile seizures are simple, meaning that they are generalized, lasting less than 15 minutes, occurring only once in a 24 hour period, with no significant postictal period. Complex febrile seizures exhibit one or more of these features. There is a family tendency, with some genetic associations. Progression to a diagnosis of epilepsy is more likely to occur in association with neurodevelopmental abnormalities, complex febrile seizures, family history of epilepsy, and longer duration of fever. 

Initial evaluation of a patient with febrile seizure includes history, examination, and diagnostic testing to identify the source of fever. Lumbar puncture may be indicated in specific populations of patients. Electroencephalogram is of limited value, more likely to be necessary and abnormal in older children, those with complex febrile seizures, those with neurodevelopmental abnormalities, and family history of febrile seizure. Per the American Academy of Pediatrics, EEG should not be considered part of the routine evaluation of healthy children with simple febrile seizure. Neuroimaging is also not indicated in the routine evaluation of first simple febrile seizure. Treatment with anticonvulsants is not generally recommended unless there is higher risk of epilepsy or abnormal neurological development. Conversely, rescue therapy may be indicated. 

This young female child with history of febrile seizures and no prescribed rescue therapy presented to the ED with high fever and two brief self-resolved febrile seizures. She tested positive for influenza A. After discussion with her pediatrician, the decision was made to observe her in the hospital overnight. This was not unreasonable, given that she had had two febrile seizures in the context of influenza A infection. However, she was overall hemodynamically stable, with no evidence of encephalitis or sepsis or significant dehydration. She did not require acute inpatient admission, and she could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis :Prostate cancer
Treatment: OncotypeDx Prostate cancer assay

The OncotypeDx Prostate cancer assay was not medically necessary.

Summary:
The patient is a male with prostate cancer. He had the Oncotype DX Prostate Cancer Assay performed.

The patient has a low-risk prostate cancer. Per AUA Guidelines, 14. "Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)."
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.

NCCN Guidelines state, "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclearany of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."