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

Diagnosis: Cough, wheezing and fever
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.

This young child was admitted following multiple bronchodilator treatments, enteral systemic corticosteroids, magnesium, and intravenous (IV) fluids in the ED. Despite this management, he continued to manifest wheezing. While it was reasonable to continue to provide care in the hospital setting, he was overall stable with no oxygen requirement or evidence of severe respiratory distress. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency room with complaints of chest pain, intermittent for a week prior to admission, and was admitted and ruled out for myocardial infarction with negative troponin. The patient was started on losartan and amlodipine for blood pressure. Echocardiogram (ECHO) showed an ejection fraction (EF) of 70% with no wall motion abnormalities. Stress nuclear study done was negative for ischemia. The health plan's determination is upheld.

The patient presented with chest pain, but was hemodynamically stable, with no acute ischemic changes on electrocardiogram (EKG) or elevated troponin. The patient was hypertensive on admission, but with control of BP (lowered to 159/77). The patient did not have objective evidence for acute coronary syndrome, or other findings of hypertensive emergency, such as heart failure, encephalopathy, acute renal injury, retinal hemorrhage or aortic dissection, which would indicate need for inpatient treatment. The patient did not have hypertensive urgency - no evidence for target organ damage, and had rapid control of blood pressure, within less than (<) 24 hours of presentation. Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis/abscess of the toe

Treatment: Inpatient admission, diagnostic evaluation, and medication management.

The insurer denied inpatient admission. That denial was upheld.

The toddler presented to the Emergency Department (ED) with a history of having banged her left foot into a door two nights prior and the foot continuing to swell since then.  She had low grade (38.2C) in the ED, with all other the vital signs stable.  The chief complaint was left 5th toe swelling and redness. White blood count (WBC) was 10.86 (WNL) CRP was 1.08 (slightly elevated) and ESR was 18 (WNL).  X-ray of the left foot was negative for fracture.  Information in the  ED provider "medical screening note" states child with left fifth toe or swelling, streaking extending to the dorsum of the foot from the fifth toe, the patient not walking, and positive questionable pus around the fifth toe.  On reviewing both physical exams by ED and Pediatrics attending it is evident there was erythema and swelling at the left 5th toe with possible pus around the nail bed, but only mild erythema extending to the dorsum of the foot (approximately 3 to 4 cm in size).  The admitting pediatric nurse noted contusion to the left fifth toe and toe nail.  Pediatric Attending noted left fifth digit bruising on the nail bed, no pain to palpation, erythema and swelling extending up dorsum foot to malleoli without streaking, no induration or fluctuance.   The ED Provider's admitting reason was cellulitis requiring intravenous (IV) antibiotics.

The signs of infection worsened on day two of admission with fever, likely fluctuance consistent with abscess (paronychia) and that podiatry removed the nail, and culture ultimately yielded MRSA.  However, at presentation the paronychia was not severe, the cellulitis component was minimal, and there was no lymphangitis or fasciitis.  There was no evidence that the infection was spreading.  Some dorsum of foot erythema is expected with a paronychia.
  
Cellulitis and abscess of the toe can certainly be treated as an outpatient if there is no evidence of spreading, compartment syndrome, or lymphangitis.  Even acute osteomyelitis in children can be treated as an outpatient if it involves a small bone.  Intravenous (IV) administration of orally bioavailable antibiotics such as clindamycin is not superior therapy for cellulitis and paronychia.  Close follow-up is key.  There is no admitting ED documentation that surgical nail removal or paronychia drainage was being considered.  This toddler could have been brought back for a short-stay or even same-day surgical admission, when it was decided surgical intervention was indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #3:

The patient had a biopsy on the right lower leg with the diagnosis of malignant melanoma.  The request is for the Decision DX-Melanoma gene expression profile test.

The results of the Decision-DX Melanoma test revealed the patient has as class 1A, which has/is associated with the lowest risk of melanoma recurrence in 5 years, which suggests a very low risk of metastatic potential, which usually is already ascertained on the original biopsy.  Based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this patient.

Based on a lack of scientific evidence showing that the results would accurately guide patient care and health outcomes, the use of this testing was not supported by scientifically based guidelines of national medical research or governmental agencies.  Furthermore, based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this patient.  The Decision DX Melanoma assay was not known to be effective at the time it was performed, based on a lack of scientific evidence showing that the results will accurately guide patient care and health outcomes.  More recent studies are showing promise for the usefulness of prognostic values from this testing, but there are no long-term follow up studies available.  In this case the testing would not have been considered effective or useful in treatment planning.  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.  Therefore, this study/test is not sensitive or specific enough to define its clinical role.
Appeal type: Experimental/Investigational
Decision: Upheld

Reviewer #2:

The patient has cutaneous melanoma.  There is no clinical information provided.  The patient underwent Castle Biosciences' Decision DX test, which showed that he had a class 1A tumor, which is associated with a low risk of metastasis.  

In this case there is no clinical information provided and no information regarding the patient's primary cutaneous melanoma.  Current guidelines to do not recommend the use of Decision DX in any stage of melanoma.  Decision Dx is a gene expression profile test that is used to stratify risk of metastasis in patients with melanoma.  Gene expression profiling like the requested Decision DX has not yet been accepted as standard of care in treating patients with cutaneous melanoma.  The American Joint Committee on Cancer (AJCC) and National Comprehensive Cancer Network (NCCN) guidelines for clinical decision making and follow up for patients with cutaneous melanoma do not currently incorporate gene expression profiling.  In fact, at the NCCN Guidelines for Melanoma V.1.2018 Panel Meeting on 06/28/2017 22/22 dermatologists voted not to include Decision Dx in the NCCN guidelines.

Given that these assays are not recommended in clinical guidelines and the data pertaining to this assay's use is not yet accepted, the information gleaned from the assay itself would not materially or appropriately affect the treatment or follow up approach of most practicing dermatologists.  Therefore, the Decision DX Melanoma test date of service 09/14/2018 is not considered likely to be more beneficial for this patient that any other standard testing.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Melanoma

Treatment: Skin biopsy and DX Melanoma test

The insurer denied coverage for Decision DX Melanoma test. That denial was upheld, as three out of three reviewers determined this test is not likely to be more beneficial than any other standard testing.  

Reviewer #1:

The patient underwent Decision DX Melanoma testing on skin biopsy from the right lower leg.  The the Decision DX class was 1, and the sub-class was 1A.

This 31 gene assay for predicting future recurrence of melanoma is still in funding stages.  To date, results remain inconclusive regarding the efficacy of this tool for improving health outcomes on a large scale.  The patient is diagnosed with malignant melanoma.  Melanoma is a deadly cancer, 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 CNS) (National Comprehensive Cancer Network, 2017).      

Although Decision-DX Melanoma assay is promising, given the lack of evidence and based on NCCN guidelines, which do not support use of this test, this test has not been shown to improve health outcomes in melanoma and is not considered a standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis

Treatment Requested: Cosentyx

The insurer has denied coverage of cosentyx as there are preferred drug options available to the patient. The determination was upheld.

The patient has a history of pustular psoriasis of the palms of the hands and the soles of the feet.  Treatment the patient has tried and failed include Otezla, XTRAC laser 4 year, halobetasol, mometasone, triamcinolone, Humira, UV therapy, and moisturizers.  

"Commonly used systemic agents include methotrexate, cyclosporine, acitretin (Soriatane, Connetics Corporation), and apremilast (Otezla, Celgene).3234 Biologic therapies are the next step if systemic agents fail to produce an adequate response.33 Established biologic treatments for adults with moderate-to-severe plaque psoriasis include adalimumab (Humira, AbbVie); etanercept (Enbrel, Amgen); infliximab (Remicade, Janssen); secukinumab (Cosentyx, Novartis); and ustekinumab (Stelara, Janssen) (Table 1).34 Adalimumab and etanercept are the top U.S. therapies for advanced plaque psoriasis, followed by ustekinumab.34" (Fellner C., 2016).

In order to be approved for Cosentyx, the insurer indicated a patient must try, fail, have a contraindication to, documented adverse effect to or provide any clinical reason why the preferred medications (methotrexate or cyclosporine) cannot be used.  

There are effective, safe alternatives that have not been trialed.  There are insufficient head to head trials showing superiority of Cosentyx to the preferred medication.  Therefore, the request for Cosentyx Sensoready 300 Dose 150mg/ml sc soaj is not considered medically necessary.

The carrier's denial of coverage for Cosentyx Sensoready 300 Dose 150mg/ml sc soaj is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment Requested: Cosentyx

The insurer has denied coverage of cosentyx as there are preferred drug options available to the patient. The determination was upheld.

The patient has a history of pustular psoriasis of the palms of the hands and the soles of the feet.  Treatment the patient has tried and failed include Otezla, XTRAC laser 4 year, halobetasol, mometasone, triamcinolone, Humira, UV therapy, and moisturizers.  

"Commonly used systemic agents include methotrexate, cyclosporine, acitretin (Soriatane, Connetics Corporation), and apremilast (Otezla, Celgene).3234 Biologic therapies are the next step if systemic agents fail to produce an adequate response.33 Established biologic treatments for adults with moderate-to-severe plaque psoriasis include adalimumab (Humira, AbbVie); etanercept (Enbrel, Amgen); infliximab (Remicade, Janssen); secukinumab (Cosentyx, Novartis); and ustekinumab (Stelara, Janssen) (Table 1).34 Adalimumab and etanercept are the top U.S. therapies for advanced plaque psoriasis, followed by ustekinumab.34" (Fellner C., 2016).

In order to be approved for Cosentyx, the insurer indicated a patient must try, fail, have a contraindication to, documented adverse effect to or provide any clinical reason why the preferred medications (methotrexate or cyclosporine) cannot be used.  

There are effective, safe alternatives that have not been trialed.  There are insufficient head to head trials showing superiority of Cosentyx to the preferred medication.  Therefore, the request for Cosentyx Sensoready 300 Dose 150mg/ml sc soaj is not considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Substance Detoxification 
 
Treatment: Inpatient Admission

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

This is a female patient admitted to inpatient substance detoxification treatment in early 2019 for detoxification from heroin and alcohol.  She reportedly had a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 16 and Clinical Opiate Withdrawal Scale (COWS) of 17 and had withdrawal symptoms including tremors, sweats, nausea, vomiting, joint pain, yawning, sleeping problems, diarrhea, irritable mood, and anxiety.  She had past inpatient substance detoxification and rehabilitation treatments.  She reportedly had a past psychiatric hospitalization for bipolar disorder.  She was started on Methadone and Librium for detoxification.  She completed detoxification several days after her admission and was then converted to rehabilitation status.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  It also states that patients with significant alcohol use including large quantities and long durations of use are at higher risk for delirium tremens which is considered a life threatening condition.  It is reported that delirium tremens can occur within 3-4 days after stopping alcohol use.  This patient was having withdrawal symptoms on admission and continued to have reports of withdrawal symptoms throughout the first several days of admission and continued with two detoxification medications and had the detoxification treatment reportedly completed.  She took detoxification medication to modify withdrawal including Librium and Methadone and detoxification was reportedly completed within the fifth day of her admission.  She was at risk for complicated and life threatening withdrawal symptoms 3-4 days after admission and considered a risk and in need of at least 96 hours or 4 days of treatment in this inpatient hospital as a result.  

The carrier's denial of certain days of coverage for the inpatient hospital services is modified.
Appeal type: Medical necessity
Decision: Overturned

The patient presented for inpatient detoxification treatment in order to address substance use disorder with opioid (heroin) and stimulant (cocaine), and sedative-hypnotic-anxiolytic (benzodiazepine/Xanax) class substances of abuse. The patient has a history of substance use disorders beginning in adolescence with escalating use of multiple substances and progression of the disease. The patient was participating in a medication assisted treatment program with Suboxone 8/2 milligrams (mg) twice daily and other services including recovery meetings with relapse. The patient had been using heroin with up to one bundle daily together with Xanax at one mg twice daily and intermittent use of one-half gram of cocaine with intranasal administration. Thus, the patient had failed medication assisted treatment and had lost a job , as well as having strain with family that motivated/prompted self-referral for detoxification and substance use disorder treatment.

The health plan's determination is overturned. The Medically Supervised Withdrawal (Detoxification) Services at the inpatient level of care 01/16/2019 forward is medically necessary for this patient. The comorbid substance use disorders complicated this case with a dangerous combination of an opioid and benzodiazepine, as the patient was using cocaine intermittently, as well as heroin daily with Xanax which again, represented a dangerous combination. The use of multiple substances of abuse is pertinent to the selection and necessity of an inpatient treatment setting in this case scenario, as well as consideration of the patient's lack of sober supports and ongoing psychosocial stressors and lack of coping skills, as well as her continued use while receiving outpatient/medication assisted treatment. The case is complicated by severe psychosocial stressors in multiple domains and co-occurring anxiety, depressive and trauma related disorders and persistent withdrawal symptoms that did warrant the continued inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

The patient is an adult who was admitted  following medical screening to inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol, stimulant (Cocaine), and opioid (heroin) use disorders. The patient had experienced moderately severe alcohol and opioid withdrawal at the time of admission with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 16 and Clinical Opiate Withdrawal Scale (COWS) scale score of 17.The patient had severe withdrawal symptoms in the past requiring detoxification services on multiple occasions. Substance-related treatments mostly consisted of detoxification treatments with limited rehabilitation services and relapses following the detoxification treatments. The patient was admitted for inpatient level care and placed on a detoxification regimen with a Librium and Methadone taper, vitamin and nicotine replacement therapy, and medical monitoring; the patient was offered smoking cessation educational sessions. The patient required the use of Vistaril and Clonidine to manage withdrawal symptoms and associated symptoms of agitation/irritability, anxiety, insomnia and opioid withdrawal that gradually diminished. The patient was discharged with transfer for inpatient residential level substance use disorder rehabilitation treatment and with recommendations for clinically appropriate aftercare with his primary care clinician, as well as recommendation for involvement in 12-step recovery meetings with Alcoholic and Narcotics Anonymous (AA and NA). Patient was discharged with immediate transfer for rehabilitation substance use disorder treatment at another treatment facility. The inpatient admission and continued stay for detoxification treatment, withdrawal management and stabilization were medically necessary. The  services through discharge could not have been provided at a lower level of care in this case scenario. The patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care. Medical necessity for the admission and the continued inpatient services, is met in this case, and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria, referenced below. This answer and determination is also consistent with New York State instruction concerning medical necessity reviews including the appropriate application of the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and Guidelines. The HP determination is overturned in whole.