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

Diagnosis: Opiate Detoxification
 
Treatment: Inpatient Admission

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

This is a female patient who was admitted to inpatient substance detoxification treatment on in early 2019 due to opiate detoxification. She had withdrawal symptoms including sweats, tremors, and anxiety. She had a Clinical Opiate Withdrawal Scale (COWS) of 11. She continued to have withdrawal symptoms though lessened while in hospital. She was reportedly using 6 bags of heroin per day and also using Buprenorphine. She had 2 past inpatient substance detoxification and rehabilitation treatments. She also had reports of anxiety and depression. She took Methadone during this hospital admission and then discharged. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports 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. In this case this patient had use of multiple substances including heroin and buprenorphine and was at risk for death from overdose and also moderate to severe withdrawal. According to the LOCADTR she did require 24 hour treatment. She could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use substances despite multiple past inpatient substance detoxification and rehabilitation treatment, and due to long term substance use, required detoxification medication to modify withdrawal. She likely would have relapsed again as evidenced by relapsing after past treatments, and she also had comorbid depression and anxiety. 

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued inpatient admission
The proposed treatment, continued inpatient admission, was medically necessary for this patient.
The substance use disorder treatment in this case could not have been effectively provided at a lower level of care. The patient in this case was using large quantities of heroin and cocaine that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Again, detoxification, as indicated, and other treatments pertinent to the detoxification treatment episode could not have been effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms that were being effectively addressed with methadone and supportive measures provided during the time interval under review. The patient had associated clinical features that included an anxiety and depressive disorder treated with doxepin and prn medications to address anxiety and insomnia, and he presented with a lack of sober supports and limited insight, impaired judgment and poor control of impulses that also supported the request for continued inpatient admission. 
Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did warrant and require the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the co-occurring psychiatric disorders and severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria-referenced below.
The requested benefit of continued inpatient admission 04/13/2019 through 04/14/2019 is clinically appropriate, medically necessary and warranted, and is therefore a covered benefit in this case scenario. The continued inpatient level treatment through discharge could not have been 
effectively provided with lower level services, as noted in the answer to question 2. Thus, the requested benefit is not excluded under the plan, and should be covered.
Appeal type: Medical necessity
Decision: Overturned

The patient self-referred and presented to the emergency department with complaints related to alcohol withdrawal. The patient was admitted  following medical screening to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder. The health plan's determination is overturned. 
The patient in this case presented with a diagnosis of severe alcohol use disorder with symptoms of withdrawal, and comorbid cannabis use disorder. The patient had a history of trauma with co-occurring mood disorder with symptoms of depression that was related to and triggering the alcohol use disorder.
The presenting clinical features and risk for withdrawal seizures and other psychosocial complications of alcohol use disorder did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The patient's continued inpatient stay with detoxification, withdrawal management, and other medical services through discharge could not have been effectively or safely provided at a lower level of care in this case scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation with rapid ventricular response
 
Treatment: Inpatient admission, medication, monitoring

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

The patient had a past medical history notable for hypertension, irregular heartbeat, and tobacco use.  He presented to the Emergency Room (ER) with complaints of chest pain and dizziness.  He was found to be in atrial fibrillation with a rapid ventricular response.  His heart rate was 122 in the ER.  EKG confirmed atrial fibrillation.  He was treated in the ER with diltiazem intravenous push and started on oral diltiazem.  Heart rate improved to the 70s.  Physical examination was unremarkable.  Troponin I was 0.277; felt to be due to his rapid heart rate.  Echocardiography showed a normal left ventricular ejection fraction with hypertrophy of the interventricular septum.  He was started on Xarelto and was discharged home. 

Inpatient admission was not medically necessary. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bilateral knee osteoarthritis
 
Treatment: Medication-Euflexxa knee injections

The insurer denied the coverage for Euflexxa knee. The denial was upheld.

This is a female patient with bilateral knee osteoarthritis.  Treatment included prior Euflexxa knee injections.  Currently under review is the insurer's denial for requested additional Euflexxa knee injections.  

Viscosupplementation is a therapeutic modality proposed for the treatment of osteoarthritis based on the physiologic importance of hyaluronan in synovial joints.  Its therapeutic goal is to restore the visco-elasticity of synovial hyaluronan, thereby decreasing pain, improving mobility and restoring the natural protective functions of joint hyaluronan.  Euflexxa is one of several hyaluronic acid products available in the USA.  

Based on the above, the medical necessity for Euflexxa Intra-Articular Injections is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Growth hormone deficiency GHD
 
Treatment: Medication- Nutropin

The insurer denied coverage of Nutropin. The denial was upheld. 

This is a female child diagnosed with growth hormone deficiency (GHD).  This request is for Nutropin.  She has central precocious puberty (CPP) and she is on Lupron. She started growth hormone (GH) therapy.  Her GH stimulation test with clonidine and L-dopa peaked at 6.8 and 9.3 respectively. Her height velocity was reported to be 5.4 cm/year. In late 2018 she was at Tanner 3-4 and breast tissue slightly less stimulated than last visit. Earlier that year her insulin like growth factor 1 (IGF1) was 331, her insulin like growth factor binding protein 3 (IGF-BP3) was 4614 and growth hormone (GH) was 3.5.  
		
This patient met biochemical criteria.  GH stimulation testing peaked at less than 10ng/ml.  The patient had a normal IGF1.

The patient did not meet auxological criteria as pretreatment height and height velocity are normal.

The Pediatric Endocrine Society recommends against making a diagnosis of growth hormone deficiency based solely on failed growth hormone stimulation testing.

The patient does not have a pre-treatment height less than or equal to -2.25 SD.  The patient therefore does not meet idiopathic short stature criteria.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hyperglycemia noted to have blood glucose of 470 at home. Per his parents, he had not been compliant with medication. He had 3 emergency room (ER) visits for hyperglycemia in the last 1.5 months. As per his father, the target glucose is 120. He takes 35 Units (U) Tresiba daily and Novolog with meals. The health plan's determination of medical necessity is upheld. The psychiatrist who evaluated the patient stated he was not refusing insulin or engaging in poor self-care in an effort to harm himself and he did not require inpatient hospitalization for psychiatric stabilization. He was psychiatrically cleared for discharge. Although he demonstrates a history of "substantial and chronic poor metabolic control" evidenced by his elevated hemoglobin A1c level of 11.4%, he still does not meet further criteria outlined by the American Diabetic Association for admission under these circumstances.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a female who had 3 suspicious lesions on the left thigh that were evaluated using Reflectance Confocal Microscopy (RCM).  Diagnoses include mild, moderate and severe atypia.  The subject under review is whether the use of Reflectance Confocal Microscopy in this case is likely to be of greater benefit for this patient's diagnosis than any standard treatment.  The health plan's determination is upheld, in whole.  Researchers tested the applicability of confocal laser scanning microscopy (CLSM) to the diagnostic discrimination of benign nevi and melanoma.  Five independent observers without previous experience in CLSM received a standardized instruction about diagnostic CLSM features.  Subsequently, 117 melanocytic skin tumors (90 benign nevi and 27 melanoma), imaged using a commercially available, near-infrared, reflectance confocal laser scanning microscope, were evaluated by each observer.  Logistic regression analysis revealed that mainly cytomorphology, architecture and keratinocyte cell borders should be taken into account for diagnostic decisions.  These investigators concluded that this first sensitivity and specificity study with CLSM has yielded promising results.  In one study, the presence of bright cells in a pagetoid pattern on RCM imaging led to a false-positive diagnosis of melanoma in 24 of 39 cases assessed.  It is often not possible to distinguish severely dysplastic nevi from malignant melanoma.  The use of RCM is considered experimental/investigational.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a female with suspicious lesions on the left thigh noted on dermoscopic evaluation, and for which Reflectance Confocal Microscopy was performed.  The confocal diagnosis of a left posterior thigh nevus was read out as a melanocytic nevus with marked architectural disorder and mild atypia, while a nevus of the left lateral thigh was read out as having moderate atypia, and a nevus of the left medial thigh was noted to have severe atypia.  The subject under review is whether the reflectance confocal microscopy is likely to be more beneficial for this patient than standard treatment.  The health plan's determination is upheld, in whole.  Although Reflectance Confocal Microscopy (RCM) is a fascinating and interesting new technology, with greater sensitivity and specificity than standard dermoscopy, its role in comparison to the standard histological criteria of a skin biopsy is not yet established.  The appropriate use and clinical utility of RCM is not confirmed with respect to when a skin biopsy (or at the very least a complete/excisional skin biopsy) is not ideal or indicated.  At this time, complete excision of a suspicious nevus is the gold standard, and with histological evaluation to determine whether a nevus shows mild, moderate, or severe atypia (or even melanoma) being the standard of care to address and appropriately diagnose/treat a suspicious nevus.  At this time, therefore, modern dermatology references and literature reviews only support RCM as investigational--despite increasing evidence that it has a reassuring role to patients who might wish to avoid biopsies (with associated discomfort and scarring).  However, such reassurance is not consistent with the necessary approach to changing or suspicious nevi, which is to have a low threshold to biopsy/removal of such nevi, with any inconvenience of having that biopsy/removal having a much lower, if not insignificant, influence on the question of whether to promptly remove what might possibly be an early or evolving melanoma.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is a female with 3 suspicious lesions to the left thigh evaluated with reflectance confocal microscopy, and atypia was noted.  The subject under review is whether the use of the reflectance confocal microscopy is likely to be more beneficial than any standard treatment for this patient's condition.  The health plan's determination is overturned, in whole.  Biopsy and histologic evaluation have been the gold standard to diagnose skin tumors.  Reflectance confocal microcopy (RCM) is a noninvasive, innovative diagnostic technique that enables visualization of different skin layers at an almost histologic resolution.  RCM has been proven beneficial in management of various cutaneous lesions.  This prevents unnecessary biopsies.  Current literature supports use of RCM.  In a recent review which compared dermoscopy and confocal microscopy, eight published studies were included in the analysis, involving 1141 skin lesions, which reported a per-lesion analysis of dermoscopy and RCM.  Within the same patient group and at the per-lesion level, RCM significantly increased the detection rate of malignant skin tumours by 7.7% (95% confidence interval [CI] 0.01-0.14). RCM imaging combined with dermoscopic examination is guiding the triage of lesions into those that appear benign, which are being spared from biopsy, against those that appear suspicious, which are then biopsied.  Current evidence supports that RCM prevents unnecessary biopsies Based on the current medical literature, the RCM is likely to be more beneficial for this patient than standard treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnoses: attention deficit hyperactivity disorder, major depressive disorder, generalized anxiety disorder

Treatment: Psychological testing

The insurer denied coverage for psychological testing. The denial was upheld.

The patient was experiencing symptoms of anxiety and depression, and he had difficulty sitting still, was restless, fidgeting, impulsive, distractible, forgetful, and had difficulty with organization.  For this reason, he presented to a provider for additional diagnostics. The provider performed Greenlight testing, which revealed diagnoses of generalized anxiety disorder, major depressive disorder, recurrent; rule out attention-deficit hyperactivity disorder, combined type.  The plan was to follow up with a nurse practitioner for medication evaluation.

It is not considered standard practice to perform psychological testing, unless there is a need for intellectual functioning testing, adaptive functioning testing, or cognitive functioning testing.  In this case there were no indications the patient needed these dimensions assessed.  According to the medical literature psychological testing is not considered a standard diagnostic work up for mood disorder diagnoses nor a standard for the diagnosis or treatment of anxiety disorders.  A clinical diagnostic assessment by a psychiatrist, psychologist or mental health provider is considered the standard.  If a provider needs additional information to assist in assessing intellectual or cognitive functioning or to assess for possible neurological deficits, neuropsychological tests can be performed by a psychologist.  This need was not reported in the notes.  Psychological testing is only indicated if there is a strong indication that useful information from testing would impact the patient's care and treatment or make a diagnosis that a provider is unable to make by other methods; such as a psychiatric evaluation.  There was no specific reported evidence to support the need for psychological testing.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cavovarus deformity
 
Treatment: Computerized Motion Analysis Study

The insurer denied the Computerized Motion Analysis. The denial was reversed.
This patient has a cavovarus deformity, increasing pain, and skin breakdown in the right extremity.  The patient's foot is severely inverted preventing the patient from walking on it.  He puts weight on the lateral edge of his foot and has no stability or ability to walk on it.  The plan was for the surgeon to correct the position of the foot with surgical intervention so the patient would walk normally.
Computerized Motion Analysis (Spine and Gait) has become the standard for treatment decision-making and evaluation in pediatric foot deformities.  The primary use of clinical gait analysis is to allow informed orthopedic surgical decision making in children with physical disabilities impairing their walking ability.  
Gait analysis provides the most accurate and clinically accessible method of movement assessment, superior to what is available with visual assessment.  It provides the necessary information to guide treatment that is not available by visual assessment or traditional static measures such as x-rays or physical examination.  
Coverage for a gait lab study is medically necessary.  Based on the above, the medical necessity for a gait lab study Computerized Motion Analysis (Spine and Gait) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

The patient was diagnosed with cutaneous malignant melanoma status/post (s/p) wide local excision. The use of the Decision Dx melanoma gene assay is under review.

The health plan's determination is overturned. The patient is a young male with early stage melanoma. Cancer at a young age is not normal even if it is early stage. The DecisionDx assay allows the physician to better formulate a treatment plan based on tumor biology. Based on both current literature and clinical practice guidelines, the Decision Dx gene assay is widely used in the clinical setting to help facilitate clinical decision making.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glaucoma
Issue under review: Vyzulta

Determination:
The Vyzulta is not medically necessary.

In this case, a patient suspected of having glaucoma based on elevated intraocular pressures is requesting coverage of Vyzulta. 

Vyzulta is a prostaglandin analog FDA-approved for the reduction of intraocular pressure in patients with open-angle glaucoma or ocular hypertension. 

Medeiros et al compared the intraocular pressure (IOP)-lowering effect of latanoprostene bunod (LBN) 0.024% with timolol maleate 0.5% in a prospective, randomized, double-masked, parallel-group, noninferiority clinical trial. Adults with OAG (open-angle glaucoma) or OHT (ocular hypertension) from 46 clinical sites were randomized 2:1 to LBN instilled once daily (QD) in the evening and vehicle in the morning or timolol instilled twice a day (BID) for three months. A total of 387 subjects (LBN, n = 259; timolol, n = 128) completed the study. Analysis of covariance showed that mean IOP reduction with LBN was not only noninferior to timolol but significantly greater (P <= .025) than timolol at all but the first time point in this study (week 2, 8 AM). Of LBN- and timolol-treated subjects, respectively, 31.0% and 18.5% (P = .007) had their IOP reduced >=25% from baseline, and 17.7% and 11.1% (P = .084) had their IOP reduced to <=18 mm Hg over all time points/visits in this study. Ocular treatment-emergent adverse events, while uncommon, appeared more frequently in the LBN group (all mild-moderate except one case of severe hyperemia). The authors concluded that LBN 0.024% QD in the evening was noninferior to timolol 0.5% BID over three months of treatment, with significantly greater IOP lowering in subjects with OAG or OHT at all but the earliest time point evaluated, and demonstrated a good safety profile. 

Liu et al compared the diurnal and nocturnal effects of latanoprostene bunod 0.024% solution with timolol maleate 0.5% solution on intraocular pressure (IOP) and ocular perfusion pressure in a prospective, open-label randomized crossover trial. Twenty-five patients (aged 43-82 years) with ocular hypertension or early primary open-angle glaucoma were enrolled and twenty-one subjects completed the study. The authors found that during the nocturnal period, latanoprostene bunod caused more IOP reduction and more increase of ocular perfusion pressure than timolol. 

Coverage of Vyzulta was previously denied as there was no documentation that the patient had tried and failed the health plan's preferred medications, including latanoprost and bimatoprost 0.3%.

Upon appeal, it is identified that the patient has tried Simbrinza, Alphagan, Travatan and Cosopt. The provider notes that the patient has tried samples of Vyzulta, which have lowered intraocular pressures by about 5 mm Hg. No information is provided as to why the patient could not try the preferred alternatives of latanoprost or bimatoprost.  A review of the peer-reviewed literature does not establish
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Malignant Melanoma
 
Treatment:  Melanoma gene expression profile test

The insurer denied the gene expression profile test.  The denial was upheld.

The patient had a biopsy from the right chest with a diagnosis of malignant melanoma with a 2.5 mm thickness.  The treating provider is requesting approval for the Decision Dx-Melanoma gene expression profile test.

The results of the Decision DX Melanoma test revealed the claimant as class 1A, which suggests a very low risk of metastatic potential.  Furthermore, based on the results of the original biopsy and clinical findings, this testing would not be of value in treatment planning for this claimant.  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.