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

Orthopedic/Musculoskeletal - Knee Problem/Pain
Pharmacy/Prescription Drugs

The patient is a female with a complaint of right knee pain and known osteoarthritis. The patient had progressive right knee pain after undergoing arthroscopic knee surgery. The provider in this case recommended a series of Euflexxa injections to provide the patient more pain relief because a cortisone injection and oral non-steroidal anti-inflammatory drugs (NSAIDs) did not provide the patient adequate pain relief. The subject under review is the medical necessity of the Hyaluronan injections for this patient. 

The health plan's determination is upheld.

The requested Hyaluronan injections were not medically necessary for this patient. The rationale of this determination is based on the provided medical records which document that the patient had pain from knee osteoarthritis after undergoing right knee arthroscopy. The current, peer-reviewed orthopedic literature, including recent articles by Tammachote and colleagues, and by Jevsevar and associates in The Journal of Bone and Joint Surgery found that viscosupplementation injections such as the Euflexxa injections provided in this case, are not an effective treatment for knee osteoarthritis. The article published by Tammachote and colleagues was a prospective, randomized study which compared a Hylan injection to an injection of corticosteroid in a series of patient with knee osteoarthritis. The authors concluded that, "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." Similarly, Jevsevar and associates found that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid (HA) treatment over placebo." Therefore, injections such as Euflexxa have been found to be of limited benefit for patients with knee osteoarthritis in comparison to other available treatment options for this condition and their medical necessity is not established.
Appeal type: Medical necessity
Decision: Upheld

Appendicitis
Inpatient Hospital

The patient is a previously healthy male who presented to the emergency department (ED) with a history of progressively worsening abdominal pain of one day duration. His evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. The heart rate was 75/minute. Lab data identified a white blood cell (WBC) count of 8.4 thousand (K). CT scan yielded the diagnosis of acute appendicitis without perforation. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained.
The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated appendicitis. He was provided IV fluid and perioperative antibiotics. His vital signs remained normal following ED presentation. He tolerated a diet and was discharged from the hospital.

The health plan's determination is upheld.

This patient presented with abdominal pain. His evaluation with examination, lab data, and CT scan confirmed the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, IV antibiotics and appendectomy. The early post-surgical course was uncomplicated, and the patient was clinically stable. He was stable for discharge from the hospital.
The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient required urgent surgical intervention for acute appendicitis, however, a lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. There was no documentation of hemodynamic instability, intra- or peri-operative complications, severe pain, or unstable comorbidities. The member tolerated oral hydration, diet and medication. Pain was well controlled. In the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure (appendectomy) may be performed at a lower level of care. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled.
The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have provided for presurgical assessment, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring if needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Multiple sclerosis
Treatment:  Continued rehabilitation stay 

The service in question, continued rehabilitation stay, is not medically necessary.

In the present case, the patient is reported to have multiple sclerosis with an "aggressive" course.  Premorbidly, she had already functionally declined to the level where was using a wheelchair, was having falls, was receiving assistance most of the time and where she required assistance for her instrumental activities of daily living.  She was hospitalized following a fall at home during a transfer.  There were no documented significant sequela from the fall, such as a fracture or intracranial bleeding.  She was medically stabilized and transferred to a skilled nursing facility.  As of the dates of service under review, the patient had undergone a prolonged course of inpatient rehabilitation.  She made gains in multiple domains but continued to require significant assistance for her self-care.  Her ambulation was not improving to a level where there would be a reasonable expectation that she would be able to be independent with transfers or household ambulation in a functional and safe manner.  She was not back to her premorbid baseline, but she did have a condition which had been advancing in an "aggressive" manner.  There were otherwise no documented ongoing medical or nursing needs requiring ongoing care.  The patient could have returned to the community at the wheelchair level with custodial level assistance and ongoing therapies at the home or outpatient level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: NSCLC
Issue under review: Guardant360 test

Determination:
The health plan should not cover the Guardant360 test.

There is no evidence that patients with known driver mutation negative NSCLC derive benefit from NGS (next generation sequencing) panel testing.  The SHIVA study has shown that the use of NGS panel testing as a means to select anti-cancer therapy is of no clinical benefit and does not lead to improved outcomes over standard therapy.  Therefore, the proposed testing is not likely to be more beneficial than other standard therapy. The NCCN only supports this testing approach as part of initial evaluation of metastatic NSCLC, and does not recommend the routine use of this testing in patients who have undergone and tested negative for appropriate drivers and have progressed on multiple standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: NSCLC
Issue under review: Guardant360 test

Determination:
The health plan should not cover the Guardant360 test.

Liquid biopsies can be performed when a tissue biopsy is inaccessible or unavailable. While the current focus is dominated by DNA, additional components of a liquid biopsy include ribonucleic acids (RNA), circulating tumor cells (CTCs), extracellular vesicles (EVs), and tumor educated platelets (TEPs). The latter components are mainly of research interest. As more translational research is performed, these additional components of a liquid biopsy may have increasing clinical use in the future. 

Methods that are currently used to detect or measure ctDNA can broadly be divided into two categories: polymerase chain reaction (PCR) based and next-generation sequencing (NGS) based. NGS is broader and has greater promise. Although liquid biopsy may be an attractive tool for cancer screening in asymptomatic patients, such applications will need to be carefully and thoughtfully considered to avoid excessive patient suffering and burden due to false-positive results. In the short term, liquid biopsies may be more helpful to confirm malignancy in patients with already clinically or radiographically apparent lesions.

Currently, Guardant360 is sold in 30 countries, including in the U.S. as a laboratory-developed test. It is not yet approved by the FDA, and the liquid version is not listed by NCCN. The FDA has so far only approved one blood-based cancer test, FoundationOne, which detects mutations in the EGFR gene in non-small cell lung cancer patients.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: MDD, PTSD, Anxiety
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was medically necessary.

The patient has a diagnosis of mental illness including MDD (major depressive disorder), PTSD (posttraumatic stress disorder), and Anxiety. His homeless shelter called EMS due to the patient's suicidality and panic attack symptoms.  He reported plans to walk in front of the subway.  

The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were they to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality, the patient remained depressed.  The patient had multiple static risk factors for potentially dangerous behaviors, including substance abuse, prior suicide attempts, and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained depressed was acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a medical history of asthma and polysubstance dependence including nicotine, crack/cocaine, heroin and opiates who was admitted for accidental drug intoxication after being given an extra dose of Methadone while in inpatient rehabilitation. She was alert, awake and oriented without neurological abnormalities, she did not have any respiratory distress or depression, she was hemodynamically stable without arrhythmias and she did not require any intravenous medications. The health plan's determination is upheld. The patient was admitted for observation in the intensive care unit where her vital signs including oxygen saturation and respiratory rate were monitored for any signs of desaturation and/or respiratory depression. Her electrocardiograms (EKGs) were monitored for the QTc interval and for any arrhythmias along with a basic chemistry panel. She was previously given naloxone at the rehab center and no further doses were required after admission. After 24-hours of monitoring there was no adverse events despite the increased dose of Methadone that was administered at the rehab center. The following morning the patient left against medical advice. Standard initial management for opioid overdose should focus on support of the patient's airway and breathing. Attention should be paid to the depth and rate of ventilation along with pulse-oximetry. Administration of naloxone, a short-acting opioid antagonist, is usually the initial part of the management plan. The goal of the naloxone administration is not a normal level of consciousness but rather adequate ventilation. Specifically, Methadone can cause QT interval prolongation and Torsade de Pointes. If the QT is determined to be greater than 500 msec, its recommend that the patient be observed on a cardiac monitor for a 24-hour period, this patient had a QT of 478 msec. Hypocalcemia, hypokalemia, and hypomagnesemia should be corrected when present, which were all within normal limits for this patient.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension, hyperlipidemia, atrial fibrillation, coronary artery disease, chronic obstructive pulmonary disease (COPD) and cocaine abuse. He presented to the emergency department complaining of shortness of breath, chest pain and a dry cough. His cardiopulmonary exam was unremarkable. His serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. His electrocardiogram showed no acute changes; his QT interval was prolonged (this was said to be chronic). A chest x-ray showed left lower lobe atelectasis versus infiltrate. He was treated with aspirin, morphine and nitroglycerin and admitted to the hospital to rule out acute coronary syndrome. Serial troponin levels were normal and no electrocardiographic changes evolved. His cough was attributed to COPD and he was treated with bronchodilators and antibiotics. The health plan's determination is upheld.
This patient, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He 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 of care. This approach has been shown to be safe and and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. Moreover, once ACS had been ruled out with repeat enzymes and electrocardiograms (within 24 hours of presentation), the reason for continued hospitalization is not evident in the records provided. No further testing for ACS was performed and no further treatment was instituted.
The patient was also treated for a possible COPD exacerbation based on the complaints of a cough. He was not tachypneic, tachycardic or hypoxic. His mental status was normal. He did not shows signs of respiratory distress. Based on the information provided, this did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive heart failure

Treatment: Inpatient stay

The insurer denied coverage for inpatient stay. The denial was upheld.

This patient is a female with a past medical history notable for heart failure with preserved ejection fraction, atrial fibrillation, on anticoagulant, hypertension, hyperlipidemia and prior stroke. She presented to the ER with complaints of shortness of breath. The onset was 2 weeks prior to presentation. The symptoms worsened when lying supine. She had been treated with levofloxacin for 5 days. Vital signs noted blood pressure 172/98, otherwise unremarkable. She was admitted and evaluated by cardiology, and deemed safe for discharge the day after presenting to the ED.

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

Inpatient admission was not medically necessary for this patient. The patient was admitted with symptoms of congestive heart failure. However, care could have been rendered under observational status. There was clinical congestive heart failure with objective findings supporting necessity of observational care. Inpatient admission status was not met due to lack of severity of disease or comorbidities. There was no myocardial ischemia, hemodynamic instability, no electrolyte abnormalities, hypoxemia, or other indications for acute inpatient admission status during the stay. Per MCG 23rd Edition Guideline Heart Failure: Observation Care OCG: OC-024 (ISC), the patient's care could have been provided under observational level of care. 

Based on the above, the medical necessity for the inpatient stay is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: large carious lesions involving the pulp chambers

Treatment: D3330 (root canal) tooth 15, D2751 crown - porcelain (tooth 15, and 30); and D3348 retreatment of previous root canal therapy-molar (root canal, tooth 30)

The insurer denied coverage for D3330 (root canal) tooth 15, D2751 crown - porcelain (tooth 15, and 30); and D3348 retreatment of previous root canal therapy-molar (root canal, tooth 30). The denial was reversed.

This patient is a male patient who presented to the dentist for evaluation and comprehensive dental treatment.  Endodontic therapy (including retreatment of #30) was recommended on multiple teeth including #15 and #30 due to large carious lesions and failing root canal on #30, with subsequent recommended treatment of full coverage crowns to be placed.

The insurer has denied these services stating that the services are not medically necessary as these teeth are not supports for a partial denture or bridge.  

Upon review of radiographs, they support the recommended treatment. The teeth have large carious lesions involving the pulp chambers radiographically or periapical pathology on #30, both requiring endodontic therapy as identified by the dentist.  All have adequate residual coronal structure for support of crowns and minimal periodontal alveolar bone loss.  The standard of care in general dental practice would be endodontic therapy for these teeth which would have an excellent long term prognosis with the recommended treatment. Further, standard of care in dental practice would be full coverage restorations on endodontically treated teeth as recommended. 

Reverse denial and approve coverage for coverage for D3330 (root canal) tooth 15, D2751 crown - porcelain (tooth 15 and 30); and D3348 retreatment of previous root canal therapy - molar (root canal tooth 30) as medically necessary as the clinical and radiographic documentation support these services, and these services would be a standard of care in general dental practice.  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 D3330 (root canal) tooth 15, D2751 crown - porcelain (tooth 15, and 30); and D3348 retreatment of previous root canal therapy-molar (root canal, tooth 30) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with hyperhidrosis, treated with Drysol, Qbrexza, Robinul and Botox injections. The provider is requesting Botox injections every 3 months. At issue is the medical necessity of Botox injections every 3 months

The health plan's determination is upheld. In general, there appears to be an increase in the duration of efficacy of botulinum toxin A injections with the repetition of injections in patients with primary axillary hyperhidrosis. There is no documentation of worsening or lack of control and therefore Botox injections every 3 months is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Breathing Problem
Inpatient Hospital

The patient is a male with a history of chronic obstructive pulmonary disease (COPD), asthma, bronchiectasis, and methadone use. He presented to the emergency room with a one day history of increased shortness of breath, productive cough, and leg edema. He reported presenting to another emergency room (ER) about one week before and was prescribed a 3-day course of antibiotics, which he completed. The vital signs were normal including a respiratory rate of 20. The oxygen saturation was 98% on room air. Lung exam revealed rhonchi, but no rales or wheezes. There was some bilateral lower leg edema. The chest x-ray revealed the usual bronchiectasis. Labs were non-contributory. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with supplemental oxygen, nebulizers, inhalers, and oral medications. Bilateral lower extremity venous Doppler exams were negative for thrombosis. The hospital course was clinically uneventful, and the patient was discharged.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints. His vital signs were normal, he was not hypoxic, and there was no evidence of sepsis, mental status changes, respiratory failure, or metabolic disarray. There was no wheezing and he had good air movement. The services provided - nebulizers, inhalers, and oral medications - were not at the acute inpatient level of intensity, and the level intensity did not increase during the course of the hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Hip Problem/Pain
Physical Therapy

The patient is a male with the chief complaint of pain of the right hip. Physical therapy services were initiated for a chief complaint of right hip pain. This review is for physical therapy modality CPT 97140. Physical therapy initial evaluation noted pain in the right hip that began after training for the New York City Marathon. Chief complaints decreased walking tolerance, running tolerance and decreased joint mobility and range of motion. 

The health plan's determination is upheld. The Physical Therapy Services in question are not medically necessary for this patient. The medical records do not support the need for manual therapy of the target muscle. There are no specific hip range of motion measurements showing baseline versus (vs) post treatment changes, specific measurements of pain levels and or other mobility issues related to the right hip which would require continued skilled physical therapy treatment with manual care.
Appeal type: Medical necessity
Decision: Overturned

Sickle Cell Disease
Inpatient Hospital

The patient is a male with known sickle cell disease who presented to the emergency department (ED) with diffuse pains all over his body not controlled by oral narcotic analgesics at home. His vital signs and physical exam were unremarkable; lab work was normal except mildly elevated white blood cell (WBC) count to 15 K. The chest x-ray (CXR) was normal. He was started on intravenous (IV) hydration and required IV narcotic analgesics for pain control.

The health plan's determination is overturned. The inpatient hospital admission is medically necessary for this patient. Sickle cell pain crisis usually will need aggressive hydration and pain control with IV narcotics which usually requires 2-4 days of hospitalization per accepted standards of care.
Per Milliman Care Guidelines (MCG) for inpatient admission for sickle cell crisis, treatment or monitoring in an inpatient setting is indicated for continuous parenteral narcotics (every 4 hours in this patient). Per InterQual guidelines, an inpatient admission is warranted with a WBC >15K and need for treatment with analgesics and IV hydration therapy.