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

Dx: Orthopedic/Musculoskeletal
Tx: Inpatient Hospital
Denied: Inpatient Hospital
Denial overturned in whole

his case describes a male patient with a history of a left distal radius open reduction internal fixation (ORIF) years prior, who while away from home sustained a fall onto his left upper extremity resulting in a laceration and left elbow fracture. The patient underwent irrigation and debridement of this open elbow fracture at an outside hospital and was discharged and instructed to seek follow up close to his home. The patient then had an evaluation with an orthopedic surgeon who recommended immediate admission through the Emergency Department for definitive orthopedic care. The patient underwent irrigation and debridement of the open wounds as well as open reduction and internal fixation of the proximal ulna and radial head replacement. The patient remained in the hospital. At issue in this case is the medical necessity of the inpatient hospital stay.

The health plan's determination is overturned in whole. 

The inpatient hospital stay was medically necessary. The rationale for this determination is based upon the provided medical records which document that this patient had a significant open fracture of left elbow which necessitated a complex surgery. The medical necessity of the inpatient stay in this case is established based on the need for the extensive elbow operation and the need for 24 hours of post-operative antibiotics administered after the operation for the prevention of infection.

The inpatient stay is supported based upon review of the current, peer-reviewed orthopedic literature. The care rendered in this case is consistent with the treatment recommendations documented by Wong and colleagues in the Hand Clinics Journal in 2015. In addition, the inpatient hospital stay is deemed medically necessary for the administration of post-operative antibiotics for the open elbow fracture sustained by this patient. This is consistent with the recommendations of the current, peer-reviewed literature on this topic as published by Warrender and associates in the Hand Clinics Journal in 2018.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Periodontal Bone Loss/Defect, Apical Pathology 
 
Treatment: Bone Graft and Guided Tissue Generation on Tooth 18

The insurer denied the Bone Graft and Guided Tissue Generation on Tooth 18. The denial was reversed.   

This is a patient who presented for a dental evaluation for dental treatment. Radiographic images were performed that revealed that tooth #18 is non-maintainable due to severe periodontal bone loss/defect issues and apical pathology. Recommendations were made for extraction of tooth #18 and placement of a graft for ridge preservation prior to placement of an endosteal implant.

Based on the radiographic images, it is noted that #18 is non-maintainable due to severe periodontal bone loss/defect issues and apical pathology.  To maintain ridge height for future prosthetic rehabilitation with an endosteal implant in the area, the dentist has recommended the aforementioned grafting procedure.  Ridge preservation procedures with bone grafting are an accepted standard of care service in dental practice and substantiated by peer reviewed literature as documented below. As this is a standard treatment, the graft procedure for ridge preservation is deemed dentally/medically necessary.

The health care plan did not act reasonably or with sound medical judgement or in the patient's best interest.

Based on the above, the medical necessity for the bone graft and guided tissue generation on tooth 18 performed is substantiated.  The insurer's denial is reversed.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is diagnosed with stage IV non-small cell lung cancer (adenocarcinoma). The Guardant360 was ordered. There is no documentation providing the rationale for such a test.
At issue is whether the proposed health service or treatment Guardant360 genetic testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination is upheld. The proposed service, Guardant360 test, is not likely to be more beneficial than any standard treatment or treatments for the patient's life threatening or disabling condition or disease.
The National Comprehensive Cancer Network (NCCN) Guidelines recommend the following mutation studies for advanced lung cancer to use in the selection of systemic therapy: epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), ROS1, BRAF, Kirsten rat sarcoma viral oncogene homolog (KRAS), programmed death-ligand (PDL-1), RET, MET, Tumor mutational burden, human epidermal growth factor receptor 2 (Her2) neu, and neurotrophic tyrosine receptor kinase (NTRK).
Cell-free/circulating tumor deoxyribonucleic acid (DNA) testing should not be used in lieu of a histologic tissue diagnosis. Studies have demonstrated cell-free tumor DNA testing to have compromised sensitivity with up to a 30% false negative rate. The standard for analytic performance characteristics of cell-free tumor DNA have not been established and no guidelines exist regarding the recommended performance characteristics of this type of testing. Such testing can identify alterations that are unrelated to a lesion of interest. The use of this type of testing can be considered in specific circumstances, such as the patient is medically unfit for invasive tissue sampling and, in the initial diagnostic testing, if following pathologic confirmation of a non-small cell lung cancer diagnosis there is insufficient material for molecular analysis.
If the patient was untreated at diagnosis, when results for EGFR, ALK, ROS1, BRAF are not available and when tissue-based testing is infeasible (i.e. quantity not sufficient for tissue based testing or invasive biopsy is medically contraindicated). The other limited indication is for the treated patient at progression on or after chemotherapy or immunotherapy who have never been tested for EGFR, ALK, ROS1, BRAF and for whom tissue-based testing is infeasible (i.e. quantity not sufficient for tissue-based testing from the original biopsy) or for patients progressing on any tyrosine kinase inhibitor (TKIs).
Therefore, since there was no indication of either of these scenarios, the use of the Guardant360 is considered not likely to be more beneficial than standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient is diagnosed with non-small cell lung carcinoma (NSCLC) (adenocarcinoma). The oncology clinical note indicates that the patient was on treatment with Tarceva and complained of new lower back pain. A positron emission tomography (PET)/ computed tomography (CT) scan performed was read as showing a new fludeoxyglucose (FDG) avid lesion in (lumbar) L5 consistent with metastatic disease. A Guardant360 liquid biopsy was drawn.
At issue is whether the proposed health service or treatment Guardant360 genetic testing likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The health plan's determination is overturned. The Guardant360 liquid biopsy is likely to be more beneficial than standard treatment for the patient's life-threatening disease. The use of this test in this patient's situation is supported by national expert consensus panels and relevant peer-reviewed medical literature. Also, the local coverage determination MolDX: Guardant360 in NSCLC also states the test is covered in this patient's specific clinical situation (progression on tyrosine kinase inhibitor [TKI] therapy).
In its 2018 Guidelines, the College of American Pathologists, the International Association for the Study of Lung Cancer, and the Association for Molecular Pathology states that, "Physicians may use cell-free plasma deoxyribonucleic acid (DNA) methods to identify epidermal growth factor receptor (EGFR) T790M mutations in lung adenocarcinoma patients with progression or secondary clinical resistance to EGFR-targeted tyrosine kinase inhibitors." The patient demonstrated progressive disease on Tarceva (a TKI) on positron emission tomography (PET) - computed tomography (CT), which was read as showing new (lumbar) L5 bony metastasis. Therefore, he meets the criteria for Guardant360 testing in this guideline.
The peer-reviewed clinical decision-making resource UpToDate states, "Clinical standards are rapidly evolving, but based on available evidence, we offer liquid biopsy to EGFR mutation-positive patients who have progressed on Erlotinib, Gefitinib, or Afatinib to look for the T790M mutation. If positive, such patients can be treated with Osimertinib."
The authors of "Implications of Plasma-Based Genotyping with the Delivery of Personalized Therapy in Metastatic Non-Small Cell Lung Cancer," (see reference, below) conclude, "Integration of plasma next generation sequencing (NGS) testing into the routine management of stage IV NSCLC demonstrates a marked increase of the detection of therapeutically targetable mutations and improved delivery of molecularly guided therapy."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The Inpatient admission was not medically necessary.

The patient is a male with a past medical history significant for HTN (hypertension), dyslipidemia, CAD (coronary artery disease), s/p (status post) CABG (coronary artery bypass graft) in 2016 and bioprosthetic aortic valve replacement for bicuspid aortic valve. He presented to ER for complaints of two episodes of chest pain, which were relieved with nitroglycerin. 

The patient was hemodynamically stable. ECG (electrocardiogram) revealed no ischemic changes. Cardiac troponins were drawn serially and were normal. The patient had a cardiac catheterization previously (one month prior to this admission) and required no revascularization. He was treated with medical therapy for angina. 

During this admission, the patient was seen in consultation by cardiology, and no further ischemic testing was deemed necessary. The patient was discharged home with a plan for outpatient follow-up with cardiology.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. The patient had a known history of CAD (coronary artery disease) and angina and had a coronary angiogram one month prior to admission, with no need for revascularization. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma 
Treatment: Inpatient admission 

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

The proposed inpatient admission was not medically necessary. 

The patient is a male infant born prematurely at 37 weeks gestation with strong family history of asthma that presented to the emergency department (ED) late with three-day history of runny nose and nasal congestion and five-day history of cough and wheezing. Earlier in the day, the patient developed difficulty breathing. He had no fevers and was still drinking well. Vital sign included temperature 36.7, heart rate 137, and respiratory rate 34 with 100% oxygen saturation in room air. Examination was significant for strong cry, moist mucous membranes, nasal flaring, wheezing, retractions, and non-focal neurologic exam. He was treated with nebulized saline, after which he was audibly wheezing. Rapid testing revealed positive respiratory syncytial virus (RSV). Because of persistent symptoms, he was treated with three DuoNebs and a dose of Decadron. Chest x-ray was obtained but was difficult to interpret because it was rotated. 

The patient's symptoms persisted so he was admitted to the pediatric floor for continued breathing treatments. Admission orders included intravenous (IV) fluids, regular diet for age, frequent suctioning, nebulized saline and albuterol every three hours, and anti-pyretics as needed. Upon re-evaluation, the patient was feeding well with no respiratory distress, maintaining saturations in room air. He was deemed stable for discharge to continue nasal saline nose drops as needed. 

This male infant with history of late preterm birth and family history of asthma presented to the ED with signs and symptoms of bronchiolitis as well as reactive airway disease. Testing revealed infection with RSV. He was initially treated with nebulized saline, but was transitioned to albuterol because of audible wheezing. He continued albuterol treatments and was given a dose of corticosteroid, consistent with management of reactive airway disease/asthma exacerbation. Following admission and continuation of albuterol and saline, his respiratory distress improved sufficiently to discharge home. While it was reasonable to continue monitoring this infant in the hospital, he was overall hemodynamically stable, with no oxygen requirement, no signs of sepsis or impending respiratory failure, and no significant dehydration. He did not require acute inpatient admission and could have been safely managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overdose
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The proposed treatment was not medically necessary. The patient was clinically stable and had a limited plan of care anticipated for him.

Following this patient's ED evaluation, he was clinically stable. He was lethargic but had normal vital signs. There was no concern that he could not protect his airway. At no point was hypotensive. His symptoms were attributed to drug overdose. His testing in the ED had been unremarkable. The patient was kept in the hospital because he remained lethargic in the ED. The admission note for this patient indicates that he would be kept on a cardiac monitor until his mental status normalized. He would be observed for signs of drug withdrawal. No other testing was anticipated for the patient according to the admission note. At the time this patient was kept in the hospital, it would have been reasonable to believe that this limited plan of care could be accomplished for a stable patient with a short stay in the hospital. For this reason, an observation level of care would have been appropriate.

The patient had no severity of illness to warrant an inpatient admission. He had alteration of mental status, but a CT scan was normal and his blood work was normal. His altered mental status was attributed to drug overdose. No additional testing was planned to look for other potential causes of altered mental status. He had stable vital signs and was protecting his airway.

The patient had no intensity of services to warrant an inpatient admission. He would be kept on a cardiac monitor until his mental status normalized. No additional testing was planned for the patient. He ultimately required a psychiatric evaluation due to agitation that was likely related to drug withdrawal.

In conclusion, the patient was clinically stable following his ED evaluation. A limited plan of care was anticipated for him. An observation level of care would have been appropriate for the patient. The Health Plan acted reasonably in denying coverage for this inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Calculus in right ureter 
Treatment: Inpatient admission 

The inpatient admission was not medically necessary.

The patient is a male with diabetes and hypertension.  The patient presented to the hospital with right lower quadrant pain.  Labs were notable for a potassium 3.1, glucose 217, magnesium 1.6, creatinine 1.1, and white blood cell count 17,600.  The urinalysis was positive for blood.  The patient was afebrile with a blood pressure 143/80 and pulse 89.  Computed tomography of the abdomen/pelvis demonstrated an obstructing 0.5 by 0.6 millimeter (mm) calculus in the right proximal ureter with hydroureteronephrosis and right nephric fat stranding.  Intravenous fluids, potassium supplementation, and Toradol were provided and lisinopril and hydrochlorothiazide were held.  The creatinine rose to 1.3 during the hospital stay before dropping to 1.0 and the white blood cell count normalized.  Urology recommended no surgical intervention.  The patient improved and was discharged on Percocet and Tylenol.

The patient had obstructing nephrolithiasis, but it was unilateral and the patient did not have a solitary kidney or a transplanted kidney.  The patient had only a mild decline in renal function with a rise in creatinine to 1.3 from 1.1, with a prompt subsequent improvement to 1.0 with intravenous fluid administration.  The urinalysis was negative except for blood and there was no evidence of a urinary tract infection or pyelonephritis.  The patient did not require surgical intervention and there was no evidence of uncontrolled pain with requirement for frequent or continuous administration of parenteral analgesics.  The patient remained hemodynamically stable and afebrile.  The white blood cell count normalized during the hospital stay.

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute coronary syndrome
 
Treatment: Inpatient hospital admission 

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

This patient is a woman with a past medical history notable for hypertension, diabetes mellitus, hyperlipidemia, obesity, and sleep apnea. She presented to the ER with complaints of left-sided chest pain for 2 weeks duration. She had neck discomfort. EKG was unremarkable. She was admitted for acute coronary syndrome. She ruled out for myocardial infarction with negative biomarkers. Echocardiography showed ejection fraction 65%. She was discharged home with recommendations for an outpatient stress test. 

The patient presented with chest pain.  The initial evaluation in the ER was unremarkable, including non-diagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

The health plan acted reasonably with sound medical judgment 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: Overturned

The patient is a transgender female to male patient (FtM) is requesting coverage of chest confirming surgery i.e. mastectomy. The patient began living as a boy , started hormone blockers and testosterone . On physical examination, sternal notch to nipple distance is 17 centimeter (cm) bilaterally, nipple to inframammary fold distance is 5 cm bilaterally. The physician has recommended mastectomy via periareolar skin incision without skin excision. 

The health plan's determination is overturned. Gender Affirming Top Surgery is medically necessary for this patient. The patient meets the World Professional Association for Transgender Health (WPATH) criteria for surgery.
Appeal type: Medical necessity
Decision: Overturned

Dx: Orthopedic/Musculoskeletal
Tx: Home Health Services
Denied: Home health Services (increase in hours)
Denial: Overturned in whole

The patient is a female with a past medical history of osteoarthritis, coronary artery disease, hypertension, gastroesophageal reflux disease (GERD), hypothyroidism, hyperlipidemia and urinary incontinence who had been approved for personal care aide (PCA) services 24 hours live-in/day, 7 days/week. The patient's family requested to decrease PCA services to 24 hours live-in/day, 3 days per week with a new private aide the other 4 days per week. The patient had assessment tool done on 5/1/19 and on 11/26/19 without any change in her activities of daily living (ADL) and Instrumental activities of daily living (IADL) needs. The aide was no longer available due to health issues and on 1/9/20 the family requested to have PCA services increased to 24 hours per day live-in per diem 6 days per week. The insurer denied this request.
The subject under review is the medical necessity for the change in hours.

The health plan's determination is overturned, in whole. 

Yes, the requested service of personal care aide level 2 services (24 hours per day-live in per diem, 6 days per week) is medically necessary for this patient.
The patient had been previously assigned PCA services 24 hour live-in/day, 7 days/week and the patient's family requested a decrease in services as they were able to make other arrangements. The arrangement of a private live-in aide was unable to be continued and the family and they requested to have PCA services provided to the patient similar to before except they were able to provide one day of 24 hour coverage, hence requesting PCA services 24 hour live-in per day, 6 days per week. The patient had previously qualified for services 24 hours/day, 7 days/week with assessment done in the spring and at her assessment in the fall did not have any change in her level of assistance, therefore qualifying the for the same, previous level of PCA services (although current request was for 6 days/week instead of 7 days/week).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Colitis
Treatment:  Inpatient admission
The insurer denied coverage for inpatient admission.  The denial is upheld. 

This patient is a female who presented with abdominal pain, vomiting and diarrhea.  The patient was afebrile with initial tachycardia.  On exam, the patient had no abdominal rebound or guarding.  The patient's white blood cell (WBC) count was elevated at 16.62.  The patient's renal function was normal.  The patient's computed tomography (CT) scan of the abdomen and pelvis revealed colitis.  The patient was treated with intravenous antibiotics.  With treatment, the patient was noted to feel better and able to tolerate a diet.

Based on the review of the MCG Criteria for Admission for Gastroenteritis (M-170), the clinical indications for inpatient admission includes having a severe infection, such as bloody diarrhea, severe abdominal pain, peritoneal signs, hemodynamic instability, severe dehydration or severe vomiting that is not responsive to treatment.  Based on the review of this patient's medical records, the patient did not have these clinical conditions that met the MCG criteria for inpatient admission.  The patient had gastroenteritis, but the patient's clinical symptoms rapidly improved with intravenous (IV) antibiotic administration.  During this patient's inpatient stay, the patient had received IV antibiotics, IV hydration and antiemetics, which all could have been provided in the Emergency Department with Observation status.  Thus, this patient's inpatient admission was not medically necessary to treat this patient's medical condition.

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

The carrier denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.