Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory system /Other 
Treatment: Surgical services 
The insurer denied vagus nerve neurostimulator  
The denial is overturned in whole

The patient diagnosed with severe obstructive sleep apnea (OSA). Per the provided documentation, underwent a sleep study  which showed an apnea hypopnea index (AHI) of 37.9 with no central sleep apneas. The patient was seen by the otolaryngology physician reported at that time that the patient  could not tolerate continuous positive airway pressure (CPAP).The patient's body mass index (BMI) at that time was 24.5 kilograms per square meter (kg/m2). A drug induced sleep endoscopy was performed which showed no signs of complete concentric collapse of the velopharynx.
Yes, placement of a hypoglossal nerve stimulator is likely to be more beneficial then any standard treatment for OSA.
The first line treatment for severe OSA in a non-overweight patient is a continuous positive airway pressure device (CPAP). In patients who cannot tolerate these devices, then surgical options are considered to either cure OSA or improve CPAP tolerance. Traditional surgeries for OSA involve correcting sites of airway obstruction (eg - large tonsils, large uvula/soft palate, nasal blockage, large base of tongue, etc.). In patients with severe OSA, these surgeries rarely correct sleep apnea, but instead have the goal of improving CPAP tolerance. Of note, this patient had a normal nasal exam and small tonsils based on the office note from previous appointment and therefore would not be a good candidate for any of the traditional airway procedures for OSA.
The hypoglossal nerve stimulator was US Food and Drug Administration (FDA)-approved in 2014 for the treatment of moderate and severe obstructive sleep apnea. A five-year study indicated that the treatment was effective and improved sleepiness, quality of life and respiratory outcomes.
In their updated (2017) position statement, The American Academy of Otolaryngology-Head and Neck Surgery stated it considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP). Candidates for this therapy are selected based on appropriate polysomnographic testing, age, body mass index and objective upper airway evaluation.
The current US Food and Drug Administration (FDA) eligibility criteria for upper airway stimulator implantation includes age of at least 22 years, an apnea-hypopnea index (AHI) of 15-65, a lack of central apnea and a favorable pattern of the palatal collapse during drug-induced sleep endoscopy. The cited literature also notes that patients with obstructive sleep apnea, unable to tolerate CPAP, and with an elevated BMI can be successfully treated with upper airway stimulation therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory system /Other 
Treatment: Surgical services 
The insurer denied vagus nerve neurostimulator  
The denial is overturned in whole 

The patient with a history of obstructive sleep apnea. A most recent study confirmed obstructive sleep apnea (OSA) with sleep study This showed an apnea hypopnea index (AHI) of 37.9. The minimum oxygen desaturation was 81%. Other pertinent vital signs include a body mass index (BMI) of 24.54.
There is sufficient evidence to support upper airway surgery (UAS) in certain instances. Woodson et al (2015) and Strollo et al. have shown significant safety and benefit for patients with OSA. Other authors have even commented that "once it becomes a standard therapy, its advantages might prove sufficient to challenge CPAP as the first-line therapy." (Mwenge et al 2015). In patients with a lower BMI and a severe AHI (such as this patient), the study published by Soose et al further supports the use of UAS surgery. They found that in those patients with "severe OSA and body mass index <= 32 kg/m2, hypoglossal cranial nerve stimulation therapy can provide significant improvement in important sleep related quality-of-life outcome measures and the effect is maintained across a 2-y follow-up period."
The (Inspire) is considered by the general otolaryngology community to be an accepted surgical treatment in select patients. This is based on clinical evidence. The patient has failed a CPAP trial and is not appropriate candidate for an oral appliance. The appropriate work up for a hypoglossal stimulator was done with a sleep endoscopy which showed lack of concentric collapse of the upper airway, and significant prolapse of the tongue during sleep. Finally, the patient is at risk for developing severe medical co-morbidities if the obstructive sleep apnea (OSA) continues to go untreated.
After review of the chart information and the current literature, the proposed treatment of hypoglossal nerve stimulation (Inspire) is not investigational and appropriate for certain patients. The physician has performed the proper work up for the patient and found the patient to be an appropriate candidate. FDA approval of the device for obstructive sleep apnea, and the current research shows strong evidence that upper airway stimulation is an effective treatment in certain patients who meet a certain inclusion criterion. A hypoglossal stimulator is the most viable option for this patient for treatment for OSA.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: Inpatient stay

The insurer denied coverage for the inpatient stay.

The denial is upheld.

This is a female patient with a past medical history significant for facial abscess, status post excisional debridement with drainage who presented to the Emergency Department (ED) with complaints of left-sided facial swelling and pain. The patient's vital signs on ED presentation included: temperature 97.3 F, blood pressure 151/92, pulse 94, respiratory rate 18, and oxygen saturation 100% on room air. The patient's laboratory values were notable for the following: white blood cell (WBC) count 7.61, hemoglobin (Hgb) 14, hematocrit (Hct) 43, glucose 78, creatinine 1.0, and lactate 1.0. The patient was empirically started on intravenous antibiotics (i.e., vancomycin and Ancef) for possible odontogenic infection. The patient's maxillofacial computed tomography (CT) scan imaging showed subcutaneous fatty infiltration in the anterolateral left facial region. Infectious diseases and plastic surgery services were consulted. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue treatment on oral antibiotics (i.e., Bactrim and Keflex) as an outpatient. 

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient presented to the hospital with localized facial cellulitis following an incision and drainage (I&D). Otherwise, the patient was afebrile and hemodynamically stable with no evidence for systemic toxicity. The patient's laboratory results were unremarkable including a normal white blood cell (WBC) count. The patient's CT scan did not reveal any drainable collection and no surgical intervention was required. Based on these clinical findings, the patient did not meet criteria for acute inpatient admission. 

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

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

Diagnosis: Mood disorder
Treatment: Residential mental health
The insurer denied the residential mental health. 
The denial is upheld. 

No, the Mental Health Residential Treatment Level of Care is not medically necessary. 

The patient is a male. He has diagnoses of major depressive disorder, recurrent, moderate, parent-child conflict, and attention deficit hyperactivity disorder. He was admitted to this residential facility to address his psychological and substance abuse issues. The patient's home environment is described as chaotic and stressful due to parental arguments and verbal abuse on the part of his father, who reportedly was intimidating, demeaning, verbally abusive and historically physically abusive. 

The patient had engaged in self-cutting, but there was no evidence of active suicidality, nor evidence of any recent such behavior. The patient had made comments indicating passive suicidal ideation. 

The patient's substance abuse history includes daily use of marijuana, various psychedelics, anxiolytics, and pain medications although specific quantities and frequencies are not specified. The patient has a history of verbal aggression toward his mother including yelling, name-calling, swearing, arguing, and taunting. Non-verbal aggression includes posturing, pushing, and slamming doors. 

The patient was described as being depressed with lack of motivation, poor sleep, poor appetite, lethargy, difficulty concentrating, and feelings of worthlessness. He also had ADHD (attention deficit hyperactivity disorder) symptoms including inattention, difficulty focusing, and distractibility, but refused to take medication for ADHD. He reportedly had been prescribed Lexapro by an outpatient psychiatrist. He had been in treatment for several years with two psychologists, one of whom wrote that he "navigated" the patient to this facility. 

In the facility the patient was treated with individual psychotherapy, milieu therapy, and group therapy. He refused medications, stating he only wanted "organic things" in his body. This facility utilized various movement therapies, equine therapy, art therapy, yoga, mindfulness exercises, and breathing techniques.

For the dates of service under review, the patient showed no evidence of suicidality, behavioral dyscontrol, psychosis, inability to care for his ADLs (activities of daily living), danger to self or others, or any other problem which would require 24-hour daily supervision and treatment. He was cooperative with treatment. There was no evidence of significant acting out behaviors. His behavioral problems which prompted this admission were described as clear reactions to a pathological home situation. For the dates of service under review, nothing in the documentation reviewed indicates that this patient would not have been better served by treatment in a less restrictive community setting with intensive parental involvement.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Ductal Carcinoma in situ

Treatment: Nerve Repair with Allograft (tissue graft from a donor) or Synthetic (produced by chemicals), Nipple-Sparing; billing code 64910

The insurer denied the nerve repair with allograft (tissue graft from a donor) or synthetic (produced by chemicals), nipple-sparing; billing code 64910.

The denial was upheld.

This is a female patient who was diagnosed with ductal carcinoma in situ in one breast by Mammogram, MRI and biopsy. Bilateral mastectomies with immediate breast reconstruction, axillary node dissection, nipple sparring mastectomies with immediate sensory nerve reconstruction with allograft is being considered.

Several studies show that nipple areola sensation is diminished following nipple sparing mastectomy, and loss of nipple sensation negatively affects patient satisfaction following nipple sparing mastectomy.  According to Peled and Peled: "While newer breast reconstruction approaches utilizing nipple-sparing mastectomy (NSM) techniques and immediate reconstruction can provide excellent aesthetic outcomes, absent postoperative sensation remains a major limitationNerve grafting in conjunction with careful nerve preservation at the time of NSM and implant-based breast reconstruction is safe and effective with a 90% rate of preserved sensation. With longer follow-up, continued return of sensation or possibly improved sensation from baseline can be reasonably anticipated."   This is the only peer reviewed study on nerve reconstruction following nipple sparing mastectomy and had only 18 patients. According to a review by Ducic et al: "Contemporary reconstructive modalities focus on breast anatomy and attempt to reconstruct breasts that are soft, of adequate shape, size, and symmetry. However, a functional component, i.e. sensation, has largely been ignored. Flap neurotization addresses this shortcoming. While we are still in search of the ideal surgical technique to achieve this goal..."  The peer literature is not sufficient to confirm efficacy.

While Nerve allograft is approved by the FDA and the patient is a good candidate for nerve reconstruction, the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. There is insufficient peer evidence to support this procedure. This service is not likely to be more beneficial than any other standard procedure.                                 

The denial of nerve repair with allograft (tissue graft from a donor) or synthetic (produced by chemicals), nipple-sparing; billing code 64910 is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autoimmune encephalitis
Treatment:  Intravenous immunoglobulin (IVIG) x10 visits.
The insurer denied  IVIG injections x10 visits.
The denial is Upheld

The member is a female with autoimmune encephalitis. MRI, CSF (cerebrospinal fluid) and autoimmune antibody panel were negative.

The member does not have a condition that has been demonstrated to improve with IVIG treatment. The work-up for her condition has been negative. There are no diagnostic test results to support the diagnosis of autoimmune encephalitis. Moreover, there are no high quality clinical trials demonstrating that IVIG is effective relative to placebo or any other immunosuppressive therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis 
Treatment: Inpatient admission 

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

This is a female patient with a medical history of hypertension, caesarean section, obesity, and tobacco smoker. The patient presented to the emergency department (ED) with complaints of epigastric pain that radiated to the right and left lower quadrants with associated nausea and vomiting. The patient's presenting vital signs were:
blood pressure of 161/88, pulse of 80, and temperature of 97.9. The abdomen was soft and non-distended with normal bowel sounds; tenderness was noted in the epigastric area. There was a negative Murphy's sign. The patient was admitted to the hospital with epigastric pain, appendicitis. An ultrasound of the right upper abdomen was done that revealed cholelithiasis without evidence of cholecystitis, extrahepatic biliary ductal dilatation to 9 mm and hepatic steatosis. A computed tomography (CT) scan of the abdomen and pelvis revealed acute appendicitis, 9 mm appendicolith at the appendiceal base. The patient underwent a laparoscopic appendectomy under general anesthesia. The patient was stabilized and discharged. 

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

Acute, uncomplicated appendicitis being treated with laparoscopic appendectomy does not mandate inpatient admission. Discharge may be safely undertaken once the operation is completed and the patient's pain is well controlled with a safe discharge plan. The patient went home the following day; the patient should have been admitted to observation. In fact, data has emerged that discharge on the same day of surgery or within 12-24 hours after surgery is safe based on large national database study (Grigorian et al., 2019). Another study found that implementing a protocol to discharge patients within 24 hours of laparoscopic appendectomy resulted in a successful discharge in 95% of patients with an extremely low return to hospital rate (Bradley et al., 2019). Therefore, this patient should not have been admitted to inpatient and could have been successfully managed as an outpatient. 

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

Diagnosis: Abdominal pain and vomiting.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male who underwent an acute hospitalization.  The patient had arrived from his shelter via ambulance to the emergency department (ED) of the facility filing the appeal with emesis and abdominal pain. The patient noted a sudden onset two hours prior to arrival. The pain was epigastric, sharp and non-radiating. The patient thought the pain may have related to pizza he had ingested prior. The patient had a history of gastritis, schizophrenia, hypertension, hepatitis C, bipolar disorder and polysubstance abuse. The patient was noted to be screaming in pain and hypertensive.  The hemoglobin was 4.6 and the fecal occult blood was negative.  The patient received supportive care. The pain was felt to be possibly related to alcoholic gastritis. On the second hospital day the patient signed out against medical advice (AMA). The evaluation was unremarkable and the patient received no transfusion.

No, the inpatient admission was not medically necessary. 

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, or severe electrolyte dyscrasias.  The patient did not receive any blood transfusions or evidence acute blood loss.  As such the care could have been rendered at a lesser level.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis: Ulcerative colitis
Treatment: Entyvio
The insurer denied the Entyvio. 
The denial is overturned.

The patient is a male with ulcerative colitis. He has failed treatment with balsalazide, and developed a drug induced hepatitis with Mercaptopurine (6-MP). The physician (MD) is requesting treatment with Entyvio.

Yes, the proposed treatment is medically necessary.

The patient has moderate to severe ulcerative colitis and has failed conventional therapy. He needs treatment with biologics. While Entyvio is an acceptable treatment option, Remicade also has been found to be a safe and effective treatment option for patients with ulcerative colitis, however, is recommended to be used in combination with a thiopurine to induce remission in patients with moderate to severe disease. As the patient has had a life-threatening reaction to a thiopurine, 6-MP, Entyvio should be used to induce remission instead of Remicade, which would require the use of a thiopurine with it. Therefore, the requested Entyvio is medically necessary over the plan preferred Remicade, and the health plan did not act in the best interest of the patient by denying it.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Low back pain 
Treatment: 22899 - Intracept Procedure - intraosseous ablation of the basivertebral nerve, C9752 - Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar sacrum, C9753 - Destruction of intraosseous basivertebral nerve, each additional cerebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure)

The insurer denied 22899 - Intracept Procedure - intraosseous ablation of the basivertebral nerve, C9752 - Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar sacrum, C9753 - Destruction of intraosseous basivertebral nerve, each additional cerebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure).

The denial is overturned. 

The patient is a female with low back pain requesting an Intracept procedure intraosseous ablation of the basivertebral nerve.

Yes, the health plan should cover the proposed treatment.

Yes, the requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.

The patient has chronic low back pain and is requesting an Intracept procedure which is intravertebral ablation of the basivertebral nerve. The patient has had multiple facet injections and ablations without relief of her pain, which affects her activities of daily living (ADLs). The patient is requesting intraosseous ablation of the basivertebral nerve for treatment of her lower back pain.

A prospective randomized multi-center study of 2020, by Fischgrund, found that "CLBP [chronic lower back pain] patients treated with BVN [basivertebral nerve] ablation exhibit sustained clinical improvements in function and pain with high responder rates at a mean of 6.4 years following treatment. BVN ablation is a durable, minimally invasive treatment for vertebrogenic CLBP." A prospective study and literature review of 2020, by Kim, found that Basivertebral Nerve Radiofrequency Ablation was effective in improving the patients' pain, disability status and patient outcome. A prospective, randomized, multi-center study by Khalil, in 2019, found that "Minimally invasive RF ablation of the BVN led to significant improvement of pain and function at 3-months in patients with chronic vertebrogenic related LBP." Multiple other randomized controlled studies have shown the procedure to be effective.

The peer-reviewed medical literature has demonstrated through multiple randomized multi-center trials that intraosseous ablation of the basivertebral nerve is an effective procedure for lower back pain and the definition of experimental/investigational is not fulfilled.