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

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

The patient is a female. She presented the emergency ward with right hemibody numbness, intermittently for one month. She had a NIH (National Institutes of Health) stroke scale of 4. She was admitted for possible stroke. Her MRI (magnetic resonance imaging) was negative.

No, the Inpatient admission was not medically necessary.
The patient presented with right hemibody numbness for one month.  The possibility that this was an acute stroke or recurrent TIA (transient ischemic attack) was low (Mendelson and Prabhakaran). The diagnostic studies were negative. The neurology consult, diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Surgical Services 
The insurer denied Intracept Procedure. 
The denial is upheld in whole.

The patient is a female with low back pain. Magnetic resonance imaging (MRI) by report is significant for degenerative disc disease. The Intracept procedure is proposed to treat low back pain symptoms.

The subject under review is the medical necessity for the procedure.

The health plan's determination is upheld in whole. 

The requested Intracept procedure is not medically necessary for this patient.

A prospective case series and review of literature of basivertebral and sinuvertebral nerve ablation states (in part) "A review in literature is done on the pathoanatomy, pathophysiology and pain generation pathway in degenerative disc disease and chronic back pain. 30 patients with 38 levels of intervertebral disc presented with discogenic back pain" [1]. The case series and review of literature is limited to a small number of subjects.

A guideline issued by the International Society for the Advancement of Spine Surgery Guideline on intraosseous ablation of the basivertebral nerve (BVN) for the relief of chronic low back pain concludes (in part) "Intraosseous ablation of the BVN is a relatively new minimally invasive treatment for the relief of chronic low back pain (CLBP) that is diagnosed using well-established clinical and magnetic resonance imaging (MRI) findings. The procedure is supported by level 1 evidence including 2 randomized controlled trials (RCTs) demonstrating a statistically significant decrease in pain and an improvement in function with outcomes sustained to at least 24 months in a limited number of studies" [2]. Multiple limitations of the guideline present, including:

1) Industry funding is a potential source of study bias for the available data reviewed. 2) Limited number of studies. 3) Short-term follow up for the majority of studied patients. 4) Unknown effect on the primary degenerative process.

A prospective, open-label, single-arm, multi-center study of intraosseous basivertebral nerve ablation for the treatment of chronic low back pain [3] describes improvements in pain and function following treatment, but the study is limited to 28 patients.

In short, reliable evidence shows that the consensus among qualified objective experts regarding the inherent nature of the Intracept Procedure is that further clinical studies, clinical outcomes research, or clinical trials are necessary to determine its safety, efficacy and anticipated outcomes as compared with the standard means of treatment of the condition in question and is therefore not considered the standard of care. It would therefore not be considered medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Primary axillary hyperhidrosis. 
Treatment: Formulary exception for Botox, Pre-service. 

The insurer denied the Formulary exception for Botox, Pre-service. 
The denial is overturned. 

The patient is a man with primary axillary hyperhidrosis, for whom Botox injections are requested. He was prescribed topical Drysol. The hyperhidrosis interferes with the patient social and/or professional life. He has no co-morbidities. The prior authorization form filled out notes that the patient has failed to respond to topical aluminum chloride or has developed a severe rash. 

Yes, the health plan should cover the Formulary exception for Botox. 

Topical antiperspirants are the preferred initial treatment for axillary hyperhidrosis, because they are widely available, inexpensive, and well-tolerated therapies. Topical glycopyrronium is an alternative first-line treatment and an option for patients who present with a history of poor responses to prescription antiperspirants.  Patients who do not achieve sufficient improvement in axillary hyperhidrosis with topical antiperspirants may benefit from botulinum toxin injections or microwave thermolysis. Systemic therapies (anticholinergics, clonidine, beta-blockers, and benzodiazepines) can be effective for primary focal hyperhidrosis. The potential adverse effects of systemic agents inhibit the routine use of these therapies. Additional studies are necessary to confirm the long-term efficacy and safety of anticholinergic drugs when utilized for this indication. 

Based on current guidelines in the published peer-reviewed literature, the patient has failed first-line therapy with topical aluminum chloride. Botox is an appropriate second line of therapy for this patient. Systemic therapies are not recommended due to the potential for side effects and lack of studies establishing long-term efficacy and safety of anticholinergic drugs for primary axillary hyperhidrosis.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic procedure

Diagnosis: Malocclusion.
Treatment: Braces and Orthodontic Visits. 
The insurer denied Braces and Orthodontic Visits. 
The health plan's determination is overturned. 

The patient in question is a male with an anterior crossbite on tooth #7. He presents with a Class III subdivision Right malocclusion with mild crowding in the maxilla and mandible. He is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite.

Braces and orthodontic visits are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth #7, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
If left untreated the damage that will occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is deemed medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.

Treatment: Procedure code 0466T, Inspire upper airway stimulation system should be overturned.

The insurer denied coverage for the procedure code 0466T, Inspire upper airway stimulation system.

The denial is overturned. 

This is a female with a diagnosis of hypertension as well as obstructive sleep apnea (OSA) and Graves' disease. The patient has been recommended to receive implantation of the upper airway stimulation device. The patient has a body mass index (BMI) of 30.2.  She has an apnea-hypopnea index (AHI)  of 32.9. The documentation also details this patient has had a trial and failure of continuous positive airway pressure (CPAP). She had complaints of the mask causing skin irritation. She has undergone a drug-induced sleep endoscopy which reveals anterior and posterior collapse. The submitted documentation includes a chart note of when she was being seen for an initial consultation regarding OSA. The documentation does indicate she does have comorbidities that include hypertension. She also claims of falling asleep mid conversation. She stated she is now unable to drive. The documentation indicated the patient at this visit was recommended to undergo a drug-induced endoscopy. The patient did undergo the procedure and has further been recommended to undergo implantation of the inspire upper airway stimulation unit.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome. The procedure has final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for the requested procedure. This is the best available treatment for this patient at this time. The requested service is likely to be more beneficial than any other standard treatment for this patient. As with any invasive procedure there are risks involved. However, this patient has failed other standard treatment such as CPAP. 

The carrier's denial of the procedure code 0466T, Inspire upper airway stimulation system should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.

Treatment: Procedure code 0466T, Inspire upper airway stimulation system should be overturned.

The insurer denied coverage for the procedure code 0466T, Inspire upper airway stimulation system.

The denial is overturned. 

This is a female patient diagnosed with severe obstructive sleep apnea (OSA). The patient's diagnosis is based on a sleep study which showed an apnea-hypopnea index (AHI) of 32.9 and no evidence of central sleep apnea. The patient has a normal body mass index (BMI) of 30. The patient has tried multiple masks both full face and nasal in order to use her continuous positive airway pressure (CPAP) machine. The patient is not tolerant to it and cannot wear the masks for more than two hours at night. A sleep endoscopy was performed showing no concentric collapse. The treating provider is requesting plan approval for treatment with inspire upper airway stimulation system, 0466T.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

OSA "is the most common form of sleep-disordered breathing. The standard treatment, continuous positive airway pressure (CPAP), has limited long-term compliance. Alternative treatment options are required and new methods, including hypoglossal nerve stimulation (HNS) and continuous transcutaneous electrical stimulation (CTES)" (Campbell, et al., 2015).

"The AHI was reduced between 50% and 57%, and the Oswestry Disability Index (ODI) was reduced between 48% and 52%. Despite using different hypoglossal nerve stimulators in each subgroup analysis, no significant heterogeneity was found in any of the comparisons, suggesting equivalent efficacy regardless of the system in use" (Certal, et al., 2015).

"The trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA" (Dedhia, et al., 2015).  

The requested procedure has final approval from the appropriate regulatory bodies for this diagnosis. This patient is a good candidate for procedure code 0466T, Inspire upper airway stimulation system. Inspire therapy is indicated for patients with the characteristics of: above a certain age, moderate to severe OSA (AHI range from 15 to 65 with less than 25% central apneas), unable to use CPAP, free of complete concentric collapse at the palate, and BMI of less than 32. This patient meets all of these indicators. The procedure code 0466T, Inspire upper airway stimulation system is the best available treatment for this patient at this time. There are standard surgical risks, which are outweighed by the risks of untreated OSA. The Inspire implant procedure is likely to be more beneficial than any other OSA treatment for this patient since she has tried & failed CPAP therapy. 

The carrier's denial of the procedure code 0466T, Inspire upper airway stimulation system should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.

Treatment: Procedure code 0466T, Inspire upper airway stimulation system should be overturned.

The insurer denied coverage for the procedure code 0466T, Inspire upper airway stimulation system.

The denial is overturned. 

This is a female patient diagnosed with obstructive sleep apnea (OSA), hypertension, and Graves' disease. The patient had a body mass index (BMI) of 30.2, and apnea-hypopnea index (AHI) of 32.9. The patient had primarily central and mixed apneas of less than 25%. The patient was noted to be intolerant to continuous positive airway pressure (CPAP), had claustrophobia and the mask caused skin irritation. The patient had tried a nasal appliance without relief. The patient had the absence of complete concentric collapse per the drug-induced sleep endoscopy. The provider requested the Inspire upper airway stimulation system.

The scientific evidence in peer-reviewed literature supports improvement in health outcome and co-morbidities associated with OSA. This procedure has been approved by the Food and Drug Administration (FDA) since 2014. This patient meets the strict criteria for the inspire procedure, and therefore, is a good candidate for this procedure. This is the best available treatment for this patient at this time. The Inspire implant procedure is likely to be more beneficial than any other OSA treatment for this patient since she has tried & failed CPAP therapy. There are risks associated with surgical procedures like the Inspire implant procedure; these risks do not exist with the gold standard treatment of OSA, CPAP therapy, which this patient has tried & failed.

The carrier's denial of the procedure code 0466T, Inspire upper airway stimulation system should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial swelling secondary to angiotensin-converting enzyme (ACE) inhibitor related urticaria. 

Treatment: Inpatient hospital admission at an acute level of care. 

The insurer denied coverage for the inpatient hospital admission at an acute level of care. 

The denial is upheld. 

This is a female patient with past medical history significant for hypertension and diabetes mellitus who presented to the Emergency Department (ED) with complaints of right arm and facial swelling. According to the patient, symptoms resolved with use of Benadryl.

Vitals on presentation included: Temperature-97.7 Fahrenheit (F), Blood Pressure-166/90, Pulse-98, Respiratory Rate-18, and Oxygen (O2) saturation-98% on Room Air. Laboratory values were notable for the following: White blood cell (WBC) count-6.1, hemoglobin (Hgb)-9.9, hematocrit (Hct)-31.7, glucose-238, and creatinine-1.6.

The patient was admitted for likely urticarial swelling secondary to angiotensin-converting enzyme (ACE) inhibitor (Benazepril). She was treated with steroids and anti-histamines. Her symptoms resolved. Computed tomography (CT) scan of the neck was negative for jugular venous thrombosis, no inflammatory process or swelling. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral prednisone and Benadryl as an outpatient. 

According to documentation, the patient presented with facial swelling secondary to ACE inhibitor related urticaria. Otherwise, she was afebrile, hemodynamically stable, with no acute laboratory findings including a normal WBC. The patient denied any difficulty breathing or swallowing; saturating comfortably on room air. Based on the above findings, the patient met criteria for observation level of management. Documentation does not support need for acute inpatient hospitalization. 

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

The insurer's denial of coverage for the inpatient hospital admission at an acute level of care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient was a male with a history of diverticulitis. The patient had presented to the Emergency Department (ED) with abdominal pain and difficulty urinating.  The patient reported that for the preceding two days he had worsening abdominal pain and constipation. He used an enema for the constipation and had been having diarrhea since then. The patient reported that since the enema he has been having difficulty urinating. The morning on the day of presentation when he woke up he was having significant pain and could not void or defecate. The pain became unbearable so the patient came to the emergency department. He reported having diverticulitis in the past but the pain was never as bad. 

On examination, the patient was uncomfortable and intravenous (IV) pain medications were given.  The patient had not yet voided and there was suprapubic tenderness; a Foley was inserted and 1600 cubic centimeters (cc) of urine was passed. The patient also had a family history of prostate cancer and was followed with a urologist.  The patient reported his prostate specific antigen (PSA) level had always been normal. 

A consultation was made to urology for recommendations for urinary retention. The initial laboratory studies were remarkable for a lactic acidosis to 2.6. A computed tomography (CT) of the abdomen showed sigmoid diverticulosis and acute diverticulitis of the distal sigmoid colon. The patient was started on intravenous antibiotics and a consultation was made to gastroenterology. The patient was admitted for acute diverticulitis and intravenous pain control and intravenous antibiotics.  The patient was admitted.

No, the proposed inpatient admission was not medically necessary.
While the care as provided was medically appropriate, the level at which the care was rendered was not 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 an infection of the bowel [acute diverticulitis]; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of persistent sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Amplified musculoskeletal pain syndrome.
Treatment: Acute inpatient rehabilitation facility services.
The insurer denied coverage for acute inpatient rehabilitation facility services.

The denial is upheld. 

This patient is a female child diagnosed with amplified musculoskeletal pain syndrome (AMPS).  The patient underwent an initial physiatry evaluation and had subjective complaints of generalized joint pain, abdominal pain, and headaches.  It was noted she was significantly functionally limited due to her pain.  The physical examination revealed pain to palpation over the paraspinal musculature bilaterally.  She had pain to light touch over the joints.  Her gait was antalgic.  The provider recommended an inpatient comprehensive pain rehabilitation program be implemented as soon as possible to include physical therapy, occupational therapy, and psychology therapy.  It was noted that there was a concern that outpatient programs would not be enough to help her.

Acute inpatient rehabilitation facility services are not considered medically necessary for this patient.  The patient has AMPS and has been treated through therapy. It is understood that the provider had a concern that an outpatient program would not be enough to help with the patient.  The records do not support that the patient has been treated specifically in an outpatient AMPS program, for an adequate amount of time (3-4 months) and it did not provide adequate results.  Without documented failure of an outpatient multi-specialty involvement program specifically for the treatment of AMPS, inpatient rehabilitation would not be appropriate.

The health plan did act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for acute inpatient rehabilitation facility services is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient ischemic attack (TIA).

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

This case involves a male who presented to the Emergency Department (ED) to rule out transient ischemic attack (TIA). The patient does have a history that includes chronic lymphocytic leukemia as well as non-Hodgkin's lymphoma, sleep apnea, and anxiety. The documentation indicated the patient presented to the ED via Emergency Medical Services (EMS) as the family was concerned stating the patient was off balance and slurring his speech. The documentation indicated upon physical examination there was no significant findings. The documentation does indicate the patient was recommended to undergo laboratory and diagnostic studies. The patient underwent a chest x-ray as well as computed tomography (CT) scan of the head. The CT scan of the head revealed no acute intracranial pathology. The laboratory studies did not reveal any significant findings. The recommendation was made to admit the patient to rule out TIA versus medication side effects. The documentation does indicate he did attribute his symptoms to side effects of gabapentin. The patient was admitted and underwent an magnetic resonance imaging (MRI) of the brain. The patient underwent a neurology consultation where there were no significant neurological findings noted. An MRI of the brain revealed no acute infarct with no abnormal intracranial enhancement. The documentation detailed given the lack of adverse events, the patient was discharged with instruction to follow-up.

The patient presented to the ED with a clinical history of slurring of speech with reported difficulty with balance. After being evaluated in the ED, patient was admitted to the hospital. Diagnostic testing with CT of the head and MRI of the Brain were performed. These studies showed no acute findings. Neurology was consulted and no significant neurological findings were noted. Care provided, including specialty consultation with neurology, medical care provided, and diagnostic imaging could have been performed in the ED setting and at an observation level of care. Therefore, the entire inpatient admission was not medical necessary. 

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

The insurer's denial of coverage for the full hospital is upheld. Medical necessity is not substantiated.