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

Diagnosis: Obstructive Sleep Apnea (OSA). 
Treatment: Outpatient Surgery (64568 x 1); implanted hypoglossal nerve stimulation. 

The insurer denied coverage for Outpatient Surgery (64568 x 1); implanted hypoglossal nerve stimulation. 

The denial is overturned. 

This female patient has a history of obstructive sleep apnea (OSA). The patient was noted to have involuntary continuous positive airway pressure (CPAP) intolerance. She was previously diagnosed 2.5 years prior to presentation with an Apnea Hypopnea Index (AHI) of 30.2. She has attempted to utilize CPAP and has tried a variety of masks. She has a body mass index (BMI) of 31.4. Objectively, the nasal examination did have some irregularity of the right columellar upper lip junction on the right due to lower lateral cartilage. There was a Mallampati 3-4 configuration. The physician indicated in view of the OSA/upper airway obstruction, a flexible laryngoscopy was indicated. The documentation indicated the patient did undergo the procedure indicating there was enlarged lingual tonsils obscuring the valleculae they did partially open with tongue protrusion. The documentation indicates the patient underwent a sleep endoscopy. The documentation did indicate the patient did begin to snore and anterior-posterior (AP) collapse/obstruction became apparent. The tongue was seen to move posteriorly with greater than 75% obstruction. The epiglottis was being pushed posteriorly by the tongue but did not seem to collapse independently. Additional documentation does indicate the patient should receive the requested upper airway stimulation (UAS) device given it has been confirmed that she does not have complete concentric collapse of the upper airway. She has also failed and is intolerant to CPAP and has been initially diagnosed with severe OSA. 

The requested procedure (implantation of a hypoglossal nerve stimulator) is medically necessary and appropriate. 
   
In their updated (2017) position statement, The American Academy of Otolaryngology-Head and Neck Surgery stated, it considers UAS via the hypoglossal nerve for the treatment of adult OSA syndrome to be an effective second-line treatment of moderate to severe OSA 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 UAS implantation includes age of at least 22 years, an AHI of 15-65, a lack of central apnea, a BMI of less than 32 and a favorable pattern of the palatal collapse during drug-induced sleep endoscopy. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

Based on the above, the medical necessity for Outpatient Surgery (64568 x 1); implanted hypoglossal nerve stimulation is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Radiology Services. 
The insurer denied outpatient surgery services. 
The denial is overturned in whole.

The patient is a female patient with liver metastases from rectal cancer following previous surgical therapies and radiation, with ongoing pulmonary metastases as well. She has good performance status and presents for palliative radio-embolization procedure with ( Yttrium) Y-90 spheres.
The patient has a history of good liver function and no contraindications noted to radioembolization and with previous imaging including pelvic/rectal magnetic resonance imaging (MRI).
The pertinent past medical records show evidence for side effects of chemotherapy. Past medical history also includes colonoscopy, port placement, and post procedural fluid collection in the perineal area requiring drainage.
The subject under review is the medical necessity for the outpatient surgery services for these needed procedures including all requested current procedural terminology (CPT) codes.

The health plan's determination is overturned. 

Yes, the requested health service/treatment of outpatient surgery services, that being selective catheterizations and embolizations (CPT codes listed below) to allow Y-90 radiation bead treatment infusion is medically necessary for this patient. This patient has metastatic rectal cancer to the liver requiring liver directed loco-regional therapy to control disease and preserve liver function by way of catheter placements in the hepatic artery branches and embolization to allow subsequent safe bead infusion.
This patient has need for a Y-90 radio-embolization for control of unresectable liver metastases from colorectal cancer. This will prolong life, control intrahepatic disease and diminish future symptoms. Liver directed therapy is certainly the treatment of choice. However, to perform the mapping prior to infusion to confirm eligibility and to perform the actual infusion requires need for catheterization of liver/hepatic arteries and additional adjunct procedures.  This needs to include a series of additional procedures to allow accurate performance of the planned therapy.
This therefore requires use of the following (current procedures terminology) CPT codes as requested: 37243, and 37242. These codes are for embolization of the liver tumor and artery branches in preparation of the later Y-90 infusion. Additional codes requested include: 36248 additional branches, 36247 for third order branch, 36246 for second order branch, and 36245 for first order branch. These relate to catheterizations of multiple hepatic artery branches for evaluation, for safe planning, and any necessary therapy, all prior to the actual Y-90 administration.
Palliative loco-regional therapy is well tolerated and quite efficacious and should be authorized in total.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Type 2
Treatment: Pharmacy/Prescription Drugs/Januvia
The health plan denied the requested medication. 
The health plan's determination is overturned.

This is a male diagnosed with diabetes type 2 (T2DM). This request is for Januvia. As reported, he has a multisystem disease affecting his renal system, immune system and nervous system causing damage to his joints, heart and kidneys. He was diagnosed with end stage renal disease status post renal transplant, hypertension (HTN), gout, hyperlipidemia, hyperparathyroidism as well as diabetes with renal manifestations. He is stable on Januvia. He is on Metformin. His creatinine is now 1.1 - 1.3.

At issue is the medical necessity of the requested prescription medication.

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

Yes, the request for Januvia is medically necessary. The DPPIV Inhibitors (dipeptidyl peptidase inhibitors) have similar efficacy. There are no trials showing superiority of one DPPIV inhibitor over another, including Linagliptin (Tradjenta), Saxagliptin (Onglyza), Vidagliptin (Galvus), Alogliptin (Nesina) or Sitagliptin (Januvia) [1, 2, 3, 4]. The American Association of Clinical Endocrinologist's consensus statement regarding the treatment of patients with type two diabetes is as follows: It recommends the use of Metformin or a DPP4 (dipeptidyl peptidase 4) inhibitor or a GLP1 (glucagon-like peptide 1) agonist as a first line agent [5, 6].

In patients who are post renal transplant, such as this patient, there are no studies showing safety or efficacy of the alternative Alogliptin. The physician cites a study showing safety of Sitagliptin, which the patient is taking and has been safe and effective for the patient. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Blurred vision

Treatment: Lumigan (bimatoprost)

The insurer denied coverage for the medication Lumigan (bimatoprost).

The denial is upheld.

This is a female with blurred vision in both eyes. The blurred vision is at computer distance and at all distances and associated with dry eyes, irritation, pain, and wearing glasses. The blurred vision has been present for 1 month and is moderate in severity for both eyes. The blurred vision is relieved by blinking and the patient is treated with artificial tears and steroid eye drops.

The denial for Lumigan is upheld because there is no documentation in the medical records provided for review that the patient has tried and failed, or has an intolerance to other prostaglandin formulary alternatives, including latanoprost and travoprost.  

Although the patient reported that latanoprost and travoprost were ineffective, there is no documentation in the medical records to support this claim. There is no evidence in the literature that Lumigan is superior to other prostaglandins in controlling intraocular pressure.  

According to a review of current literature, all prostaglandin analogues have been shown to equally and significantly reduce the intraocular pressure (IOP) in glaucoma patients. In a patient without a known allergy to benzalkonium chloride or other ophthalmic preservatives, and who has not been documented to have tried other prostaglandin analogs, it is reasonable to try generic bimatoprost, latanoprost or travoprost instead of Lumigan.

The submitted documentation does not support that the requested drug will be more effective than the formulary alternative.

Based on the above, Formulary Exception for Lumigan (bimatoprost) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Cosentyx (300mg) 150mg/ml  SC SOAJ,  Pre-service
The insurer denied the Cosentyx (300mg) 150mg/ml  SC SOAJ,  Pre-service.
The denial is overturned. 

The patient is a male with severe psoriasis affecting greater than 10% body surface area (BSA). He has tried and failed to topical steroids. The request is for Cosentyx injections. He drinks two pints of vodka per day, and he is therefore not a good candidate for oral systemic medication, such as methotrexate or cyclosporine.

Yes, the treatment with Cosentyx is medically necessary.

The patient is a candidate for Cosentyx, because he has a diagnosis of moderate to severe chronic plaque psoriasis and greater than 10% BSA (body surface area) involved.

The current treatment guidelines, which are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis, recommend typical first-line treatments such as topical corticosteroids and calcipotriene, followed by typical second line treatments such as ultraviolet phototherapy, oral systemic treatments (methotrexate, acitretin, cyclosporine) or biologics. The patient has tried and failed topical treatments.

The next appropriate treatment would be phototherapy, oral systemic medications or biologics. Biologics are the most effective of these treatments. Coesntyx is indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy. Thus, Cosentyx is medically appropriate and medically necessary.

The patient is not a candidate for oral systemic medication such as methotrexate or cyclosporine, because he drinks significant amounts of alcohol on a daily basis, namely, two pints of vodka every day. Additionally, methotrexate is far less effective than Cosentyx in reducing the signs and symptoms of psoriasis. Cyclosporine is not a reasonable long-term treatment due to its side effect; it is usually used to bridge the patient to another medication which is more effective and has less potential for long-term side effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer
Treatment: Proton Beam Radiation Therapy 
The insurer denied the Proton Beam Radiation Therapy. 
The health plan's determination is upheld.

This patient is a man with a prostate-specific antigen (PSA) of 4 ng/ml. He had biopsies that revealed a Gleason 6 adenocarcinoma. He chose to observe until the PSA rose to 5 ng/ml. He had repeat biopsies that revealed a Gleason 6 adenocarcinoma again. He is now interested in radiation therapy as definitive treatment and the proton beam approach is being requested.

The proton beam radiation therapy is not medically necessary for this patient. Proton beam radiation therapy is not considered a standard treatment option for prostate carcinomas. There are not adequate medical literature published in peer reviewed journals supporting its use as equivalent, nor better or safer than standard photon radiation therapy such as 3D (three dimensional) conformal or intensity modulated radiation therapy (IMRT). There are multiple smaller studies and short term follow up studies that show the potential of proton beam radiation therapy as definitive treatment for localized prostate carcinomas, but these studies also state the need for further randomized trials to determine the efficacy and safety of proton beam radiation therapy for this diagnosis. Therefore, the requested proton radiation therapy is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Radiology Services. 
The insurer denied: three-phase bone scan. 
The denial is overturned.

This is a female who has been recommended for a three-phase bone scan. A progress note includes a complaint of right wrist pain. There is pain with using the wrist. The associated symptoms include weakness, numbness, and tingling. The physical examination of the right wrist reveals tenderness in the radial and ulnar areas, normal range of motion, 4/5 grip strength, no erythema, no scars, normal sensation, and present pulses. The note indicates right wrist x-rays from the day of the encounter show a subtle ovoid shaped area of lucency at the distal third of the radius measuring 4 x 27 millimeter (mm) in the transverse and anterior-posterior dimensions, respectively. The lucency is poorly seen on the lateral view and may represent localized cancellous bone formation in this area. It is noted that further evaluation may be helpful with a repeat oblique view of the lateral projection. The provider states the radiologist is recommending further imaging, and the patient will be called to come back in for further x-rays.

A right wrist magnetic resonance imaging (MRI) with and without contrast radiology report indicates the distal radius lytic lesion appear smaller on MRI and the lesion is circumscribed with a relatively non-aggressive appearance with at least partial sclerotic rim suspect. The radiologist states the possibility of a lytic form of fibrous dysplasia would be raised, but a lytic metastatic lesion would be hard to exclude conclusively. The radiologist indicates a bone scan could be considered further evaluation. Correlation with any known primary malignancy is also suggested. The radiologist states tissue sampling may be necessary.

The subject under review is the medical necessity for the three-phase bone scan.

The health plan's determination is overturned.

The bone scan is medically necessary. The patient has since had the right wrist MRI with and without contrast that was recommended by the health plan. The study was performed and indicated the lytic lesion of the distal radius was consistent with a possibility of a lytic form of fibrous dysplasia would be raised, but a lytic metastatic lesion could not be ruled out. The radiologist recommended a bone scan for further evaluation. The American College of Radiology Appropriateness Criteria for primary bone tumor would support a three-phase bone scan for further evaluation after radiographs and MRI with and without contrast. As the etiology of the lytic lesion remains indeterminate despite radiographs and MRI with and without contrast, further evaluation with a three-phase bone scan is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.
Treatment: Inpatient Hospital Stay.
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a history of abdominal pain and she also had nausea for approximately 48 hours prior to presentation. She had some right lower quadrant tenderness on examination and an elevated white blood cell count (WBC) and was diagnosed with appendicitis. She underwent an uneventful laparoscopic appendectomy and was discharged on the same day.

At issue is the medical necessity of an inpatient stay.

An inpatient level of care was not medically appropriate or necessary. The patient could have been safely and appropriately managed at a lower level of care. No evidence was presented in the appeal documentation or in the primary medical records that would indicate that the patient had complicated appendicitis, and the operative note clearly defines this as a case of simple, acute appendicitis without perforation of the appendix. Moreover, patients with acute non-perforated appendicitis like this child can often be discharged home the same day from the hospital, without an overnight stay. An inpatient stay could be justified if there was complicated appendicitis (eg., perforated appendicitis with generalized peritonitis), an untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition. Surgical treatment of otherwise healthy pediatric patients with acute nonperforated appendicitis is usually provided at a lower level of care.

In one study authored by Aguayo, et al, in over 500 cases, approximately 28% (number [n]=128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n=59) stayed overnight for medical reasons, 0.4% (n=2) stayed for social reasons, 3.9% (n=18) stayed because the operation ended late in the evening, and 82.8% (n=381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, probability [P]=0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P=1.0), and complication rate (0.7% versus 2.6%, P=0.3). Patients whose operation ended later in the day had a longer hospital stay. Thus, same day discharge is safe for children undergoing laparoscopic appendectomy for nonperforated appendicitis. These data strongly suggest that for most patients with acute, nonperforated appendicitis who undergo an uncomplicated appendectomy, a lower level of care thereafter is appropriate since their needs are low acuity and the recovery is generally smooth and uneventful. Based on the literature and widespread experience with modern treatment of pediatric acute appendicitis, an inpatient acute level of care is not justified for acute, uncomplicated appendicitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a past medical history (PMH) of hypertension (HTN) and was admitted with complaints of (c/o) a sudden onset of dizziness without other associated symptoms. Vital signs were notable for hypertension (HTN). The physical exam was notable for negative cerebellar signs and positive Dix-Hallpike maneuver. Lab work was unremarkable. A computed tomography (CT) scan of the head showed no intracranial bleed. An electrocardiogram (EKG) showed normal morphologies, normal sinus rhythm (NSR), no ST segment (the line on the electrocardiogram that begins with the end of the QRS complex and ends at the beginning of the T wave) changes. The patient was diagnosed with positional vertigo and treated with meclizine, intravenous (IV) fluids and an Epley maneuver, with improvement in symptoms. Neurology was consulted and confirmed a diagnosis of benign paroxysmal postural vertigo (BPPV). The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the Emergency department (ED) with sudden onset of dizziness without other associated symptoms. The patient received a thorough evaluation from neurology and was ultimately diagnosed with peripheral vertigo, likely BPPV. In addition, the radiological work-up did not demonstrate any acute findings, the patient's admission blood pressure (BP) was less than (<) 220/140, there was no eclampsia, cardiac enzymes indicative of infarction or acute coronary syndrome (ACS), hypertensive emergency, hemodynamic instability or evidence of acute end-organ injury, such as intracranial hemorrhage, acute renal failure, focal neurologic abnormalities or aortic dissection. Although there was mention of a hypertensive emergency, a diagnosis which the neurologist did not provide, the patient was documented to have a non-focal neurological examination and was awake, alert and oriented times four (AAO x4). Overall, this patient was treated with meclizine, anti-hypertensives, a radiological work-up, intravenous (IV) fluids and neurology consultation, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-displaced fractures of the left angle and right body of the mandible
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a patient who had been previously assaulted. He was evaluated by Oral and Maxillofacial Surgery due to continued pain. He was diagnosed with non-displaced fractures of the left angle and right body of the mandible. He was taken to the operating room (OR) two days after admission and underwent a closed reduction and left that day.

At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. The records indicate that this patient was seen more than a week after his trauma. He sought treatment as there was continued pain but he was in no apparent distress and had no limitation of opening. Despite this, the patient was admitted to the hospital and waited two days to have arch bars and maxillomandibular fixation applied in the operating room (OR). The patient left on his own on the same day as treatment. This treatment is commonly performed in the office with intravenous (IV) anesthesia and the patient sent home after recovering.

A study was conducted that compared the rates of postoperative inflammatory complications (POICs) in patients with isolated mandibular fractures treated in a nonurgent manner by an outpatient protocol versus a traditional, urgent inpatient protocol. The study sample was composed of 193 patients, with 82 in the outpatient group and 111 in the inpatient group. The frequency of POICs was 17.1% and 18.9% in the outpatient and inpatient groups, respectively. An outpatient model to treat isolated mandibular fractures was not associated with an increased risk of POICs. This outpatient care model reduced the hospital length of stay without increasing the risk of POICs.

An inpatient stay was not medically necessary in this case.