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

Diagnosis: Obstructive sleep apnea

Treatment: Outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve

The insurer denied coverage for outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve.

The denial is overturned.

This is a female patient with a history of obstructive sleep apnea (OSA). She has an apnea-hypopnea index (AHI) of 29. She was seen by her provider who noted an inability to tolerate continuous positive airway pressure (CPAP). Also noted was a small lower jaw and dental malocclusion. She had a previous uvulopalatopharyngoplasty (UPPP) and hyoid suspension. The patient underwent a drug-induced sleep endoscopy with no concentric collapse found.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcome with surgical implantation of an upper airway stimulation device for the hypoglossal nerve for the diagnosis of OSA. "The American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS] considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and 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" (AAO-HNS 2019).     

Hypoglossal nerve stimulator is Food and Drug Administration (FDA) approved. This patient is a good candidate for outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve. The patient meets the standard criteria for an upper airway stimulator. She has OSA documented by a polysomnography (PSG) and her drug-induced sleep endoscopy did not show a concentric pharyngeal collapse. 

Outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve is the best available treatment for this patient at this time. The patient tried CPAP and could not tolerate it. She then had uvulopalatopharyngoplasty (UPPP) and hyoid suspension, which did not provide complete benefit. The upper airway stimulator has demonstrated benefit in patients with OSA, like this patient.     
  
The requested service of the outpatient implantation of an upper airway stimulator device for the hypoglossal nerve is likely to be more beneficial than any of the standard treatment/procedures for this patient, as this patient has already tried the other standard treatment choices without improvement.                                                    

Denial of outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea

Treatment: Outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve

The insurer denied coverage for outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve.

The denial is overturned.

This is a female patient who has been diagnosed with obstructive sleep apnea (OSA). Documentation indicated that the patient has failed the use of continuous positive airway pressure (CPAP). Documentation also indicated that she is unable to sleep with the mask. She has previously had surgical intervention to include uvulopalatopharyngoplasty (UPPP). There are limited alternative treatment options available and due to her OSA severity she is not a candidate for an oral appliance. The patient has also undergone a sleep endoscopy confirming that she does not have complete concentric collapse of the upper airway. The patient has an apnea-hypopnea index (AHI) of 29.8 with a body mass index (BMI) of 24.9. The doctor recommended an upper airway stimulation device for the hypoglossal nerve.

The upper airway stimulation device for the hypoglossal nerve has been shown to improve and sometimes cure obstructive sleep apnea (OSA), both objectively and subjectively. Treatment of OSA has been shown to improve overall health & lessen other co-morbidities. The procedure is Food and Drug Administration (FDA) approved. The patient is a good candidate for outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve, as the patient appears to meet the strict indications criteria. It appears that this implant procedure is the best available treatment for this patient at this time.

Due to this patient's severe OSA, and her inability to tolerate CPAP, there are no other standard treatments/procedures for this patient, besides the upper airway stimulation device for the hypoglossal nerve. Therefore, this procedure is likely to be more beneficial than any other standard procedures/treatments.

Denial of outpatient surgical implantation of an upper airway stimulation device for the hypoglossal nerve is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied the Dupixent.
The denial is upheld. 

The patient is a man with follicular eczema (atopic dermatitis) of the hands and forearms and prurigo nodularis for who Dupixent is requested. He had started NBUVB (narrowband ultraviolet B) but was worsening after four sessions. At the time of the visit, he was prescribed Protopic, Eucrisa, Halobetasol, and Hydroxyzine. He also received intralesional Kenalog injections.

No, the treatment with Dupixent is not medically necessary.

The patient has atopic dermatitis limited to the hands and forearms and has initiated treatment with topical Eucrisa and Protopic without follow up response documentation. It is also not documented what the severity of his disease is. In view of the small BSA (body surface area), new treatment prescribed and lack of follow up to assess for response to treatment, Dupixent is not considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chorea. 
Treatment: Xenazine. 
The insurer denied the Xenazine. 
The denial is upheld. 

The patient is a male with chorea secondary to a right thalamic hemorrhage. He has tried and failed Sinemet. 

No, the treatment with Xenazine is not medically necessary. 

There are no high-quality clinical trials to support the efficacy of Xenazine for the treatment of chorea secondary to infarction. The medical literature is limited to case reports only. There are no standard of care clinical guidelines supporting the efficacy of Xenazine for this condition. The manuscript referenced by the attending physician (AP) is not a clinical trial or consensus guidelines. The fact that the chorea looks similar to Huntington's chorea is not evidence of a similar neuropathology or that Xenazine would be equally effective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Pharmacy/Prescription Drugs (Otezla)
The health plan denied the requested prescription drug (Otezla). The health plan's determination is upheld.

The patient is a female with moderate to severe psoriasis. The condition involves the palms, hands, nose, scalp, underarms, neck, and popliteal fossae. According to a clinic note, Ketoconazole shampoo was used weekly but "made her scalp feel like a balloon". Topical Triamcinolone ointment, as well as topical Clobetasol solution and ointment, were also previously prescribed.
Otezla is preferred by the treating physician because of the potential for less immunosuppression. Health plan coverage of Otezla is under review for medical necessity.

The health plan denial of Otezla medical necessity coverage is upheld, in whole.

No. The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, alternative oral therapies, and/or Phototherapy. The requested Otezla is not medically necessary. The alternatives are all appropriate, time-tested, and are not proven to be any less medically appropriate or safe with respect to immunosuppression and the current COVID-19 pandemic.
Modern dermatology literature [2-5] supports use of preferred medications as similarly efficacious to the requested Otezla, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and recommend the use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Otezla is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Musculoskeletal/Orthopedic. 
Treatment: Home Health Care. 
The insurer denied: CDPAS 24-hour continuous care 7 days a week. 
The health plan's determination is overturned in whole.

The patient is a female with past medical history of functional quadriplegia, Alzheimer's dementia, chronic neck pain, oxygen dependent chronic obstructive pulmonary disease (COPD), hiatal hernia, bladder stone, recurrent urinary tract infection (UTI), atrial fibrillation, aortic stenosis, hypertension, and hyperlipidemia who was assigned Consumer Directed Personal Assistance Service (CDPAS) services 11 hours/day to total 77 hours/week.

The provider and patient advocate requested external appeal of denial of increase in CDPAS services. The patient's advocate letter reiterated the above history and noted the patient's daughter is forced to provide activities of daily living (ADL) and instrumental activities of daily living (IADL) care throughout the day and night and the daughter is physically exhausted and unable to provide care in this capacity any longer.
The subject under review is the medical necessity for the CDPAS 24-hour continuous care, 7 days per week for this patient.

The health plan's determination is overturned in whole.

Yes, the requested health service/treatment of Consumer Directed Personal Assistance Services, 24-hour continuous care, 7 days per week is medically necessary for this patient. The patient has medical condition of progressive Alzheimer's dementia documented in medical records with noted advanced arthritis and oxygen dependent COPD requiring assistance with all ADLs and IADLs. Furthermore, the patient sustained a hip fracture for which the family opted not to fix surgically and therefore the patient will be non-weight bearing, causing her to need a higher level of assistance with ADLs. The patient has documented decubitus ulcer worsening following her fracture and her provider recommends repositioning every two to three hours. The daughter is no longer able to perform 24 hour informal care for the patient. The patient has urinary and bowel incontinence with the need for assistance with toileting and incontinence cares. The patient has unscheduled and unpredictable needs over a span of time. The patient has care needs that span 24 hours and task based tool should not have been used to calculate the patient's CDPAS hours. The patient's overnight needs would not allow a home care assistance 5 hours of uninterrupted sleep. An increase in personal care service hours is not solely for safety and supervision but to assure the safe completion of ADLs and IADLs. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID 19, Respiratory Failure
Treatment Long term Acute Care
The insurer denied the Long term acute care
The determination is upheld.


The patient has a past medical history of hypertension, diabetes mellitus, morbid obesity, sleep apnea on bi-level positive airway pressure (BiPAP) therapy, possible chronic obstructive pulmonary disease (COPD) and a history of deep vein thrombosis (DVT) on Coumadin. He was initially admitted for acute hypoxic respiratory failure secondary to coronavirus disease (COVID-19) pneumonia requiring mechanical ventilation support. His course was complicated by ventilator associated pneumonia due to methicillin-resistant staphylococcus aureus (MRSA) and critical care myopathy. At issue is the medical necessity of a long term acute care admission.
The requested health service/treatment of long term acute care admission (LTAC) was not medically necessary for this patient.
This patient was admitted to long term care acute after hospitalization for acute hypoxic respiratory failure secondary to COVID-19 pneumonia requiring tracheostomy placement with mechanical ventilator dependence. Per the clinical information, the patient was awake and responsive, had been decannulated and was on 2 liters per minute of supplemental oxygen via nasal cannula with an oxygen saturation greater than (>) 91%. The patient was not on any medications that would require an acute care stay. The patient had a feeding tube but was transitioned to oral feeding. In addition, his other comorbidities were stable, his lab values were within acceptable limits, his medication regimen was stabilized, and telemetry did not demonstrate any dysrhythmias. In addition, although the patient was on BiPAP, it was for nocturnal use only for the treatment of sleep apnea. All of the above requirements did not require frequent nursing care > 6.5 hours per day, daily physician assessments or by themselves require an acute care stay level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suicide attempt
Treatment: Continued inpatient admission
The insurer denied the continued inpatient admission.
The denial is upheld. 

The patient is a male community college psychology student. He was involuntarily admitted to this facility from another hospital where he was employed as a security guard after he had ingested Robitussin, Advil, Zyquill, and Benadryl in a possible suicide attempt. 

The patient reported that after he came home from work, he had difficulty sleeping, and he took the overdose. He identified stressors as tension with his adoptive parents, difficulty at school, a recent break up with a partner, and being unable to fall asleep after working 24 hours. 

The patient reported a first suicide gesture after he came out as gay, and his parents were not accepting. At that time, he was not hospitalized, nor did he have any outpatient treatment. 

The patient denied having been in outpatient treatment or taking psychiatric medication. On the unit, he was begun on Wellbutrin XR (extended release), which was titrated upward. He minimized his suicide attempt, but he admitted to having depressive episodes and needing to learn coping skills. The patient's mother confirmed that she found a suicide note that the patient had left for her in the kitchen. She stated that the patient had wanted her to go to counseling with him, but that she had refused.

At the time of admission, the patient denied active or passive thoughts of suicide. His diagnosis was major depressive episode.  He denied substance abuse, and his mental status examination was negative for signs of psychosis. His mood was anxious but euthymic, and his insight and judgment were described as poor. The attending physician described him as being future-oriented and motivated toward stability. He attributed his overdose to having felt overwhelmed by multiple stressors, combined with coming off an overnight shift and not sleeping.

The patient's hospital course was uneventful. Wellbutrin XR (extended release) was titrated to 300 mg (milligrams) daily. He consistently denied suicidal ideation, intent, or plan throughout his stay. His mood remained good and he remained future oriented. The patient's mother attended a family meeting and was supportive of the patient. She agreed to attend family counseling with him as per his request. He was discharged home.

No, the Continued inpatient admission was not medically necessary.

From the time the patient was admitted and throughout his stay, he categorically denied suicidal ideation and intent. He remained future-oriented with plans to continue his schooling. He was cooperative with treatment.  His mood was described as euthymic. For the dates of service under review, nothing in the documentation reviewed indicates that this patient could not have been treated equally safely and effectively in a less restrictive setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pituitary Tumor. 
Treatment: Pharmacy/Prescription Drugs (Omnitrope). 

The health plan denied the requested medication. 
The health plan's determination is overturned. 

This is a male with a history of pituitary tumor status-post transsphenoidal surgery with resultant central hypothyroidism, hypogonadism, and growth hormone deficiency. IGF-1  (insulin-like growth factor) was 108 (56-203 ng/mL) after being off Omnitrope for a month. Peak growth hormone was 1.1. ng/mL after Glucagon stimulation. He underwent a second stimulation test which he failed (peak growth hormone 0.1). He has tried Nutropin A1 and Nuspin. 

The request for Omnitrope is under review. 

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

The requested Omnitrope is for a medically necessary indication. This patient has a history of a pituitary tumor status-post surgical resection. Therefore, he has a known cause of his growth hormone deficiency. He is at high risk of growth hormone deficiency given he also has central hypogonadism and central hypothyroidism. He has failed growth hormone stimulation tests, including a Glucagon stimulation test, which confirmed his diagnosis of growth hormone deficiency. 

Without Omnitrope, this patient will be at risk of complications of untreated growth hormone deficiency including hyperlipidemia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malignant neoplasm.
Treatment:  Continued inpatient hospital stay.

The insurer denied coverage for the continued inpatient hospital stay.  The denial is overturned.

This is a female patient with a medical history of left retroperitoneal liposarcoma status post left colectomy, left nephrectomy, left splenectomy, distal pancreatectomy, left salpingo-oophorectomy and proton therapy.  A recent computed tomography (CT) scan showed increased right lower lobe nodule consistent with metastasis, for which the patient was scheduled for thoracic surgery.  The patient presented to the hospital for video assisted thoracic surgery (VATS).  The patient underwent a thoracoscopy, surgical with therapeutic wedge resection, robotically assisted procedure for pre-operative diagnosis of malignant neoplasm of lower lobe, right bronchus or lung.  She was discharged home on day 5 of admission with outpatient follow-up.

The patient was status post lung resection of VATS in the right lower lobe (RLL).  The patient had trace pneumothorax despite a chest tube in place on days 2 and 3 of admission.  The chest tube was removed early in the morning on the day prior to discharge.  Pneumothorax was still present.  Combining the pneumothorax and the patient requiring intravenous (IV) pain medications including Fentanyl, IV patient-controlled analgesia (PCA) Dilaudid, diclofenac, gabapentin, and Toradol, weaning of pain medications, observing pneumothorax/respiratory status, it was reasonable to observe the patient on the day prior to discharge.  Safe discharge with oral medications to handle the patient's pain control and stable respiratory status on day 5 of admission was very reasonable and good clinical medicine.  The doctors also fulfilled the New York State Laws for Safe Patient Discharge. 

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

The carrier's denial of coverage for the continued inpatient hospital stay from days 4 to 5 of admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male.  At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN), dyslipidemia, chronic obstructive pulmonary disease (COPD), non-obstructive coronary artery disease (CAD), congestive heart failure (CHF) with an ejection fraction (EF) of 20-25%, chronic kidney disease (CKD), and cocaine use disorder.  The patient presented for evaluation of chest pain. The patient was admitted for the same complaint and was discharged two days prior to this admission with a plan for outpatient follow-up. 

The patient was hemodynamically stable. Electrocardiogram (ECG) did not reveal acute ischemic changes. Troponin was mildly elevated and trended down on repeat labs. The patient was admitted to telemetry to rule out acute coronary syndrome (ACS). No inpatient ischemic work-up, such as stress test or cardiac catheterization, was planned. His medical therapy was adjusted, and the patient was discharged home with a plan for outpatient follow-up.

No, the proposed inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. He had a known diagnosis of chronic systolic congestive heart failure (CHF). His prior work-up revealed non-obstructive coronary artery disease (CAD). There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. No further ischemic work-up was planned. The patient was discharged on medical therapy with a plan for outpatient follow-up. The clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: ruptured membranes.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This patient is under consideration for acute inpatient level of care for the indication of a 21-week pregnancy with vaginal bleeding, cramping and leakage of fluid (ruptured membranes). In this case, the patient presented with bleeding and premature preterm rupture of membranes (PPROM) at 21 2/7 weeks. The patient was noted to have a blood type of A positive. The patient had a white blood cell count 10.3. Glucose was normal at 92. Antibody screen was negative. The patient had a hemoglobin of 11.8 and normal complete metabolic count. At presentation, the patient was afebrile at 97.8F with a heart rate of 108 and oxygen saturation 100% on room air. Blood pressure was 116/65. The patient denied pain or discomfort. The patient reported that she had soaked 2 pads at morning and had occasional leakage of fluid since that time. She also had cramping that started 30 minutes prior that was associated with shivering. She denied chills, fever, shortness of breath, chest pain, nausea, vomiting or changes in bowel movements or urinary complaints. Her review of systems was negative except for vaginal bleeding and pelvic pain.

Based upon a review of the medical records and the recommendations of the American College of Obstetrics and Gynecology (ACOG), the acute inpatient level of care was not medically for the indication of a 21 week pregnancy with vaginal bleeding, cramping and leakage of fluid (ruptured membranes). In this case, the pregnancy was previable (less than 23 weeks gestation) and would not have been considered in the management of the case. The patient had no signs of active blood loss or hemorrhage and had no evidence of infection or chorioamnionitis. Given the previable pregnancy, there was no role for fetal monitoring or planning for delivery or resuscitation of a viable infant. Rather there was monitoring for maternal signs and symptoms of excessive bleeding which was absent and maternal infection which was also absent. Given these findings, the care provided could be a lower level of care and would not have required acute inpatient level of care.