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

Diagnosis: End stage Parkinson's Disease, advanced dementia, and spinal stenosis
Treatment: Increase in personal care aide hours from 48 hours a week to seven days 24 hours a week (live-in)
The insurer denied the increase in personal care aide hours from 48 hours a week to seven days 24 hours a week (live-in).
The denial is overturned. 

The patient is a female with end stage Parkinson's disease, advanced dementia, and spinal stenosis.  The patient requires total care with most aspects of adult daily living.  The patient's comprehensive community assessment reports demonstrate progressive dramatic decline in ability to perform adult daily living task and progressive required assistance to remain independent in her current living environment.  

Based upon the comprehensive community assessment reports, plus the recent letter from the patient's primary care physician, the patient has demonstrated progressive dramatic decline in her abilities to provide self-care and to assist with adult daily living task.  The patient's primary care physician documents limited mobility, gait instability, falls and risk of additional falls, difficulty with most activities of daily living (ADLs) and difficulty sleeping.  The patient also demonstrates increased frequency "freezing" episodes where she becomes frozen in place and not able to move which often leads to falls or near falls.  Needs cannot be "tasked" or "scheduled" as they are continuous and unpredictable and the patient does not have reliable significant assistance from her family to assist her with ADL care during non-service hours.
Appeal type: Experimental/Investigational
Decision: Overturned

Cancer
Pharmacy/Prescription Drug

Diagnosis: Bilateral Optic Nerve Tumors
Treatment: Mekinist 0.5 MG OR TABS
The insurer denied Mekinist 0.5 MG OR TABS. 
The health plan's determination is overturned. 

The patient is a female with a diagnosis with optic pathway glioma and diencephalic syndrome. She has been treated with standard of care chemotherapy, including carboplatin/vincristine and weekly vinblastine. She has progressive disease effecting vision and pituitary function. Her tumor was positive for BRAF-KIAA1549 fusion, a common molecular abnormality in pediatric low-grade gliomas.

Mekinist 0.5MG OR TABS is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There is no clear standard of care for multiple recurrent pediatric low-grade gliomas. MEK inhibitors have been tested in multiple prior and ongoing trials and have had very promising results, especially in tumors harboring BRAF fusion abnormalities. They are oral agents and very well tolerated. This patient has limited treatment options for a life-threatening disease.  She has tried and failed all other more "standard" treatment options, and the use of Mekinist is supported by her tumor tissue and the current standards of care in the field. The use of Mekinist is supported by published data on its use as well as the ongoing clinical trial by Children's Oncology Group.
Appeal type: Experimental/Investigational
Decision: Overturned

Cancer
Pharmacy/Prescription Drug

Diagnosis: Bilateral Optic Nerve Tumors
Treatment: Mekinist 0.5 MG OR TABS
The insurer denied Mekinist 0.5 MG OR TABS. 
The health plan's determination is overturned. 

The patient is a female with an aggressive optic glioma. She initially presented with severe failure to thrive and nystagmus, caused by bilateral optic nerve tumors extending back to the optic chiasm, thalamus and midbrain. Her tumor was causing diencephalic syndrome. 

Mekinist 0.5mg tabs is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has a multiply recurrent / refractory pilocytic astrocytoma of the optic nerve that has failed multiple conventional treatments. The provider has recommended Mekinist based on a specific mutation that was found in her tumor tissue, specifically a BRAF-KIAA1549 fusion.
In regards to the current standards of care in the field and the medical literature, the use of Mekinist is clinically appropriate. The National Cancer Institute (NCI) states that the standard treatments for recurrent low-grade astrocytomas such as this patient's pilocytic astrocytoma may include surgery, chemotherapy and/or targeted therapy with or without chemotherapy. This patient has already tried and failed the use of vinblastine, carboplatin, vincristine thioguanine, procarbazine, CCNU. This patient has limited treatment options for a life-threatening disease. She has tried and failed all other more "standard" treatment options, and the use of Mekinist is supported by her tumor tissue and the current standards of care in the field.
Appeal type: Experimental/Investigational
Decision: Overturned

Cancer
Pharmacy/Prescription Drug

Diagnosis: Bilateral Optic Nerve Tumors
Treatment: Mekinist 0.5 MG OR TABS
The insurer denied Mekinist 0.5 MG OR TABS. 
The health plan's determination is overturned. 

The patient is a young girl who was diagnosed with bilateral optic nerve tumors which were biopsied and found to be a grade II pilomyxoid astrocytoma. She presented with severe failure to thrive and nystagmus. Under review is the use of Mekinist 0.5 MG OR TABS.

Mekinist is likely to be more beneficial than any standard treatment for this patient's brain tumor. The patient has already received multiple regimens of standard chemotherapy which is the standard for treating this low grade astrocytoma. The only remaining standard option is radiation therapy to the tumor. This is not recommended at this time as the recommendation is to wait until the patient reaches an age so as to reduce the potential toxiticites of radiation on the developing brain. The use of Mekinist is supported by published data on its use as well as the ongoing clinical trial by Children's Oncology Group.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's colitis
Treatment: Inpatient stay
Decision: Denied

Summary:
The patient has a history of Crohn's colitis. The patient had a right hemicolectomy for terminal ileitis. The patient also had a history of hypertension and hypothyroidism noted. 

The patient had presented after a witnessed collapse from severe weakness from persistent nausea, emesis, diarrhea and abdominal pain. The patient had been lost to follow-up with her GI (gastroenterology) doctor and had been non-compliant with her medications. The patient's presenting vital signs were all normal. The patient appeared cachectic on examination, and lower abdominal cramping was noted. The patient noted the symptoms were similar to prior acute flares. The patient noted weight loss, fevers, sweats and weakness. The white count was 10.5. A CT scan showed diffuse ileus with concern for enteritis and colitis. There was a cystic lesion in the pancreatic tail. The patient was admitted for treatment and supportive care.

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 a flare of her Crohn's disease; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  The entirety of the care as delivered could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache, neck pain and paresthesias in his right arm
Treatment: MRI of the cervical spine
Decision: Denied

Summary:
The patient is a  male with complaints of headache, neck pain and paresthesias in his right arm. He had a normal neurological examination.

The patient had neck pain and a normal neurological examination. Standard of care guidelines do not support advanced neuro-imaging in this clinical context (normal examination and no red flag signs or symptoms) unless the patient has tried and failed physical therapy and conservative intervention (e.g. NSAIDs [nonsteroidal antiinflammatory drugs]) for his condition. The medical records do not support that he tried any intervention.  Studies have demonstrated that the diagnostic yield of MRI cervical spine in this clinical context is very low. 

The MRI cervical spine was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces
Decision: Approve

Summary:
The patient is a  female requesting orthodontic benefits.

The patient has a deep, impinging overbite with soft tissue damage on the palate. This is an "automatic qualifier" according to the handicapping index scale. Orthodontic treatment is needed to correct this, and the case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

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

The Inpatient admission was not medically necessary.

The patient is a female with rheumatoid arthritis, opiate dependence, alcohol abuse, bipolar disorder, psoriasis, and hypertension. She presented to the hospital with chest pain.  

The patient's labs were notable for a hemoglobin 10.8 and creatinine 1.9.  The patient was afebrile, with a blood pressure 108/56.  The electrocardiogram showed sinus rhythm without acute ischemic changes, and cardiac enzymes were negative.  The chest x-ray showed no acute process.  The blood alcohol level was 163.  The patient was monitored on telemetry and intravenous fluids were provided.  The patient was unable to tolerate a nuclear stress test due to claustrophobia.  Cardiology deemed the patient not to be a candidate for cardiac catheterization.  The creatinine dropped to 0.9.

There was no evidence of acute coronary syndrome.  Cardiac enzymes were negative, and the electrocardiogram showed no acute ischemic changes.  The patient did not have evidence of alcohol control.  Renal function improved promptly with intravenous fluid administration.  The patient did not have hyperkalemia, uremia, acidosis, or volume overload.  Dialysis was not required.  There were no decompensated medical comorbidities.  The patient remained hemodynamically stable.

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

Diagnosis: Abdominal pain and vomiting.
Treatment: Inpatient admission.

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

No, the inpatient admission was not medically necessary. 

The patient is a male patient who has a medical history of alcohol abuse and type II diabetes. The patient presented with mild hypertension and otherwise normal vital signs. The patient had epigastric pain, nausea, and one episode of dark non-bilious emesis. The patient had been drinking up to the prior evening. The patient had severe, ten out of ten abdominal pain similar to prior episodes of pancreatitis. The computed tomography (CT) scan of the abdomen and pelvis showed no acute findings. The lab values showed a lipase of 262. The patient was admitted for a history of alcoholism, a concern for bleeding, and alcoholic gastritis. 

The patient did not evidence hemodynamic instability as there was no notation of hypotension. The patient did not evidence any active bleeding or anemia. The patient had only one episode of emesis. The patient did not have an elevated blood urea nitrogen (BUN) or creatinine showing no signs of dehydration. Also, an upper gastrointestinal (GI) source of bleeding would cause an elevated BUN. 

As such, 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 abdominal pain with a history of alcoholism and prior pancreatitis; 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, 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

Digestive System/Gastrointestinal.
Inpatient Hospital.

Diagnosis: Abdominal Pain.
Treatment: Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is a female with history of alcoholic liver cirrhosis with refractory ascites status/post (s/p) TIPS, anemia, and gastrointestinal (GI) bleed who presented to the emergency department (ED) with complaint of worsening abdominal distension. The patient described diffuse abdominal pain, worse on the right, that was dull, constant, non-radiating, rated as 10 out of 10, not relieved by Tylenol. 

The Inpatient Hospital Admission was not medically necessary for this patient. The patient was hemodynamically stable. There were no severe electrolyte abnormalities that required correction. There was no documentation of a severe or persistent altered mental state. There was no evidence of active bleeding. There was no evidence of an abdominal infection, thus antibiotics were not given. There was no documentation that observation level of care was attempted. There was no documentation to suggest that the patient required intravenous fluids or medications. There was no documentation of the patient needing any type of surgical intervention. There was no evidence of any clinical needs that would have required an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive system / Other.
Treatment: Inpatient hospital.

The insurer denied the inpatient hospital stay. The denial is overturned in whole. 

This is a patient with significant past medical history of autism and Lyme disease who presented with watery diarrhea for about 2 weeks. Per parent the patient had fever beginning at 101.5. 

Yes, the requested health service/treatment of inpatient stay was medically necessary for this patient. This patient presented with 2 weeks of diarrhea that was then compounded by 24 hours of vomiting 10-20 times. The  initial assessment described him to have dry mucous membranes, ill appearance, sunken eyes and tachycardia. Laboratory results revealed metabolic acidosis with CO2 of 15. The presentation was concerning as clearly, the patient was unable to orally replace his losses. Also, of note was his hemoglobin and hematocrit upon admission of 15.8/45.6 which appeared to demonstrate hemoconcentration. After the patient was rehydrated in the hospital and labs were repeated, the hemoglobin and hematocrit normalized to 12.7/37.1. 
This patient required intravenous (IV) hydration to compensate for GI losses that he was unable to match orally. Also, of note this patient had sustained tachycardia for >24 hours after admission. The heart rate (HR) was 106-150 but mostly 120s-130s. His respiratory rate (RR) was also slightly elevated 24-33. The tachycardia most likely was compensation for the fluid deficit and increased RR compensation for the s metabolic acidosis. The night prior to discharge his vital signs finally began to normalize and his laboratory values repeated on the day of discharge also reflected the same. Based on these findings, this patient would meet criteria for inpatient admission for close monitoring of his intake and out puts, IVF and repeat laboratory studies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Community acquired pneumonia (CAP)

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admissions. The denial is upheld.

The patient was then a male patient with history of abdominal aortic aneurysm (AAA), atrial fibrillation status post ablation, congestive heart failure (CHF), hypertension, and coronary artery disease with stent placement. The patient presented to the Emergency Department (ED) with complaints of substernal chest pain with nausea and fevers. The patient's pain was pleuritic in nature, which was accompanied by shortness of breath. The patient was treated with aspirin and sublingual nitroglycerin on way to hospital. In the ED, the patient's vital signs were: temperature 99.8 F, respiratory rate 18, blood pressure 124/72 mm Hg, and heart rate 65. On exam, the patient was noted to be not in acute distress, non-toxic in appearance; lung and cardiovascular exam was unremarkable. The patient's bloodwork showed: white blood cell (WBC) count of 6.6K, hemoglobin (Hb) of 12.3, BUN/Creatinine 11/1.0, troponin <0.01, and electrolytes within normal limits. The patient's chest x-ray showed right lower lobe infiltrate. The patient's electrocardiogram (EKG) showed no acute ischemic changes. 

The patient was admitted on with diagnosis of community acquired pneumonia (CAP), and was placed on intravenous (IV) Rocephin and Doxycycline. As per the H&P note, the patient was afebrile and hemodynamically stable. The patient's physical exam was unchanged. The patient continued to complain of chest and back pain from which he was being treated with analgesics. The patient's computed tomography angiogram (CTA) ruled out pulmonary embolism. The patient's ultrasound of the lower extremity ruled out deep venous thrombosis (DVT). The patient's serial EKG and troponin was negative, and suspicion for myocardial infarction was ruled out. The patient was continued on antibiotics for the treatment of pneumonia.

Based on literature review, the patient did not need acute inpatient hospitalization. The patient's initial workup in the ED was negative for myocardial infarction, including his negative troponin level and unremarkable EKG. The patient was noted to have pneumonia but was afebrile and hemodynamically stable. The patient was able to tolerate oral intake, and has not failed outpatient treatment on oral antibiotics. The patient could have been placed in Observation status while diagnostic testing and treatment was initiated. Once this patient's chest pain's suspicion for myocardial infarction and pulmonary embolism was ruled out, the patient could have been discharged home on oral antibiotics and pain medications, and followed up as outpatient. The patient's CURB 65 score for pneumonia severity was zero. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer#1

Diagnosis: Obstructive sleep apnea (OSA)

Treatment: Procedure hypoglossal nerve stimulation

The insurer denied coverage for procedure hypoglossal nerve stimulation. The denial is reversed.

This patient is a male with the diagnosis hypertension, attention deficit hyperactivity disorder and obstructive sleep apnea (OSA).  A sleep study found an apnea-hypopnea index (AHI) 24.5of events per hour.  His was documented as being obese which a body mass index (BMI) of 33.86.  The patient's intolerance to continuous positive airway pressure (CPAP) was documented. A drug induced sleep endoscopy was performed which found no evidence of complete concentric collapse at the nasopharynx, velopharynx or soft palate.  There was anterior posterior collapse. 

The uses of hypoglossal nerve stimulation as an effective intervention for obstructive sleep apnea has been widely documented. 2,7-11 The effectiveness of hypoglossal nerve stimulation was compared to an ablative  surgical procedure and found to result in lowering the AHI of patients to  < 5  events/hour.3 

The use of hypoglossal nerve implant has been approved twice by the FDA12,13 and several medical societies14-16. The FDA approved the use of hypoglossal stimulation for patients who fulfilled the following criteria all of which were met by the patient.
"The device, as modified, will be marketed under the trade name Inspire Upper Airway Stimulation (UAS) System and is indicated to treat a subset of patients with moderate to severe obstructive sleep apnea (OSA) (apnea-hypopnea index [AHI] of greater than or equal to 15 and less than or equal to 65).  Insp1re UAS is used in adult patients 22 years of age and older who have been confirmed to fail or cannot tolerate positive airway pressure (PAP) treatments (such as continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BPAP] machines) and who do not have a complete concentric collapse at the soft palate level."13

There is substantial peer reviewed outcome studies which support an improvement in health with the uses of hypoglossal stimulation. 2,10,17-22 Hypoglossa1 nerve stimulation has been approved twice by the FDA.12,13

The patient is an excellent candidate for hypoglossal nerve stimulation as he fulfills all of the FDA criteria (see above).  Hypoglossal nerve stimulation is the best available treatment for this patient at this time as other therapies, such as tracheostomy, carry greatly increased risks for quality of life,23 morbidity and mortality. 

The used of hypoglossal nerve stimulation for OSA is likely to be more beneficial than and other standard treatment for the patient's OSA. The patient fulfills all the criteria for hypoglossal nerve stimulation which is the best alternative at this time for the care of his OSA.  

The carrier's denial of coverage for the procedure hypoglossal nerve stimulation to treat the patient's obstructive sleep apnea should be reversed.