Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypercholesterolemia.

Treatment: Formulary Exception for Lipitor 40 milligrams (mg).

The insurer denied coverage for the Formulary Exception for Lipitor 40 mg.

The denial is overturned. 

This is a female patient with hypercholesterolemia treated with Lipitor 40 milligrams (mg) daily. Her physician provided documentation that the patient has tried several formulations of statin medications. The patient has tried all other formulary statin medications and in each case adverse reactions were noted. 

Several studies have been published evaluating the comparative efficacy of generic vs name brand drugs. In this case there is no difference in efficacy between Lipitor vs Atorvastatin. However, in this case the patient appears to have a demonstrable difference in cholesterol levels when on Lipitor as compared to generic alternatives. Her physician documents adverse side effects to the generic formulations on the formulary. Studies have demonstrated that a small number of individuals require reversion to name brand medications following switchover to generic formulations. In this case the patient should be prescribed Lipitor given adverse reactions. The requested drug is, for this patient, more effective than the formulary alternatives.

The carrier's denial of the request for Formulary Exception for Lipitor 40 mg is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.
Treatment: Nerve treatment (procedure codes 64568 and 0466T).

The insurer denied coverage for nerve treatment (procedure codes 64568 and 0466T).
The denial is overturned.

This is a male patient with a history of obstructive sleep apnea (OSA), loud snoring and daytime sleepiness. Medical history noted that this patient had tried continuous positive airway pressure (CPAP) for over a year, and this was not alleviating his conditions. The patient has a body mass index (BMI) of 27.8. Sleep studies found that the patient has severe OSA with apnea-hypopnea index (AHI) of 39.0 and 30.0, on 2 different occasions. A drug-induced sleep endoscopy found that there was: "Evidence of palate obstruction in the [anterior-posterior palatal (AP)] direction - complete. During sleep apnea there was also mild lateral pharyngeal closure in the hypopharynx and oropharynx. There was a severe amount of base of tongue AP closure during sleep endoscopy - near complete to complete. There was no evidence of laryngeal involvement."

There is extensive literature showing the efficacy of hypoglossal nerve stimulation for the treatment of OSA. The use of hypoglossal nerve stimulation has been approved by international and national professional societies. The Food and Drug Administration (FDA) has twice approved the use of hypoglossal nerve stimulation for the effective treatment of OSA. In this case, this patient fulfilled all of the FDA requirements for the uses of hypoglossal stimulation which included AHI of greater than or equal to 15 and less than or equal to 65 (i.e. this patient's AHI was 39.0 to 30.0); who have been confirmed to fail or cannot tolerate CPAP (i.e. this has been documented for this patient); who do not have a complete concentric collapse at the soft palate level (i.e., this was documented by the patient's endoscopy). 

The scientific evidence in peer-reviewed literature strongly supports that implantation of cranial nerve - neurostimulator electrode array and pulse generator) and insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator results in improvement in health outcome. The procedure codes 65468 and code 0466T as applied to the hypoglossal nerve stimulator has been approved twice by the FDA. This patient is a good candidate for the procedures under codes 65468 and code 0466T as he meets all of the FDA criteria for implantation. 

The procedure codes 65468 and code 0466T are the best available treatment for this patient at this time. The only alternative would be a tracheotomy which carry significant morbidity and mortality and would not be utilized at this point in the care of this patient. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for nerve treatment (procedure codes 64568 and 0466T) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.
Treatment: Nerve treatment (procedure codes 64568 and 0466T).

The insurer denied coverage for nerve treatment (procedure codes 64568 and 0466T).
The denial is overturned. 

This is a male patient with a diagnosis of severe obstructive sleep apnea (OSA). The patient's apnea-hypopnea index (AHI) was 39. The provider noted that the patient had a body mass index (BMI) of 27.8. The patient predominantly had obstructive events. The patient had an inability or unwillingness to use continuous positive airway pressure (CPAP). The patient had tried to use CPAP for over 12 months without relief. The patient had the absence of complete concentric collapse at the soft palate level as seen on the drug-induced sleep endoscopy procedure. The request was received for the implantation of an upper airway stimulation device to treat severe OSA. 

The scientific evidence in peer-reviewed literature support improvement in OSA and overall health after implantation of an upper airway stimulation device. This treatment does not need final approval from appropriate regulatory bodies for the diagnosis of severe OSA as it has pre-market approval. In this case, this patient is a good candidate for this treatment. Since the patient has failed CPAP therapy, this requested service is the best available treatment for this patient at this time. 

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for nerve treatment (procedure codes 64568 and 0466T) should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Ulcerative Colitis
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient was admitted to the hospital. The patient has underlying schizoaffective disorder and was not fully cooperative with the medical staff. He has a history of coronary artery disease with percutaneous coronary intervention and stent. The patient has ulcerative colitis and admits to having abdominal pain and rectal bleeding. Prior to the admission he had vomiting which resolved. Additionally, within the same week, the patient was at another hospital for the same symptoms and left against medical advice (AMA). In the emergency room the patient was verbally abusive. The examination was notable for stable vital signs and palpation tenderness in the right lower quadrant without guarding or rebound. The patient underwent a computed tomography scan of the abdomen which demonstrated right sided colitis. Labs were consistent with iron deficiency anemia. The patient was given 1 dose of intravenous steroids, morphine, and antacid therapy. The patient was also started on Cipro/Flagyl antibiotics. On the first night he had no further bowel movements. The patient was seen by psychiatry and his medications were adjusted. The patient was cleared by cardiology for a colonoscopy. Then the patient left AMA. 
The patient did not need inpatient hospital care. Unfortunately, his underlying schizoaffective disorder has been interfering with proceeding with evaluation and management. The patient has ulcerative colitis and underwent a computed tomography scan of the abdomen which demonstrated right sided colitis. The patient had no life threatening complications related to his colitis such as severe bleeding, perforation, fistula, or abscess. He did not have severe dehydration. He could have been managed at a lower level of care. The patient could have undergone evaluation and management, including a diagnostic colonoscopy, and then been started on treatment in a lower level of care setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned.

This patient is an obese female who presented with unintentional weight gain, frontal headaches with associated nausea, and tinnitus; onset had been over the past several months. She was found to have swollen optic nerves on ophthalmologic exam. She was sent to the emergency department (ED) for a magnetic resonance imaging (MRI) scan of the brain and orbits. There was no fever, chills, photophobia, weakness, sensory loss, dizziness, ataxia, vomiting, or pain. There was no history of trauma and no routine medications or drug use.

Her ED vital signs were a temperature (T) at 98.8F, heart rate (HR) was 102, respiratory rate (RR) was 20, blood pressure (BP) was 146/89, and her oxygen (O2) saturation was 98% on room air. Her physical exam was unremarkable; visual acuity was 20/20 on the right and 20/25 on the left. There was no papilledema appreciated. The MRI scan of the brain showed mild narrowing of the distal transverse venous sinus, flattening of the pituitary gland, and prominent Meckel's caves which can be seen with idiopathic intracranial hypertension. There was also a nonspecific 6 millimeter (mm) focus of signal abnormality in the left corona radiata without enhancement. Differential diagnosis included a focus of gliosis or non-enhancing lesion. The case and MRI findings were discussed with neurology who recommended hospital admission.

During hospitalization, neurology and ophthalmology consults were obtained for further work-up of papilledema. The patient was confirmed to have papilledema with bilateral sixth cranial nerve (CN6) palsy. Additional laboratory evaluation and lumbar puncture (LP) were recommended. Her laboratory evaluations were normal. The patient underwent imaging-guided LP which had elevated opening pressure. A diagnosis of idiopathic intracranial hypertension was confirmed. Her medications on discharge included acetazolamide, ferrous sulfate, and polyethylene glycol.

At issue is the medical necessity of the inpatient admission.

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

This patient had a finding of papilledema with CN6 palsy, which is considered a medical emergency. Pathological causes, such as a tumor or other space-occupying lesion, are suspected until a diagnosis and workup are completed. In addition to an MRI scan which often requires sedation, a lumbar puncture (LP) was also necessary as part of the diagnostic work-up. In this case, due to the patient's habitus and technical specificity, the procedure required Interventional Radiology and Anesthesia expertise. Treatment, although oral, has side effects that can mimic worsening disease, and this required close monitoring while completing the diagnostic work-up. Thus, hospitalization for rapid diagnostic work-up and close monitoring for disease/symptom progression and initial treatment was appropriate.

Therefore, the inpatient admission was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied surgical removal of tooth 6 for medical necessity. 
The denial was upheld. 
This is a patient who has been denied a surgical extraction of tooth #6 as a lesser procedure would be appropriate. There are no radiographs or clinical notes.
At issue is the medical necessity of the health treatment of surgical removal of tooth 6.
The health plan's determination of medical necessity is upheld in whole.
The requested health treatment of surgical removal of tooth 6 is not medically necessary for this patient.
There are no radiographs or clinical notes provided. There is no clinical information to substantiate a surgical removal of tooth #6.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) Liver transplant
Treatment: Envarsus XR 1mg tablet ER
The insurer denied the Envarsus XR 1mg tablet ER.
The denial is overturned. 

The patient is a male. He underwent living-related left lateral segment liver transplant. He was initially managed with immunosuppression with tacrolimus, but then was switched over to Sirolimus 2 mg (milligrams) PO (by mouth) daily by his Transplant team due to questionable allergic reaction to Tacrolimus. He had serial liver biopsies in the past to monitor his graft function. The last liver biopsy revealed idiopathic chronic hepatitis of the graft or smoldering minimal rejection. His transplant hepatologist would consider starting the patient on Envarsus (long-acting tacrolimus) and then plan to taper him off of Sirolimus.

Yes, the proposed immunosuppression with Envarsus (long-acting tacrolimus) is appropriate and medically necessary.

For the management of this patient's immunosuppression, Envarsus has improved bioavailability and absorption of this form of Tacrolimus over IR (immediate release)-Tacrolimus.

Tacrolimus prolonged release (Envarsus; henceforth referred to as tacrolimus PR [prolonged release]) is a new, once-daily, prolonged-release tacrolimus formulation, utilizing a drug delivery technology designed to enhance the bioavailability of drugs with low water solubility by creating a solid solution of the drug. Pharmacokinetic analyses demonstrated that tacrolimus PR (prolonged release) is associated with a higher bioavailability, reduced peak-trough concentration fluctuation ratio, lower mean values for percentage degree of fluctuation and percentage degree of swing, and a longer time to maximum concentration than tacrolimus IR (immediate release). Tacrolimus PR (prolonged release) therefore is a promising addition to the treatment options available for kidney and liver transplant recipients. Also, after organ transplant, strategies to simplify the therapeutic regimen may improve adherence and prevent rejection and/or graft loss. The safety, efficacy, and effectiveness of Envarsus has been determined in a number of studies in liver transplant patients.

The safety and efficacy of Envarsus has been established in both renal and liver transplant patients. Due to improved bioavailability and absorption, this formulation maintains better graft survival. In addition, the compliance and adherence of the patients is better with once-a-day dosing with a longer-acting formulation as compared to IR-Tacrolimus (Immediate-released Tacrolimus).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Trauma/Injury to the left elbow. 
Treatment:  Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission. The denial is upheld. 

This patient is a male child with no prior medical history who presented to the Emergency Department (ED) with a complaint of elbow pain.  The patient reported falling onto grass near a pool and onto his left elbow with positive pain.  Physical exam was remarkable for joint swelling, pain and tenderness to the left elbow, aggravated by movement.  The patient's X-ray of the left elbow showed minimal displaced distal humerus supracondylar fracture with associated prominent anterior and posterior fat pad.  The patient was treated with Fentanyl injection.  The patient was admitted to the pediatric orthopedic unit and was prepped for surgery.  The patient was taken to the operating room the following morning and underwent closed reduction of the left elbow supracondylar fracture with pinning and long arm casting.  The patient tolerated the procedure well without complications and was stable for discharge home with outpatient orthopedic follow-up.

Based on the review of the medical record and literature, the inpatient hospital admission was not medically necessary for this patient. The records show that the patient sustained an isolated closed injury to his elbow.  The mechanism of accident was low energy.   There were no open wounds nor other conditions reported.  The patient's treatment was a closed reduction and percutaneous pinning.  The operation was of low morbidity with no surgical incision required.  There was neither blood loss nor problems with the patient's wound.  The patient's post-surgical course was uneventful.  The patient was able to tolerate pain medication orally. These clinical findings substantiate that the patient could have been kept in observation as his condition improved without evidence of need for inpatient, acute level of care. 

The inpatient hospital admission is not considered medically necessary for this patient. 

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a previously healthy female who presented to the emergency department (ED) with a history of progressively worsening abdominal pain in the right lower quadrant associated with nausea, vomiting. Evaluation included physical exam, labs, and computed tomography (CT) scan. She was without fever at the time of presentation. Lab data identified a white blood cell (WBC) count of 13.46 thousand (K). CT scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested. Neither the surgical consult nor the CT scan describe the presence of an umbilical hernia. The patient was admitted to the hospital. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld.

This patient presented with abdominal pain and was subsequently transferred. The evaluation with examination, lab data, and CT scan supported the diagnosis of appendicitis. She was admitted to the hospital. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and appendectomy performed. The early post-surgical course was uncomplicated, and the patient was hemodynamically stable and tolerating a diet on the first post-surgical day. She was discharged from the hospital the next day.

The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient presented with abdominal pain and underwent uncomplicated appendectomy.

Generally accepted guidelines of care indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications the procedure may be performed with a lower level of care status. In this case the patient tolerated oral hydration, diet and medication and pain was well controlled.

A lower level of care status would have satisfactorily provided for the care received including pre-surgical assessment, serial examination, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring, if needed, and would have been consistent with the accepted standard of medical care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: OncotypeDx Genomic Prostate Score.
The insurer denied the OncotypeDx Genomic Prostate Score.  
The denial is upheld. 

The patient is a male with prostate cancer. He had the Oncotype DX Prostate Cancer Assay performed.

The biopsy specimen was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in 1 of 12 cores. No core had > 50% involvement. The clinical stage was T1c (nonpalpable prostate cancer diagnosed by needle biopsy). The PSA (prostate specific antigen) was < 10.

No, the OncotypeDx Genomic Prostate Score performed was not medically necessary.

Per AUA (American Urological Association) Guidelines, "Guideline Statement 32. Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion)"

Per AUA Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)"

Although results are promising, further validation is necessary to understand fully the potential clinical utility of this test. The NCCN (National Comprehensive Cancer Network) Guidelines note that "Their clinical utility awaits evaluation by prospective, randomized clinical trials, which are unlikely to be done."
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient Hospital

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

This is the case of a female with a past medical history significant for hypertension and congestive heart failure, who presented with abdominal pain and fever. She was diagnosed with acute appendicitis. She underwent an uncomplicated laparoscopic appendectomy on that same day. She was ultimately discharged to home in improved condition.

The inpatient stay was not medically necessary. The patient does have a history of congestive heart failure, which was documented and reviewed prior to the surgery. The risk assessment determined that the patient was low risk for cardiac events, as the patient had been well-compensated as far as her heart failure was concerned. The safety of appendectomy as a day surgery has been well-established. Based on reviews of the literature, "laparoscopic appendectomy should be the standard of care for uncomplicated appendicitis, and numerous studies have evaluated the safety of the procedure with discharge on the same day as surgery." In fact, there are even studies documenting safe discharge from the recovery area after laparoscopic appendectomy. "Immediate discharge from the post-anesthesia care unit for patients with acute non-perforated appendicitis appears safe and effective in the community hospital setting."

This patient had acute, uncomplicated appendicitis. She had no evidence of decompensated heart failure prior to her surgery or afterward. She did not require an inpatient admission, which is in line with the evolving practice of admitting patients with acute appendicitis to an observation level of care, rather than to the inpatient setting. The reasons for inpatient admission outlined by the "ED (Emergency Department) Disposition Decision" are not sufficient. The justification that she was uncomfortable despite ED treatment is not sufficient to admit a patient, as her discomfort from appendicitis would be relieved from surgery and one would not have expected it to be relieved without surgery. The justification that she has a decreased hemodynamic reserve is true, however laparoscopic appendectomy is not generally a procedure with expected large volume ongoing blood loss. The argument that intravenous antibiotics necessitated an inpatient stay is not sufficient either, as the patient could safely receive 1 dose preoperatively and then undergo surgery and should have no further antibiotics for uncomplicated acute appendicitis. The case did not require more than 2 nights in the hospital. A lower level of care was appropriate.