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

Diagnosis: Chronic Migraines.

Treatment: Outpatient procedure (64505 x 1) sphenopalatine ganglion (SPG) nerve blocks.

The insurer denied coverage for outpatient procedure (64505 x 1) sphenopalatine ganglion nerve blocks.

The denial is overturned.

This case involves a male with a history of migraines and chronic sinusitis. A status report indicates the patient has been treated for migraines characterized by throbbing pain with sensitivity to light sound. The patient has been utilizing oral sumatriptan. Overall, his frequency of migraine was less than monthly and had decreased significantly due to sphenopalatine ganglion block protocol. Prior to this protocol his migraine frequency had been near constant. Additional documentation does include chart notes and procedure notes.  

The patient was seen for a follow-up pertaining to headaches. The patient at that time had a diagnosis of chronic migraine and was improving significantly. It was recommended that he continue with sphenopalatine ganglion blocks every 6-8 weeks. He indicated his headaches have stabilized for the most part. He stated his headache frequency was 1 time every 2-3 months. The physical exam did not reveal any significant abnormalities. The physician indicated they would repeat sphenopalatine ganglion block and continue any other preventative medication at that point. The patient was also seen for a follow-up. The documentation indicated he had some worsening pain after a sinus infection. He was being seen for a repeat sphenopalatine ganglion block at this visit. It was recommended the patient undergo the procedure and return to the office in 8 weeks.

The patient presented for a follow up with ongoing complaints related to the head. The submitted documentation indicated this patient has been undergoing an sphenopalatine ganglion protocol with significant benefit. This has significantly decreased his migraine frequency which was initially near-constant; however, after beginning the protocol he was only experiencing a headache 1 time every 2-3 months. These findings are consistent and supported by a review by Mojica et al which found "Based on current studies, SPG blockade is a safe and effective treatment for chronic headaches such as cluster headaches, migraines, and other trigeminal autonomic cephalalgias."

The health plan did not act reasonably with sound medical judgment in the best interest of the patient, as the patient has responded favorably he should continue with additional treatment. 

The insurer's denial of coverage for the outpatient procedure (64505 x 1) sphenopalatine ganglion (SPG) nerve blocks provided is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with an established diagnosis of seizure disorder. She presented to the emergency ward after a breakthrough seizure. 

At presentation, the patient had a normal neurological examination and was at her neurological baseline. CT (computed tomography) brain was negative for acute pathology. She was started on anti-epileptic medication and admitted for further evaluation. Diagnostic studies after admission were negative, and she was discharged on seizure medications. 

No, the inpatient admission was not medically necessary. 

The patient had an established diagnosis of seizure. She was noted to have stopped the use of seizure medication. She had a normal examination, including mental status, at presentation. A new seizure medication regimen was established in the emergency ward. The diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Iron Deficiency Anemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient has a past medical history of coronary artery disease (CAD) status/post (s/p) stent and pacemaker (PM), severe aortic stenosis (AS) status/post (s/p) transcatheter aortic valve replacement (TAVR), hypertension (HTN), hyperlipidemia (HLPD), chronic kidney disease (CKD), chronic iron deficiency anemia (FeDA), and cirrhosis who was admitted with complaints of (c/o) malaise, fatigue.  He denied a history of melena, dizziness, chest pain, shortness of breath (SOB), nausea, exertional dyspnea, or rectal bleeding. His vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), normal skin color. Lab work was notable for a hemoglobin of 7.6, troponin .036, creatinine 2.76, and fecal occult blood testing (FOBT +). A chest x-ray (CXR) showed no acute disease, a transthoracic echocardiogram (TTE) did not show any significant abnormalities. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) with a left bundle branch block (LBBB). The patient was diagnosed with anemia and treated with one unit of packed red blood cells (PRBCs), which led to hemoglobin improvement to 8.1 and symptomatic improvement. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o malaise and fatigue associated with anemia. He was found to have a low hemoglobin but had no history of hematochezia, hematemesis, or melena. He received one unit of PRBCs, symptomatically improved, and was discharged home in stable condition. The patient did not have hemodynamic instability, persistent orthostasis, evidence of active bleeding in the ED (such as frequent episodes of hematemesis, melena, or bright red blood per rectum (BRBPR)), coagulopathy, or known esophageal varices. This patient could have been safely observed and received diagnostic work-up, consultation, and transfusion at a lower level of care.
Per the MCG Health Inpatient & Surgical Care 24th Edition: Anemia, Iron Deficiency or Unspecified RRG, the patient did not have any hemodynamic instability, active hemolysis, active bleeding, altered mental status (AMS) that was severe, recurrent syncope, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low platelet count, severe signs/symptoms, or need for inpatient surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient was a male with a past medical history significant for hypertension and type II diabetes mellitus who came to the hospital with complaints of dizziness associated with generalized weakness, fatigue. Reportedly, he was recently evaluated by his primary care physician. He underwent bloodwork that demonstrated mildly elevated creatinine as well as elevated glucose. Reportedly, his primary care physician adjusted his medications and recommended for the patient to follow up in two weeks. The patient stated that he could not wait because his symptoms were getting worse, and this prompted him to come to the emergency department. The patient was admitted to the hospital with a diagnosis of acute renal failure, uncontrolled diabetes mellitus, and hypertension. This was treated with intravenous fluids, basal/bolus insulin coverage.

The inpatient hospital admission was medically necessary for this patient. The severity of the patient's condition and the complexity of the services provided justified admission at the acute inpatient level of care.
This patient required hydration with intravenous fluids, close monitoring of kidney function and electrolytes, initiation of treatment with insulin including teaching the patient insulin injection techniques, and adjustment of antihypertensive medications.
It was unrealistic to expect that this type of care could have been provided in a timely manner in less acute settings rather than admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite tooth 10. 
Treatment: Braces/monthly visits. 

The insurer denied braces/monthly visits. The health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 30-36 months of orthodontics to address the crowding and crossbite. 

Braces and monthly visits are medically necessary. This patient presents with an anterior crossbite on tooth 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. 

Teeth 10 and 22 are not currently touching, but when 10 erupts fully it will be in a traumatic crossbite with 22. If not corrected before this happens, the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. The requested orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of multiple substance use disorders including opioids, benzodiazepines, cannabis. The patient reported that he started using heroin in early 20's and reported using one bundle intravenous (IV) for the past nine years. The patient had a history of seven months sobriety, but relapsed one month prior to admission. The patient also reported abusing 2 milligrams (mg) daily of Xanax or Klonopin and drinking 4 to 5 beers 3 to 6 times per week. Additionally, the patient was smoking a marijuana joint 1 to 2 times per week.

The health plan's determination is upheld. The Inpatient Substance Abuse Treatment is not medically necessary for this patient. The patient did not have a life-threatening medical condition or severe psychiatric crisis requiring immediate hospitalization. Opioids were the substance that the person was using with the most potential to cause harm to self or others. The patient had clear evidence of diagnoses of both opioid use disorder and benzodiazepine use disorder. The patient was not in full remission from a substance use disorder. The patient did not have serious medical symptoms that needed to be managed in an inpatient rehabilitation setting. The patient did not have serious psychiatric symptoms that needed to be managed in an inpatient rehabilitation setting.
Appeal type: Out-of-Network Service
Decision: Upheld

Diagnosis: Endometriosis

Treatment: Out-of-Network Office Visit, Diagnostic Testing and Advanced Laparoscopy Hysteroscopy with Dilation and Curettage

The insurer denied the Out-of-Network Office Visit, Diagnostic Testing and Advanced Laparoscopy Hysteroscopy. The denial was upheld.

This patient is a young female patient with stage 4 endometriosis. She has a decade long history of extreme bladder pain, colitis and irritable bowel syndrome (IBS).  She had a cyst removed from her right fallopian tube and was treated with oral contraceptive pills.  The patient was treated for pelvic congestion syndrome with gonadal vein embolization and coil placement. She saw her primary medical doctor for treatment of endometriosis where he performed Ethicon Endoshear scissors and cup forceps to excise stage I-IV endometriosis, which included the removal an endometrial polyp. The patient continued to have the pain despite the various treatments.

According to Pfeifer S., et al., "Laparoscopy remains the cornerstone of accurate diagnosis of endometriosis. Both medical and surgical treatments for pain associated with endometriosis are effective. In women with symptoms of pelvic pain, visible endometriosis observed during surgery should be treated. The optimal surgical technique for treating endometriosis and/or endometriomas has not been established, although excision of the endometrioma cyst wall lowers the risk of recurrence compared with fenestration and ablation of the cyst wall. Surgical treatment for endometriosis, followed by medical therapy, offers longer symptom relief than surgery alone."
These are procedures that are within the expertise and skill of a board-certified, competent gynecologic surgeon.  The requested service was diagnostic testing and laparoscopic hysteroscopy with dilation and curettage (D&C) utilizing excision (not ablation) of the patient's endometriosis by an out-of-network physician. The service offered in plan, by two of three the insurer's identified in-network gynecologists is laparoscopic excision.
Appeal type: Medical necessity
Decision: Upheld

The patient was admitted with the diagnosis of dehydration. The patient presented to the emergency department with a two-day history of cough and fever with a poor appetite. A sibling was being treated at home for influenza. Vital signs on presentation: temperature 103.0, heart rate 139, respiratory rate 26, blood pressure 95/59, and oxygen saturation 95% on room air.

The health plan's determination is upheld. The inpatient stay was not medically necessary. There was no hypoxia. The examination was documented as normal apart from fever. The lab studies were normal apart from evidence of iron deficiency anemia, which would be treated as an outpatient (and appears to have been entirely ignored during this hospital stay). The patient was given two antibiotics without any evidence of a bacterial process - also not meeting any inpatient criteria. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

This patient with a history left orchitis and left painful swelling of testicle for 3 months.  The patient presented to the emergency room (ER).  The patient's vitals were stable, with a temp of 100.  On physical exam the patient had a tender left testicle. 

The health plan's determination is upheld.  The inpatient admission was not medically necessary.  The patient could have been cared for at a lower level of care.  This patient was never hemo-dynamically compromised, nor did the patient have any intra-operative or post-operative complications.  The urine culture was positive and pan sensitive to all antibiotics.  The hospital course was un-eventful.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted with the diagnosis of meningitis. The patient presented to the emergency department with a one-day history of nausea and severe headache with eye pain. Vital signs on presentation: temperature 100.1, heart rate 78, respiratory rate 20, and blood pressure 136/72. The patient was admitted to the pediatric unit. He was started on intravenous (IV) ceftriaxone and IV vancomycin with a diagnosis of meningitis. 

The health plan's determination is overturned. The inpatient stay was medically necessary. This patient required inpatient hospital care because at the time of admission he had severe pain requiring IV analgesia. He had distinctly abnormal CSF results showing a diagnosis of meningitis. While the lab results were more consistent with a viral meningitis, the high number of WBC in the CSF at such an early stage of the illness was concerning for bacterial meningitis as well.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Obstructive Sleep Apnea
Treatment: 64568 - Incision of Implantation Of Cranial Nerve Neurostimulator Electrode Array And Pulse Generator 0466T- Insertion Of Chest Wall Respiratory Sensor Electrode Or Electrode Array, Including Connection To Pulse Generator
The insurer denied the 64568 - Incision of Implantation Of Cranial Nerve Neurostimulator Electrode Array And Pulse Generator 0466T- Insertion Of Chest Wall Respiratory Sensor Electrode Or Electrode Array, Including Connection To Pulse Generator
The denial is overturned.

The patient is a male with history of obstructive sleep apnea syndrome (OSAS).  The patient has a body mass index (BMI) of 35, respiratory event index (REI) of 13 events per hour with minimum oxygen saturation of 85%, and only anterior/posterior collapse on drug induced sleep endoscopy (DISE).  The patient did not tolerate continuous positive airway pressure (CPAP) despite a one month usage trial.  The patient seeks approval of hypoglossal nerve stimulation (Inspire device) treatment.

Yes, the health plan should cover the proposed treatment.
The Academy's recommendations as well as the literature support that this procedure is the treatment of choice for obstructive sleep apnea as seen in this patient. (1-4).  The patient has the appropriate diagnostic findings and has not tolerated continuous positive airway pressure.  The procedure is not experimental/investigational (E/I), it is accepted standard of care.

Yes, the requested therapy is likely to be more beneficial for the enrollee than any available standard therapy.
This individual has severe obstructive sleep apnea which is a potentially life threatening disorder.  The patient requires therapy and has not tolerated continuous posive airway pressure.  At this point hypoglossal nerve stimulation is the only therapy that can be beneficial besides a tracheostomy which has severe life altering consequences.  As such hypoglossal nerve stimulation is the best option.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Obstructive Sleep Apnea
Treatment: 64568 - Incision of Implantation Of Cranial Nerve Neurostimulator Electrode Array And Pulse Generator 0466T- Insertion Of Chest Wall Respiratory Sensor Electrode Or Electrode Array, Including Connection To Pulse Generator
The insurer denied the 64568 - Incision of Implantation Of Cranial Nerve Neurostimulator Electrode Array And Pulse Generator 0466T- Insertion Of Chest Wall Respiratory Sensor Electrode Or Electrode Array, Including Connection To Pulse Generator
The denial is upheld.

The patient is a male with obstructive sleep apnea with an apnea hypopnea index (AHI) of 13 on a home sleep study test, and nadir desaturation to 85%.   Supine events were 22 and non-supine were eight per hour.  The patient had sleep induced endoscopy with no concentric collapse of the airway.  The patient reports failure of continuous positive airway pressure (CPAP) with mask leak after three to four hours. The patient had moderate score on Epworth sleep scale.  The patient has no associated cardiopulmonary disease.  Compliance report was documented.  Also a dental appliance was considered.

No, the health plan should not cover the proposed treatment.
The patient does not meet inclusion criteria for use of hypoglossal nerve stimulation. The patient had a home sleep study with 13 events per hour.  The criteria for use of hypoglossal nerve stimulator are moderate to severe sleep apnea with apnea hypopnea index above 15, the absence of concentric airway collapse on drug induced sleep endoscopy and failure of continuous positive airway.  This patient is documented to have difficulty using CPAP, has had drug induced sleep endoscopy (DISE) without concentric collapse but has mild sleep apnea on home sleep study.  It was noted on the sleep study report that the home study may underestimate sleep disordered breathing but no other study was performed.

No, the requested therapy is not likely to to be more beneficial for the enrollee than any available standard therapy.
As noted, the patient does not presently meet the recommended parameters for Inspire hypoglossal nerve stimulator implant.  It was noted that dental appliance was also considered for this patient who is having problems using their continuous positive airway pressure (CPAP).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Obstructive Sleep Apnea
Treatment: 64568 - Incision of Implantation Of Cranial Nerve Neurostimulator Electrode Array And Pulse Generator 0466T- Insertion Of Chest Wall Respiratory Sensor Electrode Or Electrode Array, Including Connection To Pulse Generator
The insurer denied the 64568 - Incision of Implantation Of Cranial Nerve Neurostimulator Electrode Array And Pulse Generator 0466T- Insertion Of Chest Wall Respiratory Sensor Electrode Or Electrode Array, Including Connection To Pulse Generator
The denial is upheld.

The patient is a male with a history of obstrutive sleep apnea (OSA).  His apnea hypopnea index (AHI) on sleep study was 13 with a body mass index (BMI) of 35. The patient could not tolerate continuous positive airway pressure (CPAP) and underwent a sleep endoscopy where there was no complete concentric collapse at the velum.
The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's obstructive sleep apnea.

No, based on the information provided, the health plan should not cover the proposed treatment at this time.
The provider is requesting placement of a hypoglossal nerve stimulator to treat the patient's obstructive sleep apnea (OSA). There is support in the literature for the efficacy of the Inspire hypoglossal nerve stimulator for the treatment of a subset of patients with obstructive sleep apnea (OSA) who have failed, or cannot tolerate, continuous positive airway pressure therapy.  

A prospective multi center study documented a reduction of apnea hypopnea index (AHI) out to 12 months.  In addition, there was a randomized, controlled withdrawal arm of the study which reported apnea hypopnea index (AHI) reduction out to 18 months.  Therefore, based on current scientific literature, scientific evidence would support the efficacy of upper airway stimulation therapy with a hypoglossal nerve stimulator for a subset of patients with obstructive sleep apnea who meet Food and Drug Administration (FDA) criteria for the procedure.  

In this particular case, the patient would meet Food and Drug Administration criteria for the device in terms of age and sleep endoscopy findings (there was no complete concentric collapse on sleep endoscopy).  The patient has had a previous reported failed continuous positive airway pressure (CPAP) trial.  However, the patient's body mass index (BMI) and apnea hypopnea index (AHI) do not meet medical criteria for the requested service, with the apnea hypopnea index below 15 and the body mass index over 32.