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

Diagnosis: Abdominal Pain, Sore Throat
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of major depressive disorder (MDD), obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), and polycystic ovary syndrome (PCOS) who was admitted with complaints of (c/o) a sore throat and abdominal pain associated with chills and nausea. Her vital signs were unremarkable. The physical exam was notable for a soft abdomen/non-tender non-distended (NTND). Lab work was notable for transaminitis. An abdominal ultrasound (US) showed no acute pathology, and a computed tomography (CT) of the chest showed no acute abnormalities. The patient was diagnosed with transaminitis and mononucleosis and treated with intravenous (IV) fluids and symptomatic treatment. Infectious disease (ID) evaluated the patient and thought that cytomegalovirus (CMV) was the most likely cause. The patient was discharged in stable condition.
An inpatient stay was not medically necessary.
This patient presented to the emergency department (ED) with c/o a sore throat and abdominal pain associated with chills and nausea. The patient was diagnosed with most likely a CMV infection and ID was consulted, who recommended that the patient could be worked-up as an outpatient. The patient did not meet systemic inflammatory response syndrome (SIRS) criteria and did not have associated high-risk features, such as acute renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability, bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, did not have acute kidney injury, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, immunosuppression, neurologic or severe hematologic/hepatic complications, inability to take by mouth (PO), or suspicion of splenic rupture or airway obstruction.
The patient presented with a sore throat and abdominal pain, was treated with intravenous fluids (IVF) and biochemical and microbiological work-up, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission. 
The denial is upheld in whole.

The patient is a female who fell while running and sustained a Type 3 supracondylar humerus fracture. The patient was brought to the hospital where a splint was placed on her arm, and she was admitted. The following day she was brought to the operating room and underwent closed reduction and percutaneous pinning. She was discharged to home from the post-anesthesia care unit (PACU). The subject under review is the medical necessity for the inpatient admission.

The health plan's determination is upheld.

The inpatient stay is not medically necessary. While many Type 3 supracondylar humerus fractures are severe injuries associated with a risk of nerve or vascular injury, requiring close monitoring, in this case the surgeon chose to discharge the patient from the PACU without any additional monitoring. Often there is concern about the risk of compartment syndrome or vascular impairment, and this can justify a higher level of service because of the need for close observation of neurovascular function for several hours after surgery. In this case, the injury apparently did not carry this level of concern for the treating surgeon, therefore the services provided would more appropriately be described as at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis.
Treatment: Consumer Directed Personal Assistance Services (CDPAS).
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 56 Hours per Week. 
The health plan's determination is overturned.

The patient is a female with past medical history of hypertension, osteoarthritis, hypothyroidism, systemic sclerosis, rheumatoid arthritis, osteoporosis, and gastroesophageal reflux disease (GERD) who had been assigned Consumer Directed Personal Assistance Services (CDPAS) following assessment tool that assessed the patient at total assistance for meal preparation, ordinary housework, and shopping while maximum assistance with tasks of managing medication, stairs, and transportation. The patient was assessed at extensive assistance with tasks of managing finances and phone use while limited assistance with task of bathing, dressing lower body, transfer toilet, and toilet use. With the task of personal hygiene and dressing upper body the patient was assessed at supervision while independent with tasks of walking, locomotion, bed mobility, and eating. There was a request to increase services and the patient underwent a telephonic assessment tool assessing the patient at maximum assistant with tasks of meal preparation, ordinary housework, shopping, and transportation while extensive assistance with tasks of managing medication, stairs, equipment management, bathing, and dressing lower body. 

Consumer Directed Personal Assistance Services (CDPAS): 56 Hours per Week is medically necessary for this patient. 
The patient has documented worsening rheumatoid arthritis with significant deformity of hands and feet. The patient requires assistance with activities of daily living (ADL) and Instrumental activities of daily living (IADL). The insurer assumed the daughter could provide informal help outside of the hours that an aide is available, but the daughter is not available during those times due to her own work schedule. The assessment tool underestimated the patient's care needs and, in fact, there was a decrease in care needs compared to a previous assessment tool and tasks of meal preparation, ordinary housework, managing finances, managing medication, phone use, stairs, shopping, transfer toilet, and toilet use. The patient's care needs cannot be met with adaptive equipment and medical supplies alone. The requested increase in CDPAS is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Consumer Directed Personal Assistance Services (CDPAS): 56 Hours per Week are medically necessary for this patient. 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: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Outpatient Surgical Implantation of an Upper Airway Stimulation Device (INSPIRE), Pre-service
The insurer denied the Outpatient Surgical Implantation of an Upper Airway Stimulation Device (INSPIRE), Pre-service.
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 29, an Epworth sleepiness score of 14, and an apnea hypopnea index (AHI) of 20.  The patient has no concentric collapse of the hypopharynx on drug-induced sleep endoscopy (DISE).  The patient failed continuous positive airway pressure (CPAP) and his life is severely impacted by this condition.  The patient is seeking a hypoglossal nerve stimulation procedure.

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 (OSA) as seen in this patient (1-4).  He has the appropriate diagnostic findings and has not tolerated continuous positive airway pressure (CPAP).  The procedure is not experimental/investigational, it is accepted standard of care.

This individual has obstructive sleep apnea (OSA), which is a potentially life threatening disorder.  The patient requires therapy and has not tolerated continuous positive airway pressure (CPAP).  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: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Outpatient Surgical Implantation of an Upper Airway Stimulation Device (INSPIRE), Pre-service
The insurer denied the Outpatient Surgical Implantation of an Upper Airway Stimulation Device (INSPIRE), Pre-service.
The denial is overturned.

The patient is a male with obstructive sleep apnea (apnea hypopnea index [AHI] 20 with desaturations to 83%).  He has failed ongoing use of continuous positive airway pressure (CPAP) therapy.  Physical examination included normal nasal cavity and flexible laryngoscopy.  He had a drug induced sleep endoscopy which demonstrated no concentric collapse.

Yes, the health plan should cover the proposed treatment.

The procedure and device are Food and Drug Administration (FDA) approved as referenced below and recognized in the treating community as efficacious and safe for properly selected patients.  

This patient with severe desaturations and favorable anatomy is a good candidate for this intervention.  By virtue of review of the literature, it is neither experimental nor investigational.  The efficacy is particularly evident with the withdrawal study by Woodson referenced below, which showed the efficacy of the therapy and the reversal of efficacy by discontinuing the stimulation.  It is rare in surgical interventions that such two sided evaluation can be performed.

Yes, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.

For this patient, the proposed procedure is required to treat the sleep apnea, which is not controlled by more conservative measures.  It meets the standard of care and is not for the convenience of the patient.

The principal specialty in Otolaryngology (the American Academy of Otolaryngology- Head and Neck Surgery) has examined the scientific support for hypoglossal nerve stimulator in sleep apnea and concludes:
The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an 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 (PAP).  Not all adult patients are candidates for UAS (upper airway stimulation) therapy and appropriate polysomnographic, age, BMI (body mass index) and objective upper airway evaluation measures are required for proper patient selection.  

This patient has had proper evaluation and meets clinical criteria for this intervention.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Outpatient Surgical Implantation of an Upper Airway Stimulation Device (INSPIRE), Pre-service
The insurer denied the Outpatient Surgical Implantation of an Upper Airway Stimulation Device (INSPIRE), Pre-service.
The denial is overturned.

The patient is a male with a history of obstructive sleep apnea (OSA).  His apnea hypopnea index (AHI) on sleep study was 20 with a body mass index (BMI) of 28.  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.  

The request was previously denied as not medically necessary and this is an appeal of the denial.

Yes, the health plan should cover the proposed treatment.

All records were reviewed.  The provider is requesting placement of a hypoglossal nerve stimulator to treat the patient's obstructive sleep apnea.  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 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 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 meets Food and Drug Administration (FDA) criteria for the device in terms of body mass index, age, apnea hypopnea index 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 trial.  There would be no contraindications to the procedure based on the information provided.  Therefore, based on the information provided, the medical necessity of the requested service is confirmed and the health plan should cover the proposed treatment.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cushing's Disease, pituitary surgery, and thyroid disease

Treatment: Desmopressin acetate 4 micrograms per milliliter (mcg/ml)

The insurer denied coverage for desmopressin acetate 4 mcg/ml.

The denial is overturned.

According to the medical records, the patient has a history of asthma, Cushing's Disease, pituitary surgery, and thyroid disease. Per telemedicine visit with the Neuroendocrinologist for follow up for possible Cushing's Disease, "she complained of headaches, amenorrhea, acne, muscle weakness, and depression." The patient had a resection of a microadenoma. Symptoms mostly resolved after surgery and the patient lost weight. Later, she started to gain weight and is now over 200 pounds. She also had blurry vision, acne, amenorrhea, mood changes, headaches, fatigue, and sugar cravings. The physician recommended a desmopressin stimulation test (DDAVP). The physician prescribed 10 micrograms (mcg) of desmopressin in order to complete this test.

The formulary drugs are not likely to cause the patient an adverse reaction. The formulary drugs have not been shown to be ineffective based on the patient's history. However, given the clinical circumstance, the requested drug is more effective than the formulary drug. The request is for usage of intravenous (IV) desmopressin for dynamic endocrine testing, to prove ACTH [Adrenocorticotropic hormone] dependent or pituitary Cushing's disease. This is an established protocol that is part of guidelines. 

Arginine-vasopressin (AVP), 8-lysine-vasopressin (LVP), and terlipressin have been used in a number of clinical settings. In general, these have been abandoned (due primarily to vasopressor actions and the availability of other tests), and desmopressin is the only peptide that is currently used. 

The insurer's denial of formulary exception for desmopressin acetate 4 micrograms per milliliter (mcg/ml) is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sarcoidosis
Treatment: Humira 40 mg (milligrams), Pre-service
The insurer denied the Humira 40 mg, Pre-service.
The denial is upheld.

This patient is a male with history of sarcoidosis.  The patient has previously tried and failed non-steroidal anti-inflammatory drugs (NSAIDs) and prednisone.  The patient has a history of gastritis.  Humira was initially denied due to the patient not having a diagnosis of rheumatoid arthritis, Crohn's disease, plaque psoriasis, ulcerative colitis, psoriatic arthritis, ankylosing spondylitis, axial spondyloarthritis, polyarticular juvenile idiopathic arthritis, oliogoarticular juvenile idiopathic arthritis, hidradenitis suppurativa, Behcet's disease, pyoderma gangrenosum or uveitis.  The reason for the appeal is because the provider states the patient cannot have oral medications due to gastritis.

No, the treatment with Humira is not medically necessary.

Sarcoidosis is a multisystem disease of unknown etiology characterized by tissue infiltration with noncaseating granulomas.  The granulomas may occur in any organ, but the most frequently affected sites are the lungs, lymph nodes, skin, eyes, and liver.  Glucocorticoids are the most commonly used medication for the treatment of pulmonary sarcoidosis, although no medications have been approved by the US Food and Drug Administration (FDA) for the treatment of sarcoidosis.

Clinical experts suggest that the agents that are evidenced to have the greatest likelihood of benefit in pulmonary sarcoidosis with an acceptable side effect profile are methotrexate, azathioprine (Imuran), leflunomide (Arava), and mycophenolate (CellCept).  Tumor necrosis factor-alpha (TNF-a) antagonists show promise.  Randomized trial data to guide selection among the agents are lacking.  Methotrexate is the most commonly used second-line agent and patients who fail or do not tolerate methotrexate are commonly transitioned to another second-line immunosuppressive agent.  Occasionally, two agents are used in combination, such as MTX (methotrexate) and leflunomide.

The patient has currently tried and failed three conventional oral disease modifying anti-rheumatic drugs (DMARDs).  If none of the second-line agents, alone or in combination, are effective, the next step is often a TNF-a antagonist, usually Remicade or Humira.  This patient has not tried and failed any of the second line treatments.  The provider states that due to gastritis, the patient cannot try these.  Gastritis is not a contraindication to the use of these medications.  Methotrexate comes in a subcutaneous injectable format and would be an acceptable alternative treatment option.  Therefore, the proposed treatment is not medically necessary.

The health plan acted reasonably because the patient has not tried and failed second line treatment options prior to advancing on to a tumor necrosis factor (TNF) inhibitor, such as Humira.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-Diabetes. 
Treatment: Skilled Nursing Facility-Nursing home services (long term care). 

The health plan denied Nursing home services (long term care) as not medically necessary. 
The reviewer has upheld in whole the health plan's determination. 

The patient has a past medical history significant for diabetes. He was admitted secondary to acute mental status changes secondary to hypoglycemia and hypothermia.  Patient was admitted after an acute hospital stay. History is significant for diabetes, hypertension, and history of peripheral vascular disease with left above-the-knee amputation. This review is for medical necessity of ongoing long term care. Services were denied as not medically necessary. 

Ongoing Nursing home services (long term care) is not medically necessary. The patient can ambulate, transfer, dress, and toilet independently. Care could be provided in an alternate location. Patient was admitted after an acute hospital stay. He has a history of diabetes mellitus with a left above the knee amputation. He was admitted with decreased muscle strength, balance abnormality, decreased activity tolerance and a decline in functional mobility. He was admitted for skilled physical therapy and occupational therapy services. He can use his prosthesis independently. 
The patient has made progress in rehabilitation with a return to functional status with therapeutic services. The patient was able to ambulate 300 feet with a roller walker, and he was able to navigate 15 steps. The patient lives in a 1-bedroom apartment which requires 4 steps prior to entry. It is reasonable that if the patient can navigate down the steps and ambulate independently in his apartment, perform transfers independently, toilet, and feed himself he does not medically need long term care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation and difficulty with defecation secondary to pelvic floor dysfunction

Treatment: physical therapy

The insurer denied coverage for physical therapy

The denial is upheld.

The patient has complaints of constipation and difficulty with defecation reportedly due to pelvic floor dysfunction and slow transit constipation.  Treatment included physical therapy.  Under review is the medical necessity of physical therapy.  

The physical therapy treatment notes provide insufficient objective clinical information to support the medical necessity of the services provided for the treatment dates under review.  The physical therapy treatment notes fail to provide evidence of specific impairment or significant improvement that supports the medical necessity of continuing a structured physical therapy program (after several months of treatment).  In addition, there is no documented updated care plan.  There is also lack of specific outcome measures such as the Pelvic Floor Impact Questionnaire or Pelvic Floor Distress Inventory.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the physical therapy was not medically necessary for this patient.

Based on the above, the medical necessity for the physical therapy is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned.

This patient presented to the hospital complaining of epigastric pain.  Past medical history was significant for sickle cell anemia, hypertension, and chronic kidney disease (stage 4).  Upon arrival to the hospital, he was found to be hypertensive with a blood pressure (BP) of 207/113. His pulse was 93.  Other findings on physical examination were within normal limits. Serum blood testing revealed a hemoglobin of 6.5 and creatinine of 3.2. 12 lead electrocardiogram (ECG) revealed sinus rhythm with left ventricular hypertrophy (LVH) and anterior T (interval on ECG) wave abnormalities in leads V1 (leads on ECG) and V2. The patient required treatment with intravenous hydralazine and subsequently intravenous labetalol. He was admitted to the hospital for treatment. While hospitalized he received one unit of red blood cells and was transitioned to oral antihypertensive therapy.

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Hypertensive emergency is defined as BP (greater than)>180/120 with target organ damage (Reference 1). This patient had an elevated serum creatinine and ECG revealed abnormal T waves consistent with target organ damage. The patient was also severely anemic with a hemoglobin of 6.5g/dl (grams per deciliter).  The goals of treatment for hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction (Reference 2). Given this patient's failure to respond to initial intravenous hydralazine therapy, admission to the hospital for aggressive blood pressure management was necessary. In conclusion, this patient should have been managed at a higher level of care. 

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is overturned.