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

Diagnosis: Severe Obstructive Sleep Apnea
Treatment: Professional Services; outpatient surgery (64582 x 1); hypoglossal nerve stimulator
The insurer denied coverage for Professional Services; outpatient surgery (64582 x 1); hypoglossal nerve stimulator.
The denial is overturned.

The patient presents with severe obstructive sleep apnea (OSA) with an apnea hypopnea index (AHI) of 66 despite a uvulopalatopharyngoplasty and nasal surgery. The patient has tried and failed treatment with continuous positive airway pressure (CPAP) after trying multiple masks. The patient's body mass index (BMI) is 31.6. The patient has undergone a drug induced sleep endoscopy (DISE) that showed no concentric pattern of upper airway collapse (CCC). The patient's treating provider is asking for approval of a hypoglossal nerve stimulator (HNS) to treat his OSA.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. HNS is a non-anatomical modifying surgery to treat OSA.

According to a review by Baptista, et al (2020), "Proper patient selection has a fundamental role in determining an adequate long-term clinical outcome" and "In the context of a customized management for OSA patients, the HNS represents one of the most promising tools."

Outpatient surgery, 64582 x 1, HNS needs to have final approval from the appropriate regulatory bodies for this diagnosis.

Thus, HNS has final approval from the appropriate regulatory bodies for the patient's diagnosis of OSA.

This patient is a good candidate for outpatient surgery, 64582 x 1, HNS.

The outpatient surgery, 64582 x 1, HNS is the best available treatment for this patient at this time.

A multicenter prospective observational study by Thaler E, et al (2019) examined the outcomes of patients receiving upper airway stimulation therapy (another term for HNS) for patients who had failed CPAP. The study enrolled 1,017 patients and found that both AHI and ESS (Epworth sleepiness scale) were reduced at 12-month follow-up. The study concluded that HNS "therapy continues to show significant improvement in subjective and objective OSA outcomes."

Thus, HNS does not have adverse risks over standard treatment/services left available to this patient given he has failed CPAP treatment.

This patient has already tried and failed multiple standard treatment and/or procedures for severe OSA. The next best treatment available is supported by numerous medical studies and standard of care (SOC). Although weight loss has less risk, a letter by the treating provider states, that the patient has already lost weight and his "BMI is not a factor." In conclusion, the requested service, HNS surgery is the next best treatment option for this patient. As illustrated above, it is effective and safe for this patient as supported by numerous studies involving similar patients.

The carrier's denial of Professional Services; outpatient surgery (64582 x 1); HNS should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Severe Obstructive Sleep Apnea
Treatment: Professional Services; outpatient surgery (64582 x 1); hypoglossal nerve stimulator
The insurer denied coverage for Professional Services; outpatient surgery (64582 x 1); hypoglossal nerve stimulator.
The denial is overturned.

This is a patient with a history of obstructive sleep apnea (OSA), gastroesophageal reflux disease, kidney stones and medullary sponge kidney. A sleep study carried out found that he had an AHI (Apnea-Hypopnea Index) of 66.6. 

The patient fulfills all of the criteria of the Blue Cross Blue Shield for hypoglossal nerve stimulation for the treatment of sever sleep apnea; he has severe obstructive sleep apnea, unable to use CPAP (continuous positive airway pressure), had a body mass greater than 35 kg/m (kilograms/meter) and a favorable palatal closure.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome [1-6].

Outpatient surgery (64582 x 1); hypoglossal nerve stimulator has final approval from the appropriate regulatory bodies for this diagnosis [7,8].

Based upon the insurance Surgical Treatment of Snoring and Obstructive Sleep Apnea - pages 5-6, criteria the patient is a good candidate for outpatient surgery (64582 x 1); hypoglossal nerve stimulator.

The patient is a good candidate for outpatient surgery (64582 x 1); hypoglossal nerve stimulator as he cannot tolerate CPAP and has undergone a number of surgical procedures, including nasal surgery and tonsillectomy with UPPP (uvulopalatopharyngoplasty), which have not alleviated his OSA.

The adverse risks are not increased over standard treatment/services.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient. This is evidenced by the failure of CPAP and the other surgical procedure.

The denial should be overturned as the patient qualifies for the hypoglossal nerve stimulation for the treatment of his OSA. He fulfills the criteria as noted by the insurer.

The carrier's denial of Professional Services; outpatient surgery (64582 x 1); hypoglossal nerve stimulator should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Morbid obesity
Treatment: Weight loss surgery - procedure code 43644
The insurer denied coverage for weight loss surgery - procedure code 43644.
The denial is overturned.

According to the documentation provided, this patient presented to the office for ongoing preoperative (preop) evaluation for bariatric surgery. It was noted the patient has tried for many years to lose weight following different programs and has not sustained weight loss. The patient is interested in surgery as a tool to be used in conjunction with diet and exercise and has attended an informational seminar and done research. The patient has past medical history of hypertension, type 2 diabetes, neuropathy and gastroesophageal reflux disease (GERD). The body mass index (BMI) was 32.4. The provider noted that the following clearances are required prior to surgery: cardiac, nutrition, primary care, psychology, and a referring doctor's letter of support.
 
The patient was seen for preop psychiatric evaluation. The provider noted that there was no significant psychiatric history. The provider noted that the patient appeared motivated to pursue surgery as an aid toward achieving a sustained weight loss, healthy benefits, and improved quality of life. The provider noted that there were no apparent psychological contraindications to bariatric surgery at this time.

This patient reportedly has a BMI of 32 and in addition he does have the co morbidities of type 2 diabetes with poor control that would lead to his meeting bariatric surgery criteria. Therefore, based upon these criteria the patient does meet criteria as the patient has had psychiatric, nutrition, and a cardiology evaluation preoperative. The patient does meet criteria given the new guidelines for a BMI of 30 to 35 with type 2 diabetes which is poorly controlled.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for weight loss surgery - procedure code 43644 is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease.
Treatment: Esophagus Sphincter Augmentation Device (LINX).
The insurer denied: Esophagus Sphincter Augmentation Device (LINX).
The denial is overturned.

The patient is an adult female on chronic PPIs (proton pump inhibitors), then converted over to Pepcid given her history of C. diff (Clostridium difficile). She has medically refractory GERD (gastroesophageal reflux disease) that, despite medications, continues to impact her activities of daily living. She had EGD (esophagogastroduodenoscopy), which demonstrated small hiatal hernia. This was confirmed on barium swallow. The patient has normal manometry, and she has DeMeester greater than 14. The request is for LINX system with hiatal hernia repair. 

The health plan should cover the Esophagus Sphincter Augmentation Device. 

Per the documentation provided, the patient has exhausted all of her options in terms of medication and lifestyle modification for GERD (gastroesophageal reflux disease). The patient still has symptoms, even on medications. She has had an EGD (esophagogastroduodenoscopy), which demonstrated a small hiatal hernia. This was confirmed on the barium swallow. Her manometry has shown no abnormalities, and her DeMeester score is in the 40s. She meets criteria for GERD (gastroesophageal reflux disease) surgical management. The use of the LINX system has FDA (United States Food and Drug Administration) approval. The safety and the validity of the product has been demonstrated in multiple studies. The presence of a hiatal hernia is not a contraindication and there have been multiple studies demonstrating the safety in large (greater than 3 centimeters) hiatal hernias. 

The requested health service is more beneficial. Standard hiatal hernia repairs have been shown to have a higher incidence of gas bloat syndrome, and the LINX system preserves normal anatomy, which the laparoscopic hiatal hernia disrupts.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD) with esophagitis. 
Treatment: Formulary Exception for Dexilant (dexlansoprazole). 

The insurer denied: Formulary Exception for Dexilant (dexlansoprazole). 
The denial is overturned. 

The patient is an adult female with gastroesophageal reflux disease (GERD). She has failed esomeprazole, omeprazole and pantoprazole, and has done well on Dexilant. Recent esophagogastroduodenoscopy (EGD) did show mild reflux esophagitis. The attending physician (AP) is requesting continuation of Dexilant. 

The health plan should cover the proposed treatment. 

The patient has gastroesophageal reflux disease (GERD). She has failed esomeprazole, omeprazole and pantoprazole, and has done well on Dexilant. As three of the preferred formulary alternatives, esomeprazole, omeprazole and pantoprazole, have been ineffective for the patient, the health plan should cover Dexilant.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD) with esophagitis
Treatment: Formulary Exception for Dexilant (dexlansoprazole)
The insurer denied: Formulary Exception for Dexilant (dexlansoprazole)
The denial is overturned

The patient is an adult female with gastroesophageal reflux disease (GERD). She has failed esomeprazole, omeprazole and pantoprazole, and has done well on Dexilant. Recent 
esophagogastroduodenoscopy (EGD) did show mild reflux esophagitis. The attending physician (AP) is requesting continuation of Dexilant.

The health plan should cover the proposed treatment.

The patient has gastroesophageal reflux disease (GERD). She has failed esomeprazole, omeprazole and pantoprazole, and has done well on Dexilant. As three of the preferred formulary alternatives, esomeprazole, omeprazole and pantoprazole, have been ineffective for the patient, the health plan should cover Dexilant.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Sinusitis
Treatment: Sinus Surgery
The insurer denied: Sinus Surgery
The denial is: Upheld

The patient is a male with chronic sinusitis with nasal polyps. Medical management included antibiotics, nasal steroids, saline rinses and allergy medications. Exam revealed a deviated septum, inflamed nasal mucosa and turbinate hypertrophy. Nasal endoscopy did not report nasal polyps but the patient was diagnosed with nasal polyps. Computed tomography (CT) scan reported mild mucosal thickening of anterior and posterior ethmoid sinuses bilaterally along with bilateral maxillary sinuses. Frontal and sphenoid sinuses were clear. No nasal polyps were documented. Attached CT scans are too dark to interpret.

The medical necessity for sinus surgery is the subject under review. Based on the records provided the sinus surgery for chronic sinusitis with nasal polyps is not medically necessary. 

The records are contradictory as to whether the patient had nasal polyps. The documented exam did not report nasal polyps and neither did the CT scan. Additionally, the CT scan did not report significant sinus disease that would be expected if patient had nasal polyps.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Ureteral calculus with hydronephrosis.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is overturned in part.

This is a female patient who was admitted with left renal colic and fevers. She had a history of hypertension and diabetes. Her vital signs were temperature 98.3 degrees Fahrenheit, blood pressure (BP) 126/82 and pulse 92. The white blood cell count (WBC) count was 10,000. The urinalysis had large leukocyte esterase and white blood cells (WBCs). The creatinine was 1.2. Computed tomography (CT) imaging demonstrated a 14 x 5 millimeter (mm) left proximal ureteral calculus with hydronephrosis. Intravenous (IV) pain medications, nausea medications, IV antibiotics and intravenous fluids (IVF) were administered. On the same day, interventional radiology placed a percutaneous nephrostomy tube. She received IV antibiotics. She was afebrile. The WBC count was 9000 and the creatinine was 1.0. She was discharged home after 5 days. She was afebrile and hemodynamically stable throughout the stay. At issue is the medical necessity of an inpatient stay.

An acute inpatient level of care was medically necessary/appropriate in part. The patient had an obstructing stone associated with pyelonephritis. She required urgent drainage for a potentially life-threatening condition. By the second day of the stay, she was improved and medically stable. She was adequately drained and on appropriate antibiotics. The care could have been provided at a lower level of care.

The determination is overturned in part. An acute inpatient level of care was appropriate for the first 2 days of the stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Edentulism. 
Treatment: Partial Upper Denture. 

The insurer denied: Partial Upper Denture. 
The denial is upheld. 

The patient is a male with several missing upper teeth. The patient has 7 maxillary upper teeth present: numbers 2, 4, 5, 9,10,11, and 14. The subject under review is the medical necessity for partial upper denture. 

The patient has 7 remaining maxillary teeth: numbers 2, 4, 5, 9,10,11, and 14. Teeth #4, #9, and #14 have subgingival decay on the mesial surface. Teeth #2 and #5 are non-restorable as tooth #2 has a large mesial root decay and tooth #5 has a missing clinical crown. Due to the size of the decay and amount of tooth structure remaining, the prognosis of these teeth are poor. 

The patient also has generalized severe periodontal bone loss on the upper arch. Considering that a partial upper denture would put significant mastication pressures on the remaining periodontally compromised teeth, especially in the posterior, the long-term success of this treatment option is not favorable or recommended. 
Per the standard of care, the treatment option with a better long-term outcome would be to extract the remaining maxillary teeth and deliver a complete upper denture. 
Thus, according to the above findings and the standard of care, the requested health service/treatment of a Partial Upper Denture is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who initially presented to the emergency department with progressive balance issues of 1-2 month duration, diffuse muscle aches, and bilateral flank pain. Pertinent history included ruptured cerebral aneurysm status/post (s/p) repair, hypertension, and alcohol abuse. Initial vital signs revealed a temperature of 98oF, heart rate (HR) 95, blood pressure (BP) 130/92, respiratory rate (RR) 18, and peripheral capillary oxygen saturation (SpO2) 98% on room air. Initial examination documented a Glasgow Coma Scale (GCS) 15 and National Institute of Health Stroke Scale (NIHSS) of 0. The patient was ambulatory. 

Based on the clinical documentation provided, evidence based literature and standards of care, the inpatient hospital admission was not medically necessary.  The patient had a history of a ruptured cerebral aneurysm s/p repair and right frontal encephalomalacia who presented with progressive balance issues of 1-2 month duration. An extensive evaluation was performed which was notable for a GCS 15, NIHSS of 0, and a CT head without evidence of an acute intracranial process. Nursing noted the patient was ambulatory in the emergency department. Additional diagnostic testing including a CT (computed tomography) angiogram of the brain/neck and MRI (magnetic resonance imaging) brain were performed. Both were unremarkable for an acute process, but noted a stable right frontal encephalomalacia per neurology consultation. No specific treatment was directed at the presenting symptoms. No other acute issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have severe or persistent altered mental status, neurologic finding requiring inpatient care, or CNS (central nervous system) infection. The patient also did not have ataxia with a functional disability that is severe, acute intracranial process necessitating inpatient treatment, bulbar symptoms, etiology requiring inpatient treatment (eg, poisoning), or intracranial monitoring needed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of Breath/ Trouble Breathing (asthma)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is a toddler aged child who presented to urgent care with increased respiratory effort, fever, cough, and nasal congestion. The patient presented to the ED (emergency department). The patient had received duoneb x3, solumedrol and continued to have decreased oxygen saturation, with increased accessory muscle use and oxygen requirement for appropriate oxygen saturation.

The Inpatient Hospital Admission was medically necessary.

The patient had increased work of breathing demonstrated by accessory muscle use, retractions, and continued decreased aeration on exam. The patient had a decrease in oxygen saturation, continued increase in heart rate. With the increased respiratory rate, the patient is at risk for respiratory decompensation, or aspiration. The patient received multiple albuterol treatments and steroids and continued to have a low pulse oximetry and continued decreased aeration bilaterally. The patient required continued albuterol sooner than every 4 hours, continuous oxygen and close monitoring of their clinical condition prior to being stable for care and support at home. The patient was also at risk for aspiration due to their increased respiratory rate and this also required support and monitoring while the patient demonstrated an increased respiratory rate. The admission and care were medically necessary, especially after receiving their initial care at an urgent care and being assessed at the emergency department.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: hyperlipidemia.
Treatment: Livalo.
The insurer denied Livalo. 
The health plan's determination is overturned. 

The patient is a male with hypertension and hyperlipidemia. He has previously been intolerant, with mylagias and creatine kinase elevations, to multiple statins including lovastatin, Atorvastatin, Rosuvastatin, Simvastatin and Pravastatin. He has been taking Pitavastatin (Livalo) and has tolerated it. 

A formulary exception is indicated in this case.
The formulary alternatives include Lovastatin, Atorvastatin, Simvastatin, Pravastatin, Rosuvastatin and Fluvastatin. The patient has already demonstrated intolerance to five of these alternatives (Lovastatin, Atorvastatin, Simvastatin, Pravastatin, Rosuvastatin); only Fluvastatin remains.
Unlike other statins (including fluvastatin), the cyclopropyl group on the pitavastatin molecule appears to divert the drug away from metabolism by cytochrome P450 (CYP) 3 A4 and allows only a small degree of clinically insignificant metabolism by CYP2C9. Due to its unique metabolic properties, Pitavastatin has been associated with significantly less muscle toxicity than other statins and has been shown to be tolerated by patients previously intolerant to other statins. Pitavastatin is also the most potent statin on a milligram by milligram basis, with significant reductions in low density lipoprotein (LDL) cholesterol levels seen with doses as low as 1 milligrams (mg) daily. The ability to treat with such low doses further minimizes the risk for adverse effects. Thus, Pitavastatin offers the advantage of reducing the risk for myotoxicity in high risk patients. Given this man's intolerance to multiple statins and their similarity to Fluvastatin, it is likely that Fluvastatin (the only remaining formulary alternative) would cause adverse effects. He has already demonstrated tolerance to Pitavastatin. Thus, all formulary alternatives would likely cause adverse effects.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis
Treatment: Full hospital admission
The insurer denied the full hospital admission.
The health plan's determination is upheld.

The patient is a male with medical history of diverticulitis 4-5 months prior. He presented to the emergency department with left-sided abdominal pain, constipation for several days, black stool, a month of intermittent dysuria and urinary hesitancy, and fever up to 101 degrees Fahrenheit. Vital signs were notable for rapid pulse of 136/minute. Physical examination was notable for moderate abdominal tenderness in the periumbilical region, suprapubic region, and left upper quadrant, and severe tenderness in the left lower quadrant with left lower quadrant guarding. Labs showed elevated white blood cell count of 15.6 and unremarkable comprehensive metabolic panel. Computed tomography scan of the abdomen and pelvis showed acute diverticulitis. He was treated with intravenous fluids, Dilaudid, and Zosyn. 

The inpatient hospital admission is not medically necessary, and the care provided could have been provided at a lower level of care for the duration of the stay. In patients with uncomplicated diverticulitis (without complications such as abscess or perforation), outpatient management or observation is the standard of care. The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated. A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the emergency department and then discharged with oral antibiotics. A lower level of care can be appropriate when there are significant symptoms and leukocytosis, as in this case. However, there was no protracted fever or hypotension to suggest that intravenous antibiotics in the hospital were ineffective. There had been no evidence of abscess on imaging. The patient improved on intravenous antibiotic therapy and was appropriately discharged on antibiotic therapy. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, fistula, or other complication was documented. For these reasons, the inpatient level of care was not medically necessary.