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

Diagnosis: Sleep Apnea
Treatment: Hypoglossal Nerve Stimulation (64568 & 0466T)
The insurer denied the Hypoglossal Nerve Stimulation (64568 & 0466T).
The denial is overturned. 

The patient is a male patient with severe OSA (obstructive sleep apnea) with an AHI (apnea-hypopnea index) of 53.3 and a BMI (body mass index) of 28.98.  The patient is intolerant of CPAP (continuous positive airway pressure).  DISE (drug-induced sleep endoscopy) done on showed AP (anteroposterior) collapse, making the patient a candidate for the Inspire device.  The request is for the inspire device.

Yes, the health plan should cover the Hypoglossal Nerve Stimulation.

Otolaryngology's academy's recommendations, as well as the literature, support that this procedure is the treatment of choice for OSA (obstructive sleep apnea) seen as seen in this patient. (1-4).  He has the appropriate diagnostic findings and has not tolerated CPAP (continuous positive airway pressure).  

The procedure is not E/I (experimental/investigational), and it is accepted standard of care. The nurse review and confirmation of denial packet is not correct. The quote, "Medical suites have not proven the treatment improves health of people with OSA [obstructive sleep apnea]," is not correct. The literature is clear on health improvement. (1-4)

Yes, the Hypoglossal Nerve Stimulation is likely to be more beneficial.

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

Diagnosis: Sleep Apnea
Treatment: Hypoglossal Nerve Stimulation (64568 & 0466T)
The insurer denied the Hypoglossal Nerve Stimulation (64568 & 0466T).
The denial is overturned. 

The patient is a male with a history of OSA (obstructive sleep apnea).  His AHI (apnea-hypopnea index) on sleep study was 52.1 with a BMI (body mass index) of 32.  The patient could not tolerate CPAP (continuous positive airway pressure) and underwent 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 condition.

Yes, the health plan should cover the Hypoglossal Nerve Stimulation.

Yes, the Hypoglossal Nerve Stimulation is likely to be more beneficial.

All records were reviewed.  The patient is a male with a history of OSA (obstructive sleep apnea).  His AHI (apnea-hypopnea index) on sleep study was 52.1 with a BMI (body mass index) of 32.  The patient could not tolerate CPAP (continuous positive airway pressure) and underwent 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 condition.  

There is support in the literature for the efficacy of the Inspire hypoglossal nerve stimulator for the treatment of a subset of patients with OSA (obstructive sleep apnea) who have failed, or cannot tolerate, CPAP (continuous positive airway pressure) therapy.  A prospective multi-center study documented a reduction of AHI (apnea-hypopnea index) out to 12 months.  In addition, there was a randomized, controlled withdrawal arm of the study which reported AHI (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 OSA (obstructive sleep apnea) who meet FDA (Food and Drug Administration) criteria for the procedure.  

In this particular case, the patient would meet FDA (Food and Drug Administration) criteria for the device in terms of BMI (body mass index), age, AHI (apnea-hypopnea index) and sleep endoscopy findings (there was no complete concentric collapse on sleep endoscopy).  The patient has had a previous reported failed CPAP (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 appropriateness of the requested service would be confirmed, and the health plan should cover the proposed treatment, as the requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Sleep Apnea
Treatment: Hypoglossal Nerve Stimulation (64568 & 0466T)
The insurer denied the Hypoglossal Nerve Stimulation (64568 & 0466T).
The denial is overturned. 

The patient is a male with obstructive sleep apnea with RDI (respiratory disturbance index) of 53 and nadir desaturation to 86% on sleep study.  The patient does not tolerate CPAP (continuous positive airway pressure).  The patient underwent drug induced sleep endoscopy and did not demonstrate concentric collapse of the airway.

Yes, the health plan should cover the Hypoglossal Nerve Stimulation.

The procedure and device are FDA (Food and Drug Administration)-approved as referenced below and recognized in the treating community as efficacious and safe for properly selected patients.  This patient with failure of CPAP (continuous positive airway pressure) and favorable anatomy is a good candidate for this intervention.  By virtue of review of the literature, it is neither experimental nor investigational.  This 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.  
  
Yes, the hypoglossal nerve stimulation is likely to be more beneficial.

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 following:

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: Medical necessity
Decision: Upheld

Skin Disorders
Pharmacy/prescription drugs

Diagnosis: Psoriasis
Treatment: Cosentyx
The insurer denied Cosentyx. 
The health plan's determination is upheld. 

The patient is a male with moderate to severe psoriasis (more than 30% body surface area involvement) of the face, neck, chest, abdomen, back, palms and soles, buttocks, back, genitals, legs, and arms. The patient has tried and failed topical betamethasone, 2.5% hydrocortisone, tacrolimus, and desonide cream. Phototherapy was discontinued because of burning to the patient's skin. No arthritis is reported.

Secukinumab (Cosentyx) is not medically necessary for this patient.
Alternative first-line treatments are appropriate for this patient, including lower light therapy doses used in combination with acitretin for patients who want conservative, non-immunosuppressive therapy allowing lower doses of both medications for better tolerability.
The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, and/or Phototherapy. Acitretin and alternative first-line treatments can be used if the patient is actively trying to father a child. Therefore, Cosentyx is not medically necessary.
Modern dermatology literature supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Cosentyx, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Cosentyx is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Apicoectomy and retrograde filling for tooth #3.

The insurer denied the Apicoectomy and retrograde filling for tooth #3. The determination is overturned.

The patient presented with an existing root canal on tooth number (#) 3 that had a recurrent periapical infection on the mesial root. Apicoectomy and retrograde filling are being requested at this time. At issue is the medical necessity of the apicoectomy and retrograde filling.
The requested health service treatment of apicoectomy and retrograde filling for tooth #3 is medically necessary.
The submitted radiograph shows tooth #3 with an existing root canal that has a recurrent periapical infection on the mesial root. Apicoectomy is considered a standard oral surgical procedure that is used as a last resort to surgically maintain a tooth with a periapical lesion that cannot be managed with conventional endodontic re-treatment. Because the periapical infection is minimal and the tooth appears to have a good prognosis, it is important to save the tooth and maintain the space to prevent the adjacent teeth from collapsing in and causing unnecessary occlusal problems. In addition, losing a tooth will lead to the bone level in that area receding, which will affect the adjacent teeth as well. Therefore, an apicoectomy and retrograde filling is medically necessary for tooth #3.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman. Her past medical history is significant for asthma and hyperthyroidism treated with PTU (propylthiouracil). She presented to the ED (emergency department) complaining of left leg numbness for one week, headache for three days associated with facial numbness and chest pain radiating to the left arm for one day. The chest pain was described as pleuritic in character. 

The patient's physical examination in the ED (emergency department) revealed stable vital signs and no significant abnormalities. 12-lead ECG (electrocardiogram) demonstrated no evidence of ischemia. Serum troponins were negative. CT (computerized tomography) scan of the chest was performed to rule out aortic dissection and pulmonary embolism. CT (computerized tomography) scan of the head was performed to rule out an intracranial process. 

The patient was subsequently treated with NSAIDs (nonsteroidal antiinflammatory drugs) for pain and admitted to the hospital. Exercise stress test revealed normal exercise tolerance (10 METS [metabolic equivalents]) with a normal left ventricular ejection fraction and normal perfusion.  

No, the Inpatient admission was not medically necessary.

This patient presented with atypical chest pain and no significant past cardiac history. Her pretest probability of coronary artery disease is low (Reference 1). Utilizing the HEART (History, EKG [electrocardiogram], Age, Risk factors, initial Troponin) score, she was considered low risk (Reference 2). Utilizing the TIMI (thrombolysis in myocardial infarction) risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). 

Risk assessment of patients presenting with chest pain and no significant changes on ECG (electrocardiogram) was reviewed by Hedayati et al (Reference 3). Using the HEART (History, EKG [electrocardiogram], Age, Risk factors, initial Troponin) score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. 

Using the TIMI (thrombolysis in myocardial infarction) risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI [myocardial infarction], and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. CT (computerized tomography) chest, performed in the ED (emergency department), was negative for pulmonary embolism and aortic dissection and ECG (electrocardiogram)/serum troponin levels were not consistent with a cardiac etiology. Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) Stroke
Treatment: Continued Rehab Stay 
The insurer denied the Continued Rehab Stay.
The denial is overturned. 

The patient is a female with history of altered mental status and focal neurological deficit and found to have intracerebral hemorrhage. She has relevant medical history of newly diagnosed hypertension, uncontrolled Diabetes Mellitus, Dysphagia, Anxiety, depression, hallucinations. 

Prior to admission, the patient was independent with ADLs (activities of daily living) working for the state Department of Education and living with family in an apartment with 16 steps into the apartment.

The patient was admitted. As of a month after admission, she was ambulating 10 feet with total assist/maximum assistance and using hand-rail, requiring maximum assistance for lower body dressing, requiring moderate assistance for  toilet transfers, requiring minimum assistance for bed transfer, requiring supervision for upper body transfer, and she was a high fall risk.

Yes, the Continued Rehab Stay was medically necessary.

The patient met all the criteria for acute rehabilitation care Interqual Criteria 2020 for Acute Rehabilitation in a patient with General Debility and weakness due to intracerebral hemorrhage and with ongoing clinical issues including hypertension and Diabetes Mellitus still being managed. One month after admission, she was ambulating 10 feet with total assist/maximum assistance and using hand-rail, requiring maximum assistance for lower body dressing, requiring moderate assistance for  toilet transfers, requiring minimum assistance for bed transfer, requiring supervision for upper body transfer, and she was a high fall risk.

Based on her condition meeting the above requirements, the patient has met the criteria for more intensive acute inpatient rehabilitation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class II, Class II canines, moderate crowding and deep impinging overbite) 
Treatment: Braces

The insurer denied coverage for braces.
The denial is upheld. 

This is a male child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II, Class II canines, moderate crowding and deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 17 points on review by their internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the HLD index is utilized. This index provides 6 specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and this does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 17 points (4 points overjet, 5 points overbite, 5 points anterior crowding and 3 points labiolingual spread).
 
The request for braces 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.

Based on the above, the medical necessity for braces is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient had abdominal pain and was found to have appendicitis. She was admitted and her operative report indicated inflamed appendix and no perforation. The pathology report indicated acute appendicitis and serositis with no perforation.

At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. The patient received intravenous fluids (IVF) and antibiotics. The pathology report indicated acute appendicitis and serositis with no perforation. The references noted below demonstrate the safety and feasibility of performing outpatient/23 hour appendectomy. In the era of enhanced recovery after surgery (ERAS) protocols, appendectomy is one of the conditions that has a standardized pathway of management that improves quality. It needs to be an uncomplicated case, which this was. This means there are no perforations or complications with the surgery. The patient did well post operatively and could have been discharged within 4-6 hours. Therefore, an inpatient admission was not warranted and care could have been provided at a lower level with the goal of meeting conditional discharge criteria post operatively to facilitate the patient going home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a female who developed right breast pain and redness with purulent right nipple discharge. She presented to an Urgent Care facility and was prescribed doxycycline which she took for 1 week without improvement. In fact, she developed increased swelling, redness and pain as well as fever/chills, which prompted her to go to the Emergency Department. At the time of her initial evaluation in the Emergency Department, she was febrile to 102 Fahrenheit (F) and tachycardic with her heart rate in the 130's. On examination she was noted to have erythema and induration of the right breast from the 3:00 to 9:00 axis. She had significant leukocytosis with a white blood cell (WBC) count of 27.2 thousand (K) The Emergency Department physician performed a bedside incision and drainage (I&D) that yielded 20 cubic centimeter (cc) of purulent material that was sent for culture and sensitivities. She was admitted to the hospital and was started on IV antibiotics including vancomycin and ceftriaxone. She received irrigation of her right breast wound twice daily with dressing changes. Her pain was controlled with oral pain medications. Throughout her hospital course, her pain and redness continued to improve. The next day her WBC was down to 21K, and the following day her WBC was further decreased to 13 K. She was transitioned to oral antibiotics and deemed stable for discharge to home. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld in whole.

The patient received appropriate care in the Emergency Department and subsequently in the hospital. She underwent definitive treatment of her right breast abscess (incision and drainage) while she was in the Emergency Department. While in the hospital she received IV antibiotics, dressing changes and oral pain medications, and her vital signs and laboratory studies were monitored. At no time was she hemodynamically unstable and her clinical condition continued to improve throughout her stay until her WBC had decreased to the point at which she was deemed stable for discharge.
While hospital admission was required for close monitoring of her clinical condition and administration of IV antibiotics, the identical services could have been provided at a lower level of care rather than the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient presented with a clinical exam and imaging findings consistent with appendicitis. She underwent an appendectomy and was found to have a retroperitoneal appendix without perforation or gangrene. The procedure was uncomplicated and the pathology demonstrated acute appendicitis and periappendicitis. She did well and was discharged.

Inpatient stay is not medically necessary. The references below demonstrate the safety and feasibility of performing an outpatient/23 hour appendectomy. In the era of enhanced recovery after surgery (ERAS) protocols, appendectomy is one of the conditions that having a standardized pathway of management that improves quality. The procedure needs to be an uncomplicated case, which it was in this case. This means there is no perforation or complications with the surgery. The patient did well post operatively and could be discharged within 4-6 hours. Therefore inpatient admission was not warranted, but care could have been provided at a lower level with the goal of meeting conditional discharge criteria post operatively to facilitate the patient going home.