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

Diagnosis: Severe Obstructive Sleep Apnea

Treatment: Outpatient Surgery (64568 x1)

The insurer denied coverage for Outpatient Surgery (64568 x1)

The denial is overturned

The patient is a male diagnosed with severe obstructive sleep apnea (OSA) based on sleep study with Apnea Hypopnea Index (AHI) of 49.9 and no evidence of central sleep apnea. He has a normal body mass index (BMI) of 33.2. The patient has tried continuous positive airway pressure (CPAP) machine therapy but is not tolerant to it. A sleep endoscopy was performed showing no concentric collapse.

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 therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection. CPAP is the gold standard first line but for patients who cannot tolerate CPAP and fit the inclusion criteria, the upper airway stimulator is the second line treatment. This patient meets the criteria for the upper airway stimulation device to treat his severe OSA. This patient has a diagnosis of severe OSA based on sleep study with AHI of 49.9 and no evidence of central sleep apnea. He has a normal BMI of 33.2. In addition, the patient has failed CPAP machine therapy. Lastly, a sleep endoscopy was performed showing no concentric collapse. Therefore, the coverage for Outpatient Surgery (64568 x1) Pain Management is considered medically necessary for this patient.

"Long-term 3-year improvements in objective respiratory and subjective quality-of-life outcome measures are maintained. Adverse events are uncommon. UAS is a successful and appropriate long-term treatment for individuals with moderate to severe OSA." (Woodson, B.T. et al., 2016)

More than 9 out of 10 of the respondents were interested in trying emerging technologies to treat OSA, most preferring continuous transcutaneous electrical stimulation (CTES). (Campbell, T., Pengo, M. F., & Steier, J., 2015)

This review reveals that hypoglossal nerve stimulation therapy may be considered in selected patients with OSA who fail medical treatment. (Certal VF, et al., 2015)

The trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. (Dedhia RC. et al., 2015)    

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.      
                        
The insurer's denial of coverage for Outpatient Surgery (64568 x1) is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, kidney stone
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This male patient was admitted with right renal colic.  This visit was his third to the emergency room (ER). The patient's vital signs were: temperature 98.2, blood pressure 180/95, heart rate 78.  The white blood cell (WBC) count was 10,000.  The creatinine was 1.38.  Computed tomography (CT) imaging demonstrated a three millimeter right distal ureteral calculus with hydronephrosis.  Intravenous pain medications, nausea medications, intravenous antibiotics and intravenous fluids were administered.   

Day 2, the patient had a ureteroscopy, stone basketing and stent placement.

Day 3, the patient was discharged home.  He was afebrile and hemodynamically stable throughout the stay.

No, the proposed inpatient admission was not medically necessary.
An acute inpatient level of care was not medically necessary.  Care could have been provided at a lower level of care.  The patient was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis.  Following admission, there were no unstable vital signs reported.  The patient did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting.  Pain control, intravenous antibiotics and intravenous fluids followed by ureteroscopy, stent placement in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This patient has hyperlipidemia (HLD), opioid dependency (on methadone) hepatitis C, presented to Emergency department (ED) for generalized body aches, nausea, also chronic right knee pain, bilateral foot numbness. Emergency room revealed Blood Pressure 136/60, Temperature 99.5 degrees Fahrenheit, urinalysis showed slight urinary tract infection. Chest x-ray, ultrasounds of lower extremities were negative. Cardiac ultrasound (U/S) was also negative. Liver U/S revealed slight enlargement. The patient's hospital course revealed gradual improvement, suggested urinary tract infection (UTI), possibly a viral illness. Treatment with antibiotics, supportive care improved her symptoms. She was deemed stable for discharge. The insurer has denied coverage for the inpatient hospital admission as not medically necessary, stating that required care could've been given in the ED or observation care, with follow up at her doctor's office or a clinic. The appeal on behalf of the hospital is noted and read in detail. The patient's urine culture was reported as contaminated (> 3 organisms) and her repeat urine cultures as 9/6 was < 10,000 colony forming unit per milliliter (CFU/ml) - considered insufficient to diagnose a UTI. Per MCG Health (24th): UTI and Sepsis + other febrile illness, without focal infection. 

The patient fails to meet clinical indications for admission to inpatient care. 

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient. The inpatient hospital admission was not considered to be medically necessary. 

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

Diagnosis: Engorgement. 
Treatment: Hospital Grade Breast Pump. 

The insurer denied coverage for hospital grade breast pump. 

The denial is upheld. 

According to the documentation submitted, this is a female with a history of low milk supply. She had a telemedicine visit with the lactation consultant. The patient reported being engorged. She had pain in both nipples. The consultant discussed strategies to increase supply and improve latching. A hospital grade pump was recommended to treat engorgement. 

The insurer has denied coverage for a hospital grade breast pump, as not medically necessary. In a Final Adverse Determination letter, they stated that the patient has engorgement that is not getting better with the pumps that she has. The plan covers personal use electric breast pumps and not hospital grade pumps. 

A breast pump is a device that can pump milk out of a woman's breasts. If a woman is going to be away from her baby when it is time to breastfeed, she can instead pump milk from her breasts using a pump. The breast milk can be collected, stored, and fed to her baby later. Pumping also helps the breasts make more milk. A woman can use a breast pump when she wants to breastfeed but can't because: 
- Her baby needs to stay in the hospital after birth because it was born too early or is sick; 
- She can't be with her baby all the time because of work, travel, or other reasons; 
- Some women choose to pump because they have trouble breastfeeding, but still want their baby to get the benefits of breast milk; 
- Some women pump so their partner can be more involved with feeding the baby. 

The different types of breast pumps include: 

- Electric pumps that are used in hospitals - These breast pumps are powerful and collect breast milk the fastest. They are often used by women whose babies need to stay in the hospital after birth. Women can also rent these types of pumps to use at home. 

- Personal electric pumps - These breast pumps are smaller than hospital electric pumps. They can collect breast milk fast, but usually not as fast as hospital pumps. Personal pumps can come in a carrying case. They can be good for women who pump at work. 

- Single-sided pumps - These breast pumps collect milk slower than hospital and personal electric pumps. They can be powered by hand, batteries, or electricity. They can be good for women who need to pump breast milk only once in a while. 

For mothers who do not have access to an electric pump, manual pumping can be successful, although the pumping time is longer. 

While a hospital grade pump will help the patient pump her milk faster, all breast pumps are able to collect enough milk to help with feeding of the baby. Therefore, a hospital grade pump is not medically necessary for this patient. 

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

The insurer's denial of coverage for a hospital grade breast pump is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute on Chronic Systolic Congestive Heart Failure. 
Treatment: Full Hospital Admission. 

The insurer denied coverage for full hospital admission. 

The denial is overturned. 

The patient presented to the hospital complaining of dyspnea and pedal edema for three days.  Past medical history was significant for non-ischemic systolic heart failure combined with diastolic congestive heart failure (CHF), hypertension, mitral valve regurgitation with biological mitral valve replacement, tricuspid valve repair, atrial fibrillation and hyperthyroidism.  Physical exam was significant for a respiratory rate of 24, blood pressure (BP) 149/69 and bilateral crackles on lung exam with left side more pronounced than the right side.  Serum blood testing revealed an elevated Brain natriuretic peptide (BNP) level (3040), hypomagnesemia (1.1) and hypokalemia (2.7).  Chest x-ray revealed evidence of congestive heart failure.  The patient required treatment with bi-level positive airway pressure (BiPAP) due to respiratory distress.  Electrocardiogram (ECG) revealed sinus rhythm with prolonged PR (interval on ECG) interval, left axis deviation and poor R (interval on (ECG) wave progression.  A corrected QT (interval on ECG) interval of 658 was noted.  The patient was treated with electrolyte repletion and diuresis.  In addition, endocrinology consult recommended continued use of methimazole due to elevated free thyroxine (T4) and low thyroid stimulating hormone (TSH) levels. 

Full hospital admission is considered medically necessary.  This patient presented to the hospital with acute on chronic systolic congestive heart failure.  On physical exam she had significant tachypnea and bilateral crackles along both lung fields.  The patient had multiple abnormalities on serum blood testing including an elevated B-type natriuretic peptide, hypomagnesemia, and hypokalemia.  ECG revealed a prolonged QT interval in this setting and would require monitoring on telemetry while electrolytes are repleted.  The patient required BiPAP therapy and aggressive diuresis consistent with guideline directed medical therapy for heart failure exacerbation.(1, 2) In conclusion, this patient could not have been managed at a lower level of care and required inpatient hospital admission. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the full hospital admission is reversed.  Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Growth hormone deficiency.
Treatment: Norditropin.

The insurer denied Norditropin. The health plan's determination is upheld.

The patient is a female who is seeking growth hormone (GH) treatment for the presumptive diagnosis of growth hormone deficiency (GHD). Her mother's height is 5 feet 2 inches and father's height is 5 feet 4 inches. She was initially seen in the pediatric endocrinology clinic for short stature. Her height at that time was 132.5 centimeter (cm) (-1.99 standard deviation (SD)). Her evaluation including complete blood count (CBC), comprehensive metabolic panel (CMP), erythrocyte sedimentation rate (ESR), thyroid stimulating hormone (TSH), celiac screen, IGF-1 (insulin like growth factor one), insulin-like growth factor binding protein-3 (IGFBP-3) and chromosome analysis was unremarkable. Under review is the medical necessity of growth hormone (GH).

Norditropin is not medically necessary for this patient.

Based on her recent bone age and height, this patient's adult height prediction is about 58.5+/-2 inches, which is quite shorter than an average girl (-2.27 SD (standard deviation)); however, it is within 1 SD of her genetics suggesting familial short stature. She underwent GH stimulation testing and her peak GH response was < 10. In the absence of other clinical criteria she cannot be diagnosed GHD based solely on GH stimulation testing. The Pediatric Endocrine Society guidelines recommend against reliance on GH provocative test results as the sole diagnostic criterion for the diagnosis of GHD because of limited sensitivity and specificity. This patient is quite short for her age, but she is not from tall parents and her mid-parental height is only 60.5+/-2 inches.

Growth rate varies throughout the year (growth velocity standards are available for children with early, average and late puberty), it is recommended that growth velocity should be calculated over a period of at least 6-12 months to draw meaningful conclusion. Overall, this patient had grown 6.5 cm, which gives her a growth velocity of 10.8 cm per year in 7.3 months, which is well within the normal range for her age and pubertal development. Clearly this patient does not meet clinical criteria for the diagnosis of GHD.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis vulgaris. 

Treatment: Cosentyx. 

The insurer denied coverage for Cosentyx. 

The denial is upheld. 

This patient is a male child with a diagnosis of psoriasis vulgaris affecting 50% total body surface area (TBSA) who has failed topical steroid therapy.  The provider has requested Cosentyx-secukinumab.
  
Cosentyx is not medically necessary for the patient's condition; Psoriasis Vulgaris.  There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly supports the administration of Cosentyx for this patient's condition above reasonable alternatives as an accepted standard of practice.  

There are no comparative, controlled head-to-head studies showing that Cosentyx has a superior efficacy or safety profile to alternatives such as phototherapy, etanercept, adalimumab, and ustekinumab.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient.(1,2,5)   

Within the peer-reviewed literature, Racz et al. writes, "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks."(3)  Mehta et al. writes, "Ultraviolet (UV) B [UVB] phototherapy is most appropriate for patients with >10 % affected body surface area who have not responded to topical treatments...NB (narrow band)-UVB effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile." (4)

Additionally, the Joint American Academy of Dermatology-National Psoriasis Foundation guidelines of care for the management and treatment of psoriasis in pediatric patients(5) states that etanercept and ustekinumab are recommended biologics in the pediatric population with the highest strength of recommendation (strength of recommendation A compared to B for adalimumab). Only etanercept, ustekinumab, and ixekizumab are approved by the United States Food and Drug Administration (FDA) for the treatment of psoriasis in children.(Up to Date)
  
The provided medical notes do not provide any evidence of a contraindication for the use of available therapies or unique clinical situation which would specifically warrant Cosentyx in this patient. As such, the appeal is denied as the Cosentyx is not medically necessary based on the submitted documentation. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for Cosentyx is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic idiopathic urticaria. 

Treatment: Xolair. 

The insurer denied coverage for Xolair. 

The denial is overturned. 

This is a male patient with pre-diabetes with a diagnosis of chronic idiopathic urticaria.  The patient has failed therapy during the course of an extensive work-up which ruled out lupus, dermatomyositis and other collagen vascular disease associated diagnoses. The patient has unsuccessfully been treated with multiple topical steroids (triamcinolone, mometasone), oral and topical antibiotics (mupirocin, doxycycline), as well as multiple anti-histamines (hydroxyzine and loratadine).  The patient is a poor candidate for long term systemic steroids and other immunosuppressive therapies given his medical history.  Having failed standard therapies with a contraindication to systemic therapies, the provider is requesting Xolair for treatment of the patient's chronic idiopathic urticaria. 

Xolair is Food and Drug Administration (FDA) approved for chronic idiopathic urticaria with a significantly more favorable efficacy as well as side effect profile.  Xolair is medically necessary for the treatment of this patient's chronic idiopathic urticaria based on the submitted documentation having failed standard therapies.  Xolair is approved and the determination is overturned in whole.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for Xolair is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Plaque Psoriasis
Treatment: Formulary exception for Taltz, Pre-service
The insurer denied the Formulary exception for Taltz, Pre-service.
The denial is upheld.

The patient is a woman with plaque psoriasis for whom Taltz injections are requested. She has tried and failed topical steroids, methotrexate, Stelara and Enbrel. She had an allergic reaction to Tremfya in the past.

No, the health plan should not cover the Formulary exception for Taltz. The plan offers formulary medications that are on par with the efficacy and safety of Taltz for moderate to severe psoriasis. Other than for Tremfya (allergy), there is no documentation of side effects, intolerance, or contraindication to the use of the available formulary medications, which are all approved for use in this indication.

Therefore, given the above, the health plan should not cover the formulary exception for Taltz.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent, Pre-service
The insurer denied the Dupixent, Pre-service
The denial is overturned.

The patient is a female with severe atopic dermatitis, treated with numerous topicals, antibiotics and antivirals requiring hospitalization, methotrexate, phototherapy and systemic steroids.  The provider is requesting Dupixent.

Yes, the proposed Dupixent is medically necessary.
Given the unique circumstances of this patient and severity of her disease, Dupixent is medically necessary.  This patient has failed nearly all other therapies for atopic dermatitis and has required hospitalization.  Dupixent has been studied in children as young as six months of age and trials are ongoing for children under six.  These studies have very promising results with no safety concerns.  Dupixent is the only systemic medication with a Food and Drug Administration (FDA) approval for this condition (albeit beginning at age six).  Therefore use of Dupixent would be within good standards of medical practice.  The patient does not have other alternatives, and Dupixent is likely to be far more efficacious than other therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Crohn's disease.
Treatment: Adalimumab testing.

The insurer denied Adalimumab testing.  The determination is overturned.

The patient has Crohn's disease and had been on Humira; he was also on mesalamine and methotrexate. Testing showed a low Humira level of 3.2 micrograms per milliliter (ug/mL) and lack of anti-Humira antibodies. His Humira was increased to 40 milligrams (mg) weekly. He had recurrent Crohn's disease flares. Fecal calprotectin was elevated at 507 micrograms per gram (ug/g). He presented with four bowel movements per day and intermittent rectal bleeding. Testing showed a Humira level of 9.4 ug/mL and lack of anti-Humira antibodies. A colonoscopy showed a normal terminal ileum, narrowed and deformed ileocecal valve consistent with Crohn's disease, inflammation consistent with active Crohn's disease throughout the colon, and external hemorrhoids. At issue is whether the proposed health service or treatment Adalimumab testing was likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The test was likely to be more beneficial than any standard treatment or treatments for the insured's Crohn's disease.

In this case, the Humira level and anti-Humira antibody level were checked after the patient had symptoms of uncontrolled Crohn's disease, and elevated fecal calprotectin indicating active Crohn's disease, despite a recent escalation of Humira dose. Although not recommended for routine disease monitoring, this test is recommended by guidelines in patients with ongoing disease symptoms or signs of uncontrolled disease. According to the American Gastroenterological Association (AGA) Guideline on Therapeutic Drug Monitoring in Inflammatory Bowel Disease, "In adults with active inflammatory bowel disease treated with anti-tumor necrosis factor agents, the AGA suggests reactive therapeutic drug monitoring to guide treatment changes" [1]. According to the AGA Clinical Care Pathway guidelines for the treatment of Crohn's disease, drug concentration and anti-drug antibody levels should be checked if there is a loss of response to an anti-tumor necrosis factor (TNF) medication such as Humira, with a subsequent change in management (switch within drug class, assess for inflammation, or increase dose) [2]. The American College of Gastroenterology guidelines for the management of Crohn's disease also recommend drug level testing, stating "If active Crohn's disease is documented, then assessment of biologic drug levels and antidrug antibodies (therapeutic drug monitoring) should be considered... recent guideline has suggested minimal "therapeutic" target trough levels" [3]. Current medical literature concurs with the studies cited in the guidelines [4]. For these reasons, the requested testing of Humira drug levels and anti-Humira antibodies is supported given possible loss of response to Humira.