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

Diagnosis: Chest pain and Hyperglycemia. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with a past medical history significant for Type 2 Diabetes. He was seen in the Emergency Room (ER) with concerns of right-sided chest pain, 10 out of 10 in severity, weakness, fatigue, and polyuria. The patient reported checking his blood sugar (BS) at home and it was > 500 and he had not been compliant with his medical regimen. The patient's vital signs in the ER showed pulse > 100. Exam in the ER showed the patient was in no distress, lungs were clear, gastrointestinal (GI) exam negative, there was no edema, and the neurological exam was all normal. Skin was warm/dry. The patient's electrocardiogram (EKG) showed tachycardia and non-specific ST changes. The patient had a normal chest X-ray, and his labs showed creatinine of 1.83, blood sugar of 1049, and mildly elevated liver function tests. The patient had moderate ketones in his urine. The patient's hemoglobin A1c was 14.9%. The patient's troponin was negative.  The patient was started on intravenous (IV) fluids and insulin, and was admitted to the inpatient floor. He did have a liver ultrasound which showed concerns for his gallbladder.  While admitted he was seen by Cardiology who determined that his chest pain was not cardiac related. 

This patient presented with hyperglycemia which responded rapidly to fluids/insulin and no evidence of Diabetic Ketoacidosis (DKA). There was no evidence of acute myocardial ischemia. The patient could have been managed in observation and when improved discharged for close follow-up and management of his diabetes. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral ptosis.

Treatment: Procedure Code 67900: Repair of Brow Ptosis (Supraciliary, Mid-forehead or Coronal Approach).

The insurer denied coverage for Procedure Code 67900: Repair of Brow Ptosis (Supraciliary, Mid-forehead or Coronal Approach).

The denial is overturned. 

This is a male patient with a history of ptosis involving the right and left upper eyelids.  The patient presented to the ophthalmologist's office for an evaluation.  The patient reported difficulty seeing in the superior visual field and a need to raise materials up to see them.  The physician noted that the patient had brow ptosis, dermatochalasis, and eyelid ptosis.  The patient's condition had worsened compared to the prior study.  The physician recommended an internal browpexy to treat the patient's condition. 

Based on the review of the medical record and literature, the requested procedure, Procedure Code 67900 (repair of brow ptosis) is considered medically necessary and in accordance of accepted medical standards.  The medical documentation shows ptosis causing more than 12 degrees of superior field loss in both eyes of the patient that improved with taping of the upper eyelids.  The patient's eyelid margin reflex distance (MRD1) was noted to be 1 millimeter in the right eye and 2 millimeters in the left eye, indicating visual field obstruction. The patient has bilateral brow ptosis and dermatochalasis, and internal browpexy and upper eyelid blepharoplasty were recommended.

The requested brow ptosis repair is thus, considered medically necessary for this patient's condition to improve this patient's vision and function.  The patient has bilateral ptosis affecting his vision, causing visual field obstruction. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.  

The carrier's denial of coverage for Procedure Code 67900: Repair of Brow Ptosis (Supraciliary, Mid-forehead or Coronal Approach) should be overturned.  The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease.
Treatment: Humira (CF) 40mg / 0.4ml Injector Increase, Pre-service.
The insurer denied the Humira (CF) 40mg / 0.4ml Injector Increase, Pre-service.
The denial is overturned. 

The patient's is a male with Crohn's. He has failed treatment with Remicade, as well as Humira 20 mg (milligrams) weekly, with ongoing symptoms and low serum drug levels. His provider is requesting to increase Humira to 40 mg (milligrams) weekly.

Yes, the health plan should cover the Humira (CF) 40mg / 0.4ml(milliliter) Injector Increase.

The patient has failed Humira 20 mg (milligrams) weekly with low drug levels. Medical literature supports dose intensification of biologics in patients who do not respond to FDA (United States Food and Drug Administration)-approved dosing. Dubinsky et al showed that 40 mg (milligrams) weekly adalimumab dosing was clinically beneficial for children with Crohn's disease who experienced nonresponse or flare on every other week dosing. No increased safety risks were observed with weekly dosing. Therefore, as this patient has failed Remicade, as well as Humira 20 mg (milligrams) weekly, the health plan should cover Humira 40 mg (milligrams) weekly.

The patient has failed Remicade, as well as Humira 20 mg (milligrams) weekly. Standard of care is to dose intensify biologics in patients who fail FDA (United States Food and Drug Administration)-approved dosing, prior to changing to another biologic. The patient has low serum drug levels, making it more likely that he would respond to a higher dose. Therefore, as the patient has had some, but not a complete response to Humira 20 mg (milligrams) weekly and has low serum drug levels, Humira 40 mg (milligrams) weekly is likely to be more beneficial for the enrollee than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease.
Treatment: Humira (CF) 40mg / 0.4ml Injector Increase, Pre-service.
The insurer denied the Humira (CF) 40mg / 0.4ml Injector Increase, Pre-service.
The denial is overturned. 

The patient is a male. He has had moderate to severe Crohn's disease. He failed conventional therapy and Remicade. He has been on Humira 20 mg (milligrams) every week. He still has symptoms and his drug level is low. His physician requested to increase dose to 40 mg (milligrams) weekly.

Yes, the health plan should cover the Humira (CF) 40mg / 0.4ml(milliliter) Injector Increase.

Dubinsky et al. conducted multicenter trial of Humira weekly dosing in children with Crohn's disease. They concluded that "Weekly adalimumab dosing was clinically beneficial for children with Crohn's disease who experienced nonresponse or flare on EOW [every other week] dosing. No increased safety risks were observed with weekly dosing." In this study, the Humira dose is 20 mg (milligrams) or 40 mg (milligrams) every week.

Current clinical guidelines recommend adalimumab (Humira) 40 mg (milligrams) weekly when children with Crohn's disease do not respond to the standard dosing of 40 mg (milligrams) every other week or when serum drug level is low (references 1-4). This patient has had moderate to severe Crohn's disease and did not respond to Humira 20 mg (milligrams) every week. The recommended treatment would be to increase Humira to 40 mg (milligrams) every week. Thus, Humira 40 mg (milligrams) weekly is medically appropriate for this patient's condition, and the health plan should cover the proposed treatment.

Yes, the Humira (CF) 40mg / 0.4ml Injector Increase is likely to be more beneficial.

Current clinical guidelines recommend adalimumab (Humira) 40 mg (milligrams) weekly when children with Crohn's disease do not respond to the standard dosing or when serum drug level is low (references 1-4). This patient has had moderate to severe Crohn's disease and did not respond to Humira 20 mg (milligrams) every week. The recommended treatment would be to increase Humira to 40 mg (milligrams) every week. The requested therapy Humira 40 mg (milligrams) every week is likely to be more beneficial for the enrollee than any available standard therapy.
Appeal type: Medical necessity
Decision: Upheld

Digestive System
Inpatient hospital

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

The patient is a man who presented to the hospital with a history of progressively worsening abdominal pain of 1-day duration. His evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. Lab data identified a normal white blood cell (WBC) count of 7.9. CT scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested. The patient underwent a laparoscopic appendectomy. 

The Inpatient stay was not medically necessary for this patient. The care and treatment provided could have appropriately been rendered at a lower level of care. The patient was clinically stable at the time of presentation and remained so during the hospital course of care. A lower level of care would have provided for presurgical assessment, serial examination, operative treatment and post-surgical monitoring. This lower level of care would have also allowed for overnight monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 

The patient is a female with a history of bipolar disorder, methadone use, and hypertension who presented to the hospital. She presented with a chief complaint of feeling shaky, urinating on herself, and shortness of breath in the setting of suspected seizure. She denied alcohol or drug use. 

The review of systems was negative for fevers and chills. Her vital signs showed a blood pressure at 106/74, heart rate was 66, temperature was 97.9 Fahrenheit, and respiratory rate was 18. On physical exam, her heart was regular, breath sounds were normal, abdomen was soft, and there was no cranial nerve deficit reported. 
Her labs showed a potassium at 2.7, troponin was 0.17, brain (or B-type) natriuretic peptide (BNP) was 382, creatinine was 1.09, glucose was 95, and alcohol level was negative. Her electrocardiogram (EKG) showed normal sinus rhythm with premature ventricular contractions and a prolonged QT interval. A head computed tomography (CT) scan was negative for acute findings. The patient was admitted for suspected new onset seizure versus syncope. 

The plan of care included to monitor electrolytes, monitor QT interval, neurology consult, electroencephalogram, start thiamine and folic acid due to possible history of alcohol abuse, and continue other home medications. The electroencephalogram was performed and was negative. Neurology was consulted and recommended that she continue her anti-epileptic drugs. The electrocardiogram (EKG) was repeated and demonstrated improvement in the QT interval. The patient received boluses of intravenous (IV) fluids in response to a low blood pressure. The patient remained stable and was discharged. 

At issue is the inpatient hospital admission for medical necessity. 
The health plan's determination of medical necessity is overturned, in whole. 

Yes, the requested health service/treatment of Inpatient Hospital Admission was medically necessary for this patient. 

The patient presented with suspected seizure in the setting of cardiac ischemia and required intensive care with close monitoring. The patient had an atypical presentation, involving multiple organ systems including neurology, cardiology, and psychiatry. With the elevated troponin, electrolyte abnormalities and in particular low potassium level, and concern for recent stroke, the intensity of care was appropriate for the inpatient level of care. The hospital stay included electroencephalogram, cardiac work up, and management of multiple chronic medical conditions. In addition, there was concern for syncope and she had electrolyte abnormalities at baseline at the time of presentation. Overall, the patient's complexity made inpatient level of care appropriate. 

Therefore, the requested health service/treatment of Inpatient Hospital Admission was medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ears/Nose/Throat.

Treatment: Balloon dilation of Eustachian tube, code 69799.

The insurer denied coverage for balloon dilation of Eustachian tube, code 69799.

The denial is overturned. 

This is a female patient with a past medical history of chronic otitis media, chronic mastoiditis of the left ear, retraction, adhesive middle ear disease, cholesteatoma, and conductive hearing loss.  The patient underwent a left-complex mastoid debridement under anesthesia, left balloon Eustachian tube dilation and nasopharyngoscopy.  The indications were noted to include a long history of chronic Eustachian tube dysfunction and adhesive middle ear disease on the left.  The patient had refractory chronic Eustachian tube dilatory dysfunction to all conservative measures.
As per literature review, the requested procedure, balloon dilation of the Eustachian tube results in improvement in health outcomes, especially as related to ear symptoms. Balloon dilation of the Eustachian tube has been approved by the Food and Drug Administration (FDA) for several years now. 

In this case, this patient is a good candidate for balloon dilation of the Eustachian tube since she has retraction, chronic Eustachian tube dysfunction, and adhesive middle ear disease on the left, and has failed conservative measures. Balloon dilation of the Eustachian tube is a very good treatment for this type of patient; pressure equalization (PE) tube can also be considering if not already in place.

The requested service, balloon dilation of the Eustachian tube is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for balloon dilation of Eustachian tube, code 69799 should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ears/Nose/Throat.

Treatment: Balloon dilation of Eustachian tube, code 69799.

The insurer denied coverage for balloon dilation of Eustachian tube, code 69799.

The denial is upheld. 

This is a female patient with a long history of chronic middle ear disease. The patient underwent left Eustachian tube balloon dilation and mastoid debridement for chronic adhesive middle ear disease and chronic Eustachian tube dysfunction that has been refractory to conservative management. During the operation, the left ear re-inflated.  Post operatively for a few days, the patient was able to hear, and her ear felt open. However, this was a transient relief, in which the patient reverted to hearing loss and ear fullness.  From the records available there was no further follow-up as to this patient's Eustachian tube function.

As per review of the medical record, the patient had a long history of chronic otitis media further complicated by cholesteatoma. The patient's medical condition was excluded from the populations used to study the efficacy of the device. There is no peer-reviewed evidence that the patient's condition could or could not be taking care of by the insertion of the balloon catheter.  Her history of chronic otitis media was in the exclusion criteria for two of the major controlled studies. The consensus statement noted that benefit from use of the device in patients with this patient's condition of chronic otitis media could not be determined.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome. The specific condition of chronic otitis media was an exclusion criterion for the controlled studies to show the efficacy of the device. The balloon dilation of Eustachian tube, code 69799 received a Food and Drug Administration (FDA) classification of II which meant it did not have to undergo rigorous evaluation for efficacy.

The requested service, balloon dilation of Eustachian tube is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage for balloon dilation of Eustachian tube, code 69799 should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ankylosing spondylitis. 
Treatment: Humira. 

The insurer denied Humira. 

The health plan's determination is overturned. 

The patient is a female with a history of ankylosing spondylitis (AS). The issue in this case is that Humira is being denied by the health plan. The preferred formulary alternatives are nonsteroidal anti-inflammatory drug (NSAID)s (e.g. ibuprofen, naproxen, mobic, etc). Per a note from the patient's provider, she has tried and failed gabapentin, ibuprofen, naproxen, Tylenol and diclofenac in addition to topical diclofenac. 

Humira is medically necessary for this patient. Per a note from the patient's provider, she has tried and failed gabapentin, ibuprofen, naproxen, tylenol and diclofenac in addition to topical diclofenac. Thus, the patient has tried drugs on the health plan's formulary. Humira is medically necessary for the treatment of her AS. 

Ankylosing spondylitis is a chronic condition requiring long-term treatment. Humira is a TNF (Tumor necrosis factor) blocker approved for ankylosing spondylitis, spondyloarthritis, and rheumatoid arthritis according to the American College of Rheumatology. It is the next step in treatment for this patient. 

TNFs are the standard of care for treatment of AS, after nonsteroidal anti-inflammatory drug (NSAID). The patient has already tried and failed several NSAID's. A trial of Humira (a TNF antagonist) is a logical next step in the management of this patient's AS. According to an article published on Open Access Rheumatol in 2014, 'Tumor necrosis factor (TNF) inhibitors are now well-established, effective drugs in the treatment of AS symptoms. Adalimumab, which is a fully human monoclonal antibody that binds to and neutralizes TNF, has demonstrated efficacy in treating AS symptoms, including axial involvement, peripheral arthritis, enthesitis, uveitis, gut involvement, and psoriasis.'
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.

Treatment: Hypoglossal nerve stimulation or Inspire upper airway stimulation system.

The insurer denied coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system.  

The denial is overturned.

This is a male patient diagnosed with obstructive sleep apnea (OSA).  The patient had a polysomnography (PSG) with an apnea-hypopnea index (AHI) of 32.  The patient had central/mixed calculation of less than 25%.  The patient's body mass index (BMI) was 31.7.  The patient had failed continuous positive airway pressure (CPAP) as it was uncomfortable and he could not sleep with it on.  The patient woke up more often due to the mask than the OSA.  The patient had tried several masks and machines without improvement.  The patient's drug-induced sleep endoscopy revealed no evidence of complete concentric collapse at the nasopharynx, Vella pharynx or soft palate.  The request was made for the hypoglossal nerve stimulation.

Based on the review of the medical record and literature, literature supports that this patient is a good candidate for the hypoglossal nerve stimulation. The hypoglossal nerve stimulator (i.e., the Inspire system) has final approval from the Food and Drug Administration (FDA) for this patient's diagnosis, which is severe OSA. The research supports this treatment for patients who meet the following inclusion criteria: BMI <32, meets the minimum age requirement, moderate to severe OSA, intolerance to CPAP therapy, <25% central apneas, and no concentric collapse of the velopharynx on drug-induced sleep endoscopy. In this case, this patient meets these criteria, and other interventions such as surgical procedures for the treatment of OSA have poorer outcomes with higher morbidity. 

The hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be more beneficial than any of the standard treatments/procedures for this patient.      

The carrier's denial of hypoglossal nerve stimulation or Inspire upper airway stimulation system should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea.

Treatment: Hypoglossal nerve stimulation or Inspire upper airway stimulation system.

The insurer denied coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system.

The denial is overturned. 

This is a male patient who has been diagnosed with obstructive sleep apnea (OSA).  This patient has failed and is intolerant to continuous positive airway pressure (CPAP).  The patient's drug-induced sleep endoscopy revealed no evidence of complete concentric collapse of the nasopharynx, velopharynx or soft palate.  The patient has a body mass index (BMI) of 31.7.  Furthermore, the patient underwent a sleep study revealing an apnea-hypopnea index (AHI) of 32.  The patient was seen via telehealth reporting difficulty sleeping.  The physician indicated at this visit that the patient had a prior sleep study with an AHI of 44.5.  Surgical intervention was discussed as the patient was not able to tolerate CPAP.

Based on the review of the medical record and literature, this patient is an ideal candidate for the hypoglossal nerve stimulation. This patient has a diagnosis of OSA and an apnea-hypopnea index (AHI) of 32.  The patient's body mass index (BMI) is 31.7, and the patient's drug-induced sleep endoscopy revealed no evidence of complete concentric collapse.  The patient has tried and failed first-line treatment with CPAP. Literature supports the scientific evidence and clinical improvement of health outcome with hypoglossal nerve stimulation for this patient. 

The hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be more beneficial than any of the standard treatments/procedures for this patient.      

The carrier's denial of hypoglossal nerve stimulation or Inspire upper airway stimulation system should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genetic Diseases. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Veltassa 8.4-gram (GM) powder (POW) for medical necessity. 
The denial was upheld in whole.

This patient is a female with a medical history of sickle cell anemia, asthma, hidradenitis suppurativa, deep vein thrombosis (DVT), and lupus nephritis. The patient is reported to have frequent veno-occlusive disease and hyperkalemia. The patient was recently treated for coronavirus (COVID) requiring an inpatient hospitalization. Veltassa has been prescribed to address her hyperkalemia.
At issue is the medical necessity of Veltassa 8.4-gram (GM) powder (POW).
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of Veltassa 8.4 GM POW, is not medically necessary for this patient.
While the authors of UpToDate do not recommend the use of sodium polystyrene sulfonate (SPS) if alternatives (including Veltassa) are available, the provided documentation does not demonstrate this patients' chronic hyperkalemia. SPS is not generally recommended due to its modest efficacy and the risk of intestinal necrosis, which has not been associated with Veltassa. However, the documentation (including laboratory values) demonstrating that this patient has chronic hyperkalemia has not been provided. For these reasons, medical necessity cannot be established.
Therefore, the requested health service/treatment of Veltassa 8.4 GM POW, is not medically necessary.