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

Diagnosis: Obstructive sleep apnea.
Treatment: The implant of an upper airway stimulator device to treat obstructive sleep apnea (procedure codes 64568 and 0466T).
The insurer denied coverage for the implant of an upper airway stimulator device to treat obstructive sleep apnea (procedure codes 64568 and 0466T).
The denial is upheld. 

This is a male patient with a complaint of sleep apnea. The patient indicated it has been present for years. The patient has had a prior tonsillectomy.  The patient has also trialed continuous positive airway pressure (CPAP) however complained of claustrophobia. The patient did undergo a flexible sigmoidoscopy and was recommended to undergo a sleep study. The documentation does detail this patient did undergo sleep study revealing an apnea hypopnea index (AHI) of 18. The documentation also includes a drug-induced sleep endoscopy where it was noted the patient had primarily anterior-posterior collapse with minimal lateral wall collapse. The patient has a body mass index (BMI) of 35.6. The submitted documentation does indicate the patient has been recommended to receive implantation of an upper airway stimulator despite the BMI of 35.6. The physician indicated the patient has the appropriate findings and there are limited alternative treatment options.

CPAP is a first line of treatment for obstructive sleep apnea; however, long-term use for many patients is suboptimal. The hypoglossal nerve stimulator was United States (US) Food and Drug Administration (FDA)-approved for the treatment of moderate and severe obstructive sleep apnea. A five-year study indicated that the treatment was effective and improved sleepiness, quality of life and respiratory outcomes.

In their updated (2017) position statement, The American Academy of Otolaryngology-Head and Neck Surgery stated it considers upper airway stimulation 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). Candidates for this therapy are selected based on appropriate polysomnographic testing, age, BMI and objective upper airway evaluation. 

The Adhere Registry study (2020) highlighted a 8.5% reduced odds of treatment success for each unit increase in BMI indicating that the higher the BMI in a patient, the less likely they are to successfully respond to hypoglossal nerve stimulation (HGNS). 

This device is FDA approved for patients with moderate to severe obstructive sleep apnea.

Due to his obesity (BMI >35) this patient is not a good candidate.  

This device (upper airway stimulator) is not the best available treatment at this time for this patient. This is based on the currently available evidence in the medical literature.  

This device is not likely to be more beneficial than any of the standard treatments.   

The carrier's denial of the implant of an upper airway stimulator device to treat obstructive sleep apnea (procedure codes 64568 and 0466T) should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic fibroid uterus. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a female patient with a diagnosis of symptomatic fibroid uterus who underwent an uncomplicated robotic assisted total laparoscopic hysterectomy with bilateral salpingectomy and cystoscopy.  The patient's operative blood loss was 100 milliliters. Post-operatively, the patient was stable except for one episode of elevated temperature.  The patient was admitted for post-operative care monitoring.  The patient remained stable and was discharged home. 

As per literature review, there are many ways of doing a hysterectomy.  The trend has been towards less invasive procedures.  Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions.  Robotic hysterectomies are outpatient procedures unless a complication arises.  Admission becomes necessary if the patient is hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary. 

According to the Milliman Care Guidelines (MCG), Inpatient and Surgical Care 23rd Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure.  Inpatient stay may be needed for: (1) Surgical complications (bladder ureter or bowel injury or hemorrhage); (2) Conversion to abdominal hysterectomy; (3) Complex surgery (staging of endometrial cancer); (4) Wound complications; (5) Comorbidities. 

In this case, this patient did not have any of the above MCG criteria for inpatient admission.  The patient's procedure was uncomplicated.  There was no evidence of any injury to other organs.  Postoperatively, the patient was stable.  The patient's blood loss was not extensive.  Nothing in the operative report or the progress notes suggested any serious problem that warranted inpatient admission for this patient.  As per literature review, a robotic hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. The patient's care could have been provided under observation status. 

The inpatient hospital admission 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. 

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

Diagnosis: Anomalous fetus. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 

The denial is overturned. 

The patient is a G3 (three pregnancies) P2002 (two births) female. She presented to the hospital with an anomalous fetus with Trisomy 21 for medical termination of pregnancy.  Aneuploidy was confirmed by amniocentesis. 

The patient was tachycardic with pulse 107, had normocytic anemia, and elevated specific gravity on her urinalysis.  Labor was induced with misoprostol.  The fetus was delivered and additional misoprostol was given for retained placenta. 

Post-delivery, the patient developed a fever for which she was treated with antipyretics, and clindamycin.  She was discharged on postpartum day #1. 

The facility contends that the admission was medically necessary due to tachycardia, dehydration, anemia, and post-delivery fever.  It contends that the care could not have been given in the outpatient setting due to acuity of presenting symptoms and risk of bleeding, shock, infection, uterine rupture, and death, and cites several MCG (Milliman Care Guidelines) criteria including numerous pregnancy related conditions as well as dehydration.  The health plan contends that admission was not necessary due to normal heart rate, blood pressure, breathing rate, lack of complications, uncontrolled bleeding, intractable pain, or inability to eat or drink and cites MCG (Milliman Care Guidelines) 24th edition GRG (general recovery guidelines):  MG-OBD (ISC GRG [inpatient surgical care, general recovery guidelines), Obstetric and Gynecologic disease GRG (general recovery guidelines). 

Yes, the Inpatient admission was medically necessary. 

Midtrimester medical termination of pregnancy is almost always done as an inpatient procedure with the rare exception of free-standing abortion centers in very close proximity to labor and delivery units.  Although the fetus was not of a viable gestational age in this case, monitoring for maternal health must be done as in the case of any induction of labor and subsequent delivery with full provision of inpatient monitoring and interventions.  Risks exist for complications including uterine rupture, chorioamnionitis, antepartum and postpartum hemorrhage, shock, sepsis, embolism, and delivery-related trauma to the genital tract including vaginal and cervical lacerations as in any other obstetrical delivery.  Therefore, the admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a preoperative history of low back and predominantly left leg pain related to L5-S1 stenosis. Her symptoms had failed to resolve with nonoperative therapy and she underwent an L5-S1 anterior lumbar interbody fusion (ALIF) by the attending surgeon as well as a vascular access surgeon, and then she was repositioned for a percutaneous posterior L5-S1 spinal fusion. The procedure was uncomplicated according to the operative note provided for review. Estimated blood loss (EBL) was 100 milliliters (ml). There is an event note from the post-anesthesia care unit (PACU) at about three hours postoperatively where the patient was complaining of new right leg pain to her knee. Her hemodynamic and vascular status was found to be normal, and the plan was to continue to monitor. She was admitted as an inpatient to the floor.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient stay was not medically necessary for this patient. 
There was no documentation of preoperative comorbidities that would require intensive postoperative monitoring, or any intraoperative complications, postoperative hemodynamic instability or severe new neurological deficits that would have required an inpatient admission. She did note new right leg pain immediately after surgery with transient increased right dorsi- and plantar-flexor weakness noted in the post operative day (POD) #1 note. Decadron was instituted and by the next day that motor deficit had resolved. It is unclear why she was not discharged on that day - there is notation in the progress note that she requested an additional hospital day. She was seen by both the physical therapy (PT) and occupational therapy (OT) services on POD#1 and cleared for outpatient therapy.
While it is common to observe patients undergoing anterior retroperitoneal approaches to the lumbar spine after surgery, this can be safely done at a lower level of care and the status can be changed to inpatient if there develops any complications such as a severe ileus, delayed bleeding or a new neurologic injury. In addition, if there are noted intraoperative complications such as a vascular or bowel injury, blood loss that requires a transfusion or physiological instability, then it would be appropriate to admit that patient as an inpatient. None of these occurred in this patient who was described as eating, ambulating and physiologically stable on POD #1 and discharged on POD #3.
 
All the treatment could have been safely and effectively rendered at a lower level of care status.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Parkinson's Disease
Treatment: Formulary exception for Ropinirole Extended Release, Pre-service
The insurer denied the Formulary exception for Ropinirole Extended Release, Pre-service.
The denial is upheld. 

The patient is a female with Parkinson's disease (PD). She has been treated with Sinemet. Her provider is now requesting Requip XR (extended release).

No, the health plan should not cover the Formulary exception for Ropinirole Extended Release.

There is no documented reason why the patient cannot be treated with the preferred formulary agents. All of the preferred agents are considered first-line, standard of care treatment options for PD (Parkinson's disease). There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Requip XR (extended release) relative to the preferred oral agents.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Degenerative Joint Disease; Left Hip Pain

Treatment: Inpatient hospital admission.

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This male patient has a history of coronary artery disease (CAD), hypertension (HTN), hyperlipidemia (HLD), diabetes, chronic left hip pain, and polyneuropathy. He presented to the Emergency Room (ER) with complaints of left hip pain. He has chronic left hip pain, but it got severe the morning of admission. In the ER, the physical examination revealed bilateral non-pitting edema. Erythrocyte sedimentation rate (ESR) was 51 and C-reactive protein (CRP) was 4.06. There was faint erythema with a plaque in the medical aspect of the right leg. There was limited active range of motion (ROM) of the left hip. Passive ROM was limited to 30 degrees. A computed tomography (CT) scan of the left hip revealed mild osteoarthritic changes. The patient was very unsteady on his feet and didn't feel comfortable ambulating on his own at home. ER notes indicate that discharge versus observation was discussed with the patient and he was admitted. The plan was to provide pain management, obtain a physical therapy (PT) evaluation, maintain fall precautions, and obtain an orthopedic consultation. 

Orthopedics noted that no acute orthopedic interventions were needed for degenerative joint disease (DJD) of the left hip. The patient was treated with medical management. He was weight bearing as tolerated (WBAT) on the left lower extremity (LLE.) He was allowed out of bed (OOB) with PT. Acute kidney injury (AKI) resolved. The patient was initially scheduled to be discharged but blood pressure was elevated to 177/97. Cardiology was called and recommended continuing usual doses of home blood pressure medications and adding 25 milligram (mg) of Hydralazine three times a day. An electrocardiogram (EKG) was also recommended. The patient's symptoms improved and he was discharged home with instructions for follow up.

The level of care appropriate for this admission was reviewed using MCG guidelines for Musculoskeletal Disease. The patient had left hip pain for years and it had now worsened. There was no fever or other signs of infection. There was no trauma, and CT of the left hip revealed no acute problems. He was having trouble ambulating. The patient needed PT and oral pain medication. The initial impression was DJD of the left hip and that was in fact the problem. A period of observation was appropriate to ensure his continued stability given the worsening pain, but there was no indication of an acute problem on admission requiring acute inpatient care.  

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

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

Diagnosis: Pulmonary Nodules
Treatment: Radiation Services (CT Scan)
The health plan denied the requested radiology service. 
The health plan's determination is overturned.

This is a female with an extensive history of smoking who was found to have lung nodules on previous computed tomography (CT) scans. A CT scan was ordered to be done. The patient has had previous CT scans as well as positron emission tomography (PET)/CT scans. The CT impression notes "No significant change in the 0.9x0.8 centimeters (cm) speculated subpleural nodular opacity in the right upper lobe (RUL) on image 52, however it has increased in density when compared to an earlier one when it had the appearance of a pulmonary scar." A CT scan demonstrated no change in nodular opacities in right apex. 

At issue is the medical necessity of the requested service.

The health plan's determination of medical necessity is overturned, in whole.

Given the previously demonstrated stability of the lung nodule based on previous scans, multiple PET/CT scans and non-contrasted CT scans have been performed on this patient with relatively no significant change in the appearance of these nodules. The CT of the chest of this patient is medically necessary given the malignant characteristics of the lung nodule on previous CT scans, the lack of long-term stability by CT scans, and the patient's history and overall health. There are 2 nodules in the right upper lobe. One has not changed in 2 years and thus seems to be benign. However, the other nodule has not demonstrated stability for 2 years as noted from radiology reports. Given that the nodular opacity has not demonstrated 2-year stability, another CT chest should be performed to confirm stability and likely benign condition as noted by Fleischer Society Guidelines. Malignant potential does exist given characteristics of nodule and patient's history. According to Brock calculator, this nodule has a 23% chance of being malignant. As such, given patient's history, lung nodule characteristics on CT scan, and the lack of 2-year stability noted on imaging, the CT scan of the chest is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Breast Cancer with Metastases.
Treatment:  Radiation Therapy.

The insurer denied the Radiation Therapy.  The determination is upheld.

This patient has a history of recurrent breast carcinoma post surgery, chemotherapy and left chest wall radiation therapy. She has developed widely metastatic disease. She has been treatment multiple systemic therapies as well as palliative radiation to unknown specific sites. She has progressing pain in her back and has inability to walk needing hospitalization. Palliative radiation therapy is recommended to lumbar (L) 1 and thoracic (T) 9 vertebral body metastases. There is a statement in the documents provided that 1-5 treatments are being considered. There is no other information regarding the recommended palliative radiation.

At issue is the medical necessity of the requested radiation therapy for metastases.
The requested treatment of radiation therapy for metastases is not medically necessary for this patient as there are no specifics of this radiation recommendation provided. Additional information is needed including previous radiation treatment summaries, current radiation prescriptions and clinical treatment planning notes. The standard of care treatment is 400 x gray (Gy) x5, 300 cGy (centigray) x10 with 3 dimensional (D) conformal radiation approach.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 
The insurer denied personal care services level 2 increase to 24 hrs. per day, 7 days per week split-shift total 168 hrs. per week. 
The denial is upheld.

The patient is a female with a past medical history significant for dementia of Alzheimer's type, urinary incontinence, debility, seizure disorder, pulmonary embolism, gait disturbance, falls, knee pain, chronic back pain and weight loss. The patient is requesting increase in personal care services, level 2, to 24 hours per day, 7 days a week (split shift) for a total of 168 hours a week. The patient is currently approved for live-in services 24 hours a day 7 days a week. The request for increase in services was denied based upon lack of medical necessity. The subject under review is the medical necessity for the increase in services.

No, the requested personal care services, level 2 (increase to 24 hours per day, 7 days per week split-shift for a total of 168 hours per week) is not medically necessary for this patient.
Additional services were denied by the health plan stating the following: "you are approved for a live-in, which is enough to meet all your daily and nighttime needs. At this time, your daughter has requested to place live-in scheduled on hold and continue with 63 hours a week of combination personal care services, level 2 and Consumer Directed Personal Assistance Program (CDPAP) services."
The patient has been assessed on two separate occasions. Additional services are not medically necessary. The patient had a Uniform Assessment System (UAS) State of New York evaluation along with the tasking tool which noted that the patient required a total 36 hours a week. The patient has been approved for 24 hours per day 7 days a week live-in services. The services are in excess of the noted medical need. The current number of approved hours are sufficient to meet the patient's needs. Specifically, for split shift services to be approved instead of live-in services the patient must demonstrate a sufficient need that cannot be managed by the live-in services. Specifically, that services need to be performed in the middle the night and at times that the live-in aide could not get enough sleep, sleep being defined as a continuous 5 hour stretch of time that the patient did not require any services. There was a note sent by the patient's physician stating that the patient should be changed every 4 hours to prevent skin breakdown. There is no mention as to whether there was skin breakdown already necessitating this. There were no other needs that cannot be met with a live-in aide. It is reasonable to say that the patient's needs can be met effectively with live-in services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision. 
Treatment: Pharmacy/Prescription Drugs.
The insurer denied Rituxan. 
The health plan's determination is upheld.

The patient is a female who has neuromyelitis optica. 
The patient was admitted to hospital with bilateral vision loss. She initially complained of a blind spot in her left eye. Within 2 weeks her vision had deteriorated, and the right eye was involved. She had mild discomfort in the left eye. At the time of her initial evaluation, she was almost completely blind, with minimal light perception. At issue in this review is whether Rituxan is medically necessary for the patient instead of the plan-preferred Truxima or Ruxience.

The health plan's determination is upheld in whole. 

Rituxan is not medically necessary for this patient. The patient has been diagnosed with neuromyelitis optica. She has been treated with high dose steroids, plasmapheresis, and monthly infusions of IVIG (intravenous immune globulin). Despite these treatments she has had recurrent symptoms including increased visual impairment and numbness of the feet. Her treating physician has recommended continuing IVIG (intravenous immune globulin) and starting Rituximab in the form of Rituxan.
More recently, several biosimilar forms of Rituximab have been approved by the FDA. These biosimilars include Truxima and Ruxience, both of which are the plan preferred drugs. Head-to-head studies of safety and efficacy of these drugs in comparison to Rituxan have been published.
The requested health service/treatment of Rituxan 100 mg injection is not medically necessary for this patient.