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

Diagnosis: Restless sleep and daytime somnolence
Treatment: Sleep Study (polysomnography)
The insurer denied the sleep study (polysomnography).
The denial is overturned.

The patient is a female. The service under review is sleep study (polysomnography). This service was denied coverage by the health plan as not medically necessary because the patient qualifies for a home sleep test. This decision is being appealed.

According to clinic note, the patient has a history of OSA (obstructive sleep apnea) treated with tonsillectomy in childhood, and did not have a repeat test afterwards.  Current symptoms were restless sleep and daytime somnolence. A home sleep test was ordered and performed, and did not demonstrate OSA. An in-lab sleep study was then ordered.

Yes, the requested sleep study is medically necessary.

Medically necessary services are those that are applicable and generally accepted by practice guidelines developed by the federal government, national or professional medical societies, boards and associations.

According to the relevant Clinical Practice Guideline by the American Academy of Sleep Medicine: "We recommend that polysomnography, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA." Also: "We recommend that if a single home sleep apnea test is negative, inconclusive, or technically inadequate, polysomnography be performed for the diagnosis of OSA."

This patient initially underwent a home sleep test, but the test was negative. Thus, it is medically necessary to perform an in-lab sleep study to more conclusively rule out the presence of OSA.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

According to sound medical judgment and the best interest of the patient, it would be medically necessary to perform an in-lab sleep study.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma and COPD (chronic obstructive pulmonary disease) 

Treatment: Inpatient hospital admission 

The insurer denied coverage for an inpatient hospital admission. 
 
The denial is upheld.

This is a patient with a history of Asthma, COPD (chronic obstructive pulmonary disease), and smoking.

The patient presented to her medical doctor (MD) for a visit. She was afebrile and hemodynamically (HD) stable with oxygen (O2) saturations 98% (percent) on RA (room air). Lung exam was unremarkable. Cardiovascular system (CVS) S1 (heart sound) S2 (heart sound) were N (normal).

The patient's medications included Albuterol, Breo 200-25 [LABA (Long-acting beta-agonists)/ICS (Inhaled Corticosteroids) combination], Duo Nebs (nebulizers) PRN (as needed) and Prednisone 10 mg (milligrams) per day.

PFTs (pulmonary function tests): FVC (Forced Vital Capacity) 2.82/91%, FEV1 (Forced expiratory volume) 2.0/88%, Ratio 77%, lung volumes within normal limits (WNL), DLCO (diffusing capacity of carbon monoxide) WNL.

The patient did not have Eosinophilia on her blood exam.

The patient was recommended Dupixent by her PMD (primary medical doctor).

This patient had not been treated with triple therapy such as Trelegy Ellipta or with high dose ICS, LABA and long-acting muscarinic antagonists (LAMA) or Leukotriene antagonist in a combination for at least 3 months and failed before biologics would be considered.

Moreover, this patient did not have an Eosinophilic phenotype for approval of usage of Dupixent which is an IL4 (interleukin 4) antagonist.

This patient does not meet criteria for use of Dupixent.

The insurer's denial of coverage for Dupixent for the treatment of Asthma is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID, pulmonary embolism
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female with history of COVID (Coronavirus 2019) infection complicated by pulmonary embolism who finished the course of anticoagulation and was sent to emergency room with tachycardia during a walk test. This was resolved at the time of the emergency room evaluation. 

The patient was admitted to the hospital for monitoring. This request was denied due to lack of medical necessity. This denial is being appealed.

The proposed inpatient hospital admission was not medically necessary.

This patient presented to the emergency room with palpitations and dyspnea which resolved in the emergency room. The patient was hemodynamically stable. The patient was ruled out for pulmonary embolism. The patient was not on an invasive drip or supplemental oxygen. The patient was ambulating and tolerating an oral diet. The acute in-hospital level of care was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ischemic stroke. 
Treatment: Implantable vagus nerve stimulation. 
The insurer denied coverage for implantable vagus nerve stimulation. 
The denial is upheld.

According to the documents reviewed this is a female diagnosed with left spastic hemiplegia and a seizure disorder following a cerebrovascular accident (CVA). The patient underwent rehabilitation after her CVA. She was offered Vivistim, a vagus nerve stimulator (VNS) in order to treat her limb deficit. 

All available medical documentation was reviewed. 

The scientific evidence in peer-reviewed literature does not support an improvement in health outcomes. There is insufficient peer-reviewed literature to support the use of vagus nerve stimulation for spastic hemiplegia. 

The vagus nerve stimulation has been approved by the Food and Drug Administration (FDA), based on the study by Dawson et al. Vagus nerve stimulation paired with rehabilitation for upper limb motor function after ischaemic stroke (VNS-REHAB): a randomised, blinded, pivotal, device trial. Lancet. 2021; 397 15451553. for spastic hemiplegia. However, there are still limited studies for vagus nerve stimulation. 

"VNS Rehab included 108 participants with moderate to severe arm /hand weakness, at least nine months after ischaemic stroke. They were randomised to receive rehabilitation paired with active VNS or rehabilitation paired with sham stimulation (Control). The primary outcome was the change in Fugl-Meyer Assessment Upper Extremity (FMA-UE) score on the first day after completion of in-clinic therapy. We explored the effect of VNS treatment by sex (n=70 males; n=38 females), age (65 or >65 years)), time from stroke (median time, 2 years) and baseline FMA-UE score (<=33 severe, >33 moderate). We assessed whether there was any interaction with treatment. No hypotheses were specified prior to this analysis and no formal adjustment was made for multiplicity." (Dawson et al., 2022) 

The patient is not a good candidate for implantable vagus nerve stimulation, given the lack of scientific evidence and clinical data to support it as a standard of care for spastic hemiplegia. 

There is not enough clinical evidence to support the use of implantable vagus nerve stimulation for spastic hemiplegia in patients who have had deficits for a longer period of time. The participants in the studies had an average length of time since stroke as less than two years. Therefore, implantable vagus nerve stimulation is not the best available treatment at this time. 

The adverse risks are increased over standard treatment/services, as it is an invasive procedure with known complications such as infection. 

Studies are small and limited. Furthermore, studies are ongoing for implantable vagus nerve stimulator. 

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

The carrier's denial of implantable vagus nerve stimulation should be upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Crohn's disease

Treatment: Cimzia Starter Kit 200 mg/ml (milligram/milliliter)

The insurer denied coverage for Cimzia Starter Kit 200 mg/ml 
 
The denial is overturned.

The patient has Crohn's disease. After failing Entocort she was started on Humira. On the Humira she developed a flare of Crohn's disease. Her serum adalimumab level was low, and she had very high antibody levels. She now requires a change in her biologic treatment and her physician has advised Cimzia. She plans to become pregnant, and the FDA (food and drug administration) has approved Cimzia as an anti-TNF (tumor necrosis factor) agent that is safe during pregnancy. 

The American College of Gastroenterology (ACG) has published "ACG Clinical Guideline: Management of Crohn's Disease in Adults." The guideline advises that for moderate to severe disease anti-TNF agents should be used to treat Crohn's disease that is resistant to treatment with steroids. Certolizumab is listed as a recommended treatment. 

The Annals of Rheumatological Disease 2018 Feb 77 (2):228-233 has an article titled "Lack of placental transfer of certolizumab pegol during pregnancy: results from CRIB, (a prospective, post marketing, pharmacokinetic study)." The conclusion was that Cimzia has no to minimal placental transfer from mothers to infants, suggesting lack of in-utero fetal exposure during the third trimester.

This patient has active Crohn's disease and failed Humira after developing antibodies. Since she had an excellent response to the Humira prior to developing antibodies, her physician has advised using another anti-TNF agent. Cimzia is an anti-TNF agent that is recommended by the American College of Gastroenterology. It also has the advantage of being found to be safe in pregnancy. In contrast, Stelara has been found to cross the placenta. There is no recommendation from The ACG that Stelara should be used instead of another anti-TNF agent. It is not known if the formulary agent will cause an adverse reaction although it is likely that Cimzia may be advantageous during pregnancy. Both Cimzia and Stelara are recommended drugs for Crohn's disease. However, based on the patient's prior response to anti-TNF agents and the likelihood of her becoming pregnant, it is appropriate and medically necessary for her to use Cimzia. 

The insurer's denial of coverage for Formulary Exception for Cimzia Starter Kit 200 mg/ml (milligram/milliliter) Kit is overturned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atrial fibrillation, cerebellar stroke
Treatment: Eliquis (Pre-Service)
The insurer denied the Eliquis (Pre-Service).
The denial is overturned.

The patient is a male with history of atrial fibrillation causing a cerebrovascular embolism leading to a cerebellar stroke. Eliquis was ordered as a non-formulary choice; warfarin and Xarelto are formulary choices for anticoagulation in this clinical situation. The patient also has hypertension and is on multiple medications. Radiofrequency ablation has been performed.

This is an appeal request to cover the use of Eliquis rather than the formulary alternatives, warfarin or Xarelto.

Yes, health plan should cover the proposed use of Eliquis.

Recent published studies in respected journals, including the New England Journal of Medicine and the Journal of the American Medical Association, have concluded that Eliquis is the preferred anticoagulant for this patient's condition. Large population studies have shown that Eliquis is safer and carries less bleeding risk, less stroke risk, and less complications than either Xarelto or warfarin.

Eliquis was found to be more effective than warfarin in lowering the risk of stroke and systemic embolism. People who took Eliquis also had significantly fewer bleeding episodes than those who took warfarin.

Eliquis is the only non-vitamin K antagonist oral anticoagulants (NOACs) that is better than warfarin in the prevention of stroke and results in fewer bleeding complications. Overall, all-cause mortality from direct oral anticoagulants (DOACs) appears to be lower than that from warfarin, driven primarily by a decrease in fatal intracranial bleeding risks.

Among Medicare beneficiaries 65 years or older with atrial fibrillation, treatment with rivaroxaban (Xarelto) compared with apixaban (Eliquis) was associated with a significantly increased risk of major ischemic or hemorrhagic events.

According to the article titled, "Apixaban versus Warfarin in Patients with Atrial Fibrillation" on behalf of the ARISTOTLE [Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation] Committees: "In conclusion, in patients with atrial fibrillation, apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality." 

While this patient is older, his markedly high risk with having a previous stroke is a strong compelling reason to use Eliquis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gallstones
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Upheld

The patient is a female who presented to the emergency department (ED) with right upper quadrant abdominal pain and symptoms related to her known biliary colic. She had previously been evaluated with ultrasound that showed gallstones and a thickened gallbladder in the outpatient setting. Her past medical history is notable for congenital heart disease (Tetralogy of Fallot status/post [s/p] pulmonic valve replacement). At the time of presentation the patient was without fever and the heart rate was 89/minute. She had a tender right upper abdomen per the examination. The white blood cell (WBC) count was 8.9 thousand (K). The complete metabolic panel identified normal transaminases and alkaline phosphatase with normal bilirubin. Ultrasound showed findings of gallstones and a thickened gallbladder wall. The common duct was 6-millimeter (mm) diameter. She was further evaluated with hepatobiliary iminodiacetic acid (HIDA) scan that showed non-visualization of the gallbladder. A cardiology consultation was completed. She was treated with laparoscopic cholecystectomy. The records indicate an uncomplicated cholecystectomy procedure with findings of an edematous gallbladder.

The patient was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated. Pain was controlled with oral medications following surgery. The diet was advanced. The patient remained clinically stable and was discharged from the inpatient setting. The subject under review is the medical necessity for the inpatient stay.

An inpatient stay was not medically necessary in this case. 

This patient has known biliary disease who presented to the hospital with cholelithiasis/cholecystitis. She was tender in the right upper quadrant. Based on her clinical condition and diagnostic test results, the indication for cholecystectomy was established. She was further evaluated with HIDA scan. The patient underwent an uncomplicated laparoscopic cholecystectomy procedure. There were no peri-operative complications or other clinical issues that mandated an inpatient designation. She remained stable and was discharged from the hospital on the first post-surgical day. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an inpatient stay. Additionally, there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. Inpatient stay was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care status. A lower level of care would have provided for ED assessment, surgical consultation, cardiology consultation, cholecystectomy, perioperative care and monitoring, provision of IV antibiotics and fluid, and overnight care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Moyamoya disease and hemorrhagic stroke
Treatment: Acute rehabilitation
The insurer denied coverage for acute rehabilitation
The denial is upheld

This is a patient with a history of Moyamoya disease and hemorrhagic stroke. She underwent a craniotomy for superficial temporal artery to middle cerebral artery (STA-MCA) bypass. She was transferred to acute rehabilitation. The patient was previously approved by insurance for acute rehabilitation. Under review is the medical necessity of continued acute rehabilitation.

The clinical notes support the medical appropriateness of the patient's admission to acute rehabilitation for functional deficits that were amenable for comprehensive treatment. The physical, occupational and speech therapy notes document the provision of appropriate rehabilitation therapy and the patient's gradual functional improvement. However, the clinical records do not provide sufficient evidence of functional improvement or medical necessity during the time period under review to support the continued length of stay. According to an occupational therapy note, "Patient reports she lives with her husband and son in a private house with no steps to enter and 7 steps inside; however, patient reports she lives on first floor and doesn't need to do the stairs."  This patient could have been safely discharged home, continuing rehabilitation therapy as an outpatient or via home care. In addition, there were no acute medical or complicated nursing issues that necessitated continued acute inpatient rehabilitation. 

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient in this particular case. Considerations include the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based.    

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued acute rehabilitation was not medically necessary.

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

Diagnosis: Osteoarthritis, morbid obesity, degenerative disc disease, and spinal stenosis

Treatment: Outpatient procedure (64483 x 2), pain injections

The insurer denied coverage for outpatient procedure (64483 x 2), pain injections.

The denial is overturned.

This patient has a history of osteoarthritis, morbid obesity, degenerative disc disease, and spinal stenosis. He presented to his Orthopedist's office for a follow up visit for back pain. He reported the return of 100% (percent) back pain. The patient had undergone several rounds of lumbar injections. He reported 100% pain reduction for 5 to 6 months at a time. However, the health plan denied the epidural steroid injection.

There are clinical practice guidelines that limit the number injections per year, but none state that continuation beyond 12 months is below the standard of care. 

A recent meta-analysis [1] showed long term efficacy of Epidural steroid injections: 

"Epidurally administered bupivacaine alone or with steroids are effective in managing low back and lower extremity pain. The findings of this review provide appropriate information of epidurally administered bupivacaine as an active agent (not a placebo) with level 1 evidence and almost equally effective as bupivacaine with steroids with level II evidence."

Similarly, clinical practice guidelines [2] support an injection in this case:

"Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness."

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

The insurer's denial of coverage for outpatient procedure (64483 x 2), pain injections is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal bleeding.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a G2P1011 (two pregnancies, one live birth) female. She was in a motor vehicle accident. She had a missed abortion. She continued to have vaginal bleeding.

The patient had a workup including ultrasound and MRI (magnetic resonance imaging) revealing an arteriovenous malformation in the uterus. She was given methotrexate 80mg (milligrams). Her HCG (Human Chorionic Gonadotropin) levels were dropping but she continued to have bleeding. She was admitted preoperatively for an interventional radiology procedure. She was admitted, had stable vital signs, was given an IV (intravenous), and had lab work. She underwent a uterine artery embolization through the right femoral artery. This was uncomplicated. She had stable vital signs post-procedure and was discharged that same day.

No, the Inpatient admission was not medically necessary.

In a review of the medical record, the patient was admitted overnight for IV (intravenous) access, hydration, and preoperative lab work. She was hemodynamically stable. She was not having any heavy bleeding or pain. There is no evidence that the care she received required an inpatient level of care. The same care with the same outcome could have been provided at a lower level of care. Therefore the inpatient hospital stay was not necessary.

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

There were not any criteria that required an inpatient admission.