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

Diagnosis: Sleep Apnea

Treatment: Upper Airway Stimulation Device; CPT codes 64568 (Incision for implantation of Cranial Nerve (e.g., Vagus Nerve) Neurostimulator Electrode Array and Pulse Generator) and 0466T (Insertion of Chest Wall Respiratory Sensor Electrode or Electrode Array, including connection to Pulse Generator

The insurer denied. The denial was upheld. 

Reviewer # 1:

This patient is a male with a diagnosis of obstructive sleep apnea.  The patient had a past medical history of hypertension, tonsillectomy hypertension, daytime fatigue, and uvulopalatopharyngoplasty (UPPP).  It was noted that the patient was intolerant to and failed continuous positive airway pressure as he removes the mask during sleep.  Despite his attempt to try various masks, he had no relief. It was also noted that the patient tried a dental appliance without relief.  The patient underwent a drug-induced sleep endoscopy in early 2019 which revealed anterior-posterior collapse, a favorable pattern of palatal collapse. The request was made for an upper airway stimulation device.

According to Semelka, M., et al. (2016), "Continuous positive airway pressure is the first-line treatment; adherence rates are variable and seem to improve with early patient education and support.  Other treatment modalities include weight reduction, oral appliance therapy, and surgery to correct anatomic obstructions, although there is insufficient evidence to support these types of surgeries.  Bariatric surgery can improve sleep parameters and symptoms in obese patients with obstructive sleep apnea and can result in remission in many patients."     
The carrier's denial of upper airway stimulation device; CPT codes 64568 (Incision for implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator) and 0466T (Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator [List separately in addition to code for primary procedure]) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient has newly diagnosed prostate cancer. The pre treatment prostate-specific antigen (PSA) is 12.5, clinical stage T1c. The patient has elected radiotherapy for primary management of the medical problem. Perirectal Spacers were recommended as an adjunct to the treatment to purportedly decrease the risk of radiation toxicity to bladder and rectum. This is the subject under review.

The health plan's determination is overturned. The Perirectal Spacers are likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The use of perirectal hydrogel implants has been shown to decrease rectal toxicity.
According to National Comprehensive Cancer Network (NCCN) guidelines, "The risk of late complications following radiation therapy (RT) is related to the volume of the rectum receiving radiation dosages close to or exceeding the radiation dose required to control the primary tumor. Biomaterial have been developed, tested, and Food and Drug Administration (FDA) approved to server as spacer materials when inserted between the rectum and prostate. In a randomized phase 3 multicenter clinical trial of patients undergoing intensity modulated radiation therapy (IMRT), with the risk of late (3 year) common terminology criteria for adverse events grade 2 or higher, physician recorded late rectal complications declined from 5.7% to 0% in the control versus hydrogel spacer group. The hydrogel spacer group had a significant reduction in bowel quality of life (QOL) decline." The current literature supports the use of hydrogel spacers to decrease rectal toxicity associated with radiation therapy for prostate cancer.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has a diagnosis of intermediate risk (prostate-specific antigen (PSA) 12.5, Gleason 7, cT1c) prostate cancer. The patient has elected to undergo radiation therapy for his prostate cancer. The use of Perirectal Spacers prior to radiation therapy is under review. The Health Plan considers the procedure experimental/investigational.

The health plan's determination is upheld. Perirectal Spacers are not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer, 2017 states "Daily prostate localization using image guided radiation therapy (IGRT) is essential with either 3D-CRT or intensity modulated radiation therapy (IMRT) for target margin reduction and treatment accuracy. Imaging techniques, such as ultrasound, implanted fiducials, electromagnetic targeting and tracking or endorectal balloon, can improve cure to decrease complications." The guidelines do not recommend the use of Perirectal Spacers for prevention of rectal complications. The American Urological Association (AUA) guidelines on clinically localized prostate cancer, 2017 does not comment on the use of Perirectal Spacers to be used during IMRT/IGRT.
As such, the use of Perirectal Spacers is not considered a generally accepted standard of care for all patients undergoing radiation therapy. Hence, it is not indicated in this case
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with a history of Gleason 7 (3+4) cT1c (prostate-specific antigen (PSA) 9.78) prostate cancer for which the patient elected external beam radiation therapy. The patient had a magnetic resonance imaging (MRI) of the prostate (1/29/2019) which confirmed organ confined disease and measured the prostate at 58.5 cc. The patient has nocturia x 3 as well as urgency/frequency which is managed with Flomax. The patient elected to have Perirectal Spacers placed with the intention to decrease rate of radiation proctitis. The use of the Perirectal Spacers is under review.

The health plan's determination is upheld. The Perirectal Spacers are not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
While the number of published studies reporting clinical data with spacer materials for prostate cancer radiotherapy is increasing, long term results (greater than 2 years) are not available yet. The long-term safety and efficacy of the spacers has not been established. At this time, there is a paucity of data to determine the effects of the spacers on health outcomes.
The Canadian Agency for Drugs and Technologies in Health (CADTH) 2019 report on the use of hydrogel spacers in the treatment of prostate cancer noted that the current evidence basis not adequate to evaluate the benefits of spacers and that additional high-quality studies would be useful. The use of the Perirectal Spacers in this case is not indicated at this time.
Appeal type: Medical necessity
Decision: Overturned

The patient is male to female transgender. She complains of emotional distress due to her masculine features. Her mental health professional has submitted documentation of significant mental health dysfunction due to her masculine facial appearance. Facial feminization with rhinoplasty and forehead and mandible contouring are planned. The health plan has denied the procedures as not medically necessary. The health plan's determination is overturned. 

According to the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People", 7th Edition, pages 63 and 64: "Other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adam's apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). Although most of these procedures are generally labeled "purely aesthetic," these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient's condition and life situation. This ambiguity reflects reality in clinical situations and allows for individual decisions as to the need and desirability of these procedures." 

The documentation from the patient's mental health provider describes unique clinical situations. According to the letter: "[The patient] also has difficulty looking in the mirror because she sees a face that does not correspond with her internal sense of self as a woman. She articulates ways her facial features contribute to her gender dysphoria. Specifically, she notes how the bone ridge above her eyes, her nose, and her chin size are sources of distress. She describes regularly worrying that she will not be accepted as a woman in society. She expresses fear that people will stare, make rude or inappropriate comments to intimidate her, or act violently towards her when she is out in public. She reports not letting photos of her face be seen by others unless she first carefully selects them and edits them to give herself a more feminine appearance. Her experience of gender dysphoria and resulting anxiety are constant and daily." This is a unique clinical situation in which facial feminization is required to treat the patient's severe gender dysphoria.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with alcohol and cocaine use disorders and a possible history of depression who was admitted to inpatient detoxification from He reported intermittent cocaine use, a few times per month, with the last use of cocaine the day prior. His urine was positive for cocaine. He reported daily drinking of one pint of liquor plus some beer.  His initial vital signs were normal, including a blood pressure 108/78 and a pulse of 76. His Clinical Institute Withdrawal Assessment (CIWA) score was recorded as 11 with the highest score as a "4" for anxiety. The health plan's determination is upheld.
The patient has a history of substance use disorder for which he has received help previously. On presentation to the facility, he requested a detoxification admission. It is clinically notable that his urine was positive for benzodiazepines and that his alcohol level was negative around noon, although he reported having several drinks that day.  His objective risk of alcohol withdrawal 24 hours or less after his last detox stay is very low. He has no history of a previous complicated withdrawal or seizure. He was not at significant risk of withdrawal that would require regular vital signs and medical monitoring. His CIWA score is consistent with very mild withdrawal. This reviewer completed the LOCADTR assessment based on the clinical chart and the result was a recommendation for outpatient services.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a prior diagnosis of epilepsy, taking Vimpat and Depakote, was admitted with history of two seizures during the preceding 24 hours. It was reported he hit his head during one of the seizures. It should be noted records state patient has breakthrough seizures every 3 to 6 months. In the emergency room he received Briviact. There were no seizures during the period spent in the emergency room or the period during the admission. His examination in the emergency room was reported as unremarkable; no new neurological deficits, walking without assistance. Upon admission, patient was evaluated by Neurology, which did not identify any acute abnormalities on examination. A head computed tomography (CT) and electroencephalogram (EEG) were obtained, neither reporting any acute abnormalities.  The medication doses were readjusted, with an increase in Briviact, and patient was discharged home.  The health plan's determination is upheld. 

No, an inpatient stay was not medically necessary for this patient. The patient was admitted with two seizures during preceding 24 hours. His exam in the ER was unremarkable, with no new neurological deficits. The patient was evaluated with CT and EEG, both of which were negative for acute abnormalities. The patient was seen by neurology and his medication doses were readjusted. According to the submitted records, there were no active seizures; none reported during the period spent in the emergency room or the period during the admission.
There were no reported major electrolyte abnormalities; no fever or overwhelming infection; no new or progressing neurological deficits; no major decompensation of any vital organ or hemodynamic instability.
There was no evidence the patient could not care for himself, and no procedures or treatments performed during the admission that could not have been performed at a lower level of care status. An inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with multiple medical problems most notably dementia of Alzheimer's type. The patient requested 7 days per week split shift for a total 168 hours per week of level 2 personal-care services. The health plan denied the services as not medically necessary. The health plan's determination is upheld. 

The patient has multiple medical problems most notably dementia of Alzheimer's type. He has a past medical history significant for diabetes mellitus type 2, chronic kidney disease, hypertension, coronary artery disease, hypothyroidism and chronic anemia. He has been maintained on multiple medications for hypertension and diabetes. He has had chronic dementia that was rapidly progressing over the last few months. He had several evaluations noted. A Uniform Assessment System (UAS) state of New York assessment was completed at at he beginning of the year. He had a repeat evaluation, UAS state of New York completed five months later. He was approved for 10 hours a day 7 days per week. 

The patient needs help with his daytime activities of daily living. He is able to walk indoors with a walker without supervision and use a bathroom. He is noted to wander at night meaning that he can walk on his own without falls. Typically, aide services are medically necessary for help with the performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). It is noted on 2 separate UAS that the patient requires help with the services however the services that would be considered medically necessary can be performed during the approved time period. There are no additional services that are noted that would require additional personal-care aide hours. Personal-care aide hours without performance of ADLs or IADLs are typically not considered medically necessary. For example monitoring for supervision or to prevent wandering is not necessarily considered an ADL or IADL. In order for an aide to be present during additional time additional level 1 or level 2 services need to be performed, however this is not the case.
Appeal type: Medical necessity
Decision: Overturned

Hyperbilirubinemia
Inpatient stay

The patient at the time of service was an infant  who was referred from the primary care office with hyperbilirubinemia.
Patient was born after prolonged rupture of membranes (greater than 18 hours), and mother was positive for group B streptococcus. Patient had some bruising on the head and back after delivery. Bilirubin at 2 days of life was 11 mg/dl. Following discharge to home, patient was well until 2 days prior to presentation when  noted to be more jaundiced and lethargic at home. Patient was sent back to the emergency department (ED) due to significant hyperbilirubinemia. The bilirubin level at that time was 23.2 mg/dl, with a direct bilirubin of 0.7. Patient was given a bolus of fluids at that time and was started on triple phototherapy. Bilirubin was followed every 6 hours and the patient was given intravenous fluids due to decreased intake. During the hospitalization the bilirubin trended down from 23 to 17, 15.3, and 13.6 mg/dl. The health plan's determination of medical necessity is overturned in whole. This is a young infant who presented with significantly elevated indirect bilirubin levels. This was likely related to breast-feeding jaundice and inadequate intake, as well as bruising from birth which increases the amount of bilirubin present. The patient required prompt initiation of phototherapy with ongoing monitoring and intravenous fluids to ensure that the levels came down quickly. This is necessary to protect the central nervous system from bilirubin crossing the blood-brain barrier.
For well infants greater than 38 weeks gestational age, phototherapy needs to be started when values are greater than 18 mg/dL for infants greater than 72 hours of age. In fact, exchange transfusion is required for infants at that age who have bilirubin levels greater than 24 mg/dL. This is due to the risk of neurotoxicity when bilirubin values exceed the infant's capability of albumin binding to bilirubin to prevent crossing through the blood-brain barrier. This infant exceeded the risk value of total serum bilirubin and required immediate initiation of phototherapy and treatment to mitigate the risk of neurologic injury.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces
The braces are medically necessary.

The patient has a severe overbite that causes her lower front teeth to impinge on her palatal tissues. This is an "automatic qualifying" condition according to the handicapping index. The patient also has very prominent upper anterior teeth. Due to their forward position, they will be more prone to trauma over time. Orthodontic treatment is needed to correctly move her teeth into a more protective position. Both of these conditions are a reason for there to have medical necessity for orthodontic benefits.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: PCA Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week

The insurer denied the PCA Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week. The denial was reversed. 

This is an elderly female patient with multiple medical conditions and substantial functional impairment. Her medical history includes: atherosclerotic heart disease, hypertension, hypothyroidism, dementia, hydrocephalus, osteoarthritis, gait and mobility abnormality, history of falls, dizziness, deformities of toes, urinary incontinence, fecal urgency. She currently lives with her daughter, son-law-law and grandson in a home with multiple levels, requiring use of stairs to enter and to move throughout the home.  The previous UAS from late 2018 indicates that the patient lived with her husband at that time and it was noted that the patient was receiving PCA services as a mutual case with her husband.  At the time of the previous UAS, the patient's cognitive status was less impaired as per the description in the UAS.  The patient required limited to extensive assistance for ADLs.

In early 2019 the patient reportedly fell at home, was hospitalized and transferred to a facility for sub-acute rehab.  As per the UAS from mid-2019, the patient's current functional status had declined from the time of the previous UAS. It was documented that the patient was alert and oriented to person and place only, and required constant supervision. Total dependence was needed for meal preparation, ordinary housework, managing finances, managing medications; extensive assistance was needed for toilet transfer.  ADL status and overall self-sufficiency were noted as declined and deteriorated. The patient is dependent on substantial caregiver support for all IADLs and ADLs. IADL support is mostly maximal assistance or total dependence, and ADL support is extensive or maximal assistance. She needed maximal assistance for transfers (transfer toilet), walking and stairs which involves significant weight bearing support by a caregiver. 

The insurer approved PCA services for 8 hours per day, 7 days per week.  It is apparent that the patient needs caregiver assistance beyond 8 hours per day.  It is unrealistic to consider that the patient only needs to use the toilet or has incontinence episodes during 8 hours per day.  If the aide leaves after 8 hours, then either the patient is already in bed for the night, which means she is in bed for 16 hours per day; or she is still out of bed and the family needs to assist with change of clothes, toileting needs, placement in bed, and possibly dinner if the aide leaves before dinner time.

Based on the above, the medical necessity for an increase in Personal Care Aide (PCA) Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient has a class I molar and class II cuspid malocclusion. Congenitally missing maxillary laterals and retained primary maxillary left cuspid. Mild anterior open bite and overjet. Severe mandibular crowding. The proposed treatment is braces for 24 months. The malocclusion in question does not meet the criteria used in most programs to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the patient's malocclusion would score a 14. The patient does not have any auto qualifiers present which include deep impinging overbite, anterior crossbite, overjet 9mm or greater, negative overjet of 3.5mm or greater, or impacted incisors or canines. The HP determination is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Overbite
Treatment:  Braces
The braces are medically necessary.

The patient has a deep impinging overbite with trauma to the palatal tissues.  This is an "automatic qualifying" condition for orthodontic benefits.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a class II molar and cuspid malocclusion. Moderate overjet and overbite. The patient has severe maxillary and mandibular spacing. The proposed treatment is braces for 18 months.
The subject to be determined is the medical necessity for braces.

The health plan's determination is upheld.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 10 with no auto qualifier present. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeter (mm) or greater and underbite 3.5 mm or greater. Since the HLD score is less than 26 without an auto qualifier, braces are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Open bite
Issue under review: Braces

Determination:
The Braces are not medically necessary.

Based upon the records presented, there is no evidence of an anterior open bite. The handicapping index was below 25, therefore the criteria for benefits has not been established. There is no medical necessity in this case.