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

Diagnosis: Auditory Processing Deficit

Treatment auditory / aural rehabilitation (procedure code 92507)

The insurer denied coverage for auditory / aural rehabilitation (procedure code 92507)

The denial is upheld

According to the documentation submitted, this is the case of a female with a history of auditory processing deficit who has been treated by an Audiologist. She was also seen for a second auditory processing evaluation and showed an auditory closure deficit. The patient was referred to Speech/Language Pathologist (SLP) for intervention to develop specific strategies to improve auditory closure skills using the context of the conversation and develop metacognitive strategies. Re-testing recommended in 3-6 months after receiving intervention.

There is general agreement that auditory perceptual abilities influence language development-particularly the pre-literacy skills-and that it can be difficult to separate the influence of auditory and language skills with regard to academic demands (Richard; Watson & Kidd [www.asha.org]). The act of processing speech is very complex and involves the engagement of auditory, cognitive, and language mechanisms, often simultaneously (Medwetsky).

(Richard's[www.asha.org]) continuum of processing includes both auditory processing and language processing. This continuum involves the following types of processing:

-	Central auditory processing, which begins when the neural representation of acoustic signals is processed after they leave the cochlea and travel through the auditory nerve to the primary auditory cortices of the left and right hemispheres. (Heschl's gyri).

-	Phonemic processing, during which acoustic features of the signal are discriminated utilizing phonemic skills such as sound discrimination, blending, and segmenting.

-	Linguistic processing, during which meaning is attached to the signal (begins at the level of Heschl's gyrus, expands to Wernicke's area, to the angular gyrus, and finally to the prefrontal and frontal cortex, where a response is planned, organized, and mediated).

In her repeat audiologic/processing evaluation, the audiologist focused on auditory closure, which had previously been identified as the major clinical deficit.  Specific and relevant testing was performed, the recommendation for 1:1 speech pathology was subjective since the patient had not improved since her first evaluation.  

The progress notes from the speech-language pathologist do not establish an initial plan of care.  There is no documented short term or long-term goals against which to measure any progress.

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

The insurer's denial of coverage for procedure code 92507 (treatment of speech, language, voice, communication and/or auditory processing disorder is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gastroesophageal Reflux Disease (GERD).

Treatment: procedure code 43284, surgery to place an esophageal sphincter augmentation device around the esophagus.

The insurer denied coverage for procedure code 43284, surgery to place an esophageal sphincter augmentation device around the esophagus.

The denial is overturned.


The patient was having chronic reflux symptoms. He has been on (proton pump inhibitor therapy) PPI therapy but complains of continued regurgitation. An endoscopy showed esophagitis. Motility testing with pH (potential of hydrogen) monitoring was done which showed pathologic acid reflux. There was noted to be a good correlation between heartburn and acid reflux.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conducted an updated Safety and Effectiveness Analysis of the Linx Reflux Management. With regards to safety, the conclusion was that long term follow up supports the Food and Drug Administration (FDA) conclusion that the device is safe. With regards to efficacy there were several conclusions. The Linx implant results in pH normalization, improved quality of life, and cessation of regular PPI use on a consistent basis. When compared to laparoscopic fundoplication, rates of success in alleviating gastroesophageal reflux disease (GERD) symptoms and dysphagia are similar following Linx. The long term follow up data demonstrates that the Linx Reflux Management System is effective in the management of GERD.

The scientific literature supports the use of the Linx Reflux Management System for patients with chronic reflux. It has FDA approval. The patient is a good candidate because he has been having continued symptoms on PPI therapy. There are several options for both surgical and endoscopic treatment of GERD, but the Linx system has been shown to be effective and safe. A minimally invasive treatment such as the Linx system is appropriate for patients with continued GERD symptoms after treatment with a PPI.

This treatment is likely to be more beneficial than any other standard treatment.

The carrier's denial of procedure code 43284, surgery to place an esophageal sphincter augmentation device around the esophagus should be overturned.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremities.
Treatment: Formulary Exception for Eliquis, Pre-service.
The insurer denied the Formulary Exception for Eliquis, Pre-service.
The denial is overturned.

The patient in this case is a female who was diagnosed with deep vein thrombosis (DVT). She was diagnosed with extensive lower extremity DVT following a long car ride.  She was treated with Xarelto and had improvement in symptoms and resolution of her clot on repeat ultrasound imaging.  Records indicate that she was treated with Xarelto for six months.  Records also state that she was treated with six weeks of Pradaxa due to finding a right lower lobe pulmonary embolism incidentally when she had a scan done to look for occult malignancy. She was subsequently placed on Eliquis and an appeal letter states that she was taken off Xarelto due to elevated liver enzymes.  The letter does not state when she was changed.  A progress note stated that she was to stop anticoagulation.  That same appeal letter states that the patient developed a second clot and the request now is for treatment with Eliquis.

Yes, the health plan should cover the proposed treatment with Eliquis.  Eliquis is associated with significantly lower rates of major bleeding compared to Xarelto and warfarin.
This patient has recurrent venous thrombosis.  She was treated in the past with Xarelto and had elevated liver enzymes.  Furthermore, there is ample evidence to show that treatment with Eliquis is associated with a significantly lower rate of major bleeding complications compared with warfarin or Xarelto.  Given that literature and given that this patient had previous toxicity while on treatment with Xarelto, it is concluded that the health plan should cover treatment with Eliquis in this case.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female who presented with pneumonia and dehydration.
She was well until 4 days prior to presentation when she developed a cough, fever, increased work of breathing, and vomiting. She was seen by her pediatrician and was taking acetaminophen with little relief, and began vomiting both medications and food. Her breathing became worse over time, she started to use her abdominal muscles to breath, and her last wet diaper was the prior day. She was therefore brought to the emergency department for care. She was admitted to the hospital due to respiratory distress with pneumonia and possible sepsis. 

The inpatient hospital admission was medically necessary for this patient.
This is an infant girl who presented with pneumonia, high fever and elevated inflammatory markers, and dehydration. She was ill appearing at the time of presentation and initially had a supplemental oxygen requirement. She was vomiting and unable to tolerate oral fluids. She was seen as an outpatient but continued to worsen. She required hospital admission for treatment with parenteral antibiotics, intravenous fluids to ensure ongoing hydration, and close monitoring of her respiratory status.
Indication for hospitalization for patients with pneumonia includes hypoxemia, dehydration, or inability to maintain hydration orally, and moderate to severe respiratory distress. This patient was initially hypoxemic and required supplemental oxygen, was vomiting and not drinking and had evidence of dehydration based on laboratory values including a low bicarbonate value. She was also febrile with elevated inflammatory markers and there was concern for sepsis. Therefore, inpatient hospital admission was indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal class II malocclusion.
Treatment: Braces (D8060).
The insurer denied the Braces (D8060).
The denial is overturned.

The patient is a female with a skeletal class II malocclusion. She has a deep bite with mild upper and lower crowding. 

The prior denial was for not having a "hard time with your bite".

Yes, the proposed braces are medically necessary.
The patient has severely excessive (greater than [>] nine millimeters) overjet and lip incompetence, which is an automatic qualifier, according to the handicapping index scale. The patient needs orthodontic treatment to correct this. The patient also has a severely retruded mandible. This needs to be corrected with braces to prevent airway issues (i.e. sleep apnea) in the future.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: s/p Cervical decompression and fusion
Issue Under Review: Osteogenesis Stimulator, Electrical Noninvasive Spinal Application (HCPCS Code E0748)

The health plan denied the Issue Under Review: Osteogenesis Stimulator, Electrical Noninvasive Spinal Application (HCPCS Code E0748). 

The denial is overturned.

The patient is an adult female with history of anterior cervical discectomy and fusion with delayed fusion. The treating physician ordered a Bone stimulator to help the healing process and adequate fusion.

The requested Bone Growth Stimulator is medically appropriate in a patient who has had spinal fusion at multiple level to enhance adequate healing of the fusion sites.

Also, it is medically appropriate for the medical benefit of quicker bone healing towards prevention of complication and relief of pain, required for a reason other than improving appearance. It is appropriate to meet the health needs of the patient, it is rendered in the most conservative manner and setting, as a quicker bone healing will prevent more surgery later. Its use is consistent in type, frequency and in line with scientifically based guidelines, consistent with the diagnosis of cervical spine fusion non-union. It is required for reasons other than convenience/comfort of the patient, and it is not experimental or investigational.  Studies by Gan JC et al have shown the benefit of Bone Growth Stimulator in improving bone healing and are also in line with INTERQUAL criteria, which is a national standard guideline.

The study by Kane WJ stated that Statistical review confirmed the comparability of the groups. Success, defined as radiographic fusion, was achieved in 15 of 28 control patients (54% [percent]) compared with 25 of 31 EBGS (electrical bone growth stimulation) treated patients (81%). This result is statistically significant (P = 0.026, one-tailed Fisher's Exact test).

Therefore, the use of Electrical Bone Growth Stimulator as an adduct aids the healing process after fusion, as in this instance.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: s/p Cervical decompression and fusion
Issue Under Review: Osteogenesis Stimulator, Electrical Noninvasive Spinal Application (HCPCS Code E0748)

The health plan denied the Issue Under Review: Osteogenesis Stimulator, Electrical Noninvasive Spinal Application (HCPCS Code E0748). The denial is upheld.

The patient is an adult female status post Circumferential Cervical Fusion for Cervical spondyloticmyelopathy.  Anterior C3-7 (third cervical spine vertebra-seventh cervical spine vertebra) fusion as well as posterior C3-7 (third cervical spine vertebra-seventh cervical spine vertebra) decompression and fusion with instrumentation. The surgeon performed the anterior and posterior surgery for patient with Multilevel fusion. External bone growth stimulator has been prescribed.

This is a multilevel arthrodesis and is a high risk for development of a non-union (pseudoarthrosis).  Adjunctive PEMF (Pulsed Electromagnetic Field) treatment can be recommended for patients who are at high risk for pseudoarthrosis. External Bone Growth stimulation with PEMF (Pulsed Electromagnetic Field) increased the fusion rate at six and 12 months for certain high-risk subjects who had at least one clinical risk factor of being elderly, a nicotine user, osteoporotic, or diabetic; and for those with at least one clinical risk factor and who received at least a two- or three-level arthrodesis.

There is not good scientific evidence establishing the efficacy of external bone growth stimulation in improving outcomes or even fusion rates in the cervical spine.  This remains an investigational/experimental procedure, and thus does not rise to the level of standard of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: s/p (status/post) Cervical decompression and fusion
Issue Under Review: Osteogenesis Stimulator, Electrical Noninvasive Spinal Application (HCPCS Code E0748)

The health plan denied the Issue Under Review: Osteogenesis Stimulator, Electrical Noninvasive Spinal Application (HCPCS Code E0748). 

The denial is overturned.

The patient is an adult female. She had undergone underwent cervical decompression and fusion in a two stage procedure. The patient was recommended bone growth stimulator.

The patient has findings that warrant bone growth stimulator. The patient underwent multilevel ACDF (Anterior Cervical Decompression & Fusion) and posterior fusion and has been demonstrated to benefit from bone growth stimulation. The patient has undergone an anterior/posterior cervical fusion which may increase the rate of pseudoarthrosis and reduce the fusion ability. For this reason, the use of bone growth stimulator is medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian Cancer. 
Treatment: FoundationOne CDx Test. 

The insurer denied the FoundationOne CDx Test. 
The denial is upheld. 

The patient in this case is a woman with ovarian cancer. Foundation One testing was performed. 

No. The proposed treatment is not medically necessary. 

Foundation One testing is a next generation sequencing assay that is done to look for genomic alterations in tumor tissue. This test includes over 300 genes. It is done to try to find potentially effective treatment options. There is currently no evidence based on the results of any prospective clinical trial that has shown use of broad molecular profiling can improve overall health outcomes. This specific test is not recommended as a standard test known to improve overall health outcomes by the National Comprehensive Cancer Network (NCCN) guidelines. Given these considerations, this test is not medically necessary. 

Yes. The health plan did act reasonably, with sound medical judgement and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urolithiasis. 
Treatment: Inpatient Stay. 

The insurer denied coverage for inpatient stay. 

The denial is upheld. 

This is a case of a woman that presented to the hospital complaining of right flank and abdominal pain.  Symptoms were accompanied by nausea and vomiting. Past medical history was significant for hypertension.  Upon arrival, vital signs were stable: Blood pressure 152/94mmHg, (millimeters of mercury), Pulse 81bpm (beats per minute). Physical exam revealed no abdominal distension or guarding.  Serum blood testing revealed a mild elevation of troponin 0.12ng/ml (nanogram per milliliter). Echocardiogram revealed no wall motion abnormalities and a preserved left ventricular ejection fraction. CT (computerized tomography) abdomen revealed urolithiasis and a 1.5mm (millimeter) stone was noted in the right ureter with right hydronephrosis.  Cholelithiasis without gall bladder distension was also noted. A 12-lead electrocardiogram revealed normal sinus rhythm with no evidence of ST- (Sinus Tachycardia [interval on EKG [ electrocardiogram), or T wave (interval on an EKG) abnormality.  The patient was admitted to the hospital for observation and treatment.  Following evaluation, she was discharged with a diagnosis of urolithiasis and biliary colic. 

This patient presented with abdominal pain and flank pain. She had a past medical history of hypertension. Her pretest probability of coronary artery disease was low (Reference 1).  Utilizing the HEART score (History, EKG, Age, Risk factors, and troponin), she was considered low risk (Reference 2). Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score, she also had a low risk of developing major adverse cardiac events in the subsequent 30 days (Reference 3). Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (myocardial infarction (MI)), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (all- cause mortality, MI), and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of care. 

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

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

Diagnosis: Status Asthmaticus. 
Treatment: Inpatient Emergency Admission. 

The insurer denied coverage for inpatient emergency admission. 

The denial is upheld. 

This is a female with a history of asthma and myasthenia gravis. She presented to the emergency room (ER) with complaints of a one-week history of a productive cough and chest tightness. The physical examination revealed faint wheezing. She was recently exposed to mold. The chest x-ray (CXR) was clear. Testing was positive for rhino/enterovirus. The patient was admitted with status asthmaticus. She was given albuterol every 2 hours (Q2H) and then advanced to Q4H (every 4 hours) as tolerated. She was maintained on Flovent and completed a 3-day course of steroids. Respiratory status was closely monitored. Forced vital capacity (FVC) and negative inspiratory force (NIF) were done every 6 hours (Q6H). Respiratory status improved and the patient did not need supplemental oxygen. Home medications were continued. Oral (PO) intake and output were normal. The patient remained afebrile and hemodynamically stable throughout admission. She was discharged after a period of hemodynamic stability. 

The patient could have been managed at a lower level. There was no need for repeated Magsulfate, no need for continuous nebs for prolonged time, no need for terbutaline drip or continuous steroids. The patient's saturation was 100 on RA (room air). If one were to assess the asthma severity such as pediatric Asthma severity score or Pediatric respiratory assessment Score (PRAM), the score would indicate that patient needed only a lower level of care such as observational status or outpatient. The patient was well hydrated and the bicarbonate on the BMP (basic metabolic panel) which indicates no severe dehydration.  The viral panel was positive for rhinovirus and covid was negative. Also, there was no underlying medical conditions such as Chronic lung disease or congenital heart disease. The Myasthenia gravis was stable. There was also no need for high Flow nasal cannula oxygen or BiPAP (bilevel positive airway pressure). The Hospital course was suggestive of rapidly improving clinical picture. Due to all the above reasons, it is deemed that the patient only requires observational status care. 

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

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

Diagnosis: Acute Lymphoid Leukemia. 
Treatment: Privigen. 

The insurer denied coverage for Privigen.

The denial is upheld. 

The patient is a female with acute lymphoblastic leukemia (ALL) treated with multiagent Berlin-Frankfurt-Munster (BFM) type regimen. She is currently in maintenance phase. Her immunoglobulin G (IgG) was 460. The treating provider has requested Privigen. There is no history of infections. 

Per Huq, M., et al (2022), "Hypogammaglobulinemia is a disorder caused by low serum immunoglobulin or antibody levels. Immunoglobulins are the main components of the humoral immune response and able to recognize antigens to trigger a biological response and eradicate the infectious source. Hypogammaglobulinemia is the most common primary immunodeficiency and encompasses a majority of immune-compromised patients. In order to avoid the high morbidity and mortality associated with this condition, it must be promptly diagnosed and treated. The evaluation consists of lab tests, clinical findings, vaccination response, and genetic testing. Treatment is IVIG (Intravenous immune globulin) transfusions, antibiotics, and glucocorticoids. This activity highlights the role of the practitioner or interprofessional team to appropriately assess, evaluate, manage, and treat patients with this condition." 
                                                      
IVIG would only be supported for individuals with hypogammaglobulinemia, generally IgG levels lower than 400 per the National Comprehensive Cancer Network (NCCN) and a history of recurrent infections. There is no documentation of recurrent infections and therefore no support for the requested use of IVIG in this case. Privigen to treat acute lymphoid leukemia 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 insurer's denial of coverage for Privigen is upheld. Medical necessity is not substantiated.