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

Diagnosis: obstructive sleep apnea.
Treatment: Revision or Replacement of Hypoglossal Nerve Stimulator.
The insurer denied Revision or Replacement of Hypoglossal Nerve Stimulator. 
The health plan's determination is overturned. 

The patient is a male with a history of hypertension, cardiac disease, and severe obstructive sleep apnea. His apnea hypopnea index (AHI) is 31.9 based on polysomnogram. The medical records indicate that he tried an oral appliance, and bi-level positive airway pressure (BiPAP) but was unable to tolerate and had persistent breakthrough daytime fatigue. He then underwent hypoglossal nerve neurostimulator device insertion without complication. The medical records indicate that he had a cardiac event requiring cardioversion which then rendered his previously implanted hypoglossal nerve stimulation device in operable. He still has persistent obstructive sleep apnea based on subsequent repeat home sleep studies.

Revision or Replacement of Hypoglossal Nerve Stimulator is medically necessary for this patient.
The patient had a previously inserted hypoglossal nerve neurostimulator that malfunctioned. Since he has obtained benefit in the past, it is reasonable for the device to be re-inserted.
The patient has documented severe obstructive sleep apnea based on polysomnogram, has attempted BiPAP therapy without success in the past, and has significant co-morbidities, which in the setting of severe obstructive sleep apnea may worsen his cardiopulmonary status if left untreated. He has previously undergone device insertion with success which unexpectedly malfunctioned. Re-insertion is medically necessary for this patient to treat his severe obstructive sleep apnea.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Low back pain.
treatment:  Sacroiliac joint injection.

The insurer denied the sacroiliac joint injection.  The health plan's determination is overturned. 

This is a female with a history of low back pain. She has had injections and medications without relief. The neurologic exam shows no motor, sensory or reflex abnormalities. She had "improvement" with a left sacroiliac (SI) joint injection (greater than 50%), not "robust" relief on the right. The provider has recommended repeating SI joint injections. 

Sacroiliac Joint Pain Injection is medically necessary for this patient.
Based on the standard of care, repeat SI jont injections are medically necessary.  The patient has had relief with SI injections in the past, although a recent right-sided injection gave less relief than usual. SI joint injections are supported by the literature in this case. 

Thawrani et al. cite, "Notable pain relief with intra-articular anesthetic injection under radiographic guidance has been shown to provide reliable evidence in the diagnosis of SIJ pain".  Falowski et al. cite, "A recent review of 15 publications related to spondylarthritis showed that a good response was reported in more than 80% of the cases, with a mean duration of improvement over 8 months.  Eighty-five percent of the subjects reviewed from other observational studies also obtained significant pain relief lasting for an average of 10 months.  Diagnostic or therapeutic injections should be performed using the aid of fluoroscopy, as studies have shown that only 22% of non-radiologically guided SI injections extended into the joint space". 

Jung et al. cite, "Although no "gold standard" exists, diagnostic sacroiliac joint block has been shown to be a useful confirmatory tool in assessing sacroiliac (SI) joint-mediated pain. Sacroiliac joint injection with local anesthetic and steroids can be used as a possible therapeutic endeavor to manage pain and inflammation".
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: prosthodontics fixed, pontic -porcelain/ceramic tooth 8 D6740 white glass cap teeth 7 and 9
The insurer denied prosthodontics fixed, pontic -porcelain/ceramic tooth 8 D6740 white glass cap teeth 7 and 9.
The determination is upheld.

This is a female patient who presented for the treatment of teeth number (#) 7,8,9. Provided for review are letters of denial, explanation of benefits, an American Dental Association (ADA) claim form, a release form for medical records, and full mouth radiographic images. Previous denials have been on the basis that the patient is missing more than one tooth in the maxillary prosthesis and there can be no missing posterior teeth. At issue is the medical necessity of prosthodontics fixed, pontic -porcelain/ceramic tooth 8 D6740 white glass cap teeth 7 and 9.

No, the requested health service/treatment of prosthodontics fixed, pontic -porcelain/ceramic tooth 8 D6740 white glass cap teeth 7 and 9 is not medically necessary for this patient. Currently there is nothing in the documentation to indicate why the current fixed partial denture requires replacement or that there is any issue at all. There is no indication provided through the documentation to support the medical necessity of the requested treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is an adult male who presented for LLQ (lower left quadrant) pain, fever, chills, nausea, diarrhea, and decreased oral intake. The patient's CT (computed tomography) abdomen / pelvis showed diverticulitis in the distal descending colon. The patient was started on antibiotics and IV (intravenous) fluids. Upon admission, IV (intravenous) fluids and antibodies were continued. The patient received Morphine. The patient was made NPO (nothing by mouth). Surgery, ID (infectious diseases), and 
gastroenterology was consulted. Stool studies were positive for EA E coli (enteroaggregative Escherichia coli) and Shiga toxin producing Escherichia coli. The patient was deemed to have sepsis secondary to diverticulitis and infections. Per a note, the patient had five episodes of diarrhea overnight, and then improved diarrhea. The maximum temperature was 101.5 overnight. The patient was discharged on Day #3.

The Inpatient Hospital Admission was medically necessary.

The patient had diverticulitis, positive stool for EA E coli (enteroaggregative Escherichia coli) and Shiga toxin producing Escherichia coli. The patient also had sepsis requiring intravenous antibiotics. Treatment in the emergency room alone would not have been sufficient to meet the patient's needs, due to the need for intravenous antibiotics on an inpatient basis to treat sepsis. Pre-mature discharge could have resulted in complications of sepsis, which include hypotension and end-organ failure.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Snoring. 
Treatment: Facility-based sleep study (code 95810). 

The insurer denied coverage for facility-based sleep study (code 95810). 

The denial is upheld. 

Instead of the in-lab sleep study, a home sleep study could have been done which would have answered the question whether patient is suffering from sleep disordered breathing or not. American Academy of Sleep Medicine (AASM) recommends home sleep testing for patients with body mass index (BMI) less than 40, no concern for central apnea/opioid use/no stroke/ CHF (congestive heart failure). Other indications for an in-lab sleep test is an indeterminate home sleep test result. The patient did not have CHF nor stroke. Also, the patient is not on chronic opioid therapy. There was no concern for rapid eye movement (REM) behavior disorder nor parasomnias which would need an lab sleep study. The STOP BANG (sleep apnea risk score) was 3 and hence a sleep disordered breathing needed to be ruled out and a home sleep test would have sufficed. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a facility-based sleep study (code 95810) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epididymitis 
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient was a male with unremarkable past medical history who presented to the emergency department with left flank pain/groin pain. The patient was seen by a urologist and was diagnosed with epididymitis.

The admission at the acute inpatient level of care was justified for the patient who presented with testicular pain and was diagnosed with acute epididymitis associated with sepsis. The patient met the criteria for systemic inflammatory response syndrome (SIRS) and sepsis, which can cause life-threatening organ dysfunction. The treatment of sepsis includes intravenous (IV) fluids, oxygen support, broad-spectrum antibiotics, and source control. To provide these treatments in the most efficient and timely manner, admission at the acute inpatient level of care was appropriate.

The patient presented to the hospital with testicular pain and was diagnosed with acute epididymitis that was associated with sepsis. This patient met SIRS criteria for sepsis. Specifically, the patient met the following criteria: temperature greater than (>) 38 Celsius (C) (100.4 Fahrenheit [F]), white blood cell (WBC) > 12,000/cubic millimeter (mm3) in conjunction with an obvious source of infection.

Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. Sepsis represents a spectrum of diseases with mortality risk ranging from moderate to substantial (e.g. [for example.], > 40% [percent]) depending on the various pathogens and host factors along with the timeliness of recognition and provision of appropriate treatment.

In general, the treatment of sepsis includes perfusion restoration with IV fluids and sometimes vasopressors, oxygen support, broad-spectrum antibiotics, source control, and sometimes other supportive measures. In order to provide treatment for patients with sepsis in the most efficient way and in a timely manner, admission at the acute inpatient level of care is the most appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis (hip pain)
Treatment: Hip surgery (outpatient services 27130 x1)
The insurer denied: Hip surgery (outpatient services 27130 x1)
The denial is overturned

This is an adult male patient with left hip pain and back pain. He has taken medication and tried home exercises. He has undergone several injections to his back, left hip and sacroiliac (SI) joint. The patient's body mass index (BMI) is 44.8. He has painful rotation to the left hip. His x-rays showed advanced osteoarthritis to the hip and spine. The patient was evaluated by an orthopedic surgeon who recommend hip surgery. The patient had tried dieting with a weight loss pill and did not lose weight. He could not exercise due to his pain.

The proposed treatment is medically necessary.

The medical records show severe functional loss and ongoing rest pain. The issue of weight loss has been addressed on several occasions. There is documentation of inability to lose weight. The records do show weight loss for 2 months earlier this year (i.e. 44.8-43.8). Although it was not ten percent of the Policy requirement, it would be reasonable to proceed due to the current clinical presentation. A total hip replacement in this selective situation would likely provide benefit and aid in additional weight loss and quality of life.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple sclerosis, overactive bladder, and glaucoma.
Treatment: Increase Consumer and Self Directed Personal Assistance Service to 24 Hours per Day Live-in (13 Hours per Day), 7 Days a Week, for a Total of 91 Hours per Week.
The insurer denied: Increase Consumer and Self Directed Personal Assistance Service to 24 Hours per Day Live-in (13 Hours per Day), 7 Days a Week, for a Total of 91 Hours per Week.
The denial is upheld.

This patient is an adult male with multiple chronic conditions including multiple sclerosis, overactive bladder, and glaucoma. He is appealing the denial of an increase in consumer and self-directed personal assistance service to 24 hours per day live-in (13 hours per day), 7 days a week, for a total of 91 hours per week. The patient lives with his father. The health plan denied the hours based on the following: Uniform Assessment System evaluation completed 5 months ago shows the patient needs assistance with meal preparation, housekeeping, laundry, shopping, bathing, toileting, dressing, persons hygiene, bed mobility, and eating. He needs help with walking and uses a motorized wheelchair and walker for locomotion. The plan recommends physical and occupational therapy for help with activities of daily living (ADLs) and personal care.

The proposed treatment is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient is appealing denial of increase consumer and self-directed personal assistance service to 24 hours per day live-in (13 hours per day), 7 days a week, for a total of 91 hours per week. Uniform Assessment System evaluation completed 5 months ago shows the patient needs assistance with meal preparation, housekeeping, laundry, shopping, bathing, toileting, dressing, personal hygiene, bed mobility, eating, and walking. There are no clinical records or appeal statements. The information provided is inadequate to support the medical necessity for requested live-in consumer and self-directed personal assistance service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arm pain
Treatment: Disc repair procedure (Deuk Laser Disc Repair, C3-C4 and C5-C6)
The insurer denied: Disc repair procedure (Deuk Laser Disc Repair, C3-C4 and C5-C6)
The denial is upheld

The patient is an adult male with right arm pain for ten years. The patient has attempted physical therapy, medication, and injections without improvement. The patient's exam reveals no 
focal deficit. Magnetic resonance image (MRI) shows disc herniation at C3-C4 and C5-C6. The patient was recommended for Deuk Laser Disc Repair, left, C3-C4 and C5-C6.

The proposed treatment is not considered medically necessary.

The use of laser disc repair is not considered standard of care or medically necessary. There is no data to support the procedure that was recommended. The proposed surgery has not been studied or compared in an acceptable manner to the gold standard options available. The operative report does not demonstrate any procedure that is within the standard of care, and therefore this is not considered medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Epilepsy
Treatment: Genetic Testing (81479-XU, 81407-XU and 
81405-XU) 
The insurer denied: Genetic Testing (81479-XU, 81407-XU and 
81405-XU) 
The denial is upheld.

The patient is a school-aged boy. He is noted to have a seizure disorder. His seizures consist of absence epilepsy, with left temporal encephalocele that is stable. He is noted to have a family history of focal epilepsy. However, his clinical, laboratory, imaging, electroencephalographic, or biochemical/metabolic information is not included in the review materials. The patient's provider has requested a gene panel to determine if the patient has a familial or inherited form of epilepsy to better define his diagnosis, refine his prognosis, direct his future medical and neurologic care and hopefully improve his outcomes and functioning.

The health plan should not cover the requested Genetic Testing (81479-XU, 81407-XU and 81405-XU).

Epilepsy and encephalocele are well known to occur together due to the disruption of normal neural pathways in the cerebrum to the abnormal neuronal migration causing encephalocele. Therefore, molecular genetic testing for inherited/familial epilepsies is not medically appropriate in this school-aged male child.
The requested Genetic Testing (81479-XU, 81407-XU and 81405-XU) is not more beneficial. Standard treatment with AEDs (anti-epileptic drug) is adequate for treating focal seizures in this boy with temporal lobe epilepsy associated with encephalocele.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Epilepsy
Treatment: Genetic Testing (81479-XU, 81407-XU and 
81405-XU) 
The insurer denied: Genetic Testing (81479-XU, 81407-XU and 
81405-XU) 
The denial is overturned.

The patient is a school-aged male with epilepsy. There are no clinical notes from the patient's physician. There are case notes from the case summary in the appeal information summary. Per the case notes, at the time of the request, the patient was a pre-school aged male with absence epilepsy, a left temporal encephalocele and a family history of focal epilepsy who underwent extended gene analysis for evaluation of epilepsy.
The health plan denied coverage of the request for genetic testing for epilepsy because the plan considered the request experimental except for diagnosing Dravet Syndrome. The treating physician appealed the decision with a New York State External Appeal attestation form attesting that standard health services or procedures have been ineffective or would be medically inappropriate and the physician recommended a health service based on two documents from the medical literature. This review is in regard to genetic testing for extended gene analysis testing for epilepsy.

The health plan should cover the requested Genetic Testing (81479-XU, 81407-XU and 81405-XU).

The role of genetic testing in epilepsy is evolving. However, routine evaluation of all patients who have epilepsy of unknown cause is not currently considered a standard of care. Cases in which genetic testing for epilepsy is currently considered standard of care includes case where epilepsy is infantile onset, associated with syndromic features or developmental delay or developmental regression, intractable epilepsy, familial epilepsy with multiple family members with history of epilepsy, and when there are cortical malformations. In this case, the patient has epilepsy with a brain malformation and a family history of epilepsy. The use of gene panels in epilepsy is supported by both of the publications provided by the requesting physician (Okeke, Striano).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Epilepsy
Treatment: Genetic Testing (81479-XU, 81407-XU and
81405-XU)
The insurer denied: Genetic Testing (81479-XU, 81407-XU and
81405-XU)
The denial is overturned.

The patient is a grade school-aged male with epilepsy. There are no clinical notes from the patient's physician. There are case notes from the case summary in the appeal information summary. Per the case notes, at the time of the request, the patient was a young school-aged male with absence epilepsy, a left temporal encephalocele and a family history of focal epilepsy who underwent extended gene analysis for evaluation of epilepsy. The health plan denied coverage of the request for genetic testing for epilepsy because the plan considered the request experimental except for diagnosing Dravet Syndrome. The treating physician appealed the decision with a New York State External Appeal attestation form attesting that standard health services or procedures have been ineffective or would be medically inappropriate and the physician recommended a health service based on two documents from the medical literature. This review is in regard to genetic testing for extended gene analysis testing for epilepsy.

The health plan should cover the requested Genetic Testing (81479-XU, 81407-XU and 81405-XU).

The role of genetic testing in epilepsy is evolving. However, routine evaluation of all patients who have epilepsy of unknown cause is not currently considered a standard of care. Cases in which genetic testing for epilepsy is currently considered standard of care includes case where epilepsy is infantile onset, associated with syndromic features or developmental delay or developmental regression, intractable epilepsy, familial epilepsy with multiple family members with history of epilepsy, and when there are cortical malformations. In this case, the patient has epilepsy with a brain malformation and a family history of epilepsy. The use of gene panels in epilepsy is supported by both of the publications provided by the requesting physician (Okeke, Striano).
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes.
Treatment: Formulary exception for Ozempic 0.25mg (milligrams)/0.5ml (milliliters) Pen.
The insurer denied: Formulary exception for Ozempic 0.25mg (milligrams)/0.5ml (milliliters) Pen.
The denial is upheld.

The patient is an adult female with type 2 diabetes, hypertension, hyperlipidemia, and obesity. The request for Ozempic is under review. The prior request was denied coverage by the health plan, as the patient has tried only one of the required three alternatives: Rybelsus, Trulicity, and Victoza. The provider is appealing this determination. The patient has an A1C (glycated hemoglobin) of 6.5%, and she has failed metformin and Trulicity due to nausea and gastrointestinal discomfort.

The health plan should not cover the Formulary exception for Ozempic.

This request is for Ozempic for the treatment of type 2 diabetes. The patient has an A1C (glycated hemoglobin) of 6.5%. The American Diabetes Association clinical guidelines do not support the use of additional glucose lowering medication in this patient. Ozempic has risks, including nausea and vomiting. The patient also does not have a documented contraindication to the use of Rybelsus or Victoza, the remaining formulary alternatives, which are also indicated for the treatment of type 2 diabetes. Therefore, no, the health plan should not cover the formulary exception for Ozempic.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
This patient was brought in by emergency medical services (EMS) to the emergency department (ED) with complaints of back pain after straightening up from a bent over position. The patient was unable to ambulate. The patient was admitted for lumbar strain. The patient was administered lidocaine patches and capsaicin cream. She did not receive opiates or muscle relaxants. The patient was admitted because she could not ambulate.

The patient did not have Red Flags (potentially serious and treatable symptoms) at any point and was not administered opiates or muscle relaxants. Clinical practice guidelines (1) do not support admission absent Red Flag symptoms.

Casazza (2) reviewed concerning symptoms (Red Flags) that should prompt aggressive treatment.  The patient did NOT have any of these:

"Certain red flags should prompt aggressive treatment or referral to a spine specialist, whereas others are less concerning. Serious red flags include significant trauma related to age (i.e., injury related to a fall from a height or motor vehicle crash in a young patient, or from a minor fall or heavy lifting in a patient with osteoporosis or possible osteoporosis), major or progressive motor or sensory deficit, new-onset bowel or bladder incontinence or urinary retention, loss of anal sphincter tone, saddle anesthesia, history of cancer metastatic to bone, and suspected spinal infection. Without clinical signs of serious pathology, diagnostic imaging and laboratory testing often are not required."

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital admission is not substantiated.