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

Diagnosis: Cardiac Catheterization
Treatment: Inpatient admission
The insurer is denied coverage for inpatient admission. 
The denial is upheld. 

This is a male patient with a history of hypertension, hyperlipidemia, paroxysmal atrial fibrillation (AFIB), hyperlipidemia and atrial tachycardia. He was referred for an electrophysiology study and ablation of atrial fibrillation. He underwent a successful atrial fibrillation and atrial tachycardia ablation. There were no procedural complications, and the patient was then admitted to the intensive care unit for further monitoring. He remained on continuous telemetry monitoring, supplemental oxygen, hourly vital sings and hourly neurovascular assessment checks. The patient remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no vascular access complications. The patient was subsequently discharged home after an uneventful, brief overnight hospital stay.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Inpatient admission was not medically necessary.

The patient underwent an uneventful electrophysiology study with ablation of atrial fibrillation. There were no complications. The patient remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no clinical complications or concerns noted. Per MCG 23rd Edition Guideline for Electrophysiologic Study and Intracardiac Catheter Ablation, this procedure is an outpatient one, with allowance of one night in the hospital at observational status.

The carrier's denial of coverage for Inpatient Admission is upheld. The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

This case involves a patient diagnosed with obstructive sleep apnea. There were reports of prior usage of a continuous positive airway pressure (CPAP) machine without relief.  There were reports that usage of the mask caused skin irritation, difficulty breathing, and dry mouth.  The patient was reported to wake up congested.  There were also reports of nasal congestion, sinus pain, sinus pressure, postnasal drip, and clear nasal discharge.  There were reports of 3-4 sinus infections over the previous year, which were treated with antibiotics.  Nocturnal symptoms were also reported.  On examination, a laryngoscopy was performed which revealed a deviated nasal septum to the right with a positive Muller maneuver on inspiration base of tongue.

According to a polysomnography there were findings consistent with moderate obstructive sleep apnea syndrome.

According to clinical notes, the patient presented for an evaluation following the sleep study.  There were reports of prior usage of a CPAP machine without relief.  On examination, a laryngoscopy was performed which revealed a positive Muller maneuver in the AP direction long uvula sitting on the base of the tongue and larynx normal.  The patient was recommended for a neurostimulator implant.

The use of the CPAP caused issues which had increased.  The first issue was dryness and scaling of the face, causing red blemishes.  There were also reports of the development of sinus infections.  The infections resulted in additional visits to the asthma doctor for treatment.  The infections also triggered asthmatic events.  There were also numerous episodes of dry mouth, irritated throat, and/or stuffy nose.

The patient presented with obstructive sleep apnea with an Apnea-Hypopnea Index of 19.2. He is unable to tolerate CPAP. The patient has also undergone a sleep endoscopy and the physician has confirmed he does not have complete concentric collapse of the upper airway. The patient meets the standard of care criteria for the implantation of a hypoglossal nerve stimulator. The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP).  The hypoglossal nerve stimulator has been approved by the FDA since May 2014. In addition, The National Institute for Health and Care Excellence (NICE) did an extensive literature search looking at the efficacy of hypoglossal nerve stimulation implantation for obstructive sleep apnea. 

Due to the predominance of medical literature supporting the effectiveness of hypoglossal nerve stimulation for the treatment of obstructive sleep apnea, the requested procedure is likely to be more beneficial than any other standard treatment/procedure for this patient.

The carrier's denial of inspire upper airway stimulation system (64568 and 0466T) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

This case involves a patient who has been recommended to undergo surgical intervention for the implantation of cranial nerve neurostimulator array and pulse generator.  The documentation indicated the patient is intolerant to continuous positive airway pressure and has trialed CPAP without relief.  The documentation also indicated this patient does have hypertensio n as well as daytime fatigue and difficulty driving.  Due to the obstructive sleep apnea severity he is not a candidate for oral appliance therapy.  The patient has also undergone sleep endoscopy confirming there is no evidence of concentric collapse of the upper airway.  He underwent a sleep study revealing an AHI of 19.2.  The patient's BMI is 28.7.  The recommendation has been made for the patient to receive inspire upper airway stimulation system.

The inspire surgical procedure, also known as upper airway stimulation procedure, has been approved by the FDA since 2014; it is no longer considered investigational treatment. Patient meets all of the criteria for implantation of this inspire device. He is intolerant to CPAP. He has a history of hypertension, daytime fatigue from his sleep apnea, and moderate obstructive sleep apnea (with less than 25% central sleep apnea events on sleep study). The sleep study reveals an AHI of 19.2. His BMI is acceptable at 28.7. He is not a candidate for oral appliance therapy. His sleep surgeon performed a DISE (drug induced sleep endoscopy) procedure, which showed no concentric collapse of the soft palate. The patient meets all of the criteria for the inspire hypoglossal nerve stimulator implant procedure (also known as the upper airway stimulation procedure); he is an excellent candidate for this procedure. This procedure is likely to be more beneficial than any other standard health service.

The carrier's denial of inspire upper airway stimulation system (64568 and 0466T) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea (OSA)

Treatment: Inspire upper airway stimulation system (64568 and 0466T)

The insurer has denied coverage for an inspire upper airway stimulation system (64568 and 0466T)

The denial is overturned. 

This male patient is currently diagnosed with chronic obstructive sleep apnea.  The patient underwent a sleep study revealing an apnea-hypopnea index of 19.1.  The patient's body mass index was 28.67.  The sleep study eliminated the possibility of central sleep apnea or complex sleep apnea.  The patient had failed and was intolerant to continuous positive airway pressure (CPAP) without relief.  The patient had hypertension, daytime fatigue, and difficulty driving.  There were noted to be limited alternative treatments.  The provider did not feel the patient was a viable candidate for oral appliance therapy.  After the sleep endoscopy, the provider confirmed the patient did not have complete concentric collapse of the upper airway

Therefore, the combination of indicators including severe obstructive sleep apnea syndrome without central sleep apnea syndrome, failure of CPAP treatment, and the lack of complete concentric collapse made the patient an excellent candidate for the stimulation of the upper airway via Inspire therapy.

In their updated (2017) position statement, The American Academy of Otolaryngology-Head and Neck Surgery stated it considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP).  Candidates for this therapy are selected based on appropriate polysomnographic testing, age, body mass index and objective upper airway evaluation.  The current US Food and Drug Administration (FDA) eligibility criteria for upper airway stimulator implantation includes age of at least 22 years, an apnea-hypopnea index (AHI) of 15-65, a lack of central apnea and a favorable pattern of palatal collapse during drug-induced sleep endoscopy and a body mass index (BMI) of less than 32. 

This patient has obstructive sleep apnea with an AHI of 19.1. He had a lack of central apnea and a favorable pattern of palatal collapse during drug-induced sleep endoscopy.  The patient had failed CPAP.  The BMI was less than 32. Therefore, given all of the above, the inspire upper airway stimulation system (64568 and 0466T) is likely to be more beneficial than any other standard treatment/procedure.

The carrier's denial of an Inspire upper airway stimulation system (64568 and 0466T) should be overturned.
Appeal type: Formulary Exception
Decision: Upheld

Orthopedic/musculoskeletal
Pharmacy/prescription drugs
Diagnosis: Body Aches
Treatment: Vimovo
The insurer denied Vimovo. 
The health plan's determination is upheld. 

The patient is a female with past medical history of hyperthyroidism who had been seen via telemedicine for follow up appointment with complaints of body aches and was prescribed Tylenol 500 mg -1000 mg every 6 hours as needed for pain. The patient was seen in the office with complaints of low back pain and severe left rib pain. This office visit note also indicated the patient had the diagnosis of gastroesophageal reflux disease (GERD). Assessment and plan notes to continue Vimovo 20/500 twice daily (bid).
The health plan denied coverage for Vimovo. 

A formulary exception is not indicated. The formulary drug naproxen with as esomeprazole is essentially the generic version of Vimovo and would be considered as effective as the non-formulary drug Vimovo with the same potential adverse side effects. The patient has not tried the formulary alternative of naproxen with esomeprazole, and there has not been documentation as to why this was not tried. The patient has not had failure or side effect from any formulary medication. Any of the other medications that are formulary could be combined with a proton pump inhibitor to have same therapeutic effect as Vimovo. Coverage for Vimovo is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/musculoskeletal
Nursing Services (including Private Duty Nursing)

Diagnosis: gait abnormality
Treatment: Personal Care Aide Level II Services: 56 Hours Weekly
The insurer denied Personal Care Aide Level II Services: 56 Hours Weekly. The health plan's determination is overturned. 

The patient is a female with past medical history of osteoarthritis with gait abnormality, vertigo/dizziness, asthma, chronic pain, osteoporosis, anemia, GERD, hypertension, coronary artery disease, urinary incontinence and fatigue who had been assigned PCA (personal care assistance) services 4 hours/day, 6 days/week and 3 hours/1 day per week to total 27 hours/week. There was an office note noting the patient was having exacerbation of vertigo, fatigue from anemia and significant edema from lymphedema and that patient would benefit from an increase in PCA service hours. 

The Personal Care Aide Level II Services: 56 Hours Weekly is medically necessary for this patient. The patient had previously had 27 hours/week of PCA service hours and had another 8 hours/day, 7 days/week through her husband who had dementia. According to the office note from the primary care physician (or provider) (PCP), the patient now lived alone. The office note also noted the patient had worsening dizziness/vertigo and asthma. Both of these medical conditions would make the patient require more assistance with activities of daily living (ADL) tasks of stairs, walking, locomotion, transfer toilet, toilet use and bed mobility compared to previous assessment tool. Furthermore, the patient had some shared tasks with her husband who had services 8 hours/day, 7 days/week but according to the PCP office note the patient was living alone. PCA service hours are not solely for safety and supervision but for participation with ADL's.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient was admitted to a children's hospital from an outside emergency department (ED) with back pain. She felt a sharp pain in her lower back while running around during gym class, fell to the ground, and could not get back up without assistance, due to pain. She did not have a discrete injury, urinary incontinence, extremity numbness, or previous history of back or hip pain. The teachers called Emergency Medical Services (EMS) and she was brought to the outside ED where, according to the H&P, she was given Tylenol, Motrin, and two doses of morphine. Spine films were normal. She was sent to the children's hospital for a higher level of care, because she was unable to walk due to pain. On arrival, her vital signs were normal and she was described as smiling, interactive, and well appearing, in 3/10 pain. Her exam was normal except for tenderness over the lumbar muscular area. She did not have paraspinous tenderness. She did not want to bend forward or backward or walk due to pain. The neurological exam was normal. The plan was to optimize pain control with round the clock Tylenol and IV Toradol, provide heat packs, add a muscle relaxant if necessary, and perform magnetic resonance imaging (MRI) if not improved. The rest of the hospital stay, she did not require further morphine or a muscle relaxant and the pain abated to the point where the next day it was 1/10 and she was discharged home with a diagnosis of muscle spasm. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient stay was medically necessary for this patient. This previously healthy teenager was brought by EMS to an emergency department with 10/10 back pain. She required IV morphine twice in addition to Tylenol and Motrin to manage the pain, and was still in significant pain and unable to walk when the ED made the decision to request transfer to the children's hospital for higher level of care and ongoing management of the pain. The receiving hospital was obligated by Emergency Medical Treatment and Labor Act (EMTALA) to accept this transfer based on the information provided, and the patient was still in pain, although it was less, on arrival to the children's hospital, where she received IV Toradol until the next day, when she was discharged. Milliman Care Guidelines for back pain suggest observation level for severe back pain that is unable to be managed as an outpatient and inpatient level if the pain is not brought under reasonable control after a suitable period of observation in a lesser setting. The records indicate that the patient received two doses of morphine in the ED separated in time by approximately four hours and was still in pain when she was transferred, so she did have a reasonable period of observation and met acute criteria for the one day stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trimalleolar ankle fracture
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

This is a female who twisted her left ankle. She was found to have a trimalleolar ankle fracture. She was admitted due to "she lived alone and had no support system and not negotiate 3 flights of stairs." She was optimized for surgery. She underwent open eduction internal fixation (ORIF) to her left ankle (spinal and popliteal block). The patient received physical therapy (PT) services over a course of days. She was discharged to a rehabilitation facility. 

No, the inpatient admission was not medically necessary.

The records demonstrate the patient sustained a low energy type of injury with resultant ankle fracture. There were no open wounds. There were no other medical conditions to warrant management. She underwent surgery to her left ankle. The procedure was neither complex nor extensive. Her post-surgical course was non-complicated. She was able to tolerate oral medications. There were no reported problems to her wound (noted fracture blister but no treatments provided). She did not require management for other underlying medical conditions. The services provided did not require inpatient hospitalization. PT services could have been provided at the subacute facility. Medical consultation and clearance had been completed. There were no reported reasons for the delay to surgery.   There were no other extenuating circumstances to warrant the admission and length of stay as provided. These services could have been provided at a lower level of care (observation).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left knee pain
Treatment: 27486 & 27487 - Inpatient total knee arthroplasty 
The insurer denied the 27486 & 27487 - Inpatient total knee arthroplasty.
The denial is overturned.

This is a male who underwent bilateral total knee arthroplasty (TKR). He reported pain to his left knee with no associated injury. He was found to have an effusion, night sweats and C-reactive protein (CRP) / erythrocyte sedimentation rate (ESR) of 15.4/48. The patient was diagnosed with septic arthritis.  Cultures were completed and infection was found. 

The patient underwent incision, drainage and poly exchange. He received medications for pain and intravenous (IV) antibiotics. A peripherally inserted central catherater (PICC) line was placed. Infectious Disease (ID) consultation was completed. The patient was ambulating with crutches. His cultures grew coagulase negative staphylococcus (staph). He was discharged with IV therapy to continue at home.

Yes, the proposed treatment was medically necessary.

This patient has an infection to his left total knee. Treatment options require accurate identification of the organism and urgent surgical attention. It is imperative to decrease the infectious load as catastrophic complications can occur. 

Orthopedic management of this condition would depend upon the timing and organism found. This patient has reported duration of symptoms less than 30 days. He likely had new onset infection. It would be appropriate to perform the irrigation and debridement. Most surgeons would exchange the poly as the undersurface could harbor biofilm and bacteria. A thorough irrigation, debridement and poly exchange would thus be indicated. It would not be appropriate to revise the well-fixed components at this time. 

The Evicore criteria for poly exchange make no mention of an irrigation and debridement (I&D) being performed at this same time; "this is not an isolated poly exchange, see need for I and D".

A search was performed of current orthopedic literature. The standard of care for a new onset of infection with organism of low virulence is irrigation, debridement and poly exchange. There are no other options. 

The procedure was complex and extensive.  Exposure required full opening of the knee with large incision.  The procedure would be expected to be painful and require intravenous (IV) analgesia.  IV antibiotics were essential as well with placement of PIC line.  This type of operation cannot be completed on an ambulatory surgical unit (ASU) or observation level of care.

Therefore, codes 27486 & 27487 - inpatient total knee arthroplasty, was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Genetic Disease
Inpatient hospital

Diagnosis: Sickle Cell Disease
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with past medical history of sickle cell anemia, history of acute chest in childhood, multiple admissions for sickle cell crisis, seizure disorder, history of thoracic compression fractures, tobacco and drug use who presented to the emergency department with complaints of right shoulder and back pain for 5 days. 

The inpatient admission was not medically necessary. The patient presented to the emergency department with symptoms of right shoulder pain and back pain consistent with sickle cell crisis. Initially in the emergency department, IV access was unable to be established and he was given first dose of dilaudid IM, subsequently receiving 2 mg of IV dilaudid and 5 hours later receiving 1 mg of IV dilaudid. At the time of admission, the patient did not have intractable pain and dilaudid was ordered orally every 6 hours with other non-narcotic pain medication ordered as well. The patient was given one dose of IV clindamycin in the emergency department but at the time of admission left hand cellulitis was treated with oral bactrim. The patient did not have altered mental status or unstable vital signs. The patient did not have signs or symptoms of central nervous system (CNS) injury, did not have acute chest pain with new alveolar infiltrate, hypoxia or tachypnea, and did not have emergent surgical needed. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pneumonia.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial was upheld.

This is a female patient with past medical history significant for asthma, status post cholecystectomy, who presented to the Emergency Department (ED) with complaints of chills, cough, sore throat, and chest pain.  Her presenting vital signs were: Temperature 100.0 F, blood pressure-109/73, pulse-105, respiratory rate-20, Oxygen (O2) saturation-97% on room air.  Laboratory results included the following; White blood cell (WBC) count-20.82, hemoglobin (HGB)-12.8, hematocrit (HCT)-39.6, creatinine-0.8, glucose-93, procalcitonin-0.06.  The patient was admitted to the hospital for possible pneumonia.  She was empirically started on intravenous antibiotics.  The chest x-ray was performed with normal results..  All cultures were negative.  The patient remained afebrile, hemodynamically stable, and was discharged to continue outpatient management on oral antibiotics.

According to the documentation, the patient presented with upper respiratory infection (URI) symptoms.  Otherwise, she had a low-grade fever (100 F), mild tachycardia (105 bpm). Laboratory results showed leukocytosis that could be attributed to the solumedrol received on a prior ED visit for asthma exacerbation.  The chest x-ray was negative and there was no evidence for disseminated infection.  Their clinical impression was "bronchitis."  The patient did not meet criteria for sepsis based on systemic inflammatory response syndrome (SIRS) or quick sequential organ failure assessment; (qSOFA) score.  Based on above findings, patient met criteria for observation level of management.      

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

The carrier's denial of coverage for inpatient admission is upheld.  The medical necessity is not substantiated.