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

Diagnosis: Cardiac Circulatory Problems. 
Treatment: Durable Medical Equipment. 
The insurer denied LifeVest. 
The denial is upheld.

The patient is a male with a history of cigarette smoking and chronic obstructive pulmonary disease (COPD) who presented to the hospital with chest pain and numbness of his right arm and face. He was found to have thrombus in his left carotid artery, which was treated with a stent. An echocardiogram showed a left ventricular ejection fraction (LVEF) of 25%. Cardiac catheterization performed showed severe three vessel disease. Coronary artery bypass graft surgery was recommended but had to be delayed given the patient's recent carotid intervention and need for antiplatelet therapy. He was started on guideline directed medical therapy for heart failure with reduced ejection fraction and discharged with a LifeVest wearable cardioverter defibrillator. A myocardial viability study was recommended prior to a decision regarding high risk percutaneous coronary intervention (PCI). No subsequent medical records were provided. The subject under review is the medical necessity for the LifeVest.

The health plan's determination is upheld.

The LifeVest is not determined to be medically necessary for this patient.

This patient has severe coronary artery disease and a left ventricular ejection fraction of 25-30%. Depressed left ventricular systolic function is a risk factor for, and powerful predictor of, sudden arrhythmic death. Consequently, implantation of an implantable cardioverter defibrillator (ICD) for the primary prevention of sudden cardiac death is a widespread practice, proven to be beneficial to heart failure patients with a variety of cardiac diagnoses. Current guidelines support ICD implantation in patients with ischemic cardiomyopathy and left ventricular ejection fractions of 35% or less. However, due to the possibility that left ventricular function may improve with revascularization, a 90 day "waiting period" after revascularization is recommended, in hopes that improved myocardial perfusion might result in improved left ventricular function. In order to provide a "safety net" for high risk patients during this period, many physicians recommend the use of a LifeVest wearable cardioverter defibrillator (WCD). These devices have been shown to be highly effective in terminating ventricular tachyarrhythmias, with close to a 100% efficacy, resulting in "aborted sudden death" as opposed to sudden death.

Based on the records provided, a myocardial viability study was recommended. If he had significant viable myocardium, then he would have been scheduled for PCI. No records relevant to the time period were provided for review, therefore it cannot be determined when, or if, the patient underwent PCI. Therefore, it cannot be stated that use of the WCD for the time period in question was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Respiratory system
Oxygen/Oxygen Treatments

Diagnosis; Sleep apnea
Treatment: Positive Airway Pressure (PAP) Device.
The insurer denied a Positive Airway Pressure (PAP) Device. The health plan's determination is overturned. 

This is the case of a male patient who suffers from sleep apnea. The patient also has a history of asthma and hypertension. The provider is requesting coverage for a Positive Airway Pressure (PAP) Device.

The compliance report showed that the patient used the continuous positive airway pressure (CPAP) machine 87% of the time for at least 4 hours with an average daily use of 4 hours and 19 minutes.

PAP Device is medically necessary for this patient.

Obstructive sleep apnea (OSA) is a disorder characterized by obstructive apnea and hypopnea and is associated with serious comorbidities. CPAP is a highly effective therapy for OSA.

CPAP therapy reduces apneas and hypopneas, decreases daytime sleepiness, and improves sleep architecture, daily activity, quality of life, neuro-behavioral performance, and hypertension.

Evidence suggests that to maintain treatment effects, nasal CPAP therapy for OSA needs to be used every night. Only one night without therapy can return the patient to pretreatment physiological status and disability.

According to Medicare and national guidelines, CPAP coverage requires objective evidence of adherence to use of the CPAP device. Adherence to therapy is defined as use of PAP greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three months of initial usage.

The patient compliance with the PAP is considered very adequate. Therefore, the patient does meet medical necessity of the requested service. The CPAP is considered medically necessary, as the patient is effectively using the CPAP machine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart disease, seizure disorder and gait ataxia/falls
Treatment: Increase Personal Care Services Level II From 12 Hours per Day 7 Days per Week To 16 Hours per Day, 7 Days per Week
The insurer denied the Increase Personal Care Services Level II From 12 Hours per Day 7 Days per Week TO 16 Hours per Day, 7 Days per Week
The denial is upheld. 

The patient is a female with a history of heart disease, seizure disorder and gait ataxia/falls. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 16 hours per day, 7 days per week Personal Care Services to offer increased ADL (activities of daily living) support.

No, the Increase Personal Care Services Level II From 12 Hours per Day 7 Days per Week To 16 Hours per Day, 7 Days per Week is not medically necessary.

This is a female with a history of heart disease, seizure disorder and gait ataxia/falls. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  The appeal request from the patient's medical provider indicates that the patient requires additional health aide hours for help with her conditions of heart disease, seizure disorder and gait ataxia/falls. No other specific information is included in this appeal request.

However, an assessment of the patient's functionality and ability to perform ADLs (activities of daily living) was completed and revealed that the currently approved plan of 84 hours/week Personal Assistance Services is sufficient to meet the patient's current needs. There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed Increase Personal Care Services Level II From 12 Hours per Day 7 Days per Week TO 16 Hours per Day, 7 Days per Week is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ankle pain.
Treatment: Electrical Treatment (implantable neurostimulator electrode) code: 64555, Pre-service.
The insurer denied the Electrical Treatment (implantable neurostimulator electrode) code: 64555, Pre-service.
The denial overturned.

The patient is a female with history of chronic Left ankle and foot pain with history of Left Ankle fusion. She has been treated with Nucynta, Vicodin, Gabapentin, Medical Marijuana, Tramadol, NSAIDs (nonsteroidal anti-inflammatory drugs), which she stopped due to gastric side effects, left ankle joint steroid injections, Platelet-rich plasma injection Left Ankle, use of orthotics, home exercise program, etc.

Yes, the heatlh plan should cover the proposed treatment.
The requested Percutaneous Peripheral Nerve Stimulator is medically appropriate. Based on multiple literature evidence, Neuromodulation with electric stimulus as subcutaneous/percutaneous peripheral nerve stimulation may be used in the multimodal treatment of patients with painful peripheral nerve injuries who have not responded to other therapies.

A Class 1 study shows that percutaneous electrical nerve stimulation should be considered for the treatment of polyneuropathy for its effectiveness and improvement in quality of life. The study by Trent et al showed that percutaneous peripheral nerve stimulators have been used for chronic neuropathic pain in patients with contraindications to spinal cord stimulators, and permanent lead placement has been the choice for chronic neuropathic pain, as evident in this case.

Yes, the requested Percutaneous Peripheral Stimulator is likely to be more beneficial than any other standard treatment for chronic neuropathic pain in this instance.
The requested service is medically appropriate, and withholding the procedure, in whole or in part, is reasonably likely expected to affect the patient's health. All other options for the treatment of chronic neuropathic pain have been documented to have been exhausted. The patient has failed all conservative measures, and has been ruled to be a good candidate for surgery by virtue of the Neuropsychological evaluation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ankle pain.
Treatment: Electrical Treatment (implantable neurostimulator electrode) code: 64555, Pre-service.
The insurer denied the Electrical Treatment (implantable neurostimulator electrode) code: 64555, Pre-service.
The denial is upheld.

The patient is a female with chronic ankle pain in whom a Sprint PNS (peripheral nerve stimulation) has been recommended. She has failed various medications and surgery.

No, the health plan should not cover the proposed treatment.
The patient is a female with chronic ankle pain in whom a Sprint PNS (peripheral nerve stimulation) has been recommended. She has failed various medications and surgery. She has tried medications including opiates.

The requested procedure is not a commonly accepted treatment for this condition, and has not been shown to be effective in the treatment of chromic ankle pain, as shown by high-quality RCT (randomized controlled trial). There is a randomized controlled trial in the setting of chronic pain following amputation, but not in chronic ankle pain. These pathologies are quite different. Other case reports, and observational studies show some benefits in other pain conditions.  Given the lack of data to support an invasive procedure for this type of condition, and the lack of recent imaging, the requested PNS (peripheral nerve stimulation) is not medically appropriate.

No, the requested therapy is not likely to be more beneficial.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Ankle pain.
Treatment: Electrical Treatment (implantable neurostimulator electrode) code: 64555, Pre-service.
The insurer denied the Electrical Treatment (implantable neurostimulator electrode) code: 64555, Pre-service.
The denial overturned.

The patient is a female.  Per a note the patient has history of left foot and ankle pain status post fusion of left foot at young age. Her pain is 2/10. It worsens with weight bearing and exercises. Medications help with ADLs (activities of daily living). The patient is on Nucynta and tramadol. Patient has tried NSAIDs (nonsteroidal anti-inflammatory drugs), gabapentin, and Vicodin.  Most recently, the patient has developed a right foot neuroma. The patient also has right shoulder pain. She tried multiple steroid injections to left ankle and right shoulder, which helped temporarily. The patient was advised to continue home walking and stretching regimen. Plan to taper opioid use after PNS (peripheral nerve stimulation).

The request is for peripheral nerve stimulator trial using Sprint systems 2 leads to left peroneal and tibial nerves under fluoroscopy and ultrasound.

Yes, the health plan should cover the proposed treatment Percutaneous neuromodulation therapy, including the SPRINT PNS (peripheral nerve stimulation) system (SPR Therapeutics).
The request is for peripheral nerve stimulator trial using Sprint systems 2 leads to left peroneal and tibial nerves under fluoroscopy and ultrasound to be percutaneously implanted for 60 days.

The patient has history of chronic left foot and ankle pain status post fusion. Her pain interferes with walking, weight bearing and sleep. The patient has tried pain medications, exercises and injections.

There is medical literature supporting the use of PNS (peripheral nerve stimulation) for patients with chronic pain who have failed conservative treatment. PNS (peripheral nerve stimulation) has the potential to improve functioning and reduce opioid use.

Yes, the medical records and accompanying information are sufficient to answer the following questions.
ASRA (American Society of Regional Anesthesia and Pain Medicine) advocates for PNS (peripheral nerve stimulation) coverage for eligible patients since evidence supports use of PNS (peripheral nerve stimulation) for patients who have failed conservative therapies, and PNS (peripheral nerve stimulation) has the potential to reduce opioid use and improve functionality.

The patient has tried conservative therapy and injections. The patient continues to have difficulty walking and medication dependent. PNS (peripheral nerve stimulation) can be attempted to improve functioning and reduce medication use.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class III, hypoplastic maxilla, maxillary and mandibular spacing, anterior crossbite with gingival attachment loss).

Treatment: Braces and monthly visit.

The insurer denied coverage for braces and monthly visit.

The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The Orthodontist recommended comprehensive orthodontics due to skeletal Class III, hypoplastic maxilla, maxillary and mandibular spacing, anterior crossbite with gingival attachment loss. The Orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 20 points on review by their internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating Orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 20 points (10 mandibular protrusion, 8 anterior open bite, 2 labiolingual spread).

The clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care. The healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for braces and monthly visit is upheld. Medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient with a history of obstructive sleep apnea. A most recent study confirmed obstructive sleep apnea (OSA) with sleep study in March 2017. This showed an apnea hypopnea index (AHI) of 65.5.  The minimum oxygen desaturation was 84%. Other pertinent information includes a body mass index (BMI) of 32.7  On examination, the patient was noted to have a straight septum and 0+ tonsils. There is no previous surgical history. The patient had failed continuous positive airway pressure [CPAP] (several masks), continued to swallow air with the CPAP and is not a candidate for an oral appliance. The patient suffered loud snoring, irritability and daytime fatigue.
A sleep endoscopy was performed which showed no complete collapse of the upper airway (favorable finding for hypoglossal stimulator implant).  The health plan's determination is overturned. 

The requested treatment (Inspire) is considered by the general otolaryngology community to be an accepted surgical treatment in select patients. This is based on clinical evidence. The patient has failed a CPAP trial and is not an appropriate candidate for an oral appliance. The appropriate work up for a hypoglossal stimulator was done with a sleep endoscopy which showed lack of concentric collapse of the upper airway, and significant prolapse of the tongue during sleep. Finally, the patient is at risk for developing severe medical co-morbidities if the OSA continues to go untreated.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient with sleep apnea. His apnea hypopnea index (AHI) is 65. body mass index (BMI) is 32. He cannot tolerate continuous positive airway pressure (CPAP). A sleep endoscopy did not reveal concentric collapse at the level of the oropharynx or hypopharynx. A hypoglossal nerve implant (HGNS) has been proposed. At issue is whether the proposed health service or treatment hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The health plan's determination is overturned. The requested hypoglossal nerve implant is likely to be more beneficial than standard treatment. The patient has sleep apnea and cannot tolerate CPAP. His sleep endoscopy did not reveal oropharyngeal or hypopharyngeal concentric collapse. The treating provider does not feel that there are reasonable surgical alternatives.
Based on the patient not being able to tolerate the first line therapy for sleep apnea, CPAP, and that there are no reasonable surgical options, the hypoglossal nerve implant is a medically necessary treatment. There is good literature demonstrating safety and efficacy and it is likely that the patient will have significant improvement in his sleep apnea symptoms and decreased long term morbidity if the implant is placed.
Appeal type: Experimental/Investigational
Decision: Overturned

This is a patient with a history of loud snoring, gasping for air in his sleep and swallowing air when using his positive airway pressure device. A previous polysomnogram revealed an apnea hypopnea index of 65.5 with an oxygen nadir of 95%. His body mass index was 32.7. An exam of the oropharynx revealed a normal soft palate with a midline uvula. A drug induced sleep endoscopy revealed partial anteroposterior collapse at the level of the velopharynx, partial lateral collapse at the level of the oropharynx, with complete anteroposterior collapse at the levels of the base of tongue and epiglottis. The health plan's determination is upheld.
The proposed health service hypoglossal nerve stimulation/implantation of an Inspire upper airway stimulation system is not likely to be more beneficial than any standard treatment or treatments for the insured's diagnosis, obstructive sleep apnea. Clinically this is a patient with severe obstructive sleep apnea who failed a trial of continuous positive airway pressure (CPAP) but not an oral appliance. His body mass index was 32.7 with no evidence of a weight loss program. According to Coughlin et al, rates of obesity and sleep disturbances are substantial in adults. Additional good-quality comparative studies with larger sample sizes are called for to define the patient population that is most likely to respond to this therapy option.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impaired physical function.
Treatment: Personal care services, 24 hours a day (live in), 7 days a week for a total of 91 hours a week.
The insurer denied coverage for personal care services, 24 hours a day (live in), 7 days a week for a total of 91 hours a week.
The denial is overturned. 

This is a female patient with a past medical history of coronary artery disease, chest pain, anemia, gastric bypass surgery, abdominal pain, degenerative joint disease, hypertension, hyperlipidemia, spinal stenosis, osteoarthritis, acute chronic diastolic congestive heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, unsteadiness on her feet, muscle weakness, abnormal gait and mobility and a history of falling.  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her son were present on the call. It was noted that the patient lives alone in a 2 bedroom basement apartment.

The patient's needs are: total dependence for housework; maximal assistance with meal preparation, stairs, shopping and transportation; extensive assistance for managing finances, managing medications, bathing, personal hygiene, dressing her upper and lower body, walking, locomotion, bed mobility, eating, toilet transfer and toilet use; limited assistance for phone use. An increase to personal care services, 24 hours a day (live in), 7 days a week for a total of 91 hours a week is being requested.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the determination of the insurer.  Not enough weight was given to nighttime needs.

The patient has spinal stenosis and osteoarthritis plus multiple co-morbidities. She has a greatly impaired physical function.  She is bed-bound due to anterolisthesis, starting to show signs of cognitive decline, incontinent of bowel and bladder, unable to transfer, locomote or use the toilet without assistance.  Her bed mobility is significantly impaired. Nighttime Needs Logs show episodes of incontinence (she cannot clean herself) and repositioning at random times during the night. She does have pull-ups but the episodes can be multiple and she cannot manage changes by herself, leaving her open to complications if she does not have help. There is no formal or scheduled informal care.

The above assessments would indicate that there are unscheduled tasks that need to be performed along with safety issues. The patient meets criteria for a live-in aide.

The insurer's denial of coverage for the requested personal care services, 24 hours a day (live in), 7 days a week for a total of 91 hours a week is overturned. Medical Necessity is substantiated.