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

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure 

The insurer denied: Custom fabricated abutment 
The denial is: Overturned in whole 

The patient is a male who presented to his dental provider for evaluation and treatment of tooth #13. Included for review are previous letters of appeal and denial, one page of American Dental Association (ADA) claim forms, a one page narrative from the provider, a radiographic image, and health plan documentation. Previous denials have been on the basis that the procedure was not medically necessary. Based on the provided documentation the implant bone height relative the restorative space has created specific challenges. In question is the medical necessity of the treatment of custom abutment for implant #13 (D6057). 

The health plan's determination is overturned in whole. 

The requested health service/treatment of custom fabricated abutment is medically necessary for this patient as there is minimal mesiodistal dimension relative to the implant platform height, making it inappropriate to use a standard abutment which would create hygiene challenges as well as increase the propensity towards peri-implant mucositis and peri-implantitis. 

Although standard abutments typically can be used in most instances, in this instance, a standard abutment cannot be used. The standard abutment is not recommended here due to the discrepancy between the implant platform height and diameter relative to the restorative space and occlusal platform. Use of a standard abutment would result in improper emergence profile, improper crown dimension, food retention, and overall increased propensity for peri-implant mucositis and peri-implantitis. Utilization of a custom abutment on the other hand does allow for the proper emergence profile, natural tooth contacts, embrasure spaces, and overall proper hygiene opportunity for the patient. Hence the treatment of custom abutment for implant #13 (D6057) is medically necessary for the patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Treatment: Insertion of hypoglossal nerve stimulator
The insurer denied Insertion of hypoglossal nerve stimulator.
The denial is overturned.

The patient is an adult male with history of OSAS (obstructive sleep apnea syndrome) and an AHI (apnea hypopnea index) of 22.1.  He has failed both oral device as well as CPAP (continuous positive airway pressure) treatment, because he does not tolerate either option with continued daytime somnolence and severe symptoms.  He has undergone sleep endoscopy, which did not show circumferential collapse.  He is seeking a hypo pharyngeal nerve stimulator.

Otolaryngology's academy's recommendations, as well as the literature, support that this procedure is the treatment of choice for OSA (obstructive sleep apnea) seen as seen in this patient (1-4).  He has the appropriate diagnostic findings and has not tolerated CPAP.  The procedure is not E/I (experimental/investigational), and it is accepted standard of care. 

This individual has severe OSA, which is a potentially life-threatening disorder.  The patient requires therapy and has not tolerated CPAP.  At this point, hypoglossal nerve stimulation is the only therapy that can be beneficial besides a tracheostomy, which has severe life-altering consequences.  As such, hypoglossal nerve stimulation is the best option.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Treatment: Insertion of hypoglossal nerve stimulator
The insurer denied Insertion of hypoglossal nerve stimulator.
The denial is overturned.

The patient is an adult male with a history of OSA (obstructive sleep apnea).  The AHI (apnea-hypopnea index) on sleep study was 22.2, with a BMI (body mass index) of 29.4.  The patient was not able to tolerate CPAP (continuous positive airway pressure), and he underwent a sleep endoscopy, where there was no complete concentric collapse at the velum.  An oral appliance trial failed.  The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's OSA.  

The AHI on sleep study was 22.2 with a BMI of 29.4.  The patient was not able to tolerate CPAP and underwent a sleep endoscopy where there was no complete concentric collapse at the velum.  An oral appliance trial failed.  The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's OSA.  

There is support in the literature for the efficacy of the Inspire hypoglossal nerve stimulator for the treatment of a subset of patients with OSA who have failed, or cannot tolerate, CPAP therapy.  A prospective multi-center study documented a reduction of AHI out to 12 months.  In addition, there was a randomized, controlled withdrawal arm of the study which reported AHI reduction out to 18 months.  Therefore, based on current scientific literature, scientific evidence would support the efficacy of upper airway stimulation therapy with a hypoglossal nerve stimulator for a subset of patients with OSA who meet FDA criteria for the procedure.  In this particular case, the patient would meet FDA criteria for the device in terms of BMI, age, AHI and sleep endoscopy findings (there was no complete concentric collapse on sleep endoscopy).  The patient has had a previous oral appliance trial which did not eliminate the symptoms.  There was also a reported failed CPAP trial.  There would be no contraindications to the procedure based on the information provided.  Therefore, based on the information provided, the requested service should be covered, as the requested health service is likely to be more beneficial than any standard treatment or treatments for the insured's condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Treatment: Insertion of hypoglossal nerve stimulator
The insurer denied Insertion of hypoglossal nerve stimulator.
The denial is overturned.

The patient is an adult male with obstructive sleep apnea with an AHI (apnea-hypopnea index) of 22.  His nadir for oxygen saturation was 80%.  The patient has failed oral appliance and CPAP (continuous positive airway pressure) therapies.  The patient has undergone sleep endoscopy and was found not to have concentric collapse.  

For this patient, the proposed procedure is required to treat the sleep apnea, which is not controlled by more conservative measures.  It meets the standard of care and is not for the convenience of the patient.

The principal specialty in Otolaryngology (the American Academy of Otolaryngology- Head and Neck Surgery) has examined the scientific support for hypoglossal nerve stimulator in sleep apnea and concludes the following:

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).  Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.  

This patient has had proper evaluation and meets clinical criteria for this intervention.

The procedure and device are FDA-approved, as referenced below, and recognized in the treating community as efficacious and safe for properly selected patients.  This patient with severe desaturations and favorable anatomy is a good candidate for this intervention.  By virtue of review of the literature, it is neither experimental nor investigational.  This is particularly evident with the withdrawal study by Woodson, referenced below, which showed the efficacy of the therapy and the reversal of efficacy by discontinuing the stimulation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Home health care 

The insurer denied: CDPAS 56 hours per week 
The denial is: Overturned in whole 

The patient is a female with past medical history of congestive heart failure, coronary artery disease, automated internal defibrillator, chronic pain syndrome, fibromyalgia, carpal tunnel syndrome, diabetes mellitus type 2, depression, anemia, multi joint osteoarthritis, cervical and lumbar radiculopathy, morbid obesity and sleep apnea who had been assigned 8 hours/day, 7 days/week to total 56 hours/week of personal care assistant (PCA) services based on the assessment tool performed in the summer. 

According to the uniform assessment performed two months ago, the patient had an increase in need for assistance with tasks of managing medication, phone use and transportation.  As noted in the original report, the patient had a decrease in assistance for the tasks of bathing, personal hygiene, dressing upper extremity, dressing lower extremity, toilet use and eating compared to previous assessment tool.  The most recent assessment indicated the patient had an emergency department visit in late 2019 for worsening knee pain and again in the beginning of the year for worsening right shoulder pain and was referred to pain management.  Both of these occurrences would indicate that the patient has at least the same assistance needs compared to the prior assessment. In addition, the most recent assessment indicated that the patient had informal help with her young son and did not on the prior assessment although their non availability as informal helpers did not change (and perhaps why the patient had reduction in assistance needs on the most recent assessment tool compared to the prior assessment tool). 
 
The subject under review is the medical necessity for 56 hours per week. 

The health plan's determination is overturned, in whole. 

Yes, the requested service of personal care worker services 56 hours per week is medically necessary for this patient. The patient has past medical history of significant chronic medical illnesses of coronary artery disease, congestive heart failure and multiple orthopedic and neurologic diagnoses that cause patient chronic pain. She had a previous pelvic fracture in 1995, subsequent diagnosis of cervical and lumbar radiculopathy. According to orthopedic notes the patient has multiple chronic orthopedic issues that are at baseline and patient has been referred to pain management and are not likely to improve. The patient has not had improvement in her chronic medical issues to warrant a reduction in her PCA service hours. The patient does not have an informal helper and has unscheduled care needs during the requested PCA service hours.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who underwent a left breast lumpectomy for breast cancer. Soon thereafter she re-presented with a suspicious growth at the lateral aspect of her lumpectomy incision. A fine needle aspiration (FNA) was suspicious for malignancy. The decision was made to proceed with a repeat left breast lumpectomy. She was brought to the operating room for the repeat left breast lumpectomy. Anesthesia consisted of intravenous (IV) sedation with local infiltration of 1% lidocaine. She tolerated the procedure without difficulty and blood loss was estimated to be 20 milliliters (ml). Postoperatively, she was brought to the general nursing care floor. Her condition was observed, and she was provided with her home medications as well as pain medications. On postoperative day number (#)1, she was deemed stable for discharge to home. At issue is the medical necessity of an inpatient stay. 

The health plan's determination is upheld. The patient underwent an uncomplicated repeat left breast lumpectomy under IV sedation + local anesthesia. 
The care provided included postoperative observation in the hospital and administration of home medications as well as pain medications. However, the identical services could have been provided at a lower level of care than an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of hypertension (HTN), who presented to the emergency room (ER) from a vascular surgery clinic with progressively worsening uncontrolled bilateral foot pain for 6 weeks. He was previously diagnosed with vitamin B12 deficiency as a possible cause of the foot pain, but his pain did not resolve with supplementation. Lower extremity pulses were normal, and he had 1 plus (+) bilateral lower extremity pitting edema with chronic venous stasis changes. He had pain with ambulation. Pain was only relieved at home by soaking his feet in ice water. 

The patient was admitted for evaluation and management of bilateral foot pain not controlled with oral gabapentin and ibuprofen at home. Vascular surgery was consulted. The pain was controlled with oral ibuprofen and Percocet. His home gabapentin was continued. Ultimately, it was felt the patient's symptoms were secondary to chronic venous stasis with neuropathy. No surgical intervention was needed. 

A transthoracic echocardiogram (TTE) showed normal left and right ventricle size and function, ejection fraction (EF) 58%, no significant valvular disease or pericardial effusion. Limited right upper quadrant (RUQ) ultrasound showed no portal vein thrombosis; hepatic steatosis noted without intrahepatic lesion. A lower extremity ultrasound showed no deep vein thrombosis (DVT). 

The health plan's determination is upheld. 

The patient did not have signs or symptoms of acute limb ischemia (ALI), which is a medical emergency. "The symptoms of ALI are abrupt with pain, numbness, and coldness of lower limb, and paresthesia, contracture, and irreversible purpura will appear with the exacerbation of ischemia."  "In general, ALI progresses into advanced limb ischemia within 2 weeks from its acute onset, and it has a reported mortality rate of 15%-20% due to concurrent illness such as cardiovascular or cerebrovascular disease and ischemia-reperfusion injury." 

Although he had pain, the pain was chronic for 6 weeks. He did not have numbness or coldness of his feet, no paresthesias, contractures, or irreversible purpura. He was noted to have 2+ dorsalis pedis (DP) and posterior tibial (PT) pulses of both his feet per the history and physical (H&P). The patient did not have evidence of cellulitis and was not started on antibiotics. His pain was controlled with Percocet and ibuprofen, and he did not require continuous patient controlled analgesia (PCA) for pain control.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cancer: Other
Treatment:  Radiology Services (including Ultrasound)

The patient is a female with a family history of breast cancer in her mother.  She has undergone genetic evaluation to assess her lifetime risk of developing breast cancer, and based on the Tyrer-Cuzick model her lifetime risk for developing breast cancer is 32.8%.  She has been recommended to undergo screening with mammograms, alternating with breast magnetic resonance imaging (MRI).  This is the subject of this review.

The health plan's determination is overturned.  The MRI of the breast with and without contrast including CAD is medically necessary.  This patient has a high risk of developing breast cancer as identified by models.  This patient risk based on models is 32.8%.  Based on the patient's family history and her estimated lifetime risk of developing breast cancer using risk modeling, the patient has at least a 20% increased lifetime risk of developing breast cancer, and per peer reviewed literature, mammogram alone is not sufficient to screen her for breast cancer.  Based on peer reviewed literature, she should be screened with mammogram alternating with breast MRI with CAD.
Appeal type: Medical necessity
Decision: Overturned

Missing Tooth/Teeth
Dental/Orthodontic Procedure

The patient in question is a male with a Class III malocclusion, moderate crowding and anterior crossbite of tooth #7. Tooth #3 is in crossbite as well. He is treatment planned for Comprehensive Orthodontic Treatment (Insertion of Braces) and Periodic Orthodontic Treatment Visits (Adjustment of Braces) to correct his malocclusion. This was denied by the health plan.

The health plan's determination is overturned. The Comprehensive Orthodontic Treatment (Insertion of Braces) and Periodic Orthodontic Treatment Visits (Adjustment of Braces) is medically necessary for this patient. The patient has significant maxillary crowding with tooth #7 in crossbite. This tooth has a high risk for restorative problems in the future due to its traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pockets in teeth
Issue under review:  Antimicrobial agents

Determination:
The Antimicrobial agents are medically necessary.

The patient is an adult male requesting benefits for antimicrobial periodontal therapy.

The patient had more than one 5mm pocket on each tooth in question.  Tooth #30 had one 6mm pocket.  Each tooth exhibited bleeding upon probing.  The x-rays showed mild bone loss.  The criterion for antimicrobial agents is to have at least one 5mm pocket per tooth.  This criterion is consistent with the standard of care.  Therefore, the antimicrobial treatment of five teeth, each treated at one site, is to be considered as medically necessary, for the oral health of this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Trauma/Injuries - Other
Treatment:  Inpatient Hospital

The patient is a male with a medical history of illicit drug use (amphetamines, benzodiazepines, opiates), gastroesophageal reflux disease and depression, who was admitted to a long term acute care hospital (LTACH) after a hospitalization for a fall with a laceration of his spleen requiring embolization of the splenic artery.  His course was complicated by sepsis with shock, renal failure requiring hemodialysis, left arm paralysis, deep vein thrombosis, decubitus ulcers and acute respiratory failure requiring mechanical ventilation with a failure to wean from the ventilator requiring a tracheostomy placement.

By the time of hospital discharge he was alert/awake/oriented to person/place/time, was weaned off the ventilator to tracheostomy collar, had a wound vacuum assisted closure (VAC) in place for his sacral decubitus ulcer, and was able to eat with his right arm. He was transferred to the LTACH for further care of his respiratory conditions, pressure wounds and physical rehabilitation.  On admission the patient the patient was hemodynamically stable, neurologically stable, and was not on any continuous intravenous medications.  He was on oral feeding and required basic tracheostomy care and physical therapy.

The health plan's determination of medical necessity is upheld.

Based upon the severity of illness and intensity of required therapy, the requested continued Long Term Acute Care Hospital Stay for the dates of service in question is not medically necessary for this patient.  As per the clinical documentation, the patient with a medical history of illicit drug use (amphetamines, benzodiazepines, opiates), gastroesophageal reflux disease and depression was admitted to LTACH after a hospitalization for a fall with a laceration of his spleen requiring embolization of the splenic artery.
On admission the patient was hemodynamically and neurologically stable and was not on any continuous intravenous medications.  He was on oral feeding.  Also, there was no documentation that his wounds would require more than minimal wound care or require daily physician supervision due to necrosis or need for debridement and his wound VAC was removed five days after admission to LTACH.  In addition, there is no indication from the clinical notes that the patient needs frequent nursing care greater than (>) 6.5 hours per day or daily physician assessments.  As per the physical rehabilitation physician documentation, the patient required continued rehabilitation but not at the level of an LTACH.
Although the patient required continued physical therapy and tracheostomy care, this did not require an LTACH level of care.
Therefore, the continued LTACH stay is not medically necessary for this patient for the dates of service in question.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne Muscular Dystrophy

Treatment: Emflaza
 
The insurer denied Emflaza.

The denial was overturned.

This is a male patient who is been recommended to utilize the requested Emflaza.  The documentation detailed this patient has been diagnosed with Duchenne muscular dystrophy with duplication of exon 21 in the dystrophin gene.  The patient has been recommended to utilize the requested medication as he had a history of excessive weight gain and insulin resistance for which he was currently being treated with metformin.  The patient's current BMI was in the 96th percentile for age.  Although the patient is not ambulatory, the patient continued to have functional use of upper extremities on daily Emflaza.  Any excessive weight gain according to the physician at this point would put the patient at an increased risk of losing the ability to provide self-care and independently perform activities of daily living such as feeding.  Therefore, the patient's physician indicates that a trial of daily prednisone was contraindicated.

The medical literature notes that Emflaza (deflazacort) is a corticosteroid indicated for the treatment of Duchenne muscular dystrophy (DMD) in patients 2 years of age and older. According to current peer-reviewed literature, prednisone and deflazacort have similar efficacy with regard to improved muscle strength. Deflazacort, however, is associated with less weight gain than prednisone. The documentation indicated that the patient did have a diagnosis of Duchenne muscular dystrophy and has been on treatment with Emflaza without concerning side effects.

Based on the review of the medical record and literature, Emflaza (deflazacort) is considered medically necessary for this patient. This is a male patient is post-pubertal with highest risk of weight gain occurring in this age group. Increase in weight will only worsen this patient's bone health and increase this patient's risk for contractures and fractures. The expected weight gain with Prednisolone would be greater than Emflaza. Thus, this would not be ideal in this patient who was postpubertal and was already overweight. The patient has lost ambulation and was hence unable to exercise. Discontinuation of the medication would not be medically prudent as it had been providing benefit. Therefore, the requested Emflaza 30 MG Tablet is considered medically necessary for this patient.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for Emflaza is substantiated.  The insurer's denial should be overturned.