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

Diagnosis: Cardiac catheterization 
Treatment: Inpatient Admission
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the proposed inpatient admission is not "medically necessary".

The patient is a female at the time of admission to the hospital, with a past medical history significant for HTN (hypertension), dyslipidemia, obesity, uncontrolled diabetes mellitus, CAD (coronary artery disease), status post prior PCI (percutaneous coronary intervention) of LCX (left circumflex artery) and D1, who was evaluated in outpatient clinic for exertional chest pain on walking 3 blocks. She was initially scheduled for outpatient stress test, but was subsequently sent to ER to rule out ACS (acute coronary syndrome). Her serial troponins were negative. Patient was hemodynamically stable. ECG revealed no acute ischemic changes. 2D echocardiogram was unremarkable.  The patient was transferred to Elmhurst Hospital for coronary angiogram. Catheterization revealed in-stent re-stenosis of first diagonal branch and the lesion was intervened on with new drug-eluting stent placement. The patient tolerated the procedure well, without any complications and was discharged home.

This patient was transferred from an outside hospital after ruling out for MI (myocardial infarction) with negative troponins, unremarkable echocardiogram for a cardiac catheterization for evaluation of exertional chest pain, and an uncomplicated PCI was performed. There was no evidence of acute myocardial infarction (MI), ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. There were no peri-procedural complications. Usually no acute inpatient admission is required post PCI, unless there is evidence of a bleeding or ischemic complication, peri-procedural MI, hemodynamic or electric instability. None of these complications were documented for this patient and she was discharged home in stable condition. Thus the medical record does not support medical necessity for acute inpatient care, and the services could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite; impacted tooth
Treatment: Braces
The insurer denied the braces. 
The denial is overturned. 

Yes, the Braces are medically necessary.

The patient is a female. The patient has a deep, impinging overbite with severe soft tissue damage, as well as an impacted permanent upper left canine (and extraction is not indicated). Both of these conditions are automatic qualifiers for orthodontic benefits, according to the handicapping index scale. Orthodontic treatment is medically necessary to correct these problems.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing loss 
Treatment: Binaural hearing aids 

The insurer denied the Binaural hearing aids. The denial is overturned. 

Yes, the Binaural hearing aids are medically necessary. 

The patient is a female with history of bilateral moderate SNHL (sensorineural hearing loss). The hearing loss is affecting her quality of life and causing social isolation and inability to hear in background noise. The patient has a pure tone average of 38 in the right ear and 43 in the left ear, with word identification of 70% and 66% in the right and left ears respectively. The patient is requesting bilateral aids. 

Studies have shown that age and age-related hearing loss have significant effects on individual health and wellbeing. (1-3) Restoring hearing in only one ear does not result in significant improvements (4-5). Binaural hearing is crucially important for speech perception, quality of life, and a number of psychosocial issues (2-3). Therefore, the Binaural hearing aids are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System / Neuromuscular Disorder
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a  male with a history of hypertension, diabetes, asthma, and bipolar disorder. He presented to the emergency room with head and left leg tingling and left leg weakness. He presented with the same symptoms two days previously but left against medical advice (AMA). Vital signs were notable only for a blood pressure of 169/95. On physical exam, he was in no acute distress, and appeared awake and alert. One examiner notice a possible slight weakness of the left leg compared to the right but still reported it as 5/5. Labs were non-contributory. The head computed tomography (CT) scan was unremarkable. The electrocardiogram (EKG) was noted to be negative for ischemia. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with oral medications. The hospital course was clinically uneventful, and the patient was discharged.

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

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. It is very hard to explain anatomically a serious lesion that causes tingling in the head and tingling in the leg. Objectively, his neurologic exam was normal. Based on the standard of care and peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted teeth
Issue under review: Braces

Determination:
The Braces are medically necessary.

The patient is a teen-aged female. The request is for orthodontic benefits.

The patient has multiple impacted teeth (stuck in the jawbone). These are causing spaces to be created in her upper dental arch.  Without these teeth being either removed and the spaces orthodontically closed up, or being orthodontically erupted and placed in their proper positions, this patient will most probably have future problems. Open spaces will allow food impaction and cavities to develop. Without all the teeth meshing properly, some teeth can be traumatized over time, resulting in either fracturing and/or loosening. Orthodontic treatment is medically necessary to correct these problems in this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Obstructive sleep apnea 
Treatment:  Hypoglossal nerve stimulation or Inspire upper airway stimulation system
The health plan should cover the Hypoglossal nerve stimulation or Inspire upper airway stimulation system.

The patient is a male with history of severe OSAS (obstructive sleep apnea syndrome).  The patient has a BMI of 27.1, an AHI (apnea-hypopnea index) of 21.5, and no evidence of concentric collapse on DISE (drug-induced sleep endoscopy). The patient has tried CPAP (continuous positive airway pressure) and failed and now requests surgical implantation of hypo pharyngeal nerve stimulation.

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

The Hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be more beneficial.

This patient 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:  Hypoglossal nerve stimulation or Inspire upper airway stimulation system
The health plan should cover the Hypoglossal nerve stimulation or Inspire upper airway stimulation system.

The patient is a male with a history of OSA.  His AHI (apnea hypopnea index) on sleep study was 21.5 with a BMI of 27.1.  The patient has not tolerated CPAP (continuous positive airway pressure). He underwent a sleep endoscopy, where there was no complete concentric collapse at the velum.  There is also a history of uvulectomy and tonsillectomy having been performed.  An oral appliance trial failed.  The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's OSA.

The Hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be more beneficial.

All records were reviewed.  The patient is a male with a history of OSA.  His AHI on sleep study was 21.5 with a BMI of 27.1.  The patient has not tolerated CPAP and underwent a sleep endoscopy where there was no complete concentric collapse at the velum.  There is also a history of uvulectomy and tonsillectomy having been performed.  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 uvulectomy, tonsillectomy and oral appliance therapy 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 medical appropriateness of the requested service would be confirmed, as the requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Obstructive sleep apnea 
Treatment:  Hypoglossal nerve stimulation or Inspire upper airway stimulation system
The health plan should cover the Hypoglossal nerve stimulation or Inspire upper airway stimulation system.

The patient is a male with obstructive sleep apnea (OSA).  The patient is unable to tolerate CPAP (continuous positive airway pressure) therapy effectively.  He has had sleep endoscopy, which did not demonstrate concentric collapse.  He has previously had uvulopalatopharyngoplasty without resolution of his apnea.  His latest AHI (apnea hypopnea index) is 22.

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 moderate sleep apnea 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.  

The Hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be more beneficial, and it does represent a standard treatment.

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.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hepatitis B.
Treatment: Vemlidy 25 mg.
The insurer denied Vemlidy 25 mg.
The determination is overturned.

The patient has a diagnosis of chronic hepatitis B infection. The patient is on chronic nucleoside analog therapy with tenofovir disoproxil fumarate (TDF). It was noted by the provider that the patient had deteriorating renal function and requested a switch off of the tenofovir. The plan continued to offer the formulary alternative which is the tenofovir disoproxil fumarate.
The lab results provided show that the serum creatinine rose this year between from 1.18 to 1.32 although the calculated glomerular filtration rate (GFR) remained greater than (>) 60.
The patient's provider has recommended approval for Vemlidy (TAF) due to worsening renal function however, this request was denied by the plan.  At issue is the medical necessity of Vemlidy 25 milligrams (mg) tablet.
The requested Vemlidy 25 mg tablet is medically necessary. The patient is on chronic nucleoside analog therapy with tenofovir disoproxil fumarate (TDF). It was noted by the provider that the patient had deteriorating renal function and requested a switch off of the tenofovir. The plan continued to offer the formulary alternative which is the tenofovir disoproxil fumarate.
Although the patient's renal function (GFR) remains within the normal range there has been a significant bump in the serum creatinine suggesting the patient is trending toward chronic kidney injury. TDF is associated with worsening kidney function in some patients. If possible, TDF should be avoided in patients with reduced kidney function and the patient switched to TAF. Patterns of kidney injury due to TDF include proximal tubular dysfunction, acute kidney injury, and chronic kidney disease. This can lead to renal impairment characterized by increases in serum creatinine, proteinuria, glycosuria, hypophosphatemia, and acute tubular necrosis. TAF appears to have less renal toxicity compared with TDF and is approved for use as monotherapy in patients with chronic hepatitis B virus (HBV).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female. She has a PMH (past medical history) significant for idiopathic pancreatitis s/p (status post) total pancreatectomy, cholecystectomy and auto islet cell transplantation, history of diabetic gastroparesis, IDDM (insulin-dependent diabetes mellitus), now on insulin pump, umbilical hernia repair and revision of gastrojejunostomy with Roux-en-Y, with post-operative course complicated by persistent nausea and vomiting. The EGD (esophagogastroduodenoscopy) done at that time showed a mucosal nodule, otherwise unremarkable. The Roux-en-Y anastomosis was intact with healthy appearing mucosa. She required TPN (total parenteral nutrition) for nutrition at that time.

The patient was admitted to the hospital with complaint of abdominal pain and nausea of five days duration. In the ED and during the inpatient admission, the patient was hemodynamically stable and afebrile. The physical examination was remarkable for mild abdominal tenderness. The CT (computed tomography) scan of the abdomen was normal. The patient received IV (intravenous) Morphine and IV Fentanyl for abdominal pain with an 8/10 in intensity. The patient was seen by general surgery and no surgical intervention was recommended. The GI (gastrointestinal) physician was consulted and EGD was recommended for the evaluation of abdominal pain. The patient was started on Protonix 40mg daily and IV Reglan for nausea. 

No. The proposed acute level inpatient admission was not appropriate and medically necessary for this management of this patient's condition. 

This patient was admitted with severe abdominal pain and nausea of five days duration. She had prior h/o (history of) similar episodes of abdominal pain and nausea and vomiting. In the past, she had undergone repair of the umbilical hernia repair and revision of the Roux-en-Y anastomosis. During this admission, the patient was appropriately evaluated for abdominal pain, and underwent CT scan of the abdomen which was unremarkable. Her abdominal pain and nausea was controlled with narcotics and antiemetics. She was evaluated by General Surgery and no surgical intervention was recommended. The GI consult was completed and EGD was recommended for the evaluation of her abdominal pain. 

Over next 24-48hrs, her abdominal pain and nausea improved and she was able to tolerate liquid diet well. Given this clinical scenario, the patient could have been safely managed at a lower level of care and discharged home after 48hrs when she was able to tolerate full liquid diet and her abdominal pain was controlled with oral pain medications. The GI consult could have been done on an outpatient basis.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

Diagnosis: Chest pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a  man with history of hypertension, asthma, chronic obstructive pulmonary disease (COPD), hypersensitivity, and heart failure who presented to the emergency department. He presented with chest tightness. He reported that he had associated shortness of breath and his symptoms started on the day prior to presentation. He denied headache, back pain, fevers, chills, nausea and vomiting. 

The inpatient hospital stay was not medically necessary. The patient was not hemodynamically unstable or significantly hypoxic or presenting with other acute signs or symptoms at the time of presentation. His shortness of breath required diagnostic evaluation, but in a patient with negative cardiac enzymes and no evidence of a clinically significant acute respiratory disorder, an outpatient level of care is normally appropriate. His overall evaluation was largely focused on diagnostic testing rather than acute treatment. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Skin Disorders
Inpatient hospital

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

The patient is a male who presented to the hospital with complaints of pain in the right hand associated with swelling. Reportedly, he had a physical altercation. The patient noticed swelling in his right hand. It became painful. Subsequently, the patient developed a fever.
When seen by the admitting physician, the patient had several abrasions to his hand and came to the hospital for evaluation. The initial evaluation included an x-ray of his hand. It did not show any evidence of fractures. The admitting physician stated that the patient had leukocytosis. This prompted the administration of intravenous antibiotics in the emergency department.

The inpatient hospital stay was not medically necessary for this patient. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care.
Overall, during this hospital stay, he remained in stable clinical condition and did not require any diagnostic studies or procedures necessitating admission at the acute inpatient level of care. The hospital stay was very short and was within the scope of a lower level of care.
A careful review of the patient's records demonstrated that the patient did not meet the nationally recognized criteria for admission at the acute inpatient level of care. Even though the patient possibly had a small cutaneous abscess, there was no surgical procedure performed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory system /breathing problem
Treatment: Inpatient hospital
The insurer denied the inpatient hospital stay
The denial is upheld in whole 

A patient with a history of human immunodeficiency virus (HIV), not on antiretroviral therapy, as well as diabetes mellitus with chronic insulin use, polysubstance abuse including crack cocaine and tobacco use, presented to the hospital with chest pain and shortness of breath.
No. The requested health service/treatment of inpatient hospital stay is not medically necessary for this patient. The presentation can be managed under a lower level of care.
After carefully reviewing the supplied documentation, there was no clinical indications for admitting the patient to an inpatient level of care. There is no evidence of hemodynamic instability. The electrolyte abnormalities that were present on admission appear to have been rapidly corrected. There are no cardiac arrhythmias. There was no pneumonia or pulmonary embolism, causing the patient's heart failure symptoms. There was no evidence of severe pulmonary edema, but rather mild congestion and the patient was able to saturate more than 90% on room air.
Within 24 hours of hospitalization, the patient can lie flat, and had no conversational dyspnea. There was no description of massive anasarca. There was no description of tachypnea or dyspnea that persists beyond the lower level of care. There is no alteration of mental status that severe persistent; the patient was answering questions appropriately within 24 hours of hospitalization. Initially, the increased creatinine was believed to be a new finding; however, after receiving the medical records from an outside facility, the creatinine appears to be around the baseline. Therefore, the patient's condition is chronic, slightly exacerbated, with rapid improvement with diuretic therapy within 48 hours of hospitalization. The patient satisfies criteria for a lower level of care admission. Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bladder cancer.
Treatment:  Increase in Level 2 Personal Care Services to 24 hours/day (live in).

The insurer denied the increase in Level 2 Personal Care Services to 24 hours/day (live in).  The denial is overturned. 

The patient is a male with a history of bladder cancer treated with chemotherapy.  Due to impairments related to this condition and the treatments received, he requires assistance for completion of the majority of his activities of daily living (ADLs).  An appeal review was requested for potential approval of an increase in Personal Assistance Services to 24 hours/day (live in) to offer increased ADL support.

Yes, the proposed treatment of an increase in Personal Assistance Services to 24 hours/day (live in) is deemed medically necessary. 

Recent correspondence from the patient's provider indicates that due to progressive functional decline and worsening debility, the patient is now total care for all activities of daily living, including toileting, dressing and ambulating.  For these reasons, the currently approved plan of 56 hours/week Level 2 Personal Care Services is insufficient to meet the patient's current needs.  Hence, the proposed treatment of an increase in Personal Assistance Services to 24 hours/day (live in) is deemed medically necessary.