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

Diagnosis:  Substance abuse
Treatment:  Continued inpatient detox

Summary:
Continued inpatient inpatient detox is medically necessary for this patient.  The patient in this case was using large quantities of alcohol together with cocaine and cannabis that did warrant the continued inpatient level detoxification and withdrawal management and monitoring.  Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient struggled with mild withdrawal symptoms in the context of co-occurring psychiatric disorders and with associated clinical features that included limited insight, impaired judgment and poor control of impulses.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has multiple sclerosis (MS) and has been evaluated for weakness and spasticity of lower extremity, particularly the right side.
The same letter reports that the patient has spasticity and weakness causing a foot drop, unclear mechanism, and was previously using Functional Electrical Stimulation (FES).

The health plan's determination is upheld. The Functional Electrical Stimulation (FES) Foot Drop Device: L300 Bioness Go Lower System is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. There is no literature support from any large controlled studies that the requested device is superior to standard physical therapy and devices such as ankle orthoses in patient with multiple sclerosis. There is no submitted evidence that the patient had proper trials of standard of care orthoses and failed.
Appeal type: Experimental/Investigational
Decision: Upheld

This patient has been diagnosed for multiple sclerosis (MS). The patient has had weakness and spasticity, particularly in the right lower extremity. The patient has been using the BionessL300 with great success for the past 5 years. 

The health plan's determination is overturned. The Functional Electrical Stimulation (FES) Foot Drop Device: L300 Bioness Go Lower System likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.Given all the evidence listed above, the request for FES for this patient is likely to be more beneficial than any standard treatment (AFO), especially since he is unable to ambulate safely with an ankle foot orthotic AFO due to the added weight of the orthotic preventing hip and knee flexion.
Appeal type: Experimental/Investigational
Decision: Upheld

The patient has MS (multiple sclerosis) and right foot drop. The patient has been using a functional electrical stimulator for 5 years. A replacement functional electrical stimulator (FES) for foot drop is requested.

The health plan's determination is upheld. The FES is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. At present, there is limited evidence about quality of life and impact of FES on disability. Additional large, randomized clinical trials with long-term follow-up are required to demonstrate that FES provides health benefits, to define the clinical role of FES, and to establish patient selection criteria.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tonsilitis
Treatment: Inpatient admission for tonsillectomy and adenoidectomy

The insurer denied inpatient admission. The denial was upheld.

This case involves a child who was admitted to undergo a tonsillectomy and adenoidectomy.  The patient underwent preoperative evaluation.  It was noted the patient was a low risk from a cardiovascular standpoint for surgical intervention. The patient did not have any complications during the procedure.  Postoperatively, there were also no documented complications.  The following day the patient was evaluated and it was noted that there were no overnight events.  The patient's pain was well controlled and there was good oral intake.  The patient slept well and there was no bleeding.  The examination revealed no abnormality.  The patient was breathing comfortably and it was noted he was stable for discharge.  

According to current literature, a tonsillectomy and adenoidectomy is typically an ambulatory procedure.  An inpatient admission may be needed when there is evidence of complication intraoperatively or postoperatively.  The literature details specifically a tonsillectomy or adenoidectomy, or both without complication - such as hemorrhage, is an ambulatory procedure.  

The patient underwent surgical intervention without evidence of hemorrhage.  Post-operatively the patient recovered well.  While the patient needed a short observation post-operatively to monitor his airway status, there was no documentation supporting the patient needed to be admitted to an inpatient status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal bleeding
Treatment: Inpatient admission
The inpatient admission is not deemed medically necessary. 

This female patient presented to the ER for further evaluation/management of rectal bleeding.  Intake vitals were afebrile and hemodynamically stable with no evidence of febrile temperature, malignant hypertension, profound hypotension, severe tachycardia or hypoxemia on room air.  Examination was non-focal with no significant abnormalities noted including no evidence of acute cardiopulmonary abnormalities or findings consistent with acute/surgical abdomen.  Laboratory and ECG testing was also within normal limits with exception of hyperglycemic, but no other significant abnormalities were noted, including no evidence of acute end organ damage. 

The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received IV Protonix and supportive care with IV fluids and continued cardiac monitoring.  Subsequent EGD revealed gastritis, and her rectal bleeding was deemed secondary hemorrhoids from chronic constipation.  She responded well to the prescribed therapies and was subsequently discharged in stable condition.  There is no evidence of intensification of services throughout the course of this patient's hospital stay.  Hence, the patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. 

For these reasons inpatient admission is not deemed medically necessary
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of diabetes, hypertension, hyperlipidemia, and hyperparathyroidism presented to emergency room with complaints of nausea, diarrhea and weakness. The patient was found to have a blood pressure 71/65 and reported a productive cough for 3 days, and multiple episodes of diarrhea up to 10 episodes a day. The patient complained of general weakness and one episode of fever. Stools were non-bloody and watery for 1 day duration. The patient denied any sick contacts, eating any outside food or exposure to anyone with similar complaints. Laboratory data showed blood urea nitrogen (BUN) was 22, creatinine was 1.6, and a lactate level of 2.1. The patient had a normal white blood cell (WBC) count, potassium level, and bicarbonate level. Chest x-ray was clear. The patient received 3 L of intravenous (IV) fluids, and IV Levaquin in the emergency department (ED). The Patient was admitted for dehydration, hypotension and diarrhea. The patient was continued on IV fluids. She was started on duo nebs, budesonide and continued on her home medications. Over time, the symptoms had improved and the diarrhea had resolved. Kidney function returned to normal. Blood cultures and urine cultures were negative. The patient was clinically and hemodynamically stabilized and discharged home with a plan for close follow up. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. Per the Milliman Care Guidelines (MCG) 22nd edition, the patient does not meet the criteria for inpatient admission.

There is no evidence of continued hemodynamic instability after IV fluid resuscitation.
There was no need for invasive monitoring. There was no evidence of arrhythmias, severe or worsening kidney failure, severe electrolyte abnormality of metabolic acidosis, evidence of bloody stool requiring transfusion on invasive procedures, evidence of pneumonia, hypoxemia or acute respiratory failure requiring assisted ventilation.

The patient could have been safely evaluated and treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The case involves a patient who is requesting  authorization for coverage of Aimovig for the treatment of migrane headaches.The health plan's determination is upheld.The requested treatment of Aimovig is not medically necessary for this patient. There is no specific medical necessity for Aimovig over the medications of Emgality and Ajovy.  All calcitonin gene-related peptide (CGRP) antagonists (Aimovig, Emgality and Ajovy) are FDA-approved for the treatment of episodic and chronic migraine.   There is no evidence in this case why the medications  Ajovy or Emgality, could not be utilized to treat the patient's headaches .
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent vomiting/Gastrointestinal
Treatment: Inpatient Hospital Admission

Summary:
This patient presented to the ED with recurrent vomiting, no fever, and no diarrhea. He initially did well in the ED, but began vomiting at the time of discharge. He was admitted for observation, with laboratory studies and radiographic studies to rule out surgical causes of vomiting. Because of recurrent vomiting and inability to tolerate pos, he was admitted for further management. Acute inpatient admission was medically necessary and appropriate in this case because he failed outpatient management in the ED including a prolonged period of observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angina, past medical history notable for coronary artery disease, prior coronary bypass surgery, hypertension, and hyperlipidemia

Treatment: Cardiac catheterization, inpatient admission

The insurer denied inpatient admission. That denial was upheld.

The patient presented for an elective, outpatient cardiac catheterization for symptoms of angina pectoris refractory to medical therapy. The patient underwent a left heart catheterization, which revealed chronic occlusions of the right coronary artery and circumflex artery. Attempted revascularization was unsuccessful. Therefore the procedure was stopped. There were no procedural complications, and the patient was then admitted for further monitoring. 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. 

Inpatient admission status was not medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), the clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac catheterization and stenting. The ambulatory surgery level of care would have been appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: OSA
Issue under review: Hypoglossal nerve stimulation or Inspire upper airway stimulation system

Determination:
The health plan should not cover the Hypoglossal nerve stimulation or Inspire upper airway stimulation system.

The patient is an adult female with a history of OSA.  AHI on sleep study was 51.5 with a BMI of 32.4- 33.3.  The patient could not tolerate CPAP and underwent a sleep endoscopy, where there was no complete concentric collapse at the velum.  There was also a reported failed oral appliance trial.  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 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.  However, the patient does not have a consistent BMI of 32 or less.  There is not conclusive evidence in the scientific literature that the requested service is likely to be more beneficial than any standard treatment or treatments for OSA for patients with a BMI over 32.  Therefore, based on the information provided, the previous determination would be upheld at this time.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: OSA
Issue under review: Hypoglossal nerve stimulation or Inspire upper airway stimulation system

Determination:
The health plan should cover the Hypoglossal nerve stimulation or Inspire upper airway stimulation system

The Otolaryngology 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). She has the appropriate diagnostic findings and has not tolerated CPAP.  The procedure is not E/I, and it is accepted standard of care. 

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 for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: OSA
Issue under review: Hypoglossal nerve stimulation or Inspire upper airway stimulation system

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

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 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, which were the categories of exclusion in the plan policy.  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. 

For this patient, the proposed procedure is required to treat her 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 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: Upheld

Diagnosis: Infertility

Treatment: IVF Cycle

The insurer denied an in-vitro fertilization cycle (IVF). The denial was upheld.

This patient has a history of infertility, Fragile X mutation and aneuploidy.  Per the note from fertility clinic, the patient's follicle stimulating hormone (FSH) level was 22 and her Anti-Mullerian Hormone (AMH) was 0.088, suggesting it would be lucky to get more than 2 eggs per in vitro fertilization (IVF) cycle.  She has had prior IVF treatments.  Per the Embryology Summary report, there are 6 frozen embryos in storage from all cycles. An IVF cycle has been requested. The patient and provider would like to create more embryos for possible future use.

This patient has a severe decrease in ovarian reserve due to Fragile X.  Four years ago, this patient's FSH was elevated and her AMH was very low, both suggestive of poor prognosis for more IVF cycles. Her last cycle resulted in the recovery of only one oocyte that did not fertilize. In other words, proceeding with more IVF cycles has very low odds of success and therefore, IVF is not medically necessary.

The patient has 6 frozen embryos and prior to proceeding with more IVF cycles with a very poor prognosis, the patient could use those frozen embryos. The aim of fertility treatments is to have a child and not to collect embryos. With 6 frozen blastocysts, the odds of having a live birth are definitely better than with more IVF cycles.
Appeal type: Medical necessity
Decision: Upheld

This is a patient is a who requested detoxification from alcohol and other substances of abuse including sedative-hypnotic-anxiolytic (benzodiazepine), stimulant (crack cocaine) and cannabis class substances of abuse. The patient reported using alcohol on a continuous daily basis in large quantity together with Xanax with up to 16 milligrams (mg) daily and up to 10 bags of crack cocaine, as well as tobacco. There was a longstanding history of alcohol and drug use beginning in adolescence and had an extensive substance use disorder treatment history including four recent detoxification treatments in the last 30 days. The health plan's determination of medical necessity is upheld.

The patient did not experience complications or present with severe symptoms of a co-occurring psychiatric disorder/unspecified schizophrenia, or abnormal findings on examination, or severe withdrawal symptoms. The risk for withdrawal complications including seizures and delirium tremens were minimal considering the history and recent detoxification treatments, and the patient did not pose a safety risk that would have warranted the admission and continued inpatient level services and monitoring, as requested.
Appeal type: Medical necessity
Decision: Upheld

The patient with a history of sickle cell disease presented to the hospital with worsening shortness of breath. It was determined that she was in sickle cell crisis. She was admitted to the hospital. The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld. The inpatient admission was not necessary. The patient began improving in the emergency department and there were no other concerning symptoms such as acute evidence of infection, evidence of end organ injury, or other acute abnormalities that would increase the risk of an adverse event in this patient.
Appeal type: Medical necessity
Decision: Upheld

This is a male patient with progressive right-sided weakness for six weeks and intermittent headaches. He had a history of relapsing remitting multiple sclerosis and had deferred treatment until his left leg became more symptomatic. The health plan's determination is upheld.  There was no rationale for acute inpatient treatment with Solumedrol, which can be provided as an outpatient in an infusion center, home infusion setting or physician office. The patient otherwise did not require any neurological monitoring given the stability of his complaints over six weeks. He did not require any cardiac, hemodynamic, pulmonary or other medical monitoring. His condition was not expected to deteriorate. He had no electrolyte, cardiac, hematological or other abnormalities that would require treatment in an inpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post Cardiac Catherization
 
Treatment: Admitted after Elective Stage Percutaneous intervention

The insurer denied the coverage. The denial was upheld.

This male patient with a past medical history notable for coronary artery disease, status post recent coronary stenting of the left circumflex artery, as well as hypertension, hyperlipidemia, and diabetes mellitus controlled with oral medications. He presented for elective coronary stenting of the left anterior descending coronary artery. He had stable symptoms of angina pectoris. He received a drug-eluting stent. There were no procedural complications, and the patient was then admitted for further monitoring. 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.

Inpatient admission status was not medically necessary for this patient. Per MCG Angioplasty, Percutaneous Coronary Intervention ORG: M-52 (ISC), the clinical presentation and peri-procedural course were unremarkable and uneventful, and acute inpatient level monitoring was not medically necessary or appropriate. There were no extenuating circumstances in this case which warranted inpatient admission status following elective cardiac cath and stenting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia 
Treatment: Inpatient admission
The inpatient admission was not medically necessary. 
This patient presented with hyperglycemia and dehydration in the setting of missed insulin doses. He was awaiting coronary artery bypass grafting which was rescheduled to a later date. The documentation does not support that the patient was hemodynamically unstable. He did not have acidosis to support a diagnosis of diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. He had an elevated creatinine level consistent with dehydration. The documentation does not support that the patient had severe dehydration that failed management under observation status. The patient was transitioned to subcutaneous insulin and appropriately hydrated after an overnight stay and discharged the day after admission. Therefore, the proposed inpatient stay was not medically necessary.