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

Diagnosis: Chronic Venous Insufficiency

Treatment: CPT code 36475 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated)

The insurer denied the CPT code 36475 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated).

The denial was reversed.

This is a female patient who underwent endovenous ablation therapy of an incompetent vein.  It was reported in a letter of medical necessity detailing that the patient presented with complaints of left leg pain, aching and swelling.  The patient had previously been treated with a left endovenous laser greater saphenous vein followed by sclerotherapy. The patient was doing well up until late 2019 when her symptoms returned. The patient had been utilizing compression stockings without improvement.  The physician detailed that there was no deep venous thrombosis (DVT) upon ultrasound impression.  There were posterior thigh tributaries at 6.5 mm with 4000 ms of reflux to the great saphenous vein as well as mid-thigh neo great saphenous vein 5.6 mm with 3000 ms of reflux.  The small saphenous vein also had 3500 ms of reflux.  The physician recommended endovenous radiofrequency ablation of the left small saphenous vein and ultrasound guided foam sclerotherapy. In mid 2019, the patient underwent an Endovenous Radiofrequency Ablation of the Left Small Saphenous Vein and Sclerotherapy of the Left Lower Extremity.

Based on the review of the medical record and the literature, the procedure of Left Small Saphenous Vein (Left SSV) and sclerotherapy of the left mid-thigh tributaries are medically indicated and should be approved. The rationale behind this is that with recurrent left leg edema and pain, despite previous venous interventions and utilizing conservative management with compression stockings. The patient's ultrasound revealed significant venous reflux of the left small saphenous vein and thigh tributaries.  Thus, given the clinical findings and imaging, the above stated procedures were medically indicated. 

Furthermore, much literature has been done in the past 10 years on combined endovenous thermal (EVLT or RT) ablation of varicose veins combined with foam sclerotherapy and studies reveal that the combined therapy is safe, and improve efficacy of treatments and prevent recurrence.

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 CPT code 36475 (Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated) performed is substantiated.  The insurer's denial should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment:  Inpatient admission. 

The insurer is denied coverage for inpatient admission.   The denial is upheld. 

This is a female patient with a medical history of diabetes mellitus, ulcerative colitis, anxiety, depression, hysteroscopy myomectomy, sinus surgery and Attention Deficit Hyperactivity Disorder (ADHD).  She presented to the Emergency Department (ED) complaining of palpitations and chest pain, dyspnea and diaphoresis.  Her initial heart rate was elevated with a rate of 115 beats per minute.  An electrocardiogram (EKG) was performed that showed sinus tachycardia.  Cardiologist was consulted.  The patient was admitted to the hospital.  Her medical treatment and management included blood sugar monitoring and an insulin drip, Lovenox injections, intravenous (IV) fluid bolus, Prozac, and Delzicol.  There was no evidence of either hyperosmolar syndrome or ketoacidosis.  The patient was ruled out for a myocardial infarction and was discharged to home with outpatient follow-up.

The acute inpatient hospital admission was not medically necessary.  The patient presented with sinus tachycardia which is usually a physiologic response and does not require therapy per se.  The patient's care could have been provided in the observational setting in the hospital overnight allowing for additional cardiac testing, if warranted.  Inpatient admission criteria were not met.  Although the patient had a new onset of symptoms, medical necessity criteria were not met for any other additional extenuating circumstances.  The insurer acted reasonably, with sound medical judgment, and in the patient's best interest.

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

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

The Inpatient admission was not medically necessary.

The patient was admitted to the hospital after collapsing in the park while walking. MRI showed disc extrusion at L3-4. The patient underwent lumbar microdiscectomy and recovered ability to walk and neurologic function the day after surgery. There were no complications and the patient was stable before, during and after surgery. There was no indication that the patient required inpatient admission. The patient could have been safely monitored at a lower level of care.

Ahuja et al. in 2018 found day-case lumbar microdiscectomy is viable when patients are carefully selected. Younger, fit patients living close to the hospital and operated on in the morning are more likely to be discharged on the same day. Knowledge of these factors while planning elective lists can help optimize bed space and improve spinal services.

Hersht in 2007 found analysis of the interviews yielded several overarching themes: 1) patients are surprised that back surgery can be done on an outpatient basis; 2) the amount and quality of information they receive is satisfactory; 3) the overall experience is positive; 4) trust in one's surgeon is important; and 5) some patients
have significant back pain in the early postoperative period. Lumbar microsurgical discectomy was traditionally done as an inpatient procedure, but over the last decade, there has been an ever-expanding shift toward outpatient lumbar microdiscectomy (OLM).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Withdrawal 

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is reversed.

This patient is a male was admitted for detoxification. He was in withdrawal. He initially presented with chest pain at 8 out of 10 and he had a cardiac history.  He had elevated heart rate, nausea, and a Clinical Institute Withdrawal Assessment of Alcohol (CIWA) of 5.  He reportedly had a significant medical history for coronary artery disease, hypertension, prostate issues, and he had a past gunshot wound.  He reportedly had low glucose in the 60's and was hypoglycemic, and he had an abnormal lactic acid level.  He reportedly was put on an Ativan protocol and was given 2 mg for withdrawal and detoxification.  He also reportedly received intravenous (IV) fluids.  He had a reported history of depression and sleeping problems and was taking Quetiapine.  He reportedly was recommended follow up for alcohol treatment but declined and was discharged.

This reviewer disagrees with the decision to deny coverage for inpatient hospital treatment as this patient had alcohol withdrawal symptoms and was at risk for severe, complicated, and life threatening withdrawal such as delirium tremens so he required 24 hour hospital treatment for detoxification.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  In this case this patient had been drinking large amounts of alcohol every other day including hard liquor and had active alcohol withdrawal symptoms and significant co-morbid medical issues complicating the management of withdrawal.  He reportedly had active withdrawal symptoms and required detoxification treatment to prevent more severe and life threatening withdrawal.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification settings as he continued to use large amounts of alcohol despite medical issues and he was put on a protocol for detoxification medication including Ativan to modify withdrawal symptoms and prevent worsened complicated and life threatening withdrawal, and it was reported that he was given Ativan 2 mg. He reportedly did not want alcohol follow up after detoxification so he was not considered a candidate for outpatient treatment then, and he required 24 hour detoxification in this medical hospital. 

Inpatient hospital treatment was medically necessary.   It did not appear that the health care plan acted reasonably or in the best interests of the patient then.  

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Blood Disorder.
Treatment:  Pharmacy/Prescription Drugs (Pradaxa).

The insurer denied the Pradaxa.  The denial is upheld in whole.

The patient is a male with a history of chronic deep vein thrombosis.  The patient is stated to be refractory to Eliquis and Xarelto.  The patient is on an acetaminophen-hydrocodone that is stated by the provider to interact with warfarin.  Pradaxa has been recommended and is under review.

The health plan's determination is upheld. 

The patient has failed the formulary drugs Eliquis and Xarelto, and, thus, they are not appropriate for this patient.  The formulary drug warfarin has similar clinical efficacy to the non-formulary Pradaxa and is not contraindicated in this clinical scenario.  A LexiDrugs interaction check states "...Acetaminophen may enhance the anticoagulant effect of Vitamin K Antagonists.  This appears most likely with daily acetaminophen doses exceeding 1.3 or 2 grams per day (g/day) for multiple consecutive days....  Monitor for increased therapeutic effects of anticoagulants if acetaminophen is initiated/dose increased, or decreased effects, if acetaminophen is discontinued/dose decreased....  Use for more than 3 consecutive days may warrant additional international normalized ratio (INR) testing....".

Therefore, if this patient is intensively monitored, there is likely minimal risk to the use of warfarin with his current medical regimen.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Osteoporosis.
Treatment: CPT code 82523 (Collagen cross links, any method).

The insurer denied coverage for CPT code 82523 (Collagen cross links, any method). The denial is upheld. 

The patient is a female who was seen for evaluation of osteoporosis and its treatment a test for collagen Cross Links (CPT code 82523) was performed on the patient based on the doctor's letter. She routinely order Urinary N-Telopeptide when she see patient with osteopenia or osteoporosis to determine how rapidly patient losing bone. 

The insurance denied the coverage for this test. Although there is literature like (Reference 1) suggesting that Urinary N-telopeotide can give information about risk of fracture and can be a diagnostic tool for osteoporosis, 3 important societies international osteoporosis foundation (10F)(Reference 2) the American Association of Clinical Endocrinologists/American College of Endocrinologyy (AACE/ACE)(Reference 3) and National Osteoporosis Foundation (NOF)(Reference 4). Recommending Bone markers tests only for monitoring targets for treatment of osteoporosis and not diagnostic test and that dual energy X-ray (DEXA) that measure bone mineral density (BMD is the recommended and Acceptable method of diagnosing and assessing treatment monitoring (Reference 5) and there is very good correlation between the BMD results and risk of fracture (Reference 6). 

BMD is the tool to diagnose and monitor treatment of osteoporosis and that bone marker testing can be helpful in some cases when assessing fracture risk in elderly patients, assessing therapeutic response to anti-resorptive agents, but not as a diagnostic tool for osteoporosis, as was done in this case. The requested service is not likely to be more beneficial than any other standard testing.              

Based on the above, the medical necessity for CPT code 82523 (Collagen cross links, any method), performed is not substantiated. The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Osteoporosis with current pathologic fracture.
Treatment: CPT code 82523 (Collagen cross links, any method).

The insurer denied coverage for CPT code 82523 (Collagen cross links, any method). The denial is overturned.

The patient is a female with age-related osteoporosis without current pathological fracture. Most negative T-score is in her spine at -3.4. Her FRAX score is 15% for a major fracture and 1.5% for hip fracture. The request is for CPT code 82523 (Collagen cross links) obtained. Collagen cross-links (CTX) is a good marker for bone metabolism. There is scientific evidence that shows improvement in health outcome with CPT code 82523 (Collagen cross-links, any method). 

Lorentzon, M., et al. state that, "Serum bone formation marker PINP and resorption marker CTX-I are the preferred markers for evaluating bone turnover in the clinical setting due to their specificity to bone, performance in clinical studies, wide use and relatively low analytical variability. BTMs cannot be used to diagnose osteoporosis because of low sensitivity and specificity, but can be of value in patient evaluation where high values may indicate the need to investigate some causes of secondary osteoporosis. Assessing serum levels of CTX-I and PINP can improve fracture prediction slightly, with a gradient of risk of about 1.2 per SD increase in the bone marker in addition to clinical risk factors and bone mineral density. For an individual patient, BTMs are not useful in projecting bone loss or treatment efficacy, but it is recommended that serum PINP and CTX-I be used to monitor adherence to oral bisphosphonate treatment. Suppression of the BTMs greater than the least significant change or to levels in the lower half of the reference interval in young and healthy premenopausal women is closely related to treatment adherence." 

Szulc, P., et al., & National Bone Health Alliance Bone Turnover Marker Project, "Samples for CTX-I must be collected consistently in the morning hours in the fasted state. EDTA plasma is preferred for CTX-I for its greater sample stability. Sample collection conditions for PINP are less critical as PINP has minimal circadian variability and is not affected by food intake. Sample stability limits should be observed. The uncontrollable aspects (age, sex, pregnancy, immobility, recent fracture, co-morbidities, anti-osteoporotic drugs, other medications) should be considered in BTM interpretation." 

The cross links will help determine how well the drug is working and how long therapy needs to continue for as well as guidance if therapy needs to be restarted at a future date. This is a good candidate as she has not been treated with any medications. The requested service is likely to be more beneficial than any other standard testing.                                     

Based on the above, the medical necessity for CPT code 82523 (Collagen cross links, any method), performed is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Class I, crowded occlusion.
Treatment:  Braces, Monthly visit x 12.
 
The insurer denied braces and monthly visits.  The health plan's determination is upheld. 

The patient is a male with a Class I, crowded occlusion with a deep bite.  The orthodontist states he has anterior an anterior crossbite with gingival attachment loss.  He is treatment planned for 24-30 months of orthodontics to correct his malocclusion. 

The Braces, Monthly visit x 12 are not medically necessary for this patient.  There is no medical reason to correct his mild crowding with braces.  The patient does have slightly retroclined maxillary incisors.  However, that alone is not a medical necessity to treat.  There are many ways to correct patients with a deep bite and retroclined incisors, and there is strong evidence that one treatment is not better than another.  Furthermore, retroclined incisors and deep bites may be corrected in adulthood, so there he will not lose the ability to correct his malocclusion should he choose to do so as an adult.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems-Overbite/Underbite
Treatment: Dental/Orthodontic Procedure
The insurer denied the service of Braces and Periodic Visits as not medically necessary
The denial was upheld in whole

The patient in question has a Class I occlusion with appropriate overbite and overjet. The patient has minor maxillary and mandibular crowding. They are treatment planned for 24-30 months of orthodontics with extraction of maxillary and mandibular premolars to correct their malocclusion. 

There is no medical reason to correct their malocclusion with braces. While the patient has crowded teeth, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. The patient has a Class I occlusion which is the most efficient bite for mastication. If the teeth were aligned it would provide a minor aesthetic improvement, but it would not create a medically significant improvement to the patient's health.
The patient has very minor crowding. Their overbite is minimal but appropriate and there is no indication of damage to the incisors in the photographs. The photographs provided to not indicate an anterior crossbite with gingival attachment loss of the lower incisors.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea 
Treatment: Hypoglossal nerve stimulation and obstructive sleep apnea 

The insurer is denied coverage for hypoglossal nerve stimulation and obstructive sleep apnea. 
The denial is reversed. 

This was then a male with severe obstructive sleep apnea based on sleep study with apnea-hypopnea index (AHI) 23 and a no evidence of central sleep apnea. The patient had a normal body mass index (BMI) of 22. The patient had tried multiple masks both full face and nasal in order to use his continuous positive airway pressure (CPAP) machine but was not tolerant to any of these masks; the patient was not able to wear the mask for more than two hours at night. The patient's sleep endoscopy was performed showing no concentric collapse. All of these factors made this patient a good candidate for the upper airway stimulator. 

The upper airway stimulator was FDA approved in 2014 and due to its success in improving health outcomes; the inclusion criteria were expanded in 2017 to include patients with an apnea-hypopnea index (AHI) of up to 65. The STAR trial showed long term follow-up (48 months) with significant improvement in Epworth Sleepiness Scale and Quality of Life outcomes. As per Dedhia, Strollo & Soose (2015), "The trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA." 

The Otolaryngology/Head & Neck Surgery (OTO-HNS policy) statement supports the upper airway stimulator as a second line treatment after continuous positive airway pressure (CPAP) has failed. 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. The hypoglossal stimulation therapy (Inspire therapy) is indicated for patients with the following characteristics: 22 years of age or older; Have moderate to severe OSA (AHI range from 15-65 with <25% central apneas); Unable to use CPAP; Free of complete concentric collapse at the palate; Inspire therapy has not been tested in people with a BMI greater than 32. This patient's body mass index (BMI) was 22 and met the clinical criteria for this hypoglossal stimulation therapy. 

The hypoglossal nerve stimulation for obstructive sleep apnea (OSA) is likely to be more beneficial than nay of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for hypoglossal nerve stimulation (Inspire upper airway stimulation system) for obstructive sleep apnea (OSA) should be reversed.