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

Diagnosis: Endocrine/Metabolic/Nutritional-Growth Hormone Deficiency.
Treatment: Pharmacy/Prescription Drugs-Norditropin.
The health plan denied the Norditropin as not medically necessary. The reviewer overturns the health plan determination in whole.

This is a pediatric patient with salt-wasting congenital adrenal hyperplasia, treated with hydrocortisone at a dose of 13.8 mg/m2/day and fludrocortisone 0.1 mg daily, who has had an advanced bone age and slowing of stature growth. The mid-parental target height is 68 inches. The patient has undergone serial bone age exams, all showing advancement in skeletal maturation. The most recent bone age was interpreted by the pediatric endocrinologist as 10 6/12 years and by the radiologist as 11 6/12 years at a chronological age of 7 1/12 years, predicting an adult height < 62 inches. Serial assessment of adrenal androgens revealed appropriate suppression on glucocorticoid and mineralocorticoid therapy. Growth hormone (GH) provocative testing with clonidine and arginine revealed a peak GH response of 6.4 ng/mL. GH therapy is being proposed to improve adult height prediction.

GH therapy is medically necessary. Although the patient's height is not more than 2 standard deviations (SD's) below the mean for age and gender, the markedly advanced bone age results in a poor adult height prediction that is more than 2 SDs below  genetic target height and more than 2 SDs below the mean for U.S. adult men. This short adult height prediction has been made based on serial bone age exams and despite appropriate treatment of the underlying hyperandrogenism.

GH has been shown to improve adult height prediction in children with congenital adrenal hyperplasia who have advanced skeletal maturation, and poor predicted adult height that is 2 SDs below the genetic target height and more than 2 SDs below the population mean (Lin-Su et al., 2011). Based on the Endocrine Society Clinical Practice Guideline (Speiser 2018), GH therapy can be considered for individuals whose heights are expected to be at least 2.25 SDs below the population mean. Furthermore, this patient exhibited a poor response to provocative GH testing. GH therapy is medically necessary to improve the patient's height potential. There is a limited window of time to intervene with GH therapy while the patient has open epiphyses.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use disorder, Alcohol withdrawal.

Treatment: 4 days/units of inpatient substance abuse services.

The insurer denied coverage for 4 days/units of inpatient substance abuse services.

The denial is overturned.

This is a male patient with a history of substance abuse, schizophrenia, dyslipidemia, and asthma. He was admitted for inpatient hospital detoxification. The patient reported chest pain and tremors and had an extensive history of alcohol and substance use. The patient's urine toxicology was positive for multiple substances. The patient's history was significant for inpatient substance detoxification treatments in the past without success in maintaining abstinence. The patient was admitted and treated and was discharged in 4 days.

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, the patient had been drinking large amounts of alcohol daily and using large amounts of severe substances. The patient also presented with other medical issues. The patient had a prolonged QT interval, chest pain, hypertension, and an immunocompromising illness. The patient also had active withdrawal symptoms, including tremors and anxiety, that required detoxification medication to prevent more severe, complicated, or life-threatening withdrawal. The patient's multiple substance use pattern also put him at high risk for overdose and death. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient required 24-hour treatment because he could not be safely and effectively treated in outpatient detoxification settings as he continued to use large amounts of alcohol and serious substances. The patient required and received detoxification medications to modify his withdrawal symptoms and prevent more severe, complicated, or life-threatening withdrawal symptoms. The patient had difficulty controlling his substance use and continued to use alcohol and substances daily in large amounts despite past inpatient substance detoxification treatments. Based on this patient's history, it was unlikely that he would remain abstinent if not treated in a 24-hour hospital setting. Thus, the patient required this inpatient treatment setting to prevent worsened withdrawal and to decrease the chance of overdose and relapse. The risk of life complicated withdrawal such as delirium tremens can occur 4 days after alcohol use, so this patient is required the entire time in this hospital setting. 

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

The carrier's denial of coverage for the 4 days/units of inpatient substance abuse services should be overturned. The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis: Gastroesophageal Reflux Disease

Treatment: Laparoscopic Esophageal Surgery and Hospital Admission

The insurer denied the laparoscopic esophageal surgery and hospital admission.

The denial was partially overturned.

This is a female patient with a past medical history of gastroesophageal reflux disease (GERD), hypertension, and scleroderma.  The injured worker had normal gastric emptying.  Clinical: the patient underwent testing which revealed a DeMeester score of 94.8 by pH study.  Per the Esophageal Motility Study, there was normal motility with borderline low esophageal sphincter pressure, reflux, and a hernia.  The patient's body mass index was 34.3.  The patient had previously been treated with increased doses of omeprazole, 40 mg twice a day, and an H2 blocker at night.  The patient continued to have upper GI symptoms including gastroesophageal reflux disease and intermittent dysphagia.

There is strong evidence that esophageal surgery is effective for severe gastroesophageal reflux disease refractory to medical management.  This patient has ongoing symptoms despite increasing dosage of proton pump inhibitor and an H2 blocker and therefore would benefit from esophageal surgical intervention.

As documented in the appeal letter (References #5 and #6), both the Society of American Gastrointestinal and Endoscopic Surgeons and the American Society of General Surgeons approve the use of the LINX device for severe gastrointestinal reflux disease. 

In the office visit the physician noted two possible laparoscopic surgical options, insertion of a LINX device or Nissen fundoplication, and concluded the device to be a better option for this patient.  However, the patient has a past medical history of scleroderma, and although esophageal manometry is normal, the safety and effectiveness of the LINX device has not been established in patients with scleroderma. 

Given the failure of medical management, laparoscopic esophageal surgery is the best option for this patient.  However, given the history of scleroderma, laparoscopic Nissen fundoplication is a better option for this patient than laparoscopic insertion of the LINX device. 

Esophageal surgery in the form of laparoscopic Nissen fundoplication is likely to be more beneficial for this patient than medical management.  Although, as noted by the surgeon, there is a risk of failure over her lifetime, given that the LINX device has not been demonstrated to be safe and effective in a patient with scleroderma, a laparoscopic Nissen fundoplication would be the recommended surgery. 

Laparoscopic LINX placement is not likely to be more beneficial than any standard treatments/procedures, and when indicated, can be done without a full hospital admission.

The carrier's denial of laparoscopic esophageal surgery and hospital admission should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Hypoglossal Nerve Stimulation
The insurer denied the Hypoglossal Nerve Stimulation.
The denial is overturned. 

The patient is a male with a history of severe OSAS (obstructive sleep apnea syndrome) with an AHI (apnea hypopnea index) of 40.7, an ESS (Epworth Sleepiness Scale) score of 18, and a BMI (body mass index) of 34.96.  DISE (drug induced sleep endoscopy) shows primary AP (anteroposterior) collapse, and CPAP (continuous positive airway pressure) has failed and cannot be tolerated.  In particular, due to the severe nature of the OSA, the patient is desiring to obtain a CN XII stimulator.  

Yes, the health plan should cover the Hypoglossal Nerve Stimulation.

Otolaryngology's Academy's recommendations, as well as the literature, support that this procedure is the treatment of choice for OSA 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), it is accepted standard of care. 

Yes, the Hypoglossal Nerve Stimulation is likely to be more beneficial.

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: Hypoglossal Nerve Stimulation
The insurer denied the Hypoglossal Nerve Stimulation.
The denial is upheld. 

The patient is a male with a history of OSA (obstructive sleep apnea).  His AHI (apnea hypopnea index) on sleep study was 40.7 with a BMI (body mass index) of 34.96.  The patient could not tolerate CPAP (continuous positive airway pressure) and underwent a sleep endoscopy, where there was no complete concentric collapse at the velum.  The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's OSA.  

No, the health plan should not cover the Hypoglossal Nerve Stimulation at this time based on the information provided.

No, the Hypoglossal Nerve Stimulation is not likely to be more beneficial at this time, based on the information provided.  

All records were reviewed.  The patient is a male with a history of OSA.  His AHI on sleep study was 40.7 with a BMI of 34.96.  The patient could not tolerate CPAP and underwent a sleep endoscopy where there was no complete concentric collapse at the velum.  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 reported failed CPAP trial.  However, the patient's BMI is over 32, and there is not conclusive evidence in the scientific literature that the requested service is efficacious for patients with a BMI over 32.  Therefore, based on the information provided, it cannot be stated that 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, and the requested service should not be covered by the health plan.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Hypoglossal Nerve Stimulation
The insurer denied the Hypoglossal Nerve Stimulation.
The denial is overturned. 

The patient is male with obstructive sleep apnea (OSA). He had AHI (apnea-hypopnea index) of 40.7 on polysomnogram with desaturations to a nadir of 84%. He had drug induced sleep endoscopy and did not demonstrate concentric collapse. The patient is documented to be intolerant of CPAP (continuous positive airway pressure) therapy. Hypoglossal nerve stimulation was recommended.

Yes, the health plan should cover the Hypoglossal Nerve Stimulation.

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 apnea with 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.  

Yes, the Hypoglossal Nerve Stimulation is more beneficial.

The proposed therapy is a standard of care. 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 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 (body mass index) 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: Bicondylar tibial plateau fracture.
Treatment: Hospital admission
The insurer denied coverage for the hospital admission.
The denial is upheld.


This is a female patient who injured her left leg while skiing. The patient was evaluated in the Emergency Department (ED) and was diagnosed with a bicondylar tibial plateau fracture. The patient underwent open reduction internal fixation (ORIF) to the fracture on day #2 of admission. The patient received pain medications and physical therapy (PT). The patient's Foley catheter was removed on day #3 of admission. The patient was discharged home on day #5 of admission.

The medical record demonstrates that this patient's complex orthopedic procedure was completed without issue. There were no post-surgical complications. The patient's Foley catheter was removed on a postoperative day (POD) #1. The patient was mobilized and received PT services. The patient was able to use a walker. There were no problems with her surgical site. The patient's vital signs were stable, and she was able to tolerate pain with appropriate medications. There were no underlying medical conditions to require inpatient treatment. The clinical findings fail to substantiate the need for acute inpatient admission. Observation would have been more appropriate for this patient's clinical presentation.

Based on the review of the medical record and clinical guidelines, hospital admission is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Areota
Treatment Xeljanz 5 mg
The insurer denied the Xeljanz 5 mg.
The determination is upheld.

The patient has with alopecia areata associated with over 50% scalp hair loss. The patient has significant social/psychological symptoms as a result of his condition. Injections of steroids have failed to sufficiently bring back the patient's hair. At issue is the medical necessity of Xeljanz.
The Xeljanz is not medically necessary for this patient. Xeljanz is neither proven nor confirmed to be safe and with reliable outcomes for the condition of alopecia areata. It is not confirmed to be safe for long-term use at this time and merits further study before being presumed acceptable for widespread clinical use. Alopecia areata is difficult and unpredictable to treat, as well as unpredictable in its response to treatment. Oral immunosuppressants, light therapy, contact allergen treatment and related therapies have all resulted in variable and unsatisfactory outcomes, and self-resolution is often the only choice a patient has (along with hairpieces) for severe cases. However, while Xeljanz has some promising preliminary results in open-label studies (5, 6), the overall literature and reviews on alopecia areata (1-4) mention Xeljanz only as a potential option for treatment that requires further study before being acceptable for widespread use. Xeljanz was denied Food and Drug Administration (FDA) approval for use in psoriasis, in large part for safety reasons, and is not without a significant risk of side effects that preclude an acceptable risk for treatment of the condition of alopecia areata. 
At this time, Xeljanz is only FDA-approved for rheumatoid arthritis patients who have failed methotrexate, and for psoriatic arthritis, and for ulcerative colitis-all three conditions have indications whereby the safety risks of not using treatment are significantly greater than treatment itself. Xeljanz has recently been recommended to be used with lower dosing in rheumatoid arthritis patients. The same cannot be said for Xeljanz in the treatment of alopecia areata, where physical impairment and overall health impacts are minimal to nonexistent--despite the social/psychological impacts that can occur in some patients. The proper dosing, anticipated side effects and long-term outcomes are not known at this time for Xeljanz in the treatment of alopecia areata, as well as short-term and long-term safety risks of relevance to this patient's overall health. There are no large, randomized, controlled, prospective trials demonstrating and proving the safe and effective treatment of alopecia areata with a specific dosing of Xeljanz.  Therefore, Xeljanz is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left-sided abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with persistent left-sided abdominal pain, with no associated symptoms of nausea and vomiting. He had some constipation and noted some blood in the stools. No fever or chills were present. A computed tomography (CT) scan of the abdomen done at his earlier visit to the Emergency Department revealed sigmoid thickening versus under-distention of the sigmoid colon. He was discharged home on no antibiotics. 

The patient presented again and this time was admitted to the hospital and started on intravenous (IV) Cipro and Flagyl and started on intravenous (IV) fluids, intravenous (IV) Protonix, and Carafate. In the Emergency Department, he was hemodynamically stable and afebrile. He was given one dose of intravenous (IV)  Dilaudid 0.5 milligrams for pain. His complete blood count (CBC) and chem-panel were unremarkable. He was initially made nothing by mouth (NPO) status and then started on a clear liquid diet. A Gastroenterology consult was requested, but no consult report is provided with the medical records. A colonoscopy done was normal. He was discharged home in fair and stable condition.

No, the proposed inpatient acute level admission for the management of this patient was not appropriate and medically necessary. 

The patient presented to the hospital with left-sided lower abdominal pain, possibly due to mild colitis. The patient was hemodynamically stable, afebrile and was able to tolerate clear liquid without any nausea and vomiting. His physical examination was benign. His complete blood count (CBC) and chem-panel were unremarkable. He was empirically started on intravenous (IV) Cipro and Flagyl for possible colitis and on intravenous (IV) Protonix and Carafate for possible gastroesophageal reflux disease (GERD). Overnight, he remained hemodynamically stable and during his stay for 24 hours in the hospital, he did not require any blood transfusion, endoscopic or surgical intervention. Next day, he was discharged home in a fair and stable condition. Given this clinical scenario, the patient could have been safely managed under lower level of care without compromising his care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied: Otezla. 
The denial was upheld in whole.

The patient is a female with moderate to severe psoriasis (75% body surface area involvement). The patient has tried and failed topical fluocinonide cream and solution, Enstilar foam, Taclonex solution, Luxiq foam, and clobetasol solution. Biologic agents have been avoided due to the increased risk of infection during the COVID-19 pandemic. The patient has failed courses of phototherapy in the past and has a history of basal cell carcinoma of the nose and forehead. The subject under review is the medical necessity of the treatment with Otezla for this patient.

The health plan's determination is upheld in whole.

The requested treatment with Otezla is not medically for this patient.
The patient has no documented treatment failure with, or true medical contraindication to, standard of care, first-line systemic therapies such as either methotrexate, alternative oral therapies (such as either the oral retinoid acitretin, or oral cyclosporine), and/or phototherapy. All of these medications and treatments are appropriate as first-line therapies for this patient's particular clinical scenario. Modern dermatology literature [1-4] supports use of these preferred medications as similarly efficacious to the requested Otezla, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Otezla is not medically necessary.