Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Enlarged Prostate Gland
Treatment: Prostate Artery Embolization, Pre-service
The insurer denied the Prostate Artery Embolization, Pre-service
The denial is overturned.

The patient is a male with multiple medical problems including coronary artery disease, hypertension, peripheral arterial disease, non-insulin dependent diabetes mellitus, hypercholesterolemia, and benign prostatic hyperplasia with lower urinary tract symptoms.  His lower urinary tract symptoms have recently worsened.  By International Prostate Symptom Score (IPSS) survey, he has moderate lower urinary tract symptoms and has had two recent episodes of acute urinary retention.  The patient's urologist has recommended a transurethral resection of the prostate (TURP), but the patient would like to avoid surgery and its attendant morbidity and mortality given his medial co-morbidities.

Yes, the health plan should cover the proposed treatment.
According to the position statement by the Society of Interventional Radiology multisociety consensus position statement on prostatic artery embolization for treatment of lower urinary tract symptoms attributed to benign prostatic hyperplasia, prostate artery embolization is an "acceptable minimally invasive treatment option for appropriately selected men with BPH (benign prostatic hypertrophy) and severe LUTS (lower urinary tract symptoms)" and "can be considered as a treatment option in patients with BPH (benign prostatic hypertrophy) and moderate to severe LUTS (lower urinary tract symptoms) who are deemed not to be surgical candidates for any of the following reasons: advanced age, multiple comorbidities...."

According to the review by Malling, et al, prostate artery embolization "can reduce moderate to severe LUTS (lower urinary tract symptoms) and men with BPH (benign prostatic hypertrophy) with a low risk of complications."

Yes, the requested therapy is likely to be more beneficial for the enrollee than any available standard therapy (in this case, transurethral resection of the prostate [TURP]) as prostate artery embolization has near equivalent performance in terms of clinical improvement when compared to TURP (transurethral resection of the prostate) and this patient has multiple comorbidities that pose a risk to surgery.
This patient is at a high risk for surgical procedures such as transurethral resection of the prostate (TURP). 

Prostate artery embolization is a safe procedure with very few major complications.  There are a higher frequency and severity of comorbidities following transurethral resection of the prostate (TURP) when compared to prostate artery embolization.  Prostate artery embolization avoids morbidities associated with transurethral resection of the prostate (TURP) such as bladder stenosis, urethral stricture, urinary incontinence, and erectile dysfunction.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Enlarged Prostate Gland
Treatment: Prostate Artery Embolization, Pre-service
The insurer denied the Prostate Artery Embolization, Pre-service
The denial is overturned.

The patient is a male with history of coronary artery disease (CAD), hypertension, peripheral artery disease (PAD), non-insulin dependent diabetes mellitus (NIDDM), hypercholesterolemia and benign prostatic hyperplasia (BPH) complicating with acute urinary retention. The request is for prostatic artery embolization for benign prostatic hyperplasia (BPH) treatment.

Yes, the health plan should cover the prostate artery embolization.
The patient is with extensive history of cardiac disease, coronary artery disease, diabetes, hypertension and hypercholesterolemia. The patient's prostate hypertrophy is significant enough to make him go to the emergency room twice. The patient is high risk for conventional transurethral resection of the prostate (TURP) surgery; therefore, minimally invasive treatment such as prostatic artery embolization is suitable.

Yes, the requested prostatic artery embolization is likely to be more beneficial for the enrollee than any available standard therapy.
The patient is with extensive history of cardiac disease, coronary artery disease, diabetes, hypertension and hypercholesterolemia; therefore, minimal invasive treatment such as prostatic artery embolization is suitable.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Enlarged Prostate Gland
Treatment: Prostate Artery Embolization, Pre-service
The insurer denied the Prostate Artery Embolization, Pre-service
The denial is upheld.

The patient is a male with lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH) and is requesting prostate artery embolization (PAE).

No, the health plan should not cover the prostate artery embolization.
The health plan should not cover the proposed treatment.

No, prostate artery embolization is not likely to be more beneficial for the enrollee than any available standard therapy.
Prostate artery embolization (PAE) is a Food and Drug Administration (FDA) approved procedure. A search on ClinicalTrials.gov finds many trials regarding the efficacy of prostate artery embolization (PAE). A search on PubMed.com finds many articles regarding prostate artery embolization (PAE). 


A randomized controlled trial by Abt, states that "The improvement in lower urinary tract symptoms secondary to benign prostatic hyperplasia seen 12 weeks after PAE is close to that after TURP (Transurethral resection of the prostate). PAE is associated with fewer complications than TURP but has disadvantages regarding functional outcomes, which should be considered when selecting patients. Further comparative study findings, including longer follow-up, should be evaluated before PAE can be considered as a routine treatment." 

A prospective randomized controlled trial by Gao, regarding prostate artery embolization (PAE) and transurethral resection of the prostate (TURP) states "Both procedures resulted in significant clinical improvements in the treatment of BPH (benign prostatic hypertrophy). However, the advantages of the PAE (prostate artery embolization) procedure must be weighed against the potential for technical and clinical failures in a minority of patients." 

A prospective randomized controlled trial by Carnevale, states that "TURP (transurethral resection of the prostate) and PAE (prostate artery embolization) are both safe and effective treatments. TURP (transurethral resection of the prostate) and PErFecTED PAE (prostate artery embolization) yield similar symptom improvement, but TURP is associated with both better urodynamic results and more adverse events." 

The above studies do not support prostate artery embolization (PAE) over surgery. The American Urology Association (AUA) states that "PAE (prostate artery embolization) for the treatment of LUTS (lower urinary tract symptoms) secondary to BPH (benign prostatic hypertrophy) is not supported by current data and trial designs, and benefit over risk remains unclear; therefore, PAE (prostate artery embolization) is not recommended outside the context of clinical trials. (Expert Opinion)".

Other therapies that may be available for this patient's condition include surgery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure

Treatment: Admission at the inpatient level

The insurer denied coverage for admission at the inpatient level

The denial is overturned

At issue is the case of a gentleman with a history of hypertension and active intravenous drug abuse, that presented to the hospital complaining of dyspnea, abdominal distension and lower extremity swelling over a 5 day period. Upon arrival blood pressure (BP) was 143/92 and heart rate was 104. On exam, findings were consistent with acute decompensated respiratory failure. Echocardiogram revealed heart failure with reduced ejection fraction (20%). Cardiac catheterization revealed no significant coronary artery disease (CAD). He was treated aggressively with diuretics and had a 30 pound weight reduction. He was discharged on guideline directed medical therapy.

This patient presented to the hospital with new onset acute systolic congestive heart failure. On physical exam, he had significant abdominal distention and dyspnea. Findings on echocardiography were consistent with right and left sided systolic congestive heart failure. He required aggressive diuresis with multiple diuretic agents. Following diuresis of 30 pounds of excess fluid, additional observation was necessary to ensure that he was stable on an oral medical regimen. 

Hospital observation during the transition from intravenous (IV) to oral (PO) diuretics is critical for managing patients with congestive heart failure (CHF).(1) Spironolactone response is only observed 48-72 hours after administration and careful monitoring of renal function and serum potassium levels are required.(1) The American College of Cardiology (ACC)/ American Heart Association (AHA) guidelines recommend transition to oral diuretic therapy and other guideline directed medical therapy while still in the inpatient setting.(2) In conclusion, this patient could not have been managed at a lower level of care and required inpatient admission for aggressive anti-congestive therapies.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Admission at the inpatient level of care was medically necessary.  

The insurer's denial of coverage for the admission at the inpatient level of care is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic fatigue, cognitive impairment and diffuse myalgias.
Treatment: Laboratory Testing (81383)
The insurer denied the Laboratory Testing (81383)
The denial is overturned.

The patient is a female with a history of chronic fatigue, cognitive impairment and diffuse myalgias. Extensive laboratory testing including human leucocyte antigen (HLA) subtype testing was performed to further evaluate the etiology of her conditions. Appeal review requested for potential approval of laboratory testing (81383).

Yes, the proposed service of laboratory testing (81383) is deemed medically necessary.
This is a female with a history of chronic fatigue, cognitive impairment and diffuse myalgias. Extensive laboratory testing including human leucocyte antigen (HLA) subtype testing was performed to further evaluate the etiology of her conditions. The evidence based literature clearly demonstrates that identification of specific human leucocyte antigen (HLA) subtypes is associated with various autoimmune conditions including but not limited to rheumatoid arthritis and juvenile idiopathic arthritis. Identification of these specific conditions using the performed laboratory testing is critical to forming a treatment plan for this patient. Results from the requested laboratory testing will allow for identification of the specific condition which this patient is suffering from.  The treating physician can use this vital information to offer specific medications targeted to treat only those specific conditions. For example, autoimmune/rheumatologic agents such as methotrexate, sulfasalazine and Humira would be preferred agents for the treatment of these rheumatologic diseases. For these reasons, the requested laboratory testing (81383) is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain.

Treatment: 62323 x 1, epidural steroid injections to treat back pain.

The insurer denied coverage for 62323 x 1, epidural steroid injections to treat back pain. 

The denial is overturned. 

This is a female patient with a history of lumbar radiculopathy and is status post spine surgery. She presented to the pain management physician's office for a follow up visit for increased pain. The patient reported back pain at a level of 6 out of 10. The physician noted that the patient's last epidural steroid injection provided 80% pain relief for about 3 months. The patient was able to perform activities of daily living (ADLs). The physician recommended taking Tramadol as ordered and an additional epidural spinal injection.

The patient has clearly documented lumbar radiculopathy and had a good response to a prior epidural steroid injection.

The recently published evidence-based guidelines (1) on epidural steroid injections support performing an epidural injection in this case. They concluded: "Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality randomized controlled trial (RCT) with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement." Additionally, "fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness."

Pandey (2) reviewed the efficacy of epidural steroids injected by various routes and found them all comparable.

The requested injection is medically reasonable and necessary.

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

The insurer's denial of coverage for 62323 x 1, epidural steroid injections to treat back pain is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (Class I molars, Class I canines, overjet, overbite, ectopic eruption, anterior crowding, anterior crossbite and bimaxillary protrusion).

Treatment: Full braces.

The insurer denied coverage for full braces.

The denial is overturned. 

This is a male patient who presented for evaluation for orthodontic care. The Orthodontist identified Class I molars, Class I canines, overjet, overbite, ectopic eruption, anterior crowding, anterior crossbite and bimaxillary protrusion. The Orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 26 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating Orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 26 points on the HLD index (5 overjet, 3 overbite, 3 ectopic eruption, 10 anterior crowding, 5 labiolingual spread,) which meets the threshold of 26 points to support orthodontic care.

The clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

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

The insurer's denial of coverage for full braces is overturned. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Surgical Services. 
The insurer denied hypoglossal nerve stimulation. The denial is upheld.

The patient is a male with a history of daytime somnolence, nasal and throat "obstruction", frequent snoring and witnessed apneas. His body mass index was 28 with an Epworth Sleepiness Scale score of 16/4. A polysomnogram revealed an apnea hypopnea index of 20 with an oxygen nadir of 83.6. He reported inadvertent removal of his continuous positive airway pressure (CPAP) mask in sleep with claustrophobia. Exam revealed a deviated nasal septum to the left with bilateral inferior turbinate hypertrophy and a redundant soft palate with retropalatal narrowing. A drug induced sleep endoscopy demonstrated anteroposterior collapse at the level of the soft palate. Implantation of a hypoglossal nerve stimulation system was recommended and is the service under review.

The health plan's determination is upheld.

The proposed treatment Implantation of a hypoglossal nerve system is not likely to be more beneficial than any standard treatment for treatment of the patient's moderate obstructive sleep apnea according to the peer reviewed literature. A Hayes report concluded that the overall quality of the evidence evaluating hypoglossal nerve stimulation for treating obstructive sleep apnea (OSA) is very low and concluded that stimulation of the hypoglossal nerve may provide a treatment option for patients with moderate-to-severe OSA for whom CPAP has failed to provide relief, but the procedure may carry risks for complications and post implantation surgical procedures. It states that evidence is still unclear as to whether improvements translate to better sleep quality and improved quality of life and called for additional good-quality comparative studies with larger sample to define the patient population that is most likely to respond to this therapy option. For example, a study by Woodson et al. (2018] primary limitation of study is lack of control group and the study group was limited to males that were obese, CPAP intolerant, and of European descent and therefore cannot be generalized. The study was paid for by the manufacturer with marked increase in chance of bias in results. In a literature review by Certal et al., according to the authors, the studies reviewed were based upon highly specific populations which may not be representative of the population with moderate to severe obstructive sleep apnea with the heterogenicity of comparing different devices. The authors concluded that based upon a limited number of case reports, which do not necessarily represent real world practice, and that more long-term data is required and further studies comparing hypoglossal nerve stimulation with conventional therapies are needed to definitively evaluate long term outcomes. Based upon the evidence-based literature, it cannot be concluded that the Inspire Upper Airway Stimulation system is likely to be more beneficial.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Respiratory System. 
Treatment: Surgical Services. 
The insurer denied hypoglossal nerve stimulation. The denial is overturned.

The patient is a male with moderate obstructive sleep apnea (OSA) who has failed to tolerate continuous positive airway pressure (CPAP) due to claustrophobia. A sleep study confirmed an apnea hypopnea index (AHI) of 20 with less than (<) 25% central apneas. Per office note  the patient had a body mass index (BMI) of 28. There is a report that notes the patient had a drug induced sleep endoscopy which showed no concentric collapse.
Since he has failed CPAP therapy, the next planned step in his treatment is the placement of a hypoglossal nerve stimulator.

The health plan's determination is overturned.
The proposed treatment is more likely to be beneficial than any standard treatment for the patient's severe OSA. The first line treatment for OSA is CPAP, since the patient has failed this, then surgical options are the considered. Other surgical procedures for the treatment of OSA have poorer outcomes with higher morbidity.
In their updated (2017) position statement, The American Academy of Otolaryngology-Head and Neck Surgery stated it 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). Candidates for this therapy are selected based on appropriate polysomnographic testing, age, body mass index and objective upper airway evaluation. The current U.S. Food and Drug Administration (FDA) eligibility criteria for upper airway stimulator implantation includes age of at least 22 years, an apnea-hypopnea index (AHI) of 15-65, a lack of central apnea and a favorable pattern of the palatal collapse during drug-induced sleep endoscopy. The cited literature also notes that patients with obstructive sleep apnea, unable to tolerate CPAP, and with an elevated BMI can be successfully treated with upper airway stimulation therapy.
The patient meets all FDA indications for the implantation of this device which are:
-	CPAP/bi-level positive airway pressure (BiPAP) intolerance
-	OSA with AHI 15-65
-	Age >22
-	BMI < 32
-	Non concentric collapse of the velopharynx
-	< 25% central or mixed apneas
Untreated sleep apnea is associated with a significantly increased risk of sudden death, hypertension, stroke, coronary artery disease, congestive heart failure, type 2 diabetes, depression, motor vehicle accidents, occupational accidents, lost productivity, and decreased quality of life.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine headaches.

Treatment: Formulary Exception for Ubrelvy (ubrogepant). 

The insurer denied coverage for the Formulary Exception for Ubrelvy (ubrogepant).

The denial is overturned. 

This is a female patient with a past medical history of migraine headaches. The patient has complicated migraine with symptoms worrisome for a brainstem origin.  The use of triptans in such patients has been considered prohibited because of the risk of further vasoconstriction causing a devastating brainstem stroke.  

Patients with brainstem / basilar auras were excluded from clinical trials of most triptans.  While there have been case reports of triptans used successfully in patients with basilar migraine, most Neurologists are reluctant to take this chance.  This patient's Neurologist prefers to use a non-triptan medication for this reason.  

Ubrogepant is Food and Drug Administration (FDA) approved for acute migraine treatment and appropriate for this patient with relative contraindication to triptans. The non-formulary medication is likely to produce a more clinically beneficial outcome.

The insurer's denial of coverage for Formulary Exception for Ubrelvy (ubrogepant) is overturned.