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

Diagnosis: Aspirin overdose, toxic encephalopathy, hypertension and a urinary tract infection with suicidal ideation
Treatment: Inpatient Hospital Admission

Summary: This patient with a past medical history of alcohol and illicit drug use was brought to the Emergency Department (ED) by Emergency Medical Services after she reported taking 60-80 tablets of aspirin with a suicidal intent. The patient has other past medical history of diabetes mellitus and depression. EMS found the patient combative with a blood pressure of 200/90. In the ED, the patient was complaining of chest pain/abdominal pain. She was hypertensive to 191/86 mm Hg. The patient was talking, but not making sense. A salicylate level was elevated to 36.7. The white blood cell (WBC) count was 20.6K. A urinalysis revealed leukocytes and bacteria. Urine toxicology was positive for opiates. A troponin was negative. An electrocardiogram showed sinus tachycardia with occasional premature ventricular contractions. The patient was placed on 1:1 observation due to suicidal ideation. Intravenous (IV) hydration and Zofran were given. The patient was not cooperative with treatment and was removing lines. The patient required multiple reinsertions of her IV device. The patient was admitted to the Intensive Care Unit for aspirin overdose, toxic encephalopathy, hypertension and a urinary tract infection (UTI) with suicidal ideation. As per poison control recommendations, the patient was to be on sodium bicarbonate (NaHCO3) infusion until two consecutive levels of aspirin were below 30. The patient was treated with Xanax and Haldol for agitation.

The insurer denied coverage for the inpatient hospital admission. The denial was modified.

The denial was partially approved. Based on the patient's presentation with salicylate overdose with suicidal intent and agitation, altered mental status with likely toxic encephalopathy and possible UTI, an admission was appropriate. The patient was seen by Infectious Diseases. They recommended Vantin orally for the UTI. The patient's mental status remained altered after admission. She was talking, but not making sense. She was on oral antibiotics and blood pressure medications, in addition to IV fluids and proton pump inhibitor. The patient had been seen by Psychiatry who recommended 1:1 observation. The subsequent days of the admission were denied because the patient was alert and oriented x3. She denied any complaints, and was in no acute distress. The patient was on oral medications and hemodynamically stable. Labs were unremarkable. This patient did not need further acute medical admission. The patient was stable for transfer to Psychiatry. The patient denied any symptoms other than depression. She was afebrile and hemodynamically stable. There was no acidosis or hypoxia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This young female, essentially absent of risk factors, presented with atypical pain, and transient elevation of her blood pressure. Neither her history, exam, lab tests, nor EKG were suggestive of an increase possibility of ACS (acute coronary syndrome). Determination of level of care is primarily dependent on the actual care a patient receives, and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results. It is highlighted in the orders for care. 

In this case, the patients symptoms were atypical and unlikely to be representative of acute coronary syndrome. Her exam (BP [blood pressure] normalized) and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia ("abnormal EKG" was borderline, and not uncommon in young females). CXR (chest x-ray) was normal. Echocardiogram showed no wall motion abnormality.  Nuclear scan for CAD (coronary artery disease) was not performed, per the patients request. The physicians treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as IV heparin, dual antiplatelet inhibitors, beta blockers or IV NTG (nitroglycerin).  
 
The letter of appeal was carefully considered, but it offered no evidence to support an inpatient level of care. The only cardiac care provided was telemetry, which is frequently performed in a lower level of care. The patient was admitted for monitoring, and the subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD. In fact, all tests showed absence of ischemia.  While there was always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added. 

The claim that this work-up could not be done in a lower setting is not supported by guidelines, literature or community practice. Milliman criteria requirements were not fulfilled, as there was never any evidence of ACS present. The patient did not have a "cardiac condition." All of the testing and therapy that were provided would have been appropriate, safe and guidelines-consistent in a lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital

Summary: This patient has a history of chronic neck and shoulder pain, hypothyroidism on Synthroid, shingles, presbyopia, and urinary tract infection. She underwent myocardial perfusion stress testing in 2017 for chest discomfort and had a follow-up visit in her cardiologist's office in 2019 to discuss the results, which were abnormal. During that visit, she had chest pain and was sent to the local Emergency Department (ED), then transferred to another Hospital for cardiac catheterization. Initial vital signs in the ED at 01:59 included a blood pressure of 117/73, heart rate 66, respiratory rate 16, and oxygen saturation on room air of 98%. An electrocardiogram (EKG) at 02:34 was normal. Laboratory test results from 02:23 included a white blood cell (WBC) count of 4.2, a hemoglobin of 13.7, a creatinine of 0.89 and a high sensitivity troponin <6. A Computed Tomography (CT) scan of the thoracic and cervical spine revealed only degenerative changes at C3-4, C5-6, and C6-7 and a chest x-ray was normal. She was admitted to the catheterization lab from the ED. Pre-procedure vital signs at 09:25 included a blood pressure of 118/74, a heart rate of 65, and an oxygen saturation on room air of 98%. Coronary angiography was performed from 10:10 to 10:38 and only revealed normal coronary arteries. Post procedure vital signs from 10:54 to 11:30 included a blood pressure ranging from 117/71 to 127/73 with a heart rate 60-74. There were no access site complications noted. She was discharged to home that day on pantoprazole and Synthroid.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

There is no evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to acute coronary syndrome or for diagnostic coronary angiography. The former could have been completed in the ED at the referring institution, and/or at an observation level of care, followed by outpatient same-day procedure coronary angiography. The denial of coverage for the inpatient admission is upheld because there is no evidence that this patient was at increased risk for short term adverse cardiovascular events, based on her clinical presentation and results of testing performed in the ED. The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Treatment: Implantation of an upper airway stimulation device

Summary:
Based on current scientific literature, scientific evidence would support the efficacy of upper airway stimulation therapy with a hypoglossal nerve stimulator for a subset of patients with OSA who meet FDA criteria for the procedure.  In this particular case, the patient would meet FDA criteria for the device in terms of BMI, age, AHI and sleep endoscopy findings (there was no complete concentric collapse on sleep endoscopy).  The patient has had a previous reported failed CPAP trial.  There would be no contraindications to the procedure based on the information provided.  Therefore, based on the information provided, the requested service is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Treatment: Implantation of an upper airway stimulation device

Summary:
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: Implantation of an upper airway stimulation device

Summary:
The procedure and device are FDA approved as referenced below and recognized in the treating community as efficacious and safe for properly selected patients.  This patient with moderate sleep apnea and favorable anatomy is a good candidate for this intervention.  By virtue of review of the literature, it is neither experimental nor investigational.  This is particularly evident with the withdrawal study by Woodson referenced below which showed the efficacy of the therapy and the reversal of efficacy by discontinuing the stimulation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
 
Treatment: Orthodontics

The insurer denied the orthodontic care. The denial was upheld

The patient has skeletal class I, normal vertical growth pattern, permanent dentition, class II canines, moderate maxillary and mandibular crowding, moderately excessive overjet, impacted molars and deep impinging overbite with severe soft tissue damage. 

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, a Handicapping Labiolingual Deviation Index is used. 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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 22 points (3 points overjet, 6 points overbite, 10 points anterior crowding, 3 points labiolingual spread).
In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with a family history of coronary artery disease (CAD) who awoke with a pleuritic, stabbing, non-radiating left sided chest heaviness, which improved with sitting up or lying on his right side and was aggravated by leaning forward and lying down.  Other than mild shortness of breath (SOB) and shakiness, there were no additional associated symptoms.

The health plan's determination is upheld. The patient presented with atypical chest pain, an EKG without clear cut evidence of acute myocardial infarction or ischemia and negative cardiac biomarkers.  The inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious Disease (Fever, Skin abscess)
Treatment: Inpatient Hospital

Summary: This patient presented to the Emergency Department (ED) for a chief complaint of an abscess of the left buttock.  His parent reported there was fever the day prior to presentation.  There was a family history of a sister with a recent skin abscess and a father with a past history of abscesses.  On arrival, his temperature was 102.9F, pulse was 140 and respirations were 26.  Bloodwork revealed 21.3 white blood cells (WBCs) and 68.2% neutrophils.  A bedside ultrasound showed a deep pocket abscess. Blood cultures were drawn, and intravenous (IV) Vancomycin was started.  Pediatric surgery was consulted, and the patient was admitted with concern for signs of systemic infection, likely Methicillin-resistant Staphylococcus aureus (MRSA) given the recent family history.  Antibiotics were continued and an incision and drainage was performed. Wound cultures grew moderate staphylococcus aureus and few Citrobacter freundii.  The patient spiked a temperature of 101.2F and was medicated with Ibuprofen.  He was switched to oral antibiotics and discharged home in stable condition with outpatient follow-up planned. 

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

There was a family history of a sister with a recent skin abscess and a father with a past history of abscesses.  These are described in the notes as being due to MRSA, but there is no evidence of that in the records.  In fact, the subsequent culture report yielded methicillin-susceptible Staphylococcus aureus.  The patient was fussy but consolable and well hydrated.  A left medical gluteal abscess with a 2 cm induration was described. There was no mention of erythema of signs that would indicate extensive cellulitis.  The ED physician's medical decision making note does not adequately justify the reasons for choosing IV antibiotics and a need for treatment as an inpatient.  Although febrile, his vital signs were stable. There were no abnormal laboratory criteria other than leukocytosis (21,300/cu.mm), which reflects the bacterial soft tissue infection.  The abscess was small and was incised and drained.  IV Vancomycin was probably unnecessary, and antibiotics could have been continued orally following an initial IV dose.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of multiple spinal surgeries with associated complications, including infections, hematomas and wound dehiscence.  The patient had an initial instrumented lumbar fusion that became infected.  The patient underwent further surgery for a spinal abscess with removal of the instrumentation.  The patient was admitted to undergo a hematoma evacuation, wound debridement and closure of the wound.  A rehabilitation stay was recommended.  The health plan's determination of medical necessity is upheld.  The infectious disease (ID) specialist noted that the patient was stable and recommended continuing the intravenous antibiotic Ceftriaxone for 6 more days to complete a 28-day regime, which could be accomplished at a lower level.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with severe atopic dermatitis, treated with multiple topicals including topical steroids, topical calcineurin inhibitors and Eucrisa. The provider is requesting Dupixent.

The health plan's determination is upheld. The standard treatment options for patients with atopic dermatitis include a regimen of topical steroids as well as topical calcineurin inhibitors. After topical agents fail, standard practice is to pursue systemic therapy such as phototherapy.Since the documentation does not support that the patient has tried and failed phototherapy or a systemic immunosuppressant and does not have a contraindication to these, the requested Dupixent is not medically necessary..
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression
Treatment: Continued inpatient admission

The continued inpatient admission was medically necessary.  

The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.  

The patient represented an elevated risk of dangerous behaviors including self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained depressed.  The patient had multiple static risk factors for potentially dangerous behaviors including prior suicide attempt and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained depressed and with ongoing medication changes were acute risk factors for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Surgical Services (Hypoglossal Nerve Stimulator)

Summary: Reviewer #3:  This patient has a history of OSA, atrial fibrillation, hyperlipidemia and hypertension.  Per initial consultation with his Otolaryngologist, a sleep study showed an AHI of 28.8 with 12% central/mixed apneas.   The patient has a BMI of 28.2 and had tried CPAP and an oral appliance without relief.  The patient removes his mask during sleep despite attempting several different masks.  The patient also experienced dry mouth.  A UPPP did not improve the patient's symptoms.  The patient reported fatigue, daytime sleepiness, snoring, dizziness and vertigo.  A sleep endoscopy performed on in 2018 noted airway collapse in the anterior-posterior direction, making him a candidate for Inspire hypoglossal nerve stimulator implantation. The patient did not have complete concentric collapse.

The insurer has denied coverage for Hypoglossal Nerve Stimulator-CPT codes 0466T: Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator; 64568:  Incision for implantation of cranial nerve - e.g., vagus nerve - neurostimulator electrode array and pulse generator; and 95971: Electronic analysis of implanted neurostimulator pulse generator system; simple spinal cord or peripheral - i.e. peripheral nerve, sacral nerve, neuromuscular- neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming as experimental.  The denial was reversed because the procedure is likely to be more beneficial than any other existing standard health service.

The clinical documentation supports CPAP intolerance/failure.  There was no evidence of complete concentric collapse or other significant anatomical abnormalities on screening sleep endoscopy. Therefore, the patient meets criteria for UAS via the hypoglossal nerve. Peer-reviewed medical literature supports that this treatment improves health outcome and it is FDA approved for the patient's condition. The patient is a good candidate for surgical implantation of an upper airway stimulation device via the hypoglossal nerve, and this is the best available treatment for him.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Surgical Services Hypoglossal Nerve Stimulator

Summary: Reviewer #2:  This patient has a history of OSA, atrial fibrillation, hyperlipidemia and hypertension.  Per initial consultation with his Otolaryngologist, a sleep study showed an AHI of 28.8 with central and mixed apneas less than 25% of total apneas.  The patient has a BMI of 28.2 and had tried CPAP and an oral appliance without relief.  The patient would remove his mask during sleep.  The patient had trialed several different masks.  A UPPP did not improve the patient's symptoms. The patient reported fatigue, daytime sleepiness, snoring, dizziness and vertigo.  A sleep endoscopy performed on in 2018 noted airway collapse in the anterior-posterior direction, making him a candidate for Inspire hypoglossal nerve stimulator implantation.

The insurer has denied coverage for Hypoglossal Nerve Stimulator-CPT codes 0466T: Insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator; 64568: Incision for implantation of cranial nerve - e.g., vagus nerve - neurostimulator electrode array and pulse generator; and 95971: Electronic analysis of implanted neurostimulator pulse generator system; simple spinal cord or peripheral - i.e. peripheral nerve, sacral nerve, neuromuscular- neurostimulator pulse generator/transmitter, with intraoperative or subsequent programming as experimental. The denial was reversed because the procedure is likely to be more beneficial than any other existing standard health service.

CPAP is a first line of treatment for OSA; however, long-term use for many patients is suboptimal. The hypoglossal nerve stimulator was US FDA-approved in 2014 for the treatment of moderate and severe OSA. A five-year study indicated that the treatment was effective and improved sleepiness, quality of life and respiratory outcomes. In their 3/30/16 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)." The current US FDA eligibility criteria for upper airway stimulator implantation includes age of at least 22 years, a body mass index of less than 32 kg/m2, an AHI of 15-65, a lack of central apnea and a favorable pattern of the palatal collapse during drug-induced sleep endoscopy. The patient meets the above criteria.