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

Diagnosis: Severe aortic valve stenosis 

Treatment: Transcatheter Aortic Valve Replacement (TAVR)

The insurer denied coverage for Transcatheter Aortic Valve Replacement (TAVR). The denial is upheld.

This patient is a male with a history of bicuspid aortic stenosis, hypertension, hyperlipidemia, impaired fasting glucose and Bell's palsy.  The patient had severe aortic valve stenosis and was asymptomatic.  The patient had a negative stress test for ischemia, and a transthoracic echocardiogram (TTE) showed an ejection fraction of 55-60% and severe aortic stenosis.  The patient was being considered for a clinical trial, EARLY-TAVR (Evaluation of Transcatheter Aortic Valve Replacement Compared to Surveillance for Patients With Asymptomatic Severe Aortic Stenosis).  Recommendations were to determine candidacy for the clinical trial. If the patient was a potential candidate, they would schedule a coronary angiography, TAVR CTA to assess if the patient was a transfemoral candidate and cardiac surgery evaluation.

Based on the literature review, transcatheter valve replacement is not medically necessary for this patient.  The use of aortic valve replacement, either surgical or through transcatheter delivery, is not the standard of care as supported by the fact the patient is being considered for a trial of TAVR vs clinical surveillance. Thus, TAVR is not medically necessary for this patient since surveillance - i.e. non-invasive management is the comparator.  Transcatheter aortic valve replacement has been FDA-approved for patients with severe aortic valve stenosis who are low, intermediate and high risk, as well as for those patients deemed inoperable.  The management of asymptomatic patients with severe aortic stenosis with respect to aortic valve replacement is a matter of ongoing clinical investigation. Thus, transcatheter aortic value replacement (TAVR) is not considered medically necessary to treat this patient's medical condition.

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

The carrier's denial of coverage for Transcatheter Aortic Valve Replacement (TAVR) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperkalemia

Treatment: inpatient admission

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

This patient is a male who based on the review of the medical record was admitted for hyperkalemia due to missing dialysis treatment. The patient was treated with oral potassium binder and then the patient's potassium level was normalized. The patient received routine dialysis treatment the next morning, and his condition resolved.

According to literature review, inpatient admission was not medically necessary to treat this patient's medical condition. The patient did not have severely abnormal electrolyte imbalance or life-threatening cardiac arrhythmia or significant metabolic abnormalities related to kidney function. The patient did not require vascular procedure to create new dialysis access or repair existing AVF. The patient was hemodynamically stable, with normal oxygenation and had negative cultures. The patient did not have cardiac arrhythmias or altered mental status or persistent nausea and vomiting with dehydration. There was no documentation of refractory pain. The patient was able to tolerate oral diet. There is insufficient clinical evidence to support that this patient's medical condition required inpatient level of care. This patient could have been safely managed at a lower level of care, such as observation. Thus, inpatient admission was not medically necessary to treat this patient's medical condition.
The health plan acted reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for inpatient admission should be upheld. The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II diabetes
Treatment: Formulary exception for Invokana 300MG OR TABS 
The insurer denied the formulary exception for Invokana 300MG OR TABS.
The denial is upheld.

The health plan should not cover the proposed treatment with Invokana.

This patient is a male with type II diabetes. He has been on Invokana for seven years. He has tried and failed Jardiance due to hyperglycemia. 

This patient has tried and failed Jardiance. He has not tried and failed Farxiga. Both Invokana and Farxiga are in the same drug class of sodium-glucose cotransporter-II inhibitors. Both are approved for the treatment of type II diabetes. Farxiga can be expected to work equally well as Invokana in this clinical situation. The American Diabetes Association clinical guidelines do not recommend the use of Invokana over Farxiga. Therefore, no, the health plan should not cover the proposed treatment (Invokana).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orofacial odontogenic infection 
Treatment: Inpatient admission 

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

The patient was then male child who presented to the Emergency Department (ED) on with complaints of tooth pain and cheek swelling a day after a few days dental extractions. The patient's vital signs were stable, but his lab work was significant for an elevated white blood cell count of 15.2. On exam, there was right cheek swelling with redness and tenderness to palpation extending to the eye. The patient had clinical findings consistent with an orofacial odontogenic infection. This kind of an infection may not present with fever or signs of sepsis. 

Because the patient had a 1-day history of progressively worsening facial swelling, inpatient treatment with antibiotics, until improvement in swelling, was the most appropriate management option. Literature indicates that most severe orofacial infections develop from periapical or periodontal infection and spread occurs along the anatomic pathways of least resistance, including to the soft tissues of the buccal area or into the maxillary sinus, palate, lingular, or adjacent soft tissues spaces, if spontaneous intraoral drainage does not occur. 

In this patient's case, Dentistry decided he needed extraction of additional teeth, which they performed and returned the patient to the ED. This procedure entails a small risk of further local spread of infection and hematogenous dissemination (bacteremia) which can seed native or prosthetic heart valves, or joints. Studies show that bacteremia in patients with dental caries and periodontal disease tends to be more frequent and sustained. Orofacial odontogenic infections that spread beyond the teeth and alveolar processes are polymicrobial, yielding an average of four to six isolates that are mostly anaerobes. Moreover, the patient vomited twice while awaiting the ambulance ride back to the ED. 

Based on the review of the medical record and literature, inpatient admission was medically necessary to closely monitor and treat this patient's infection. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The carrier's denial of coverage for the acute inpatient stay (inpatient admission) from should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rule out CVA

Treatment: Hospital admission

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

This patient is a female with a past medical history of diabetes mellitus, hypertension, and hyperlipidemia.  She presented to the emergency department with elevated blood pressure and numbness and tingling to the bilateral upper extremities x1 day.  The patient was in her usual state of health until the day prior to presentation when she began suffering from numbness and tingling to the bilateral hands, feet, and face.  This condition in the feet resolved, but the hands and face persisted throughout the morning.  The patient did not take her blood pressure medications the morning of presentation and went to a urology clinic follow-up. Her blood pressure was 170/110 and she had complaints of tingling. She was transferred to the emergency department for evaluation. 

The patient had no focal weakness, facial droop, word-finding difficulty, dysarthria, history of CVA, and no loss of consciousness.  The patient was a non-smoker.  The onset was sudden.  The patient was not eligible for stroke activation as this was outside of the window.  The patient's blood pressure on presentation was 175/79.  On examination the patient had decreased sensation over the left face the patient was admitted to telemetry to rule out a CVA.  The patient was discharged in stable condition. 

The inpatient hospital admission is considered medically necessary for this patient. 

The patient had markedly elevated blood pressure at a Urological appointment, and was instructed to go to the ED per review of the medical records. Although CT of the head was unremarkable, MRI of the Brain showed flair hyperintensity in the left midbrain thalamus consistent with a subacute stroke. Given the context of a subacute stroke with elevated blood pressure, the entire hospital admission was justified and medically necessary.

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

Based on the above, the medical necessity for hospital admission is substantiated.  The insurer's denial is reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer# 3	

Diagnosis: Severe obstructive sleep apnea

Treatment: hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System)

The insurer denied coverage for hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System). The denial is reversed.

The patient is a male who was diagnosed with severe obstructive sleep apnea based on sleep study with apnea-hypopnea index (AHI) of 27 and a no evidence of central sleep apnea. The patient has a normal body mass index (BMI) of 28. The patient has tried multiple masks both full face and nasal in order to use the CPAP machine but is not tolerant to it and cannot wear it for more than 2 hours at night. A sleep endoscopy was performed showing no concentric collapse.

The upper airway stimulator was Food and Drug Administration (FDA) approved in 2014 and due to its success the inclusion criteria were expanded in 2017 to include patients with an AHI up to 65.  She has a normal body mass index (BMI) of 28. The patient has tried multiple masks both full face and nasal in order to use her CPAP machine but is not tolerant to it and cannot wear it for more than 2 hours at night. A sleep endoscopy was performed showing no concentric collapse.  All of these factors make her a good candidate for the upper airway stimulator. 

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 STAR trial (Woodson, B. T. et al., 2016) showed long term follow up (48 months) with significant improvement in Epworth Sleepiness Scale and Quality of Life outcomes.
More than 9 out of 10 of the respondents were interested in trying emerging technologies to treat OSA, most preferring continuous transcutaneous electrical stimulation (CTES). (Campbell, T., Pengo, M. F., & Steier, J., 2015).
This review reveals that hypoglossal nerve stimulation therapy may be considered in selected patients with OSA who fail medical treatment. (Certal VF, et al., 2015).
The requested procedure is likely to be more beneficial than any other standard treatment/procedures.

The carrier's denial of hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2:

Diagnosis: Moderate obstructive sleep apnea

Treatment: hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System)

The insurer denied coverage for hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System). The denial is reversed.

The patient is a male who has a history of myotonic dystrophy first diagnosed a few years ago. The patient saw a provider for evaluation of obstructive sleep apnea (OSA) and complains of daytime somnolence. A polysomnography (PSG) on revealed an apnea-hypopnea index (AHI) of 27. The patient is not able to tolerate continuous positive airway pressure (CPAP) and because of the severity of the OSA would not be significantly helped with an oral appliance. A Drug-induced sleep endoscopy (DISE) performed showed non-concentric pharyngeal collapse.

Per Certal, VF et al. (2015), "This review reveals that hypoglossal nerve stimulation therapy may be considered in selected patients with OSA who fail medical treatment."

Per Kompelli, A. R., Ni, J. S., Nguyen, S. A., Lentsch, E. J., Neskey, D. M., & Meyer, T. A. (2018), "HNS is a safe and effective treatment for CPAP refractory OSA."

Per Spicuzza, L., Caruso, D., & Di Maria, G. (2015), "The stimulator device is implanted under the chest skin with an electrode placed on the hypoglossal nerve and is activated during sleep time. The Inspire Upper Airway Stimulation (Inspire Medical Systems Inc. Maple Grove, USA) is the first system recently approved by the US Food and Drug Administration for a subset of patients with moderate to severe OSA, who are unable to use CPAP."

Per Wray, C. M., & Thaler, E. R. (2016), "The only currently FDA-approved HNS device for the treatment of moderate-to-severe OSA is produced by Inspire Medical Systems, which recently published its 36-month outcomes data from its Stimulation Therapy for Apnea Reduction (STAR) trial. HNS therapy is currently indicated for moderate-to-severe OSA patients who are CPAP-intolerant, have a body mass index <32, apnea-hypopnea index <50, and without a concentric pattern of upper airway collapse on sleep endoscopy... Data from the STAR trial suggests that a subset of OSA patients can achieve a significant therapeutic response from hypoglossal nerve stimulation."                                                         

The patient meets the generally accepted standards and peer literature for an upper airway stimulation (UAS) implantation. The PSG testing is consistent with moderate to severe OSA. The patient is unable to tolerate CPAP. The patient is not a candidate for an oral appliance. A DISE exam showed non-concentric collapse. Therefore, the hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System) is likely to be more beneficial than any other standard treatment/procedure.

The carrier's denial of hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System) should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer#1 

Diagnosis: Moderate obstructive sleep apnea

Treatment: hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System)

The insurer denied coverage for hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System). The denial is reversed.

This is a patient is a male who was seen with a history of myotonic dystrophy and sleep apnea.  The documentation detailed the patient was recommended to undergo a sleep study.  The patient has had a sleep study with the use of a mouthpiece and was noted to have an AHI of 26.  The patient has trialed Pap therapy however, he could not tolerate it.  The patient complained of fatigue for many years.  The patient is noted to have moderate swallow dysfunction per swallow study and on endoscopy it was noted he had inferior turbinate hypertrophy.  The recommendation was made for a drug induced sleep endoscopy with a septoplasty and possible hypoglossal nerve stimulator.  The documentation does detail the patient was seen for a follow-up after drug-induced sleep endoscopy and septoplasty/SMR turbinates for nasal obstruction.  The documentation indicated the patient did not have significant results.  Additional documentation indicated the patient has a BMI of 28.2 and per sleep endoscopy there was no evidence of complete concentric collapse.  The recommendation has been made for this patient to utilize an upper airway stimulation system.

The patient has moderate obstructive sleep apnea (AHI-27; BMI-28.7. During the sleep study oxygen desaturations were as low as 72%.  Drug-induced sedation endoscopy did not reveal complete concentric collapse of the palate, nasopharynx, or velopharynx. The patient has been unable to use CPAP. Sleep apnea, if left untreated has the potential for serious medical sequela. This patient does not have any contraindication for hypoglossal nerve stimulation therapy. Hypoglossal nerve stimulator therapy for the treatment of obstructive sleep apnea has been in peer reviewed literature for over two decades. It is FDA approved and likely to be more beneficial than any other standard treatments/procedures.

The carrier's denial of hypoglossal nerve stimulation (Inspire Upper Airway Stimulation System) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Inpatient hospital

Diagnosis: Shortness of breath
Treatment: Inpatient Stay. The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male with history of obesity, non alcoholic steatohepatitis, and no prior history of lung disease who presented to the emergency department (ED) with complaints of shortness of breath, wheezing, and cough. He was admitted to the inpatient service where he was ruled out for respiratory viral infection. He was treated with bronchodilators every 6 hours and oral steroids. 

The inpatient stay was not medically necessary. Based on the available detailed medical records, the patient had upper respiratory symptoms likely due to obstructive airway disease, but did not have unstable vital signs, hypoxemia/ hypercarbia, or previous admissions with a need for noninvasive/ mechanical ventilation.
In addition, per the Milliman Care Guidelines (MCG) inpatient guidelines 23rd edition for chronic obstructive pulmonary disease (COPD) / asthma, this patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.  The denial is overturned.

The Inpatient admission was medically necessary.  

The patient is a G3 P1011 female. She presented to the emergency room with shortness of breath and severe abdominal pain.  

The patient's exam was remarkable for tachycardia, inspiratory wheezing, and right lower quadrant rebound tenderness.  Laboratory data revealed a falling hemoglobin from 11.2 to 9.9 and positive HCG (Human Chorionic Gonadotropin) 366.  An ultrasound demonstrated a right adnexal mass suggestive of ectopic pregnancy and free fluid in the cul-de-sac.  

The patient was admitted to the hospital and was taken emergently to the operating room for laparoscopy, at which time a right salpingectomy and evacuation of hemoperitoneum was performed in the late afternoon of hospital day #0.  She was monitored over the night and was discharged home on hospital day #1.  


Ruptured ectopic pregnancy is a bona fide medical emergency which requires a very high level of monitoring pre-operatively due to the possibility that at any time the patient could go into hemorrhagic shock, which could rapidly be fatal.  In addition, postoperatively, the patient requires more monitoring than would an elective outpatient laparoscopy that was not performed for a diagnosis that required recovery from significant hemoperitoneum and higher possibility of postoperative bleeding.  Therefore, an overnight stay at the inpatient level of care is medically necessary, and overall inpatient level of care is medically necessary for this episode of care.
Appeal type: Medical necessity
Decision: Upheld

The patient has a Class II occlusion and a slightly high overjet and deep overbite. The maxillary arch has mild crowding and the mandibular arch has moderate crowding. The patient has treatment planned for 18-24 months of orthodontics to correct the malocclusion.
At issue is the medical necessity of the orthodontic treatment.

The health plan's determination is upheld in whole. There is no medical necessity to correct the patient's malocclusion with braces. The patient has some mild to moderate crowding. Her bite is slightly deep; however, the photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient's cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There are many ways to correct a deep bite, and there is strong evidence that one treatment is not better than another [1]. The braces are not medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Marginal ulcer 
Treatment: Inpatient hospital admission 

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

This patient is a female with a previous gastric bypass presented to the hospital with abdominal pain and vomiting. The patient's recent endoscopy revealed a marginal ulcer. The patient had no reported hematemesis or melena. The patient was afebrile and had stable vitals. On exam, the patient's abdomen had some tenderness in the epigastrium but was soft without rebound or guarding. The patient was given proton-pump inhibitor (PPI) and antiemetic. The patient's bloodwork showed no leukocytosis or abnormal renal function. The patient's hemoglobin and hematocrit was 8.9 and 29 respectively, but was noted stable based on her recent labs. The patient's computed tomography (CT) scan of the abdomen was negative for acute pathology, and there was no evidence of active gastrointestinal (GI) bleeding. Due to the patient's persistent nausea and inability to tolerate oral intake, the patient was admitted for treatment with intravenous (IV) antiemetic. 

According to the MCG guidelines for vomiting (M-370), the clinical indications for inpatient admission include vomiting that is severe or persistent. This is indicated by having numerous episodes of vomiting over 24 hours and that appropriate antiemetic treatment was not sufficiently reducing the vomiting. This patient was having active vomiting on intravenous (IV) antiemetic even on the second day of inpatient admission. The patient was also unable to maintain oral hydration and required intravenous fluid during the period of observation. Though this patient did not require blood transfusion and was hemodynamically stable, the patient's hemoglobin/hematocrit was monitored as it trended down from 8.9/29 to 8.1/26 to 8.1/27 to 7.6/26 and 7.7/27. With this patient's persistent vomiting, inability to tolerate oral intake and this patient's risk for upper GI bleed and dehydration beyond the level of observation care, inpatient admission was medically necessary to treat this patient's medical condition. 

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 inpatient hospital admission at the acute inpatient level of care is reversed. The medical necessity is substantiated.