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

Diagnosis: Obstructive sleep apnea 
Treatment: Hypoglossal nerve stimulation 
The insurer is denied coverage for hypoglossal nerve stimulation (Inspire upper airway stimulation system) for obstructive sleep apnea (OSA). 
The denial is reversed. 

The patient was then a male patient with the diagnosis of hypertension and obstructive sleep apnea (OSA). The patient's sleep study carried out found an Apnea-Hypopnea Index (AHI) 23.1 of events per hour. The patient's intolerance to continuous positive airway pressure (CPAP) was documented. A drug induced sleep endoscopy was performed which found: "Findings: Velopharynx (soft palate), complete anterior-posterior obstruction. Oropharynx, no obstruction. Tongue, complete anterior-posterior obstruction. Epiglottis, complete anterior-posterior obstruction." 

The uses of hypoglossal nerve stimulation as an effective intervention for obstructive sleep apnea has been widely documented. 2, 3, 6-10 The effectiveness of hypoglossal nerve stimulation was compared to an ablative surgical procedure and found to result in lowering the Apnea-Hypopnea Index (AHI) of patients to  < 5  events/hour. 4 

The use of hypoglossal nerve implant has been approved twice by the FDA11, 12 and several medical societies. 13-15 The FDA approved the use of hypoglossal stimulation for patients who fulfilled the following criteria all of which were met by this patient. 

"The device, as modified, will be marketed under the trade name Inspire Upper Airway Stimulation (UAS) System and is indicated to treat a subset of patients with moderate to severe obstructive sleep apnea (OSA) (apnea-hypopnea index [AHI] of greater than or equal to 15 and less than or equal to 65).  Inspire UAS is used in adult patients 22 years of age and older who have been confirmed to fail or cannot tolerate positive airway pressure (PAP) treatments (such as continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BPAP] machines) and who do not have a complete concentric collapse at the soft palate level." 12 

There is substantial peer reviewed outcome studies which support an improvement in health outcomes with the uses of hypoglossal stimulation. 2,3,9,16-20 In this case, the patient is an excellent candidate for hypoglossal nerve stimulation as he fulfills all of the FDA criteria for this procedure. Hypoglossal nerve stimulation is the best available treatment for this patient at this time as other therapies such as tracheostomy, carry greatly increased risks for quality of life, 21 morbidity and mortality. 
	
The hypoglossal nerve stimulation for obstructive sleep apnea (OSA) is likely to be more beneficial than any of the standard treatments/procedures for this patient. 

The carrier's denial of coverage for hypoglossal nerve stimulation (Inspire upper airway stimulation system) for obstructive sleep apnea (OSA) should be reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary / Kidney Disorder
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a male who was admitted with left renal colic. Vital signs showed temperature 97.4 Fahrenheit (F), heart rate 60, and blood pressure 160/93. The white blood cell (WBC) count was 9600. The creatinine was 1.3. Computed tomography (CT) imaging demonstrated a 12 millimeter (mm) left proximal ureteral calculus with hydronephrosis. Intravenous (IV) pain medications, nausea medications, IV antibiotics and Intravenous fluids (IVF) were administered.
The following day, he was discharged home after treatment with an extracorporeal shock wave lithotripsy (ESWL). He was afebrile and hemodynamically stable throughout the stay. The subject under review is the medical necessity of the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient stay was not medically necessary for this patient.
An acute inpatient level of care was not medically necessary. Care could have been provided at a lower level of care. He was afebrile and hemodynamically stable throughout the hospitalization. There was no significant evidence for sepsis. Following admission, there were no unstable vital signs reported. He did not have a documented infection or kidney failure, solitary kidney or a kidney transplant, or need for an open surgery. He did not have bilateral obstruction, acute renal failure, severe vomiting. Pain control, IV antibiotics and IVF followed by ESWL in a non-toxic patient can be provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Knee Amputation, Cerebrovascular Accident 
Treatment: Consumer Directed Personal Assistance Services (CDPAS) from 49 hours per week to 84 hours per week 

The insurer is denied coverage for Consumer Directed Personal Assistance Services (CDPAS) from 49 hours per week to 84 hours per week. The denial is overturned. 

This is a male with complex medical history that includes left above knee amputation, cerebral infarction, aphasia, dysarthria, dysphagia, gastrostomy, coronary heart disease, fecal incontinence, gastroesophageal reflux disease (GERD), immune issues, insomnia, major depressive disorder, asthma, constipation, overactive bladder, gait abnormality, weakness, benign prostatic hypertrophy (BPH) with LUTS (lower urinary tract symptoms), chronic pulmonary embolism. He has severe functional impairment and is dependent on caregiver assistance for all daily activities. The patient lives with his wife who provides assistance with ADLs and IADLs, including GT feedings and medication administration via GT. The patient also has consumer directed personal assistance services (CDPAS) 49 hours per week. The wife requested increase of CDPAS to 84 hours per week, which was denied. 

The physician's letters focus mostly on the patient's neurologic impairment from a stroke, and above knee amputation. These problems appear to be the primary causes of his functional impairment and severely limited mobility. The records indicate the patient has right sided hemiplegia, dysphagia, dysarthria, expressive aphasia. The physician noted the patient had minimal improvement from rehabilitation. The UAS indicates the patient has a prosthesis (status post [above knee amputation] AKA) but has not had training with PT (reason not noted). 

The patient has extensive other medical history including Immune compromise status is noted as controlled with Biktarvy (UAS includes other drugs; not clear if these are currently taken). There is little information about the patient's pulmonary disease, except that he has prn order for albuterol (history of asthma); and he takes Eliquis (most likely for chronic pulmonary embolism). He has dysphagia from the stroke, and has a gastrostomy (PEG) for nutrition and medications. The UAS indicates patient has dyspnea with normal daily activities. The UAS also indicates patient has fatigue, limiting his ability to finish daily activities. These symptoms (dyspnea, weakness, fatigue, lower extremity pain) can adversely affect the patient's performance with daily activities, in addition to the limitations from right hemiplegia and left AKA. 

Consumer Directed Personal Assistance Services 84 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The carrier's denial of coverage for Consumer Directed Personal Assistance Services (CDPAS) from 49 hours per week to 84 hours per week is overturned. The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis 
Treatment: Formulary Exception for Taltz 

The insurer is denied coverage for Formulary Exception for Taltz. The denial is upheld. 

This patient is a male with a diagnosis of psoriasis mainly affecting the trunk and right hand as per the dermatology note. The patient had a family history of psoriasis. The patient was on Stelara and was then changed to Taltz due to an insurance issue. The patient remained on Taltz for one year until another insurance issue arose causing him to be without any treatment for several months. The patient also reported difficulty sleeping and joint pain. The patient reported the psoriasis as itchy, painful, and red. In an undated letter, the patient's treating physician believes that Taltz was the best treatment option. The physician also voiced concerns that if left uncontrolled, plaque psoriasis had a natural sequela that could result in the development of co-morbidities and greatly affect a patient's quality of life. 

According to Zerilli & Ocheretyaner (2015), "The current treatment recommendations for patients with psoriasis depend on the severity of disease. Mild disease is treated with topical therapies (e.g., corticosteroids, vitamin D analogues, tazarotene) alone or, with increasing disease severity, in combination with phototherapy and/or traditional nonbiologic systemic therapy (methotrexate, cyclosporine, acitretin). Moderate-to-severe disease typically necessitates the use of systemic agents, whether it be traditional agents or biologics (e.g., tumor necrosis factor-alpha [TNF-] inhibitors, ustekinumab). In patients presenting with [psoriatic arthritis], first-line treatment with nonsteroidal anti-inflammatory drugs is recommended in mild disease with or without the use of local corticosteroid injections. More advanced disease requires the use of oral disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, sulfasalazine, or leflunomide, and/or TNF- inhibitors or the interleukin (IL) 12/23 inhibitor ustekinumab." 

As per Leonardi et al (2019), "[Adverse events] rates remained stable in this analysis of patients with psoriasis receiving adalimumab; no new safety signals were identified compared with earlier analyses." And as per Bartos, Hill, and Feldman (2016), "When comparing medications at 1 year, response rates among the initial treatment groups
were best with secukinumab(cosentyx) (65.2%) and worst with apremilast (18.7%). Among only initial responders at 10-16 weeks who received 1 year of continuous treatment, maintenance was best with adalimumab (Humira)(95.2%) and worst with apremilast (61%)." 

All of the formulary drugs are used to treat plaque type psoriasis and psoriatic arthritis.
There are no indications that the formulary medications would be ineffective. There are differences in the response rates in the PASI scores, however, it is unpredictable to determine efficacy in any biologic medication. One cannot predict the potential for an adverse effect and any medication used. 

Based on the above, denial of Formulary Exception for Taltz is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision.
Treatment: Pharmacy /Prescription Drugs.
The insurer denied: Tepezza.
The denial is: Overturned in whole.

The patient is a male with active progressive thyroid eye disease (TED) leading to symptomatic diplopia, severe proptosis, ocular injection, chemosis, eyelid retraction and ocular exposure. He has diabetes but has undergone therapy with corticosteroids in an attempt to control his progressive thyroid eye disease with unsatisfactory results. His oculoplastic surgeon has recommended treatment with Tepezza, a Food and Drug Administration (FDA) approved inhibitor of insulin like growth factor receptors (IGF-R) which are upregulated on orbital fibroblasts in TED. His insurance company has denied this request saying that there the patient needed to have documentation as to why corticosteroids had not been tried and/or why the patient was not a candidate for orbital decompression surgery. The patient and his surgeon are appealing this decision.

The health plan's determination is overturned.

The health plan, in its determination of medical necessity, has not acted reasonably. The patient did undergo treatment with corticosteroids, so this is not a reason for denial. Further, the patient is concerned about the potential complications of orbital decompression which is a contraindication. The patient is documented to be in the active phase of TED and orbital decompression is typically reserved for the quiescent phase when there is no longer progressive inflammation of the orbit. Therefore, the reasons stated for rejecting Tepezza for this patient are not reasonable. It is also noted in one letter included for review that the patient has been in the active phase longer than the patients included in the main study of Tepezza's efficacy. While this is true there are multiple reports of Tepezza reducing proptosis and diplopia in patients who have had TED for greater than 9 months.

Tepezza is medically necessary for this patient. This patient is in the active phase of TED. The therapies for this phase include corticosteroids (which has been tried and proved unsatisfactory) and radiation therapy. Both of these therapies have multiple dose related side effects. In addition, previous radiation therapy may be a relative contraindication for Tepezza. In this patient who has active TED, has tried and failed corticosteroids, Tepezza is an FDA approved, safe alternative therapy known to reduce the signs and symptoms of TED in the majority of patients treated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty speaking and lower extremity weakness
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented to the emergency department after three episodes of inability to speak and lower extremity weakness. At presentation, her neurological examination was negative. Subsequent MRI was negative for acute stroke. 

No, the acute inpatient admission was not medically necessary. 

The member was admitted with possible TIA (transient ischemic attack). However, risk stratification based on her presentation did not warrant acute hospital admission. All diagnostic testing was negative. The diagnostic testing, treatment, monitoring and neurological consultation could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Vision 
Nursing Services (including Private Duty Nursing) 

Diagnosis: Blindness, glaucoma 
Treatment: Increase in Personal Care Assistant (PCA) Service Hours to 7 Days x 24 Hours (Continuous Services) per Week 

The insurer denied Increase in Personal Care Assistant (PCA) Service Hours to 7 Days x 24 Hours (Continuous Services) per Week. The health plan's determination is upheld. 

The patient is a male with past medical history significant for blindness in both eyes, degenerative arthritis of the knee bilateral, insomnia, hyperlipidemia, gout, asthma, benign prostatic hyperplasia (BPH), depression and glaucoma. The patient lives with his elderly wife who also has medical problems. 

The Requested Increase in Personal Care Assistant (PCA) Service Hours to 7 Days x 24 Hours (Continuous Services) per week is not medically necessary for this patient. 
There were no noted medically necessary services which required an aide to be available 24 hours a day 7 days a week for services, specifically services in the middle the night. The services can be managed through 24 hour live-in service. 

The patient was previously approved for 7 days a week 6 hours a day for a total of 42 hours a week. The plan did increase his services to 7 days a week 24 hours a day live in services. This was secondary to the patient's daughter who moved out who provided informal care. As stated by the patient's daughter, the patient does not have any nighttime needs and therefore 24-hour PCA would likely be able to obtain enough interrupted sleep, 5 hours daily. A letter from the patient's care practitioner noted no pressure sores or needs for frequent turning during the middle of the night. 

The Uniform Assessment System (UAS) State of New York noted that patient required a total of 42 hours a week of services. Specifically, there was no notation in regards to required services for activities of daily living (ADL) or Instrumental activities of daily living (IADL) in the middle of the night. Also, there was no noted specific services required such as frequent turning for pressure sores or other medications needing to be administered in the middle the night. Nocturnal incontinence can be managed by other means. 

There is no notation of record stating why an aide could not get at least 5 hours of uninterrupted sleep, specifically the UAS. There are no progress notes from the patient's physician supporting a need for an aide during the nocturnal hours, such as bedsores or other medical conditions. No physical exam from progress notes were noted in the medical record. 

Therefore, the requested services are not indicated. The services that are already being provided are sufficient to meet the patient's needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: progressive metastatic prostate cancer.
Treatment: Inpatient Admission for End of Life (EOL) Care.
The insurer denied Inpatient Admission for End of Life (EOL) Care. 
The health plan's determination is overturned. 

This is a paraplegic male with progressive metastatic prostate cancer. The patient is not eating, has not been moving his bowels regularly, has poor rectal tone, and severe bilateral lower extremity pain. Inpatient admission for End of Life Care is being requested and is under review.

The Inpatient Admission for End of Life (EOL) Care is medically necessary for this patient.
This patient has terminal, incurable prostate cancer. The authors of UpToDate state "...Hospice is appropriate when patients are entering the last weeks to months of life and patients and their families decide to forego disease-modifying therapies with curative/life-prolonging intent in order to focus on maximizing comfort and quality of life...". The patient meets these criteria, which are echoed by the National Comprehensive Cancer Network (NCCN) Guidelines, who go on to recommend the use of hospice in this clinical scenario as it has been demonstrated to measurably improve pain, symptoms, and quality of life in patients with terminal cancer and a short life expectancy.
This patient's impaired performance status (he is bed bound) with 10/10 pain and failed home hospice previously as he does not have support from family, For these reasons, the Inpatient Admission for End of Life (EOL) Care is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia.

Treatment: Consumer Directed Personal Assistance Program (CDPAP) services, 12 hours per day - 7 days per week (total of 84 hours per week).

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP) services, 12 hours per day - 7 days per week (total of 84 hours per week). The denial is overturned.

This patient is a male with multiple medical problems including Alzheimer's dementia, chronic lymphocytic leukemia and asthma.  He lives with his adult daughter.  According to the treating physician, the patient has had a dramatic decline in his functional and cognitive status. He was hospitalized following a fall with right femur fracture (non-operable). He is confined to his bed and wheelchair, incontinent and has a pressure ulcer of the right lateral foot. He requires assistance with transfers, toileting and hygiene. These activities are variable and unpredictable in timing.  Under review is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP) services, 12 hours per day - 7 days per week (total of 84 hours per week).

This patent is significantly impaired and requires assistance for activities of daily living and functional mobility at least at the requested 12 hours per day - 7 days per week (total of 84 hours per week).  The patient sustained a traumatic injury, required acute hospitalization with notable decline in functional and cognitive status; all of which support the medical necessity of the requested services.

The health plan did not act reasonably, with medical judgment or in the best interest of the patient in this particular case.  From a physical medicine and rehabilitation perspective, the requested coverage for Consumer Directed Personal Assistance Program (CDPAP) services, 12 hours per day - 7 days per week (total of 84 hours per week) is considered medically necessary for this patient.

Based on the above, the medical necessity for Consumer Directed Personal Assistance Program (CDPAP) services, 12 hours per day - 7 days per week (total of 84 hours per week) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Suspected stroke. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. The denial is upheld. 

The patient is a male. He presented to the emergency room with the complaint of transient left arm numbness and weakness. At presentation, his neurological examination was normal and CT (computed tomography) brain scan showed no acute change. 

No, the Inpatient admission was not medically necessary. 

The patient presented with transient neurological symptoms and was suspected of having had a TIA (transient ischemic attack). The risk stratification based on the patient's presenting symptoms and clinical evaluation does not support an inpatient level of admission. The monitoring, treatment, diagnostic studies and neurological consultation could have been safely and effectively accomplished at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Loss of vision
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female who presented to the emergency ward with the complaint of loss of vision in her right eye. At presentation, her neurological examination was normal and a CT (computed tomography) brain scan showed no acute change. 

No, the inpatient admission was not medically necessary. 

The patient presented with transient neurological symptoms and was suspected of having had a TIA (transient ischemic attack). The risk stratification, based on the patient's presenting symptoms, history and clinical evaluation, does not support an inpatient level of admission. The monitoring, treatment, diagnostic studies and neurological consultation could have been safely and effectively accomplished at a lower level of care.