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

Diagnosis: Migraines. 
Treatment: Pharmacy/Prescription Drugs (Nurtec). 
The health plan denied the requested prescription drug (Nurtec). 
The health plan's determination is upheld. 

This patient is a right-handed female who was seen with complaints of intermittent shaking of the upper extremities without clear precipitants, severe headaches with partial response to Advil, and poor coordination and balance. She was recently diagnosed with hypothyroidism and had improved slightly with supplementation. Since her previous visit, she had recurrence of headaches lasting four days and was unilateral in character with nausea. Indomethacin had not been of benefit. She complained of decreased libido. A brain magnetic resonance imaging (MRI) performed and an electroencephalogram (EEG) performed were normal. Examination revealed normal general appearance, skin, mental status, cranial nerve, motor, reflex, sensory, coordination and gait examinations. The diagnoses were for headache, syncope and collapse and tremor. Indomethacin was prescribed. Rimegepant (Nurtec) was prescribed. There is no documentation of any migraine prophylactic therapy. The reason for denial on prior review was that the patient did not meet formulary criteria for the medication. A specific rationale was not provided. 

The health plan's determination is upheld, in whole. 

Nurtec is not medically necessary for this patient. This is a patient with a history of migraine, who is not on a migraine prophylactic medication. She is not taking a migraine prophylactic medication, and there is no documentation of the prior and failure of any other abortive medication or contraindication to other abortive medications, including triptans. She has no contraindication to triptans such as cardiac disease or stroke. There is no evidence in the peer-reviewed with medical literature that Nurtec or other CGRP (calcitonin gene related peptide inhibitor) targeted oral migraine abortive agents are superior to triptans such as Sumatriptan, Naratriptan, or Zolmitriptan, in the treatment of acute migraine. The patient has no prior documented prior trial and failure of triptans, and there is no documentation of any contraindication to all triptans. In the absence of these findings, there is no rationale why the patient cannot utilize an oral migraine preventative medication and the use of Nurtec is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer (Parotid)
Treatment: Radiation Therapy (Proton Beam Radiotherapy)
The health plan denied the requested radiotherapy. 
The health plan's determination is upheld.

This patient is a male with a T1N0M0 (stage 1) mucoepidermoid carcinoma of the right parotid. The patient has undergone resection but with close margins and a post-resection positron emission tomography (PET) - computed tomography (CT) demonstrated findings concerning for residual disease. Adjuvant radiation with proton therapy was recommended and is under review.
At issue is the medical necessity of the requested procedure.

The health plan's determination of medical necessity is upheld, in whole.

No. Proton beam radiotherapy offers the opportunity to deliver very high doses to the targeted tumor while maximally sparing adjacent critical tissues, including the brain, spinal cord, contralateral salivary tissues, and the oral cavity. However, there is a paucity of data demonstrating that this modality improves on conventional radiotherapy. A search of clinical trials.gov revealed no studies (active or closed) addressing this. The National Comprehensive Cancer Network (NCCN) recommends conventional photon therapy with proton therapy to be "...considered when normal tissue constraints cannot be met by photon-based therapy....". There is no evidence in the included documentation that photon-based therapy is inadequate for this patient; it appears to have been recommended only based on theoretical concerns. For these reasons, medical necessity has not been demonstrated for this service in this clinical scenario.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Gastroesophageal reflux disease

Treatment: Formulary Exception for Sucralfate 1 milligram/10 milliliters Suspension

The insurer denied coverage for Formulary Exception for Sucralfate 1 milligram/10 milliliters Suspension.

The denial is upheld.

This is a female patient who is being followed in the liver disease clinic. The patient has a diagnosis of gastroesophageal reflux disease (GERD). It is reported that the patient has failed pantoprazole and omeprazole trials. The patient also has a diagnosis of peptic ulcer disease. The patient is awaiting a liver transplant for her decompensated cryptogenic cirrhosis.

UpToDate has an article titled "Medical Management of gastroesophageal reflux disease in adults."  The article addresses surface agents and alginates. It states that sucralfate adheres to the mucosal surface, promotes healing, and protects from peptic injury.  However, given the short duration of action and limited efficacy as compared to Proton Pump Inhibitor's (PPI's), the use of sucralfate is limited to the management of GERD in pregnancy.

In this case, this patient has reflux disease that is reported to not be responsive to PPI therapy. There is a limited benefit to giving sucralfate for the treatment of GERD. However, the insurance company states that sucralfate tablets are on their formulary.  Sucralfate tablets are an acceptable alternative to sucralfate liquid. Using sucralfate tablets would not likely cause an adverse reaction. The patinet's medical chart does not document that sucralfate tablets were ineffective. There is no documented scientific study which has shown that sucralfate liquid is more effective than sucralfate tablets.  Thus, the request for the drug would not be more effective than the formulary option. 

The carrier's denial of Request for Formulary Exception for Sucralfate 1 milligram/10 milliliters Suspension should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), prostate cancer and atrial fibrillation
Treatment: Personal Care Aide (PCA) Level II: 10 Hours per Day - 7 Days per Week - a Total of 70 Hours per Week.
The insurer denied the Personal Care Aide (PCA) Level II: 10 Hours per Day - 7 Days per Week - a Total of 70 Hours per Week.
The denial is overturned. 

The patient is a male with a history of coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), prostate cancer and atrial fibrillation. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review has been requested for potential approval of 70 hours per week of Personal Care Aide services to offer increased ADL (activities of daily living) support.

Yes, the proposed 70 hours per week of Personal Care Aide services is deemed medically necessary. 

This is a male with a history of coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), prostate cancer and atrial fibrillation. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to worsening gait ataxia, increased falls, worsening dyspnea and generalized weakness, the currently approved plan of 42 hours per week of Personal Care Aide services is insufficient to meet the patient's current needs.  For these reasons, the proposed treatment with 70 hours per week of Personal Care Aide services is deemed medically necessary for increased assistance with activities of daily living (ADLs).
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Cardiac/Circulatory Problems. 
Treatment:  Pharmacy/Prescription Drugs. 

The insurer denied:  Neoral.  The health plan's determination is overturned in whole.

The patient is a female born with atrioventricular (AV) canal defect with double outlet right ventricle, for which she underwent Fontan surgery.  She subsequently had heart transplantation for complications of Fontan physiology that led to severe protein-losing enteropathy (PLE).  She has been well with no symptoms.  Her most recent cardiac biopsy on showed International Society for Heart and Lung Transplantation (ISHLT) grade 0.  She has been on Neoral brand of cyclosporine for years and has had excellent results so far, as evidenced by the biopsy showing grade 0 rejection.  The subject under review is whether Neoral would be more effective as the formulary drugs.

The health plan's determination is overturned in whole.

Yes, the formulary drugs will not be as effective as the non-formulary drug Neoral.  There are studies in renal transplant patients, which showed that generic cyclosporine has decreased bioavailability compared to the branded ones.  Evidence on their efficacy and safety is inconclusive.  Tighter regulatory requirement for approval of generic drugs with narrow therapeutic index is needed.  Neoral in this patient's case is medically appropriate until there is further evidence of equal bioavailability in both branded and generic drugs.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Renal transplant.
Treatment:  Envarsus XR (extended release).

The insurer denied Envarsus XR.  The health plan's determination is overturned. 

The patient is a male with end-stage renal disease status post renal transplant.  The patient previously changed from short acting tacrolimus to Envarsus XR due to erratic tacrolimus levels and tremors.  The provider wishes to continue Envarsus XR.  This is the subject of this review.

A formulary exception is indicated in this case.  The physician has documented that the patient failed tacrolimus, due to erratic blood levels and tremor, which is a common side effect of this medication.  Gengraf is contraindicated, as it is less efficacious for prevention of renal transplant rejection.  Lastly, Envarsus XR is the long-acting formulation of tacrolimus, and it is Food and Drug Administration (FDA) -approved for renal transplant rejection prophylaxis.  In summary, the formulary drugs have had adverse effects (tacrolimus) and would not be as effective as the non-formulary drug (Envarsus XR).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Metastatic Pheochromocytoma with skull, lung and sacral metastases.
Treatment:  Stereotactic body radiation therapy.

The insurer denied the Stereotactic body radiation therapy.  The denial is overturned.

The patient is a female with recurrent metastatic pheochromocytoma status post
resection referred for radiotherapy.

Yes, the health plan should cover the proposed treatment.

The proposed treatment with SBRT (stereotactic body radiation therapy) would be the most effective treatment for this case with the lowest toxicity.

Yes, multiple randomized trials are available to support the use of SBRT (stereotactic body radiation therapy) in this case with improvement in overall survival and minimal toxicities.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: abdominal aortic aneurysm.
Treatment: Fenestrated Endovascular Stent Graft Device and One (1) Inpatient Day. 
The insurer denied the Fenestrated Endovascular Stent Graft Device and One (1) Inpatient Day. 
The health plan's determination is overturned. 

The patient is a man with high blood pressure, hyperlipidemia, and coronary artery disease, who was found to have a 4.5 centimeter (cm) abdominal aortic aneurysm on abdominal computed tomography (CT) scan. He was found to have tenderness with palpation of his abdominal aortic aneurysm. The patient was diagnosed with a symptomatic abdominal aortic aneurysm and was offered repair of his aneurysm. The patient was offered a fenestrated endovascular aneurysm repair due to the anatomy of his aneurysm.

The Fenestrated Endovascular Stent Graft Device and One (1) Inpatient Day is medically necessary.
Endovascular aneurysm repair with a fenestrated aortic endograft is the most appropriate procedure for this patient.
The patient has a symptomatic 4.5 cm abdominal aortic aneurysm that requires repair. The treatment options are open surgical repair or endovascular aneurysm repair. Endovascular aneurysm repair is associated with lower postoperative complications, reduced length of stay, less postoperative pain, and quicker return to normal activities compared with open surgical repair. The anatomy of his aorta and aneurysm requires a fenestrated endovascular graft.
Fenestrated endovascular grafts are approved by the US (United States) Food and Drug Administration. The use of this type of endovascular graft is medically necessary in this patient.
The standard of care for any uncomplicated endovascular aortic aneurysm repair is at least one day inpatient stay or more if indicated. For more complex endovascular aneurysm repairs, more than one day in patient stay may be indicated. For this particular case, fenestrated endovascular aortic aneurysm repair may require more than one day of inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Small fiber and autonomic neuropathy. 
Treatment: Intravenous Immune Globulin. 
The insurer denied Intravenous Immune Globulin. 
The health plan's determination is upheld. 

The patient is a male. A letter of medical necessity from the provider indicates a diagnosis of idiopathic progressive neuropathy and dysautonomia/autonomic neuropathy. He had findings consistent with autonomic neuropathy on examination and on autonomic testing. He had abnormal intraepithelial nerve fiber density. The provider recommended the use of Gammagard (IVIG) to treat his autonomic an small fiber neuropathy. 

The Intravenous Immune Globulin is not medically necessary for this patient. There is no evidence the peer-reviewed medical literature that IVIG is safe and effective for the treatment of small fiber neuropathy or autonomic neuropathies. There have been no randomized controlled trials supporting its efficacy. There have been non-randomized studies showing possible efficacy. However, efficacy cannot be determined in a non-randomized clinical trial. A randomized controlled trial, if positive, will provide class I or class II evidence of efficacy. This evidence does not exist in the medical literature. There is therefore no peer-reviewed medical literature supporting the efficacy of IVIG in the treatment of small fiber neuropathy or autonomic neuropathy (postural orthostatic tachycardia syndrome) and its use is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental problems (skeletal Class II, proclination, mandibular crowding, severe overjet)
Treatment: D8080 comprehensive orthodontic treatment of adolescent dentition
The insurer denied coverage for D8080 comprehensive orthodontic treatment of adolescent dentition.
The denial is overturned.

This is a male child with a medical history of maxillary incisor trauma due to severe proclination who was presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II, proclination, mandibular crowding, and severe overjet. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of overjet greater than 9 millimeters with incompetent lips or reverse overjet greater than 3.5 millimeters with reported masticatory/speech difficulties. The insurer has denied coverage for the orthodontic treatment as not medically necessary.

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, the 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 claims an automatic qualifying condition of overjet greater than 9 millimeters with incompetent lips or reverse overjet greater than 3.5 millimeters with reported masticatory/speech difficulties. This automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.
 
Regarding the validity of the HLD index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  

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

The carrier's denial of coverage for D8080 comprehensive orthodontic treatment of adolescent dentition is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Possible Seizure/Head Bobbing
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male. The patient has history of abnormal head movements with singular head bobs/head drops approximately twice a week. These incidents became more frequent and lasted for longer periods of time. The patient was then seen by a neurologist and underwent an EEG (electroencephalogram), which was negative. The patient's episodes persisted but not as frequently. 

The patient was brought to the emergency room on the advice of his neurologist after two episodes of vomiting, which were not associated with head movement episodes, as well as almost falling over while brushing his teeth. Exam in the emergency room was essentially unremarkable. 

The patient was admitted for further management and workup, including neurology consult and video EEG (electroencephalogram). According to the Discharge Summary, there were no further acute events, and the parents reported no head drops or abnormal movements since he was admitted.  His vital signs remained stable and he remained without fever and without neurological deficits throughout his admission.  The patient was placed on video EEG monitoring for 48 hours, and this showed diffuse theta slowing, occasional bilateral generalized amplitude spike or poly-spike wave discharges in sleep, but no seizures were confirmed. Discharge diagnosis was listed as seizure. The patient was prescribed Depakote and was to follow-up with his neurologist in three weeks. 

Yes, the Inpatient stay was medically necessary.

The patient had drop attacks suggestive of seizures.  Atonic seizures manifesting with loss of tone in the neck and body and legs are manifestations of seizure disorder and are especially dangers due to high risk of trauma during the falls.  Routine EEG (electroencephalogram) did not discover the nature of the patient's illness.  Therefore, inpatient video EEG (electroencephalogram) was medically necessary to capture the actual events and/or to capture prolonged interictal activity, to make an appropriate diagnosis, either of nonepileptic spells or of seizures.  Such diagnosis was made, based on the EEG (electroencephalogram) slowing and presence of spikes, and medication was started, improving patient's health and lowering the likelihood of any further seizures.  Therefore, the treatment is medically necessary by virtue of being generally accepted, appropriate for the patient's condition, and having substantial potential to improve the patient's health.

The patient was suspected to have a severe case of epilepsy, known as atonic seizures/drop attacks.  Outpatient evaluation failed to determine the diagnosis.  Therefore, inpatient admission with video EEG (electroencephalogram) was medically necessary to make an appropriate diagnosis and to decide about antiepileptic management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: New onset atrial fibrillation, Chest pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is a female patient with a medical history notable for hypertension, diabetes mellitus, transient ischemic attack, recurrent syncopal episodes, and obesity. She presented to emergency department with complaints of chest pain and palpitations that began on the morning of her arrival. The patient reported having a sensation of impending doom. She reported the chest pain worse with exertion and associated with shortness of breath. The patient was placed on continuous cardiac and pulse oximetry monitoring. Physical examination was unremarkable. Lab studies were not significant and troponin levels were negative.  An electrocardiogram (EKG) showed atrial fibrillation with rapid ventricular response. A cardiology consult noted the patient had new onset atrial fibrillation, a moderate heart score, and negative troponins. The patient was admitted to the telemetry unit for further evaluation and management of new onset atrial fibrillation, chest pain and palpitations. The patient was started on long term anticoagulation and diltiazem for rate control. An echocardiogram and nuclear perfusion stress test were within normal limits. No further cardiac testing was recommended. The patient was cleared for discharge home on day 3 of admission with instructions to follow up with her primary care physician as an outpatient.  

The patient presented with atrial fibrillation, which was new onset. The remainder of the cardiac workup was unremarkable, including negative cardiac troponins. The patient remained clinically and hemodynamically stable throughout the hospitalization. Inpatient admission was not medically necessary for this patient. Cardiac testing was unremarkable, and no further cardiac intervention was indicated or recommended. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Inpatient admission criteria were not met. Criteria for any other additional extenuating circumstances were not met. 

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.