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

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 
The insurer denied: 7 days x 24 hours (continuous services). The denial is upheld in whole.

The patient is a female with past medical history of dementia, major depressive disorder, gastroesophageal reflux disease (GERD), hypothyroidism, diabetes mellitus (DM) Type 2, osteoarthritis, hyperlipidemia, recurrent falls, coronary artery disease, and permanent pacemaker in situ who had been assigned Personal Care Assistant (PCA) service hours 5 hours/day, 7 days/week to total 35 hours/week based on assessment tool performed. At the assessment the patient was assessed at maximal assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, stairs, transportation, bathing, dressing lower body, walking, locomotion and toilet use. 

The patient was assessed at requiring limited assistance for tasks of phone use, dressing upper body, and transferring to the toilet, and requiring supervision with task of personal hygiene. For tasks of bed mobility and eating the patient was assessed as independent. The patient's spouse died and he had received PCA service hours around the clock prior to his passing. The patient's primary care physician (PCP) provided a letter stating the patient's medical diagnoses while also "writing to request an urgent increase in hours of home care" for the patient. The letter stated the patient had rapidly deteriorating mental state and physical health, had urinary and fecal incontinence requiring multiple daytime and nighttime changing of soiled diapers to prevent skin rash and irritation, requires continuous supervision and assistance with movement and mobility, and believed it was very important and medically necessary for the patient to have two split shifts of 12 hours of home care daily and nightly, 7 days per week. 

The subject under review is the medical necessity for the PCA services 7 days x 24 hours (continuous services) per week.

No, the requested PCA services are not medically necessary for this patient. Despite the patient's PCP notes indicating the medical necessity for the requested PCA services the insurer must rely on the last UAS done to determine PCA service hours, but the family has refused to allow another UAS assessment tool to be performed. With the information provided regarding the patient it is unclear if the patient's needs span 24 hours. The patient had 24 hour continuous PCA service hours as a mutual case with her husband who was since deceased. The family and PCP are stating the patient had severe decline in physical and mental function over an 8 month period of time needing to increase her PCA service hours to 24 hours/day. There is not sufficient documentation of night time needs necessitating split-shift continuous hours. The patient's PCA was administering medication which is outside of the scope of their practice.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Eosinophilic esophagitis with esophageal stricture
Treatment: Formulary exception for esomeprazole 40 mg pack
The insurer denied the Formulary exception for esomeprazole 40 mg pack.
The denial is overturned. 

This patient is a male with eosinophilic esophagitis and esophageal stricture, with recurrent food impactions. He has failed treatment with esomeprazole capsules and lansoprazole capsules, with vomiting of pills. Esomeprazole 40 milligram (mg) suspension packet has controlled his symptoms. The attending physician (AP) is requesting esomeprazole 40 mg suspension packet.

Yes, the health plan should cover the proposed esomeprazole 40 mg pack.

The patient has eosinophilic esophagitis with esophageal stricture. He is unable to tolerate proton pump inhibitors (PPIs) in capsule form, vomiting the pills. Esomeprazole in suspension packets have worked well to control his symptoms. As PPI suspension packets are standard of care in patients who require PPIs and are unable to swallow or who have vomiting of PPIs in pill form, the use of esomeprazole suspension packets is standard of care. All of the PPIs on formulary are capsules, and the patient is unable to tolerate capsules. Therefore, the health plan should cover esomeprazole suspension packets.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Constipation.
Treatment: Linzess 145MCG OR CAPS.
The health plan denied Linzess 145MCG OR CAPS.
The determination is overturned.
The patient has constipation. She has been on Linzess 145 micrograms (mcg), with 1-2 bowel movements per day. She failed Amitiza 8 mcg twice daily  due to nausea. She also failed Miralax due to persistent intermittent constipation, lactulose due to diarrhea, Colace due other ineffectiveness, Metamucil and Benefiber due to gas, probiotics due to ineffectiveness, and over the counter laxatives due to severe cramping. At issue is the medical necessity of Linzess 145 mcg .

The Linzess is medically necessary. The patient has chronic constipation. The American Gastroenterological Association Medical Position Statement on Constipation states that when first-line laxatives fail, such as osmotic laxatives and fiber, a newer agent such as Amitiza or Linzess should be considered [1]. In multicenter, randomized, blinded, placebo-controlled Phase III clinical trials, Linzess significantly increased weekly spontaneous bowel movements in patients with chronic constipation of multiple types [2-4]. In this case, the patient had failed multiple laxatives including osmotic laxatives and the formulary alternative Amitiza, and was stabilized on Linzess; for these reasons, the request for Linzess is supported as medically necessary for the treatment of constipation.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Clear cell renal cell carcinoma.
Treatment:  MVASI.

The insurer denied coverage for MVASI.  The denial is overturned.

This is a male patient with untreated metastatic kidney cancer.  The request is being considered for medical necessity for MVASI with Votrient by his treating provider. 

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcome for this patient with a diagnosis of metastatic kidney cancer.  As per National Comprehensive Cancer Network (NCCN), MVASI is used as standard of care.  MVASI is the best available treatment for this patient as this time.  Based on the documentation provided for review, there is no contraindication to MVASI listed in the chart.  Therefore, this patient is a good candidate for MVASI. 

"In the last decades, the prognosis of metastatic renal cell carcinoma (mRCC) has remarkably improved following the advent of the "targeted therapy" era.  The expanding knowledge on the prominent role played by angiogenesis in RCC pathogenesis has led to approval of multiple anti-angiogenic agents such as sunitinib, pazopanib, axitinib, cabozantinib, sorafenib, and bevacizumab.  These agents can induce radiological responses and delay cancer progression for months or years before onset of resistance, with a clinically meaningful activity.  The need for markers of prognosis and efficacy of anti-angiogenic agents has become more compelling as novel systemic immunotherapy agents have also been approved in RCC and can be administered as an alternative to angiogenesis inhibitors..." (D'Aniello et al.).     

The requested service is likely to favor benefit over risks in this patient.  This patient has metastatic kidney cancer; MVASI is recommended to be used in treatment for this type of cancer and is supported by NCCN and literature.  The requested medication is likely to be more beneficial than any other standard services. 
                                                 
The carrier's denial of MVASI should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Clear cell renal cell carcinoma.
Treatment:  MVASI.

The insurer denied coverage for MVASI.  The denial is overturned. 

This is a male, who was seen by a Medical Oncology specialist who is requesting coverage of MVASI for use in the 1st-line setting for Stage IV clear cell kidney cancer, to be used as part of a clinical trial.  MVASI is a vascular endothelial growth factor inhibitor indicated for the treatment of metastatic clear cell renal cell carcinoma, as well as colorectal cancer and cervical cancer.

Scientific literature supports a result of improvement in health outcome with the use of bevacizumab [MVASI].  Bevacizumab in combination with interferon alfa is now approved for treatment-naive advanced renal cell carcinoma in both the United States and Europe.  Its objective response rates of 30% and progression-free survival rates of 9-10 months are comparable to the other approved first-line multi-tyrosine kinase inhibitors, sunitinib and pazopanib.  It is being planned to be given during the clinical trial with another treatment approved drug pazopanib (Votrient).    
 
The patient is a good candidate for MVASI.  He has stage IV clear cell renal cell carcinoma; he is treatment naive as well, so it is being used as a first line therapy.  MVASI (bevacizumab) is supported by the National Comprehensive Cancer Network (NCCN) as a first line treatment.

"Single-agent bevacizumab has acceptable toxicity and moderate disease-stabilizing activity in selected patients with mRCC [metastatic renal cell carcinoma] who have failed prior VEGFR [Vascular Endothelial Growth Factor Receptor] TKI [targeted tyrosine kinase inhibitors] and mTOR [mammalian target of rapamycin] inhibitors.  These data support clinical benefit to continued ongoing VEGF [Vascular Endothelial Growth Factor] inhibition.  Further prospective studies of bevacizumab alone or with alternative targeted agents in previously treated populations with mRCC are warranted." (Turnbull et al.). 

MVASI has been proven to be beneficial in clear cell renal cell carcinoma; however, it has not been studied to be used in combination with a tyrosine kinase inhibitors (TKI) drug like Votrient, which is also approved for use in clear cell renal cell carcinoma, so this is where the trial comes in, testing these 2 drugs that are approved in clear cell renal cell carcinoma to see if there is a further improvement in health outcome for treatment naive patients.  Therefore, the use of MVASI is likely to be more beneficial than any other treatments. 

The carrier's denial of Mvasi should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Clear cell renal cell carcinoma.
Treatment:  MVASI.

The insurer denied coverage for Mvasi.  The denial is overturned.

This is a male patient with stage IV clear cell kidney cancer, and the request is for MVASI to be used as part of a clinical trial.  The patient underwent left radical nephrectomy in the past.  The pathology report showed a 7.6 centimeter clear cell carcinoma, Fuhrman Grade 3 with lymphovascular invasion and clear margins.  The patient also underwent a thyroidectomy that showed a papillary carcinoma with positive margins.  The restaging computed tomography (CT) showed multiple bilateral lung nodules, as well as enlarged prevascular and left hilar lymph nodes.  The biopsy showed clear cell renal cell carcinoma.

Scientific evidence in peer-reviewed literature supports a result of improvement in health outcome of the use of Mvasi for this patient's diagnosis.  Bevacizumab [MVASI] is a monoclonal antibody that binds circulating Vascular Endothelial Growth Factor (VEGF) and prevents its interaction with Vascular Endothelial Growth Factor Receptor (VEGFR) and has been shown to be of use in advanced or metastatic clear cell renal carcinoma.        

MVASI is approved by the Food and Drug Administration (FDA) and is supported by the National Comprehensive Cancer Network (NCCN).  This patient is a good candidate for MVASI , which is used as a front line drug in clear cell renal cell carcinoma. 
  
This patient has clear cell renal cell carcinoma, and the plan is to have him participate in a trial using standard of care first line drug bevacizumab (MVASI) and Votrient, which is also another approved drug for clear cell renal cell carcinoma.  Therefore, the requested service is likely to be more beneficial, as it has been demonstrated that bevacizumab is beneficial in scientific studies.    
                                                  
The carrier's denial of MVASI should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic uterine sarcoma 
Treatment: Imatinib Mesylate 400 milligrams or tabs
The insurer denied the Imatinib Mesylate 400 milligrams or tabs.
The denial is upheld. 

The patient in this case is a female who was diagnosed with uterine sarcoma. She was treated with surgery and did well until metastatic disease was diagnosed. She was started on chemotherapy treatment with gemcitabine and docetaxel. She had disease progression after two cycles of treatment. She was tried on doxorubicin, but had significant side effects requiring dose reduction. She also had further disease progression on that treatment.  

FoundationOne testing was performed and revealed KIT gene/platelet-derived growth factor receptor (PDGFR)-alpha amplification. She was treated with pazopanib. Repeat imaging revealed mixed response and she was then treated with pazopanib combined with sirolimus because of the results of molecular testing. Further imaging done revealed continued disease progression. She was then treated with trabectedin with further disease progression. She was then started on ipilimumab and nivolumab. A request was made for off-label imatinib treatment.

No, the requested imatinib mesylate is not medically necessary.  

Imatinib is a tyrosine kinase inhibitor active against proto-oncogene c-KIT and platelet-derived growth factor receptor (PDGFR)-alpha. It is a standard treatment for BCR/ABL [a gene sequence] positive chronic myeloid leukemia (CML) and also c-KIT or PDGFR-alpha (platelet-derived growth factor receptor) mutation positive gastrointestinal stromal tumor (GIST). There is currently no evidence that imatinib is active against KIT amplified (but not mutated), non-GIST (gastrointestinal stromal tumor) sarcoma. There is no published study supporting the potential efficacy of this agent for the use intended in this case and National Comprehensive Cancer Network (NCCN) guidelines do not endorse this use of imatinib. Given lack of sufficient supporting evidence and also lack of consensus guideline endorsement, this treatment cannot be considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis
Treatment: Entyvio
The insurer denied the Entyvio.
The denial is overturned. 

The patient is a female with ulcerative colitis. Her attending physician (AP) is requesting treatment with Entyvio.

Yes, the proposed treatment with Entyvio is medically necessary. 

The patient has ulcerative colitis. No clinical information is provided. Entyvio was denied as the patient has not failed Xeljanz. As Xeljanz is not medically necessary, or Food and Drug Administration (FDA) approved for ulcerative colitis, unless patients have failed an anti-tumor necrosis factor (TNF), and as there is no documentation that the patient has failed an anti-TNF (tumor necrosis factor), Xeljanz is not appropriate. Additionally, Entyvio is FDA (Food and Drug Administration) approved, safe and effective as a first line biologic treatment for ulcerative colitis.  Therefore, the requested Entyvio is clinically appropriate and accepted standard of medical care, and the health plan did not act reasonably, with sound medical judgement, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Evaluation  
Treatment:  Dental Services: D2740- Porcelain Crown and D2950- Core Buildup Including Pins.

The insurer denied coverage for Dental Services: D2740- Porcelain Crown and D2950- Core Buildup Including Pins.  The denial is upheld. 

This is a female patient who had a dental evaluation.  The recommendation was for full coverage crowns for teeth numbers 18 and 19.  The insurer has denied these services stating the there is no clinical/radiographic evidence, such as traumatic injury or recurrent decay provided to support the necessity of these services, and, therefore, the services do not meet medical necessity criteria. 

Based on a review of the bitewing radiographs and intraoral clinical images, both teeth numbers 18 and 19 have direct placement composite restorations that, although worn, appear to be stable and intact.  It appears that there is no evidence of fracture or other pathology specifically affecting these teeth.  There does not appear to be any radiographic evidence of caries/recurrent decay on these teeth.  The radiographs and clinical images do not substantiate the requested dental services, as enumerated above; therefore, the crowns are deemed not medically necessary.

Dental Services: D2740- Porcelain Crown and D2950- Core Buildup Including Pins were not medically necessary.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient.

Based on the above, the medical necessity for Dental Services: D2740- Porcelain Crown and D2950- Core Buildup Including Pins is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The health plan's determination is overturned. 

The patient is a woman with a history of alcohol abuse, depression, hypertension, seizures, pancreatitis, substance abuse and hyperlipidemia, who presented to the emergency department for detox.  She stated that she last drank early that morning and reported withdrawal symptoms of increased Anxiety, tremors and myalgias.  She denied fevers, headache, hallucinations, chest pain and shortness of breath.  Social history was notable for smoking one pack of cigarettes per day.  Vital signs showed blood pressure 113/79, and heart rate 75.  On physical examination, heart was regular, breath sounds were normal, and her mood appeared anxious.  Labs showed white blood cell count (WBC) 6.88, hemoglobin 14.2, platelets 216, glucose 108, calcium 9.3, Magnesium 1.77, and folate 12.8.  Alcohol level was negative and urine drug screen was positive for benzodiazepines.  The patient was admitted for alcohol withdrawal.  The plan of care included admission to the detoxification unit, begin rehab, smoking cessation counseling and nicotine patch, Motrin as needed for pain, multivitamin, Zofran as needed, folate, thiamine, and Librium Taper. 

The inpatient admission was medically necessary.  The patient's admissions were related to alcohol withdrawal seizures.  She was seen by neurology and was at an increased risk of recurrent seizure due to her prior history of seizures and witnessed seizure episode.  She was hemodynamically stable but patients with alcohol abuse, who are experiencing withdrawal, can rapidly deteriorate clinically, with delirium tremens, seizures requiring intensive care unit management and inability to protect the airway, and prolonged disability.  Overall, the intensity of care required for patients with active withdrawal is increased, and the inpatient level of care is appropriate.

Inpatient level of care is appropriate for a patient with withdrawal and with evidence of alcohol withdrawal seizures.  The episodes may be self limited or may progress to seizures, loss of ability to protect the airway, and other complications.  These types of patients require a higher level of care and inpatient level of care is appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite.
Treatment:  Braces.

The insurer denied the Braces.  The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits.

Yes, the Braces are medically necessary.

There is a definite crossbite between teeth numbers 7 and 26.  The health plan states this is not there, but the photos clearly show this to be the case.  This is an automatic qualifying condition according to the handicapping index scale when there is a cross bite between anterior teeth with gingival attachment loss).  Therefore, the braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Shoulder injury.
Treatment:  Medical Equipment (devices for cold therapy and compression).

The insurer denied the Medical Equipment (devices for cold therapy and compression).  
The denial is upheld. 

The patient is a male with history of severe right shoulder injury.  An MRI (magnetic resonance image) of the right shoulder revealed an acute full-thickness rupture of the supraspinatus and infraspinatus tendons with labral tear.  This was treated through rotator cuff surgery.

The surgeon prescribed a pneumatic compressor and fluid circulating cold pad for post-operative care. 

No, the Compression Device is not medically necessary.

The pneumatic compression device was not provided in a manner that is in accordance with or consistent with generally accepted standards of medical practice in the US (United States) for the treatment of swelling post-rotator cuff repair. 

A randomized controlled trial by Kraeutler et al. showed that there is not a significant benefit to the use of Compressive Cryotherapy over standard Ice Wrap in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression.

The compression device is not medically necessary and unlikely to be more beneficial than any standard treatments for an immobile shoulder s/p (status post) rotator cuff repair that is likely to be helped with traditional physical therapy along with ice.