Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic idiopathic Constipation
Treatment: Formulary exception for Trulance
The insurer denied the Formulary exception for Trulance
The denial is overturned

The patient is a female with chronic idiopathic constipation. She has failed Linzess, Amitiza and Lubiprostone. She has done well on Trulance for several months. Her provider is requesting continuation of Trulance.

Yes, the health plan should cover the Formulary exception for Trulance.
The patient has failed the formulary drugs Linzess and Lubiprostone. Given that the patient has failed these two drugs, and given that the patient has done well on Trulance, it would be reasonable and consistent with the standard of care that the patient be continued on Trulance. Therefore, the health plan should cover the formulary exception for Trulance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Scleroderma and inflammatory arthritis. 
Treatment: Rasuvo. 

The insurer denied coverage for Rasuvo. 

The denial is overturned. 

According to the medical records, the patient is a with a history of scleroderma and inflammatory arthritis. Patient responded well to methotrexate but could not tolerate oral methotrexate. Provider prescribed Rasuvo which is the topic of this review. 

The patient has inflammatory arthritis with scleroderma and methotrexate was helping. Methotrexate has been used in scleroderma patients with success. 

The patient could not tolerate oral Methotrexate and cannot prepare the Methotrexate injections. Therefore, Rasuvo is considered medically necessary for this patient. Therefore, the request should be approved for therapy for a duration of 12 months. 

"Diffuse systemic sclerosis carries a high morbidity and mortality. The Prospective Registry of Early Systemic Sclerosis (PRESS), a multicentre incident cohort study of patients with early diffuse cutaneous systemic sclerosis, has the goal of advancing the understanding of disease pathogenesis and identifying novel biomarkers. In this review, PRESS investigators discuss the evidence pertaining to the more commonly used treatments for early diffuse SSc (systemic sclerosis) skin disease including methotrexate, mycophenolate, cyclophosphamide, azathioprine, and intravenous immunoglobulin. This review highlights the unmet need for effective treatment in early diffuse SSc as well as its more rigorous study. Nonetheless, the PRESS investigators aim to decrease intra- and inter-institutional variability in prescribing in order to improve the understanding of the clinical course of early diffuse SSc skin disease." (Frech, T. M. et al. 2013). 

"Methotrexate is an FDA [Food and Drug Administration] approved folic acid antagonist indicated for the treatment of rheumatoid arthritis because of its high potency and efficacy in such patients; it can also be useful in patients with juvenile idiopathic arthritis.[1] Gubner first suggested methotrexate use in rheumatoid arthritis after performing a double blinded-placebo controlled clinical trial of methotrexate in patients with rheumatoid arthritis.[2] Aminopterin was originally considered the parent compound for the methotrexate was first used successfully to treat childhood leukemia." (Hannoodee, et al., 2021). 

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

The insurer's denial of coverage for Rasuvo is overturned. Medical Necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Tricuspid regurgitation.
Treatment: TTVR (transcatheter tricuspid valve repair) with TriClip implantation.

The insurer denied the TTVR with TriClip implantation.  The denial is overturned.

The patient is a female for which a percutaneous tricuspid valve replacement is under review. There was a history of colon cancer, GERD (gastroesophageal reflux disease), and pulmonary hypertension. There was severe tricuspid regurgitation with NYHA (New York Heart Association) II class symptoms. There was also orthopnea. The right ventricle was moderately dilated, and by echocardiography there was estimated moderate pulmonary hypertension.

Yes, the health plan should cover the TTVR (transcatheter tricuspid valve repair) with TriClip implantation.

Percutaneous valve repair has been developed to treat those with clinically significant valve abnormalities who are at high or prohibitive surgical risk. Experiences most extensive for the aortic and mitral valves. In these settings, the technique has been demonstrated effective towards valve abnormality treatment. Similarly, percutaneous repair of the tricuspid valve has been established as a feasible safe and effective treatment for those with clinically significant tricuspid regurgitation who are at essentially high surgical risk. This individual developed severe symptomatic tricuspid regurgitation requiring valve correction. Based primarily on her age she was an estimated at least intermediate, if not high risk. In this setting a percutaneous tricuspid valve replacement is a reasonable safe and effective treatment approach. It is therefore considered medically appropriate in this case.

Yes, the requested service is more beneficial.

The procedure under review is a percutaneous treatment. It is not a surgical approach. Based primarily on age, a surgical approach would likely be at an unacceptable risk level.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Tricuspid regurgitation.
Treatment: TTVR (transcatheter tricuspid valve repair) with TriClip implantation.

The insurer denied the TTVR with TriClip implantation.  The denial is upheld.

The patient is a female with symptomatic TR (tricuspid regurgitation). She was recommended for an intervention to fix the tricuspid valve. Cardiovascular surgeon deemed her not a good candidate for surgical repair, and she was referred to an interventional cardiologist specializing in structural heart. She was enrolled in Trilumiante Pivotal Trial. This was described as an active clinical trial.

No, the health plan should not cover the TTVR (transcatheter tricuspid valve repair) with TriClip implantation.

This is an investigational trial of a new device and technique. The treatment is classified as experimental/investigational, and is described as such by the appeal letter.

No, it is not known that the TTVR (transcatheter tricuspid valve repair) with TriClip implantation is more beneficial than known therapies.

This procedure has not been proven to be beneficial at this time. The purpose of the investigation is to demonstrate efficacy and non-inferior to standard treatment. It is ongoing and no evidence has yet been established for its safety and benefit.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immunologic Disorders. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Simponi 50mg. 
The denial is overturned. 

The patient is a female with seropositive (rheumatoid factor (RF) positive [+], cyclic citrullinated peptide (CCP) +, anti-nuclear antibody (ANA), Sjogren's syndrome B (SSB) +) and non-erosive rheumatoid arthritis (RA), history of positive tuberculosis (TB) test and status/post (s/p) 6 months of treatment in Dominican Republic. She was previously on methotrexate (MTX) 25 milligrams (mg) weekly, SSZ 1.5-gram (g) twice a day (BID) and golimumab (Simponi) 2mg/kilograms (kg), and prednisone 5mg every other day. (On Plaquenil in the past and does not recall why this was stopped). On a prior visit she complained of nausea with MTX, so she was switched to leflunomide. Recommended was continuation of therapy with golimumab being changed from intravenous (IV) to subcutaneous (SC). She has improved significantly on this medication with latest Clinical Disease Activity Index (CDAI) of 3. No synovitis on exam. The provider planned to switch golimumab 2mg/kg every (q) 8 weeks to monthly 50 mg subcutaneous injections. She is to continue leflunomide 20mg and sulfasalazine while on the subcutaneous biologic. 

At issue is the medical necessity of Simponi 50mg. 

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

The requested health service/treatment of Simponi 50mg is medically necessary for this patient. 

This patient has been on the requested treatment with improvement. She has already failed oral disease-modifying antirheumatic drug (DMARDs) in the past. This is a continuation of a therapy not an initiation of therapy, and there has been improvement in CDAI on the requested medication. This patient has already been tested for tuberculosis and has been treated in the past.  In such a scenario we do not keep repeating the test as they will show up as a false positive based on prior infection. The patient denies any symptoms of tuberculosis and has already been treated for a positive test in the past. The patient has shown improvement on the requested treatment. 
Therefore, the requested health service/treatment of Simponi 50mg is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Physical Therapy. 
The insurer denied Physical Therapy. 
The denial is upheld. 

The patient is a male with left foot dystonia. He had a history of running four miles a day for 10 years, then would run two miles barefoot. He developed left foot dysfunction. He could no longer run. He had a history of right knee anterior cruciate ligament (ACL) tear years ago. He previously underwent physical therapy. The subject under review is the medical necessity for the physical therapy.

The health plan's determination is upheld.

The requested physical therapy is not medically necessary for this patient. The patient has left foot dystonia. He had a history of running four miles a day for 10 years, then would run two miles barefoot. He developed left foot dysfunction. He could no longer run. He had a history of right knee ACL tear 10 years ago. He previously underwent physical therapy. Lower extremity active range of motion was within normal limits.  Strength was 3+(plus)/5 to 4+/5.  The pain level was 2. On subsequent date lower extremity strength was 4-(minus)/5 to 4+/5. Based on the standard of care, the patient could participate in a home exercise program to include strengthening and range of motion exercises. Physical therapy from is not medically necessary as there was no documentation of significant improvement in strength, pain levels, range of motion of function during the time frame in question. The peer-reviewed medical literature in the United States at this time would not include physical therapy during these dates. Further the medical standard of care does not support physical therapy during these dates.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decreased Mobility. 
Treatment: Home Health Care. 

The insurer denied Personal Care Aide Hours: 7 Days per Week, Live-In. The health plan's determination is overturned. 

The patient is a female with past medical history of mitral valve prolapse, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), dementia, urinary incontinence, and wheelchair bound status who underwent a universal assessment assessing the patient at total assistance with tasks of ordinary housework, stairs, and transportation while maximum assistance with tasks of meal preparation, shopping, and bathing. With tasks of managing finances, managing medication, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of phone use, equipment management, personal hygiene, and bed mobility. The patient was assessed at independent with task of eating. Notes from the assessment stated the patient lived alone. 

Personal Care Aide (PCA) Hours: 7 Days per Week, Live-In is medically necessary for this patient. 

There is documentation of cognitive and functional decline based on the documentation of the recent assessment. The patient's provider documents medical necessity of increased PCA services. The patient requires at least extensive assistance with tasks of locomotion, transfer toilet, and toilet use. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan incorrectly assumed the patient's informal supports could provide assistance with ADLs and IADLs outside of all of the currently approved hours. Taking into account clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide Hours: 7 Days per Week, Live-In, are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer/Anal/Rectal Cancer. 
Treatment: Radiation Therapy. 

The health plan denied the requested proton radiation therapy as not medically necessary. 

The health plan's determination is upheld. 

This is a male with a history of stage IVA -T3N1bM1a poorly differentiated adenocarcinoma of his distal rectum with metastases to his liver, abdominal/pelvic nodes, and bone. He was treated with induction chemotherapy followed by preoperative chemoradiation to his pelvis and Abdominal Perineal Resection (APR). He was then treated with systemic immunotherapy. He presents now with disease extension to his penis and bilateral pelvic lymph nodes. He has been recommended to proceed with a course of palliative external beam reirradiation. 

At issue is the medical necessity of proton beam radiation therapy. 

I uphold in whole, the health plan's determination of medical necessity. 

No, the requested proton radiation is not medically necessary for this patient. Proton radiation is not medically necessary for all patients in the patient's setting. The treating provider has not supplied a proton/photon plan comparison to show that photon-based radiotherapy cannot provide adequate safety/precision. The American Society for Radiation Oncology (ASTRO) Model Policy for proton radiation does not support its use for management of pelvic malignancies outside the context of a clinical trial. Furthermore, there are not any high-quality clinical outcomes published in the medical literature that support proton radiation therapy for the patient's metastatic rectal cancer. Given the patient's stage IV disease, it is unclear that proton radiation would yield a clinically significant improvement in outcomes during his lifetime.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Dementia. 
Treatment: Increase Personal Care Aide (PCA) Services For a Total of 112 Hours Per Week. 

The insurer denied the Increase Personal Care Aide (PCA) Services For a Total of 112 Hours Per Week. 

The denial is overturned. 

The patient is a male. His conditions include advanced Alzheimer's dementia. Denial of increase in personal care aide (PCA) services to 16 hours per day in 2-8-hour shifts for a total of 112 hours per week is being appealed. The health plan approved 49 hours per week. 

Uniform Assessment Systems (UAS) evaluation performed shows the patient has moderately impaired cognition and functional status: total dependence with meal preparation and housework; maximal assistance with managing finances and medications, bathing, lower body dressing, and toileting; extensive assistance with personal hygiene, upper body dressing walking, locomotion, and bed mobility; and supervision with eating. He requires assistance of walker and caregiver when ambulating.

An appeal statement from a provider notes the patient lives with his wife who has her own medical conditions. The patient is unsafe to be left unassisted due to cognitive decline, osteoarthritis, disorientation and inability to perform ADLs (activities of daily living) independently. He does not differentiate night from day. An appeal letter from the patient's provider notes the patient needs total assistance with all ADLs (activities of daily living) and IADLs (instrumental activities of daily living). He has insomnia and awakens multiple times during the evening hours. Logs provided show the patient getting nighttime assistance approximately every 2 hours with transferring and toileting. 

Yes, the Increase in Personal Care Aide (PCA) Services For a Total of 112 Hours Per Week is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase in PCA (personal care aide) services to 16 hours per day in two 8-hour shifts for a total of 112 hours per week, is being appealed. The health plan approved 49 hours per week. 

This patient has progressive Alzheimer's dementia. UAS (uniform assessment system) evaluation performed shows the patient requires assistance with all ADLs (activities of daily living), except eating. Appeal statements note the patient requires assistance with all ADLs (activities of daily living) during both day and night time. Logs have been provided showing the patient getting frequent assistance throughout the night for transfer and toileting. The patient's needs for assistance with ADLs (activities of daily living) and personal care cannot be met with the approved PCA (personal care aide) 49 hours per week. The requested increase in PCA (personal care aide) to 112 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This is a woman who presented to the emergency department (ED) via Emergency Medical Services (EMS) with acute left-sided chest pain that started while she was undergoing hemodialysis. Her medical history was remarkable for heart failure with preserved ejection fraction, end-stage renal disease, human immunodeficiency virus (HIV) infection, cervical cancer, morbid obesity and hypertension. In the ED, her blood pressure was 92/59 with a heart rate of 80 beats/minute. Her room air oxygen saturation was 97%. Her cardiopulmonary physical exam was unremarkable. An electrocardiogram showed sinus rhythm with QT prolongation; there were no acute ischemic changes. Her serum troponin level was normal. Her N-terminal proBNP(N-terminal pro-brain natriuretic peptide) level was 3840. Chest X-ray showed cardiomegaly with mild interstitial edema. The patient was treated with acetaminophen and admitted to the hospital to rule out acute coronary syndrome. 

The inpatient stay was not medically necessary.
This woman, with multiple cardiac risk factors, presented with symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. She was in sinus rhythm and hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. Per the nephrologist's note, she was not grossly volume overloaded. She did not require intensive monitoring or infusion of intravenous cardioactive medications. While her blood pressure was measured at 79/50, the patient was asymptomatic and there was some question as to whether the measurement was accurate. No specific treatment was required and subsequent measurements were within normal limits. The care this patient received did not require an inpatient admission and could have been provided at a lower level. This approach has been shown to be both safe and effective and is in accordance with current guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is overturned.


The patient has an anterior crossbite on tooth 9. He presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. Tooth number (#) 3 is missing. He is treatment planned for 30-36 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to a lack of medical necessity.
At issue is the medical necessity of braces.

This patient presented with an anterior crossbite on tooth 9, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) Given the way that tooth 9 contacts tooth 24, it is a virtual certainty these teeth will develop abnormal wear if the crossbite is not corrected in a timely manner.
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem.

Therefore, the treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied Comprehensive orthodontic treatment, monthly visits. 
The denial is upheld. 

The patient is a female with Class II malocclusion, mild mandibular crowding and moderate maxillary spacing. There is moderate overjet and severe overbite. The patient is recommended for braces and monthly visits.
At issue is the medical necessity of Comprehensive orthodontic treatment, monthly visits.

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

The requested health service/treatment of Comprehensive orthodontic treatment, monthly visits are not medically necessary for this patient.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 10 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9-millimeter (mm) or greater and underbite 3.5 mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. According to the standard of care, braces and month visits are not medically necessary for this case.
Therefore, the requested health service/treatment of Comprehensive orthodontic treatment, monthly visits is not medically necessary.