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

Diagnosis: Malignant neoplasm of head, face and neck.
Treatment: MRI (Orbit, Face and Neck; with Contrast Materials - CPT 70542).
The insurer denied: MRI (Orbit, Face and Neck; with Contrast Materials - CPT 70542).
The denial is upheld.

The patient is an adult male. The patient in this case was diagnosed with left tonsil cancer. At the time of diagnosis, he had a PET/CT (positron emission tomography/computed (tomography) performed. Following that, an MRI (magnetic resonance imaging) was done. This was an MRI (magnetic resonance imaging) of the orbit, face and neck with contrast. This MRI (magnetic resonance imaging) was done at the time of diagnosis. 

The requested MRI (magnetic resonance imaging) (Orbit, Face and Neck; with Contrast Materials) was not medically necessary.

This patient was diagnosed with a p16 (cyclin-dependent kinase inhibitor 2A) positive tonsil cancer. PET/CT (positron emission tomography/computed tomography) was done, and MRI (magnetic resonance imaging) was obtained. MRI (magnetic resonance imaging) of the neck is standard in this setting. MRI (magnetic resonance imaging) of the orbit, face and neck is not standard of care for evaluation of a tonsil cancer, and it exceeds in scope that level of care needed to provide accurate diagnosis. This test was therefore not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Vitiligo
Treatment: Opzelura (ruxolitinib)
The insurer denied Opzelura (ruxolitinib). 
The health plan's determination is upheld.

The patient is a female with vitiligo. Her back is affected. She has failed triamcinolone, selenium sulfide and fluconazole. 

A formulary exception is not indicated in this case. 
The formulary drug topical tacrolimus would not be ineffective, would not be as effective as the non-formulary drug Opzelura, and would not have adverse effects.
Based on the current evidence-based literature, the requested Opzelura cream for vitiligo is not indicated. There is no documentation provided that the patient has tried and failed the conventional therapies for vitiligo, such as the calcineurin inhibitor topical tacrolimus. Calcineurin inhibitors such as tacrolimus ointment are a first-line treatment for vitiligo and should be tried and failed prior to initiating Opzelura.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Strokes with residual right-sided hemiparesis, diabetes, hypertension, and osteoarthritis
Treatment: Increase in Home Health Care (HHC) level 2 per 15 mins to 24 hours/day (live in)
The insurer denied the increase in HHC level 2 per 15 mins to 24 hours/day (live in).
The denial is overturned.

The patient is an elderly female. She has a history of strokes with residual right-sided hemiparesis, diabetes, hypertension, and osteoarthritis. Her most recent stroke occurred this year. She lives alone. Denial of increase in home health care (HHC) to 24 hours/day (live in) is being appealed. The health plan approved 56 hours/week. Uniform Assessment System (UAS) evaluation completed last month shows modified independent cognition and functional status: total dependence with meal preparation homework, lower body dressing and locomotion; maximal assistance with managing finances and medications, shopping, bathing, and toilet use; extensive assistance with walking and toilet transfer; limited assistance with upper body dressing and bed mobility; and independent with eating. Compared to UAS evaluation completed last year, there has been a decline in functioning with all ADLs (activities of daily living), except eating. The patient has occasional bowel and bladder incontinence. A letter from the patient's daughter reports the patient's debility as a result of strokes. The patient 
requires a wheelchair for locomotion. She needs help with transfers and diaper changes. A letter from the patient's provider notes the patient was admitted to SNF (skilled nursing facility) after a stroke. She is recommended for discharge with 24/7 care.

The increase in HHC level 2 per 15 mins to 24 hours/day (live in) is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs, including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase in HHC to 24 hours/day (live in) is being appealed. The health plan approved 56 hours/week. This patient has multiple chronic conditions and is status post a recent stroke with residual right-sided hemiparesis. She has been in a SNF level of care since for 3 months. UAS evaluation completed last month shows she requires assistance with all ADLs, except eating. Compared to UAS evaluation completed last year, there has been a decline in functioning with all ADLs, except eating. She has occasional bowel and bladder incontinence. The appeal statements support an increase in personal care hours. She uses a wheelchair for ambulation. She requires diaper changes due to incontinence. There has been a significant decline in the patient's functional status. She has significant limitations that do not allow assistance with her ADLs to be met with the approved personal care of 56 hours/week. The personal care to 24 hours/day (live in) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, cervical radiculopathy, myasthenia gravis
Treatment: Increase Home Health Care (HHC) level 2 per 15 minutes to 24 hours/day (split shift)
The insurer denied the increase in HHC level 2 per 15 minutes to 24 hours/day (split shift).
The denial is overturned.

This elderly male patient has conditions including Parkinson's disease, cervical radiculopathy, myasthenia gravis, hypertension, and heart failure. The denial of an increase in home health care (HHC) 24 hours/day (split shift) is being appealed. The health plan approved an increase to 24 hours/day, live-in.

Uniform Assessment System (UAS) evaluation completed 3 months ago shows moderately impaired cognition and functional status: maximal assistance to total dependence with all activities of daily living (ADLs), except extensive assistance with bed mobility. He requires assistance with transferring and changing positions. He has bowel and bladder incontinence. UAS evaluation shows a deterioration from evaluation performed last year. A letter from the Provider notes the patient has several gait and balance issues, involuntary movements, back and joint pain, hallucinations, disorientation, difficulty transferring, weakness, and bradykinesia. He is wheelchair bound. He has significantly deteriorated since COVID (Coronavirus disease). He requires total assistance with ADLs. He needs to be turned every two hours to avoid bed sores. A letter from the Social Worker notes the patient requires total assistance with all ADLs and references the letter from the Provider.

The proposed treatment is medically necessary. 

Personal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift PCS is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has multiple chronic conditions. The denial of an increase in HHC to 24 hours/day (split shift) is being appealed. The health plan approved an increase to 24 hours/day, live-in. UAS evaluation completed 3 months ago shows severely impaired cognition and functional status maximal assistance to total dependence with all ADLs, except extensive assistance with bed mobility. He is incontinent of bowel and bladder. The appeal statements support the patient is dependent with all ADLs and requires frequent assistance with toileting, transfers, and turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved personal care 24 hours/day, live-in, is inadequate to meet the patient's needs for assistance with ADLs. The proposed 24 hours/day, split shift, is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes

Treatment: continuous glucose monitoring device (CGM) and supplies, A4239 x 1 &amp; E2103 x 1

The insurer denied coverage for continuous glucose monitoring device (CGM) and supplies, A4239 x 1 and E2103 x 1

The denial is overturned
 

The patient is seeking authorization for continuous glucose monitoring device (CGM), and supplies A4239 x 1 and E2103 x 1. The patient was diagnosed with uncontrolled insulin requiring type 2 diabetes mellitus complicated by peripheral neuropathy, microalbuminuria, and retinopathy.

A request was noted for continuous glucose monitoring device with supplies. The patient was diagnosed with type 2 diabetes mellitus with unspecified complications. The patient had wide fluctuations in blood glucose values which ranged from 40 to 400. The patient was receiving 4 insulin injections a day. The patient was testing their blood sugar 6 times a day. There was a dawn phenomenon with morning hyperglycemia. There was fasting hyperglycemic of greater than 150. The patient's hemoglobin A1c was 12.7. The patient completed a comprehensive diabetic education program.

Per the cited references, continuous glucose monitoring (CGM) is indicated for those with intensive insulin regimen (4 or more daily insulin injections, or use of continuous subcutaneous insulin infusion pump) when the patient is educated or scheduled to be educated on use of continuous glucose monitoring. 

In this case, the patient had uncontrolled type 2 diabetes mellitus that required glucose monitoring 6 times a day and insulin 4 times a day. While it is noted that the patient had some difficulty with compliance in the past, this does not negate the need for continuous glucose monitoring. The patient has elevated hemoglobin A1c which places the patient at increased risk for numerous complications of diabetes mellitus. Additionally, the documentation details routine laboratory has been completed over several years and that the patient is currently being compliant with routine follow-up. It is standard of care for continuous glucose monitoring in patients with intensive insulin regimens and the monitoring is likely to result in improvement of health status for the patient with better glycemic control. As such, the continuous glucose monitoring device and supplies as medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for a continuous glucose monitoring device (CGM) and supplies, A4239 x 1 and E2103 x 1 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Hypertension, Chronic Kidney Disease, and Incontinence. 
Treatment: 24 hours per day, 7 days per week (Split-Shift). Total 168 hours per week Consumer Directed Personal Assistance Services (CDPAS) Level 2 

Determination: The 24 hours/day, 168 hours/week, split shift, Consumer Directed Personal Assistance Services (CDPAS) Level 2 is medically necessary. 

The patient is an elderly female. Her medical conditions include dementia, hypertension, chronic kidney disease, and incontinence. Denial of 24 hours per day, 7 days per week (split-shift), total 168 hours per week consumer directed personal assistance services (CDPAS) is being appealed. The health plan approved 84 hours per week. Uniform Assessment System (UAS) evaluation shows the patient needs assistance with bathing, personal hygiene, dressing, walking, toileting, and eating. A letter from the patient's provider notes the patient requires assistance with ADLs (activities of daily living) and incontinence care during day and night. She wakes up four to five times per night and requires assistance. Medical records have been provided supporting her medical history. 

This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation shows the patient needs assistance with bathing, personal hygiene, dressing, walking, toileting, and eating. An appeal statement from her provider notes that she has bowel and bladder incontinence. She requires daytime assistance as well assistance four to five times per night with toileting. The appeal statement supports that the patient requires continuous assistance with toileting that will not give an aide five hours daily of uninterrupted sleep during the aide's shift. The approved CDPAS (consumer directed personal assistance service) of 84 hours per week is insufficient to meet this patient's needs for day and nighttime assistance with ADLs (activities of daily living). The requested increase to 24 hours per day, 7 days per week (split-shift), total 168 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Wheelchair bound
Treatment: personal care services, 24 hours a day, 7 days a week (live-in) for a total of 91 hours
The insurer denied personal care services, 24 hours a day, 7 days a week (live-in) for a total of 91 hours
The determination is overturned.

This a female patient with a medical history notable for cognitive impairment, weakness, and wheelchair bound status. The patient is approved for 7 hours per day, 7 days per week (49 hours per week) of personal care services. The patient and her care team requested an increase to 24 hours a day, 7 days a week (live-in) for a total of 91 hours per week, and this request was denied by the health plan.
The patient's legal team submitted a letter on her behalf for this review. It outlines the current status of the patient's situation. She is residing in a nursing home and requires additional hours to be safely discharged back to the home setting. They document that the patient's physicians have attested to this need for increased personal care hours. She requires 100 percent (%) assistance with transfers and toileting and is unable to make her needs known. Therefore, they feel that she medically requires live-in personal care.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person at the nursing home where the patient is currently residing. The patient's cognition was severely impaired; she was alert and oriented 0-1; she was not able to direct her own care. For her instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, finances, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires total dependence for bathing, dressing, walking, locomotion, toilet transfer, and toilet use. She requires maximal assistance for hygiene and bed mobility. She requires extensive assistance for eating. She is wheelchair bound. She is frequently incontinent of urine and occasionally incontinent of stool.
At issue is the medical necessity of personal care services 24 hours a day, 7 days a week (live-in) for a total of 91 hours.

The requested health service of personal care services, personal care services, 24 hours a day, 7 days a week (live-in) for a total of 91 hours is medically necessary for this patient.
The patient has advanced dementia, incontinence of stool and urine, and is not able to direct her own care. She requires total dependence for most ADLs and IADLs including transfers, locomotion, and toileting. Her personal care needs can be expected to be continuous and unscheduled throughout the day and night. She cannot be left in one place in a diaper for most of the day and night; this failure to meet her personal care needs could result in skin breakdown and/or infection. Therefore, the increase in personal care hours to a live-in aide is medically necessary and appropriate.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia. 
Treatment: Peroral Endoscopic Myotomy (POEM) Procedure. 

The insurer denied the Peroral Endoscopic Myotomy Procedure. 
The health plan's determination is overturned. 

The patient is a female with achalasia status post Heller myotomy 30 years ago. She has had dysphagia, regurgitation, nausea, vomiting (with a need to sleep upright), unintentional weight loss, and chest pain. The esophagogastroduodenoscopy showed esophageal achalasia. The esophagogram showed severe dilation of the esophagus and a bird beak esophagus. The esophageal manometry was consistent with type 2 achalasia. 

Peroral endoscopic myotomy is supported as likely to be more beneficial than any standard treatment or treatments for the treatment of the patient's achalasia. The American Gastroenterological Association best-practice for peroral endoscopic myotomy states that "if the expertise is available, POEM should be considered guideline as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes" (Kahrilas, et al.). The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, recommending POEM for the treatment of achalasia (Khashab, et al.). Clinical studies and trials have shown comparable efficacy with surgery when expertise in POEM is available (Barbieri, et al.; Schlottmann, et al.). However, despite comparable efficacy, POEM is significantly less invasive than surgical intervention, resulting in less postoperative pain and a more rapid recovery (Docimo S, et al.). There are several peer-reviewed publications (including prospective studies) to support the use of POEM as safe and effective after failure of Heller myotomy (Huang, et al.; Fernandez-Ananin, et al.; Ngamruengphong, et al.; Zhang, et al.). In this patient with symptoms including dysphagia and chest pain, the use of POEM is supported by current medical literature and guidelines. For these reasons, POEM should be considered likely to be more beneficial than any standard treatment or treatments for the patient's achalasia. 

The health plan's determination regarding the proposed health service or treatment is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Achalasia. 
Treatment: Peroral Endoscopic Myotomy (POEM) Procedure. 

The insurer denied the Peroral Endoscopic Myotomy Procedure. 
The health plan's determination is overturned. 

The patient is a female with symptomatic achalasia. The patient was initially treated with a laparoscopic Heller myotomy (LHM) with fundoplication. The patient is currently experiencing significant solid food dysphagia. Her Eckardt score is 10 corresponding with significant symptoms. She underwent barium esophagram which confirmed a dilated, tortuous esophagus with a bird's beak at the gastroesophageal (GE) junction.
The patient's provider has recommended a peroral endoscopic myotomy (POEM) procedure to treat achalasia and relieve symptoms. 

The proposed health service or treatment Peroral Endoscopic Myotomy (POEM) Procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The literature, as well as real world accumulated experience demonstrates that POEM will be the most beneficial to the patient - the outcomes will be expected to be as good as LHM with significant less morbidity. The highest quality study was performed by Werner, et al. In this study, 221 patients were randomly assigned to undergo either POEM (112 patients) or LHM (109 patients). Clinical success at the 2 year follow-up was observed in 83.0 percent (%) of patients in the POEM group and 81.7% of patients in the LHM group (difference, 1.4 percentage points; 95% confidence interval (CI), 8.7 to 11.4, for noninferiority). Serious adverse events occurred in 2.7% of patients in the POEM group and 7.3% of patients in the LHM group. Improvement in esophageal function from baseline to 24 months did not differ significantly between the treatment groups, nor did improvement in the score on the Gastrointestinal Quality of Life Index. Real-world experience parallels this data and POEM has surpassed LHM as the primary treatment for patients with achalasia. It is certainly not an experimental procedure at this juncture. 

The health plan's determination regarding the proposed health service or treatment is overturned in whole.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Gender Dysphoria. 
Treatment: Estradiol Valerate 40 mg/ml (milligrams/milliliter). 
The insurer denied: Estradiol Valerate 40 mg/ml. 
The denial is upheld. 

This is an adult male diagnosed with Gender Dysphoria. This request is for Estradiol Valerate 40 milligrams/milliliters (mg/ml). According to the provider, patches do not provide adequate dosing options for treatment of gender dysphoria. The health plan listed formulary alternatives are estradiol patches, and estradiol tablets. 

The health plan should not cover the proposed treatment. 

The Endocrine Society Clinical Practice Guidelines support the use of estrogen HRT (Hormone Replacement Therapy) to treat male to female adult transgender patients with gender dysphoria [1]. Treatment with estrogen is standard of care for adult and late adolescent male to female transgender patients [2-4]. Outcomes have been examined and there is no increase in mortality in treating male to female transgender patients with estrogen [3, 5]. 
There are no studies showing superiority of intramuscular estrogen over transdermal estrogen. Transdermal estrogen is the first line treatment due to its low risk of thromboembolic events. 
Intramuscular estrogen can lead to higher levels of estrogen and can be used in patients who have failed transdermal estrogen. Intramuscular and oral estrogens have a higher risk of thromboembolic events. The patient can try transdermal estrogen prior to switching to intramuscular estrogen. The requested treatment is not expected to be more effective than the formulary alternative transdermal estrogen. It is expected to have more adverse events than the transdermal estrogen. 
Therefore, the health plan should not cover the proposed treatment.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine. 
Treatment: Nurtec.
 
The insurer denied Nurtec. The health plan's determination is overturned. 

The patient is a female with migraine. Treatment with Nurtec ODT (oral disintegrating tablet) is the subject of this review. The drug was denied because the member has not tried and failed the plan formulary drugs (Ubrelvy, Aimovig, and Emgality). 

Based on the records provided, Nurtec ODT is prescribed as an abortive therapy. The patient has tried and failed Ubrelvy, which is the only formulary alternative that is Food and Drug Administration (FDA) approved as an abortive therapy. The formulary alternatives of Emgality and Ajovy are for migraine prevention. As such, the patient has tried and failed the only reasonable formulary alternative for acute treatment of migraine. It should also be noted that the patient has tried and failed 3 triptans including sumatriptan, rizatriptan, and frovatriptna. Therefore, a formulary exception is indicated for this patient.