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

Diagnosis: Miller-Fischer syndrome 
Treatment: Nursing home level of care
The insurer denied the nursing home level of care. The health plan's determination is overturned. 

The patient is a female with a significant history of Miller-Fischer syndrome with diffuse axonal sensory motor neuropathy resulting in functional paraplegia. In addition, she has the diagnoses of major depressive disorder, anxiety, bipolar disorder, and schizoaffective disorder. Per the clinical information provided, she is bedbound due to her neurological condition requiring assist to move/transfer. She is incontinent of both bowel and bladder requiring full bathroom assist and she is on a mechanical soft with thin liquids diet requiring assistance with all meals. Although the patient has a home, the home environment would not be considered safe as she does not have documentation of caregivers demonstrating willingness and ability to manage care.

The Nursing Home Level of Care is medically necessary for this patient.
This patient was admitted to the nursing home (NH) with a primary diagnosis of Miller-Fischer syndrome with diffuse axonal sensory motor neuropathy resulting in functional paraplegia. Per the clinical information provided, she is bedbound due to her neurological condition requiring assist to move/transfer. She is incontinent of both bowel and bladder requiring full bathroom assist and she is on a mechanical soft with thin liquids diet requiring assistance with all meals. Although the patient is alert, due to her neurological condition she remains confused with episodes of hallucinations. Based on the information provided, the patient would not be able to participate in care for herself, she cannot understand when/where to seek help and would require full care 24-hours per day for her activities of daily living (eg, meals, bathing, toileting, medications, and move/transfers). Based on the assessments, although the patient has a home, the home environment would not be considered safe as she does not have documentation of caregivers demonstrating willingness and ability to manage care. In addition, she required behavioral therapy for her diagnoses of major depressive disorder, anxiety, bipolar disorder, schizoaffective disorder and would not be able to receive effective treatment in the outpatient setting due to mobility and caregiver limitations.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Prostate Cancer-Prostate Adenocarcinoma.
Treatment: Radiation Therapy.
The health plan denied the requested radiation therapy. 
The health plan's determination is overturned.

This is a male with a history of clinically localized intermediate risk adenocarcinoma of his prostate gland. He opted to proceed with a course of definitive external beam radiotherapy with curative intent. The request is for approval of 39 fractions of daily intensity modulated radiation therapy (IMRT).

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

Yes, the requested 39 fractions of IMRT are medically necessary for management of this patient's prostate cancer. Conventionally fractionated IMRT is widely utilized throughout the oncology community nationwide. Moderately hypofractionated IMRT (i.e., 28 fractions) is not proven to be superior in the patient's clinical setting, and there is a lack of high-quality mature data to confirm equivalent safety/efficacy in the long term, which is especially important for such a young man like this. Many experts would advocate that, given the patient's long-life expectancy, conventionally fractionated IMRT is the gold standard for a relatively young patient.

It is not appropriate to deny conventionally fractionated radiotherapy for management of localized prostate cancer, as this is supported by expert consensus national guidelines and numerous high quality prospective clinical outcomes published in the peer reviewed medical literature.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Back pain, opioid dependence.
Treatment: Suboxone.
The insurer denied the Suboxone.
The determination is upheld.


The patient was diagnosed with opioid dependence, in remission. The patient was prescribed Suboxone 8 milligrams (mg)/2 mg number (#) 20, 1 film per day reported to be continued therapy that was started over a year ago. It was noted that previous therapies attempted include Subutex 2 mg, which did not help the patient. The patient has a history of abusing tramadol and did well with Suboxone. The request for Suboxone was denied by the insurance carrier, citing that the nonformulary medication exception review policy states that the doctor must show that the patient has had serious side effects or drug failure with all formulary alternatives within this drug class. Formulary alternatives include buprenorphine tablets, nuprenorphine/naloxone film, Zubsolv which may work for this patient's condition.

An appeal form states that the patient has tried and failed buprenorphine, which was not effective. The patient is required to take brand-name.

A follow-up visit indicated that the patient presented for pain management. She has a history of a lumbar discectomy and was abusing tramadol to help control her lumbar pain, taking 50 mg, 10 tablets at a time, 3-4 times per day. The patient had seizures on 3 separate occasions from tramadol abuse. She was prescribed and buying Suboxone from the streets on and off in the past, which was therapeutic and tolerable. She tolerates Suboxone well and wants to continue it, currently stable on the regimen with over 50% benefit. The patient was prescribed Suboxone 8 mg/2 mg #20. It was noted the patient has a pain contract, a urine drug screen was appropriate. At issue is whether the formulary drug will be or has been ineffective, would be less effective as the non-formulary drug or would have adverse effects.

The formulary drugs buprenorphine/naloxone film (generic Suboxone) and Zubsolv would not be or have not been ineffective, would not be less effective as the non-formulary drug, Suboxone 8mg/2mg FILM or cause adverse effects. The provider states that the patient did well with Suboxone and previous therapy attempted included Subutex, which did not help the patient. An appeal letter states that the patient has tried and failed buprenorphine, which was not effective. However, Suboxone contains morphine as the primary ingredient with the additional ingredient of naloxone. There is no evidence to suggest that the generic version of buprenorphine/naloxone would not provide an equivalent effect. There is no documentation that the patient had serious side effects or drug failure with all formulary alternatives, including the generic version of buprenorphine/naloxone or Zubsolv, given that these medications contain the same ingredients as the requested brand-name Suboxone.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal-fracture.
Treatment: Inpatient Hospital. 
The insurer denied the inpatient stay. 
The denial is upheld.

The patient is a male who was riding a dirt bike and struck the back of a car at high speed. He was brought to the emergency department where evaluation and x-rays confirmed a right bi-condylar tibial plateau fracture. The patient has no significant medical history and sustained no loss of consciousness or any other associated injuries. The right tibial plateau fracture was a closed injury with no associated nerve or blood vessel injury. He was cleared for surgery on the right tibial plateau fracture from the trauma service. Orthopedic consultation was completed and a recommendation was made for open reduction and internal fixation surgery for the tibial plateau fracture. There was a concern for compartment syndrome in the right leg based on the mechanism of his injury and its severity; however, sequential physical examinations ruled out compartment syndrome and the surgery was subsequently completed. There were no documented complications of the operation and his lab values and vital signs remained stable. He was deemed stable for discharge home. At issue in this case is the medical necessity of the inpatient hospital stay.

The health plan's determination is upheld.

The requested health service/treatment of an inpatient hospital stay was not medically necessary for this patient. This determination is based upon the provided medical records, which do not document any complications of either the hospital stay or of the operation. The patient had normal vital signs and lab values during the entire hospital stay. In addition, the trauma service in this hospital cleared this patient for tibial plateau surgery and there was no evidence of compartment syndrome in the right leg, as documented. There was no clear rationale for the delay of this patient's surgery. The open reduction and internal fixation surgery completed on that date was consistent with the recommendations of the current, peer-reviewed orthopedic literature as documented by Unno and colleagues in the Journal of Orthopedic Trauma in 2017. The medical necessity of an inpatient hospital stay, however, is not established based on the supplied medical records. There were no documented complications of the surgery and there were no peri-operative complications documented for this patient. Thus, the inpatient hospital stay was not medically necessary. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System-Other-Bilateral Lung Transplant
Treatment: Diagnostic Testing-Respiratory Viral Panel
The health plan denied the Respiratory Viral panel as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

This patient has a bilateral lung transplant for cystic fibrosis (CF) complicated by bronchiolitis obliterans, hypertension (HTN), diabetes mellitus type 2 (DM2), chronic kidney disease (CKD), and basal cell cancer, who was undergoing bronchoscopy for surveillance in the setting of an asymptomatic worsening of pulmonary function test (PFT) values. Post-procedure chest x-ray (CXR) found a new, hazy left lower lobe (LLL) airspace opacity. A bronchoalveolar lavage (BAL) culture ultimately grew Pseudomonas, and levofloxacin was started.

The Infectious Agent Detection by Nucleic Acid (deoxyribonucleic acid (DNA) or ribonucleic acid (RNA)), Respiratory Virus Panel was medically necessary. He had worsening lung function without explanation. Society guidelines and standard of care documents would suggest using viral polymerase chain reaction (PCR) to help establish a diagnosis. Most documents suggest looking for a broad variety of viruses, with many listing at least 7-8 different varieties as a minimum number of varieties. Some studies used panels that looked at up to 19 viruses. Associations have been found between viral infection and acute rejection, and therapies are available for some of these infections. As such, a broader panel such as the one used in this case, was both medically necessary and supported by the literature as well as recommended within cited society guidelines and expert authors from UpToDate.

The patient had worsening PFTs, concerning for rejection. Guidelines would suggest evaluating for a variety of infections, including viral infections and that a broader based diagnostic approach with viral PCR is recommended. This would be required for diagnosis and to guide treatment. The cited guidelines below recommend a broad based viral assay, making this part of generally accepted standard of care. Such testing would be clinically appropriate, would not be for the patient's convenience, and obtaining this testing would not influence the setting.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: ADHD (attention deficit hyperactivity disorder).
Treatment: Formulary exception for Vyvanse 30MG OR CAPS, Pre-service
The insurer denied the Formulary exception for Vyvanse 30MG OR CAPS, Pre-service
The denial is overturned. 

The patient is a adult male diagnosed with attention deficit hyperactivity disorder (ADHD)-unspecified type several years ago. The patient has been prescribed Vyvanse 30 mg (milligrams) daily for up to two years with improved symptoms and functioning. The patient's prescribing clinician is requesting coverage for continued treatment with Vyvanse for the treatment of ADHD (attention deficit hyperactivity disorder). The patient was previously treated with Eveko (amphetamine sulfate tabs) at a dose of 15 mg (milligrams) twice daily without benefit and/or adverse effects causing tolerability problems.

The health plan denied coverage for continued use of Vyvanse indicating that Vyvanse is non-formulary. Formulary alternatives include generic formulations of Adderall XR (extended release), Strattera, Concerta, and Focalin XR (extended release). The health plan requires that formulary drugs must be tried and failed before authorization of a coverage exception for Vyvanse.

Yes, the health plan should cover the formulary exception for Vyvanse.
The service provided is in keeping with prevailing standards of medical practice for the condition under treatment in this case with an evidence-base treatment. The requested services/treatment being provided in this case is clinically appropriate, and is backed by credible scientific evidence known to benefit patients with the condition diagnosed in this case.

Vyvanse at a daily dosage of 20-70 mg (milligrams) daily for the treatment of attention deficit hyperactivity disorder (ADHD) is reasonable (30 mg [milligrams] daily dose in this case), in the patient's best interest, and consistent with prevailing standards of medical practice, as well as the FDA (United States Food and Drug Administration) indicated use for the treatment of ADHD (attention deficit hyperactivity disorder).

Specifically, in this case, the patient has been prescribed the requested treatment with Vyvanse 30 mg (milligrams) daily for two years in order to address symptoms of ADHD (attention deficit hyperactivity disorder). Thus, it is in the patient's best interest to continue to receive this medication that the clinician had determined provides clear therapeutic benefit, especially with respect to daily and social and occupational functioning.

In summary, the requested benefit with Vyvanse 30 mg (milligrams) daily is provided for the purpose of treating ADHD (attention deficit hyperactivity disorder), and is clinically appropriate and indicated. It is entirely consistent with nationally recognized scientific evidence and prevailing medical standards, and clinical guidelines and the scientific literature, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neurofibromatosis type 1.  
Treatment: Mektovi. 

The insurer denied Mektovi. 
The determination is upheld. 

The patient has neurofibromatosis type 1 (NF-1). He was diagnosed with this condition clinically, on the basis that he has multiple cafe au lait spots, inguinal and axillary freckling, and Lisch nodules on his iris. Therefore, he meets clinical criteria for NF-1. He also has a mass in his left orbit and left forehead. The mass displaces the left eye, is causing facial deformity, and threatens vision in the left eye. Based on magnetic resonance imaging (MRI) characteristics of the mass and on the fact that the patient has NF-1, the mass is most likely a plexiform neurofibroma. 

In an attempt to reduce the growth and size of the plexiform neurofibroma, the patient's neurologist has recommended treatment with Mektovi (binimetinib). The insurance company has denied coverage of the Mektovi on the basis that it is not medically necessary ant Mektovi is under review for medical necessity. 

The patient has a plexiform neurofibroma. Binimetinib (Mektovi) has not been shown to be safe and effective for the treatment of plexiform neurofibromas. 
Neurofibromatosis type 1 (NF-1) is an autosomal dominant genetic disorder characterized by multiple systemic findings that often involve overgrowths and neoplasms. One such overgrowth is the plexiform neurofibroma, a hamartoma consisting of multiple cell types that grows along peripheral nerves. In patients with NF-1, plexiform neurofibromas can occur anywhere in the body, but most commonly occur on the hand and face, where they can have serious cosmetic effects and can impair function. 

Clinical trials have shown that plexiform neurofibromas can be reduced in size through the administration of selumetinib, a mitogen activated protein kinase inhibitor (MEK inhibitor). Selumetinib is available only in solid form and cannot be administered in a liquid form. Binimetinib (Mektovi) is another MEK inhibitor and can be compounded into a liquid form. Thus, as a liquid, it could be administered to young children, like this patient, who cannot swallow solid tablets. However, binimetinib (Mektovi) has not been shown to be safe and effective for the treatment of plexiform neurofibromas. Binimetinib (Mektovi) has been shown to be safe and effective only for the treatment of cutaneous melanoma, glioma, meningioma, and astrocytoma. However, the patient not have any of those conditions. 

Therefore, binimetinib (Mektovi) cannot be considered medically necessary for the treatment of the patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease
Treatment: Increase Personal Care Aide (PCA) Services Level 2: For A Live-In Per Diem, 24 Hours Per Day- For A Total Of 7 Day (s) Per Week (the health plan approved 38.5 hours/week)
The insurer denied the Increase Personal Care Aide (PCA) Services Level 2: For A Live-In Per Diem, 24 Hours Per Day- For A Total Of 7 Day (s) Per Week (the health plan approved 38.5 hours/week)
The denial is overturned. 

The patient is a female with a history of Alzheimer's disease, Anxiety/Depression, Hypertension, Insomnia and Osteoarthritis. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of Live-In Per Diem, 24 Hours Per Day- For A Total Of 7 Day (s) Per Week Personal Assistance Services to offer increased ADL support.

The proposed treatment of Live-In Per Diem, 24 Hours Per Day- For A Total Of 7 Day (s) Per Week Personal Assistance Services is deemed medically necessary.

This is a female with a history of Alzheimer's disease, Anxiety/Depression, Hypertension, Insomnia and Osteoarthritis. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 
Recent correspondence from the patient's physician indicates that due to progressively worsening functional/cognitive decline and gait ataxia, the patient is now confused to person, place and time. She can no longer reliably recognize her daughter and does not recognize her daughter's home. She no longer remembers how to safety operate a microwave or stove. Consequently she is not eating meals routinely and often forgets to take her medications. Her gait is significantly deteriorated. Her balance continues to be poor and she suffers from low back pain, which affects her mobility. For these reasons, the currently approved plan of 38.5 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. Hence, the proposed treatment of Live-In Per Diem, 24 Hours Per Day- For A Total Of 7 Day (s) Per Week  is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits. 
The denial is overturned.

The patient is a female with a Class I malocclusion and anterior crossbite of #8-9. Teeth 8 and 9 have significant wear as a result of this crossbite. She has severe crowding in the maxilla and mandible. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. The subject under review is the medical necessity for braces and monthly visits x12.

The health plan's determination is overturned.

The requested treatment is medically necessary for this patient. This patient presents with an anterior crossbite and 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 These problems are much more time consuming and complicated to correct than the patient's current orthodontic problem.
The patient has significant maxillary crowding with teeth 8 and 9 in crossbite. These teeth already have restorative needs due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult.4 Further damage to 8 and 9 is likely without resolving the crossbite. Treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Heart Disease. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is the case of a male that presented to the hospital for elective cardiac catheterization with percutaneous coronary intervention. He had a past medical history of coronary artery bypass graft, diabetes mellitus, and hypertension. He was referred for catheterization following complaints of chest pain with exertion and a positive myocardial perfusion study.  Percutaneous coronary intervention to the first diagonal artery was successfully performed. No intra or peri-procedural complications were noted and the patient was discharged the following day. 

This patient presented for elective percutaneous revascularization. He underwent an uncomplicated procedure and was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between low risk patients that are discharged on the same day as compared to patients admitted to the hospital.(1-4) Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care.(4) In conclusion this patient could have been treated at a lower level of care. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.