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

Diagnosis: Multiple Myeloma in Relapse
Treatment: idecabtagene vicleucel 460MIL AUTO BCMA CAR+T (B-cell maturation antigen- targeted chimeric antigen receptor) 
The insurer has denied  idecabtagene vicleucel 460MIL AUTO BCMA CAR+T. 
The health plan's determination is overturned.

This is a male patient with a relapsed refractory multiple myeloma, immunoglobulin (IgA) kappa, and free Kappa who presented with multiple plasmacytomas and extensive cord compression, requiring radiation therapy (RT). The patient has undergone many lines of therapy, including Revlimid-Velcade-Dexamethasone (RVD), dexamethasone, cyclophosphamide, etoposide, and cisplatin (DCEP), Daratumumab-pomalidomide-Carfilzomib and Dexamethasone, Cisplatin, Doxorubicin, Cyclophosphamide, and Etoposide (D-PACE) with successful stem cell mobilization, Teclistamab, and Talquetamab. The treating hematologist is requesting anti-B cell maturation antigen (BCMA)-directed therapy, idecabtagene vicleucel.
The requested treatment is medically necessary.
 This patient is not refractory to anti-BCMA therapy, as previous exposure to teclistamab was limited to three cycles and there was clinical evidence of pseudoprogression. There is no clear evidence that this patient is refractory of anti-BCMA targeting therapy. Previous exposure to anti-BCMA therapy is not a contraindication to the use of idecabtagene.
Idecabtagene vicleucel (ABECMA) is a B-cell maturation antigen (BCMA)-directed genetically modified autologous T-cell immunotherapy indicated for the treatment of adult patients with relapsed or refractory multiple myeloma after four or more prior lines of therapy, including an immunomodulatory agent, a proteasome inhibitor, and an anti-cluster of differentiation (CD)38 monoclonal antibody.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, diabetes, coronary artery disease, muscle weakness, chronic pain, fatigue, and hyperlipidemia
Treatment: Increase Personal Care Services to 12 Hours A Day, 7 Days Per Week
The insurer denied: Increase Personal Care Services to 12 Hours A Day, 7 Days Per Week
The denial is overturned.

The patient is an elderly female. Her medical conditions include osteoarthritis, diabetes, coronary artery disease, muscle weakness, chronic pain, fatigue, and hyperlipidemia. Denial of increase personal care services to 12 hours a day, 7 days per week is being appealed. The health plan approved increase to 7 hours per day, 7 days per week. The patient's Uniform Assessment System (UAS) evaluation completed last month showed minimally impaired cognition and functional status requires maximal assistance to total dependence with all ADLs (activities of daily living), except extensive assistance with bed mobility and eating. She has bowel and bladder incontinence. A letter from the patient's niece reports the patient lives alone and has no children. She had a fall 2 months ago that resulted in a head wound. She is frail and now requires physical assistance to get out of the bed, on/off toilet, and with personal care. A letter from the patient's provider reports the request for additional services is needed for progressive functional and cognitive decline. The patient is unable to perform ADLs (activities of daily living) independently. She needs to be changed frequently due to urinary incontinence.

The requested Increase Personal Care Services to 12 Hours A Day, 7 Days Per Week is medically necessary. 

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 personal care services to 12 hours a day, 7 days per week is being appealed. The health plan approved increase to 7 hours per day, 7 days per week. This patient has multiple chronic conditions. She lives alone. Uniform Assessment System (UAS) evaluation completed last month shows the patient requires maximal assistance to total dependence with all ADLs (activities of daily living), except extensive assistance with bed mobility and eating. She has bowel and bladder incontinence. The appeal statements support the patient has progressive functional and cognitive decline and is dependent with all ADLs (activities of daily living). She requires frequent assistance with toileting due to urinary incontinence. This patient has significant physical limitations and needs significant assistance to complete ADLs (activities of daily living). The approved personal care services of 7 hours per day, 7 days per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase to 12 hours a day, 7 days per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis
Treatment: Stelara SQ 90 mg every 4 weeks
The insurer denied Stelara SQ 90 mg every 4 weeks
The determination is upheld.

The patient is a male with ulcerative colitis. He has failed corticosteroids (budesonide), mesalamine (Canasa), and infliximab (due to secondary nonresponse). He started Stelara, with subsequent improvement in symptoms. A colonoscopy showed multiple ileal ulcers, colitis in the right and transverse colon, and pseudopolyps. Fecal calprotectin was elevated at 547 micrograms per gram. At issue is the medical necessity of Stelara 90 milligrams (mg) every 4 weeks for the treatment of Ulcerative Colitis.

The request for Stelara 90 mg every 4 weeks is not medically necessary, as dosing every 6 weeks has not been attempted.
The patient has failed multiple conventional therapies, as well as infliximab; he then had improvement on Stelara [1-3]. Stelara has shown efficacy for the treatment of Ulcerative Colitis in a Phase III trial, UNIFI [1,4]. This trial demonstrated that a single intravenous dose of Stelara induced clinical remission in a significantly greater proportion of patients than placebo did, as measured by both clinical response and endoscopic response; this result was attained in a patient population which was 50% biologic-refractory. Recent studies have demonstrated that Stelara dose escalation is safe and well-tolerated for the treatment of inflammatory bowel disease, with recovery of effectiveness in patients with active disease [5-7]. A recent study showed that 43 percent (%) of Ulcerative Colitis patients on Stelara required dose escalation, and over 50% of those with dose escalation achieved corticosteroid-free remission, and long-term improvement in endoscopic inflammation [8]. In this case, the patient has Ulcerative Colitis, and has failed multiple guideline-recommended alternatives, with active disease symptoms and objective markers of active disease after initial response to Stelara. As the patient had initial improvement on Stelara with subsequent loss of response, a dose increase to Stelara 90 mg every 6 weeks is supported, but the lowest effective dose should be used to avoid adverse effects of off-label dose escalation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mobility issues. 
Treatment: One Day per Week of Social Day Care Service. 
The insurer denied One Day per Week of Social Day Care Service. 
The health plan's determination is upheld. 

The patient is a female with medical history notable for mobility issues and arthritis. The patient and her care team requested one day per week of social day care (SDC) service.
The patient provided a letter of support on her own behalf. The letter states that the patient does not have a home care attendant on Wednesdays and Thursdays. She is requesting SDC for Thursdays to allow her to be given the opportunity to socialize. She states that it is "very difficult for me mentally...I can't be alone for a long time."
The health plan states that SDC provides 4 hours of services and two meals. This would be a duplication of her current consumer directed personal care assistance services (CDPAS). 

One Day per Week of Social Day Care Service is not medically necessary for this patient.
The patient receives consumer directed personal care hours. She does not have any documented unmet personal care needs. The plan authorized one day per week of social day care if the patient was willing to have this in lieu of 4 hours per week of CDPAS. This is medically appropriate given that there was no documentation submitted regarding unmet personal care needs and the addition of SDC would be duplication of services. The patient may also adjust her CDPAS hours to allow them to fall on her current days off. There is insufficient documentation that the patient requires one day per week of social day care in addition to her current CDPAS hours.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Zepbound (tirzepatide). 
The insurer denied Zepbound (tirzepatide). 
The health plan's determination is upheld. 

The patient is a female diagnosed with obesity. She has a history of coronary artery disease (CAD), osteoporosis, hyperparathyroidism, and spinal issues. This request is for Zepbound. As reported, she tried Wegovy but had to stop due to severe diarrhea. Orlistat is contraindicated due to diarrhea. Qsymia is contraindicated due to CAD. Saxenda is not available due to a national shortage. 

A formulary exception is not indicated in this case. 
Tirzepatide in the form of Zepbound is Food and Drug Administration (FDA) approved for obesity treatment. It has been shown to be safe and effective in the treatment of obesity. The standard of care based on multiple societal guidelines recommends treatment with FDA approved treatments for obesity. It requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI (body mass index) of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension, and hyperlipidemia. 
The patient in this case is reported to have a contraindication to Qsymia due to CAD. The patient has failed Wegovy due to side effects. The patient is reported to be contraindicated to Orlistat due to side effects; however, the medical records do not support this. Lastly, the patient cannot try Saxenda due to a national shortage. 
There are no studies demonstrating the superiority of the requested medication over the preferred formulary alternative Orlistat. The patient can try Orlistat. It is not expected to be ineffective or have adverse reactions. The request does not meet the standard of care and a formulary exception is not indicated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Irritable Bowel Syndrome with Diarrhea
Treatment: Viberzi 75mg (milligram) Tablet
The insurer denied: Viberzi 75mg (milligram) Tablet
The denial is upheld.

The patient is an adult female with Irritable Bowel Syndrome with Diarrhea. Her physician is requesting treatment with Viberzi. Viberzi was denied, as the patient has not failed diphenoxylate/atropine and cholestyramine.

The health plan should not cover the proposed Viberzi.

Viberzi was denied, as the patient has not failed the plan preferred. diphenoxylate/atropine and cholestyramine. There is no medical literature to support that Viberzi is more effective than diphenoxylate/atropine and cholestyramine for the treatment of irritable bowel syndrome with diarrhea, or that the preferred agents would cause more adverse effects. Therefore, the health plan should not cover Viberzi.
Appeal type: Formulary Exception
Decision: Upheld

Digestive System.
Pharmacy/prescription drugs.

Diagnosis: irritable bowel syndrome, constipation-predominant.
Treatment: Motegrity.
The insurer denied Motegrity.
The health plan's determination is upheld. 

The patient is a female with irritable bowel syndrome, constipation-predominant. She has attempted Linzess, Miralax, Dulcolax, glycerin suppositories, and fiber. Motegrity is being requested for the treatment of irritable bowel syndrome, constipation-predominant. 

A formulary exception is not indicated in this case. The formulary drug lubiprostone has not been ineffective and would not necessarily have adverse effects. The American Gastroenterological Association guidelines for treating irritable bowel syndrome constipation-predominant recommend lubiprostone (Amitiza), but not Motegrity. Lubiprostone has shown safety and efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain. In a direct-controlled comparison, Motegrity has not demonstrated higher safety or efficacy than lubiprostone. Additionally, Motegrity is not Food and Drug Administration (FDA) -approved for the treatment of irritable bowel syndrome constipation-predominant. At the same time, lubiprostone is FDA-approved and effective for the treatment of irritable bowel syndrome constipation-predominant. For these reasons, Motegrity is not indicated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Pre-diabetes and obesity. 
Treatment: Mounjaro (tirzepatide). 
The insurer denied coverage for Mounjaro (tirzepatide). 
The denial is upheld. 
 
The formulary alternatives are Trulicity, Ozempic and Victoza. The patient has only failed Ozempic. The remaining formulary alternatives are likely to cause adverse reactions in the patient, as the patient does not have type 2 diabetes, which is the approved indication for the formulary alternatives.

The formulary alternatives are Trulicity, Ozempic and Victoza. The patient has only failed Ozempic due to side effects. The patient cannot try the remaining formulary alternatives as the patient does not have type 2 diabetes which is the Food and Drug Administration (FDA) approved indication of the formulary alternatives.

The requested medication Mounjaro (Tirzepatide) is FDA approved for the treatment of adults with type 2 diabetes (1-3).  It is a glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist. Tirzepatide in the form of Zepbound is FDA approved for obesity (4). There are no studies demonstrating the superiority of the requested therapy over the preferred formulary alternatives. 

The patient cannot try the remaining formulary alternatives as the patient does not have type 2 diabetes, which is an approved indication for the formulary alternatives. The patient is diagnosed with obesity. 

The requested therapy is not likely to be more effective than the formulary alternative. 

The request does not meet the standard of care. 

The formulary drugs are expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication. 

The formulary drug is not expected to be ineffective. 

The non formulary drug is expected to be more effective than the formulary alternatives but is not approved for the requested use. 

The carrier's denial of a request for a Formulary Exception for Mounjaro (Tirzepatide) to treat  prediabetes and obesity is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar fracture
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is overturned. 

The patient is a female with a history of a fall down the stairs and low back pain. She was found to have a mild superior endplate fracture of L (lumbar) 1. After imaging studies, neurosurgery recommended conservative therapy. The patient was admitted for pain control and discharged in stable condition. 

The inpatient hospital admission was medically necessary for this patient. The patient had an acute L1 compression fracture requiring pain management for severe back pain. The patient also had complaints of ankle pain. The patient could not have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer, dizziness, difficulty swallowing
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld. 

The patient is a female with a history of left breast invasive ductal carcinoma (IDC) with recent completion of chemotherapy and radiation therapy, chronic obstructive pulmonary disease (COPD), hypertension (HTN), depression, Xarelto for pulmonary embolism (PE) who presented with dizziness, odynophagia, nausea. She had swallowing difficulty and underwent an esophagogastroduodenoscopy (EGD) showing Schatzki's rings requiring endoscopic dilatation. She did have some bleeding following the dilatation and has had painful swallowing. She was offered a repeat endoscopy, but she declined it until she finishes her chemotherapy. In the emergency room (ER), she was hemodynamically stable and was not in acute distress. Her exam showed mild right chest wall tenderness.  An abdominal ultrasound (US) did not show any acute pathology. Computed tomography (CT) angiogram showed moderate right pleural effusion and patchy airspace disease. Deep vein thrombosis (DVT) was negative on a duplex scan. She was found to have a urinary tract infection (UTI) and was treated with intravenous (IV) ceftriaxone initially and then switched to oral cefpodoxime to complete 7 days of therapy. No inpatient intervention was planned and the patient was discharged with a plan to follow up with gastroenterology (GI) in the outpatient setting.
At issue is the medical necessity of inpatient admission.
The request for inpatient stay was not medically necessary for this patient. this patient. The patient had moderate anemia from gastrointestinal (GI) blood loss versus chemotherapy, was hemodynamically stable, had no sepsis or severe sepsis. She had no difficulty to take oral medications. The care provided to the patient was suitable for a lower level of care with subsequent transition to the outpatient settings.
The patient was hemodynamically stable. She had mild to moderate anemia in the setting of recent chemotherapy and possibly post-procedure bleeding in settings of hypo coagulation. She had stable hemoglobin and did not require frequent blood transfusions. She was appropriately treated with a proton pump inhibitor (PPI) and required non-urgent endoscopy in settings of hemodynamic stability as was eventually suggested for this patient [1,2]. She had a mild urinary tract infection (UTI) and was treated initially with intravenous (IV) antibiotics and then oral antibiotics. She did not need any IV antibiotics. She was hemodynamically stable. She had no sepsis or severe sepsis. She had no confusion, encephalopathy, hardware infection or difficulty taking oral medications. Her quick sequential organ failure assessment (qSOFA) was zero as well with very low morbidity and mortality risk [3,4]. Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: coronary artery disease
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a female who presented to the hospital for elective cardiac catheterization. Over the previous three to four months, she had experienced two episodes of exertional chest pain; a cardiac stress test was abnormal. Her past medical history was remarkable for hypertension and hyperlipidemia. She had a family history of premature atherosclerotic disease. The Cardiac catheterization revealed single vessel coronary artery disease. There was a significant stenosis in the right coronary artery that was treated with a stent. The procedure was uncomplicated. 

The inpatient hospital admission was not medically necessary.
This patient presented for elective cardiac catheterization. The procedure revealed single vessel disease in the right coronary artery that was successfully treated with a stent. While some period of observation immediately following percutaneous coronary intervention (PCI) is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, an inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. Per the 2018 update to this document, with the exception of patients with ST segment elevation myocardial infarction, most stable patients can be discharged post-PCI on the day of the procedure provided they are at their baseline functional and mental status and all of their baseline comorbidities are stable. This woman's procedure was uncomplicated and she had no post-procedure complications. An inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned



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

The patient is a female who has a Class II malocclusion with protrusive maxillary incisors. She has a 6-millimeter (mm) overjet and a 5 mm deep bite. She has moderate maxillary and mandibular crowding. She is treatment planned for orthodontics to correct this malocclusion but her insurance company rejected the claim on the basis that treatment is not medically necessary. At issue is the medical necessity of braces.

There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma.(1) Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. Additionally, overjets of 6 millimeters (mm) are shown to negatively affect the oral health quality of life of patients. (2) For these reasons, the treatment is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention-deficit/hyperactivity disorder (ADHD).
Treatment: Formulary exception for Adderall XR (extended release).

The insurer denied Formulary exception for Adderall XR.  The denial is overturned.

The patient is an adolescent female diagnosed with attention-deficit/hyperactivity disorder (ADHD). She also has Celiac disease. Her provider has recommended that she use the brand Adderall XR (extended release).

The health plan should cover the formulary exception for Adderall XR.

The patient has yet to try and fail formulary alternatives. However, the patient should not try the generic versions of the medication or other generic alternatives, as she has Celiac Disease. There is a risk of the patient having a negative reaction. Therefore, the health plan should cover the formulary exception for Adderall XR (extended release).