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

Diagnosis: Breast Cancer
Treatment: Preservice for Initial Phase: 9 fractions (treatment sessions) of three dimensional (3D) conformal and Boost Phase: 1 fractions (treatment sessions) of 3D conformal

The insurer denied coverage for the preservice for Initial Phase: 9 fractions (treatment sessions) of three dimensional (3D) conformal and Boost Phase: 1 fractions (treatment sessions) of 3D conformal.
The denial is upheld. 

This is a female patient who underwent a left breast biopsy with findings consistent with grade 2 ductal carcinoma in situ (DCIS) and 98% estrogen receptor (ER)/ progesterone receptor (PR) positive that were spanning a large portion of her breast. The patient underwent a left breast partial mastectomy. The results revealed multifocal DCIS, which could not be measured. The superior margin was less than a millimeter (ml). She underwent re-excision of her left breast DCIS. The pathology revealed 1.3 centimeters (cm) of residual DCIS, with the final margins negative. The plan was for adjuvant radiation.

The preservice for Initial Phase: 9 fractions (treatment sessions) of three dimensional (3D) conformal and Boost Phase: 1 fraction (treatment sessions) of 3D conformal is not considered medically necessary for this patient. National Comprehensive Cancer Network (NCCN) Guidelines for breast cancer Version 6.2020 indicate that post-lumpectomy treatment can be delivered in 25 to 28 fractions or 15 to 16 fractions, with the preference for 15 to 16. A boost can be delivered in 4 to 8 fractions. The records provided indicate that the physician requested/treated with a 16-fraction plan. There is no information provided as to why a change to 25 fractions is better than 16. The 16-fraction regimen, while not mandatory, is sufficient and medically reasonable given no information to say why it is not adequate. 

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

Based on the above, the medical necessity of the preservice for Initial Phase: 9 fractions (treatment sessions) of 3D conformal and Boost Phase: 1 fractions (treatment sessions) of 3D conformal is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara injection 90 milligrams/milliliters (mg/ml) every 4 weeks

The insurer denied coverage for Stelara injection 90 milligrams/milliliters (mg/ml) every 4 weeks.
The denial is overturned. 

This is a female patient who has Crohn's disease involving the small and large intestine. She has used Remicade in the past. She had developed a flare of her disease and was started on Stelara more recently with maintenance every 8 weeks. She developed increased symptoms 6 weeks after the treatment. A colonoscopy showed a severely inflamed terminal ileum. In view of the severe inflammation in the terminal ileum and loss of response at the 6 week point, the physician has advised increasing the Stelara frequency to every 4 weeks.

Clinical Gastroenterology and Hepatology (2020) has an article titled "Effectiveness of Ustekinumab Dose Escalation in Patients with Crohn's Disease." The conclusion was that shortening the Ustekinumab [Stelara] 90 milligrams dose interval to every 4 weeks in Crohn's patients who did not respond to doses every 8 weeks, improved clinical and biological indices of disease activity. Similarly, Khorrami et al found that dose escalation including every 4 weeks at 90 milligrams was successful in improving patients. Patients who lose response to the standard dose of Ustekinumab might benefit from dose interval shortening which was effective and safe.

This patient has had Crohn's disease that has been resistant to multiple treatments. Stelara has helped but was not lasting for 8 weeks. The scientific peer-reviewed literature supports using Ustekinumab at 4 week interval dosing. 

The healthcare plan did not act reasonably or in the best interest of the interest of the patient. Stelara 90 milligrams/milliliters (mg/ml) every 4 weeks is medically necessary for this patient. 

Based on the above, the medical necessity for Stelara injection 90 milligrams/milliliters (mg/ml) every 4 weeks is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Basal cell carcinoma of the face.
Treatment: Superficial Radiation Therapy (SRT).
The insurer denied the Superficial Radiation Therapy (SRT).
The denial is overturned. 


The patient is a man with two basal cell carcinomas on the face (forehead and nasal sidewall) that would have resulted in a large surgical defect on the face. The patient chose superficial radiation therapy over Mohs surgery as the definitive treatment option.

Yes, the Superficial Radiation Therapy (SRT) was medically necessary.

Currently available treatments for non-melanoma skin cancers (NMSC), and specifically basal cell carcinoma, include destruction, surgery, photodynamic therapy, topical therapies, several energy-based therapies and various forms of radiation therapy (RT), although no specific treatment choice algorithm exists. In many cases, cure rates using radiation therapy (RT), and specifically superficial radiation therapy (SRT) for the treatment of melanoma skin cancer (MSC), are similar to surgical options. Cosmesis with appropriate energies and fractions might be superior to surgery for non-melanoma skin cancer (NMSC) in certain anatomic locations. Some anatomical areas are more suitable for treating non-melanoma skin cancer (NMSC) with superficial radiation therapy (SRT), including on the lower extremities below the knee and the nasal alar rim, ear, and perioral and periorbital areas. Some patients are more appropriate as candidates for treatment with superficial radiation therapy (SRT) based on local skin factors and comorbidities, especially patients who cannot be treated surgically due to advancing age, preexisting medical conditions, or patient preference. 

Superficial radiation therapy (SRT) should be the first option for treating appropriate types of non-melanoma skin cancer (NMSC) tumors in suitable patients, as cure rates are similar to most surgical options, and there exists superior cosmesis in certain anatomic locations. 

Therefore, given the above, the superficial radiation therapy (SRT) was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient has a Class II occlusion and moderate overbite. The maxillary arch has mild crowding, and the mandibular arch has mild spacing. He is treatment planned for 18-24 months of orthodontics to correct his malocclusion. At issue is the medical necessity of braces.

There is no medical reason to correct the patient's malocclusion with braces. He does have a deep bite, however, that alone is not a medical necessity to treat. The patient has some maxillary crowding. His bite is deep but there is no indication of damage to the incisors or the palate in the photographs, and his cephalometric radiograph shows the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided there is severe soft tissue damage (or any soft tissue damage); the photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. Therefore, the braces are not medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Class III malocclusion
Treatment: Comprehensive Orthodontic Treatment 
The insurer denied Comprehensive Orthodontic Treatment. The health plan's determination is overturned. 

The patient in question is a male with a Class III malocclusion, moderate crowding and anterior crossbite of teeth #7-#10. He is treatment planned for 24-30 months of orthodontics with extraction of teeth #21 and 28 to correct his malocclusion. This is the subject of this review.

The Comprehensive Orthodontic Treatment of the Adolescent Dentition and Periodic Orthodontic Treatment Visit (as Part of Contract) x 12 is medically necessary for this patient.
The patient has significant maxillary anterior crowding with teeth #7-#10 in crossbite. These teeth have a high risk for restorative problems in the future 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. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Otezla.
The insurer denied the Otezla. The denial is overturned. 

The patient is a woman with psoriasis affecting the arms, legs, abdomen and scalp for whom Otezla is requested. She has tried and failed multiple topical steroids.

Yes, the treatment with Otezla is medically necessary.

The patient has severe psoriasis of the scalp, arms, legs and trunk and has failed topical steroids. Phototherapy is not appropriate for sensitive areas (scalp) and impossible to safely obtain during the COVID-19 (Coronavirus disease) pandemic. Conventional systemic therapy (methotrexate, acitretin) has a side effect profile that is significantly worse than that of Otezla, with no efficacy benefit. Cyclosporine is not a reasonable long-term treatment for moderate to severe psoriasis due to their severe side effect profile.

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy (Celgene).  Otezla is an oral small molecule inhibitor of PDE4 specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis (Celgene). 

The patient has moderate to severe psoriasis for which therapy with Otezla is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headache
Treatment: Trokendi XR (extended release) 200 milligram (MG) CAP
The insurer denied the Trokendi XR (extended release) 200MG CAP. 
The denial is upheld. 

The patient is a female with migraine headache disorder. Her provider is requesting topiramate XR (extended release) for migraine prevention. She has tried and failed topiramate IR (immediate release).

No, the treatment with Trokendi XR (extended release) is not medically necessary.

Although the patient has tried and failed topiramate IR (immediate release), there is no documented reason provided as to why the patient cannot be treated with the preferred agent topiramate ER (extended release). This medication works via the same mechanism as the requested medication and is considered a standard-of-care treatment option for migraine prevention. There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of topiramate XR (extended release) relative to the preferred topiramate ER (extended release).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: History of atrial fibrillation, hypertension, dyslipidemia, CAD (coronary artery disease), status post AF (atrial fibrillation) ablation
Treatment: Watchman LAA (left atrial appendage) occlusion device 
The insurer denied the Watchman LAA (left atrial appendage) occlusion device.
The denial is upheld. 

The patient is an male with a past medical history of atrial fibrillation, hypertension, dyslipidemia, CAD (coronary artery disease), status post AF (atrial fibrillation) ablation with pulmonary vein isolation, in NSR (normal sinus rhythm), status post ILR (implantable loop recorder) with no recurrent AF (atrial fibrillation) episodes detected. The patient has been managed with Eliquis for primary prevention of thrombotic complications. There is no history of significant bleeding, GI (gastrointestinal) bleeds, traumatic falls, intracranial hemorrhage, etc. (et cetera). 

The patient had been at times non-complaint with the anticoagulation. As per the record, he did not renew his prescription at the pharmacy during his September office visit.  The use of Watchman LAA (left atrial appendage) occlusion device was requested by the treating physician. 

No, the Watchman device is not medically necessary.

The patient has a history of paroxysmal atrial fibrillation, status post ablation, and is currently on chronic anticoagulation with Eliquis. His CHADS-VASC (congestive heart failure, hypertension, age >= 75, diabetes mellitus, prior stroke or TIA or thromboembolism, vascular disease, age 65-74, sex category) score is elevated, and thus he is a candidate for continued anticoagulation. There are no documented bleeding episodes. There is no history of coagulopathy. He has no history of intracranial hemorrhage, GI (gastrointestinal) bleeding, etc. (et cetera). There is no history of renal dysfunction, liver dysfunction, major bleeding, or alcohol use. There is no documented contraindication to the use of anticoagulation. There have been episodes of non-compliance documented, with no documented history of interventions to improve medication compliance.

Watchman LAA (left atrial appendage) occlusion device has been shown to be non-inferior to Warfarin in clinical trials in terms of ischemic CVA (cerebrovascular accident) prevention and is considered a reasonable alternative in patients with non-valvular atrial fibrillation, who are not candidates for anticoagulation. The strategy of using LAA (left atrial appendage) occlusion devices for CVA (cerebrovascular accident) prevention in patients with no direct contraindications to anticoagulation is not currently considered to be the standard of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes.
Treatment: Humalog (Kwikpen).

The insurer denied Humalog. The health plan's determination is upheld. 

This patient is a male diagnosed with T1DM (type I diabetes mellitus). As reported, he is on Humalog 10 units 3 times per day; and Lantus. He was initially on glyburide with some improvement. He was misdiagnosed as T2 DM (type II diabetes mellitus) until he saw an Endocrinologist and he had positive antibodies. He was started on metformin and insulin. He was on Novolog; metformin 850 mg and Lantus. His Hemoglobin A1C were 9.9 %; 7.7 %; and  7 %. He was switched from NovoLog to Humalog. There is no clear reason given despite the fact that the patient had an A1c at goal on NovoLog.
Under review is the use of Humalog (Kwikpen).

The requested medication is Humalog (Kwikpen). There are no studies demonstrating the superiority of one rapid acting insulin analog over another. The formulary drug NovoLog has been effective and has not had adverse side effects. The other formulary drug Apidra is expected to be as effective as Humalog. Adverse effects are expected to be similar between the two drugs. Therefore, a formulary exception in this case is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Parkinson's Disease.
Treatment:  Personal care aide (PCA) a total of 168 hours per week; Level 2, 12 hours per day -7 days per week; 12 hours per day 7 day per split shift.

The insurer denied the Personal care aide (PCA) a total of 168 hours per week; Level 2, 12 hours per day -7 days per week; 12 hours per day 7 day per split shift.  The denial is overturned. 

The patient is a male with a history of Parkinson's disease, chronic low back pain and associated gait ataxia.  Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).  Appeal review requested for potential approval of 168 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the proposed treatment of 168 hours/week Personal Assistance Services is deemed medically necessary. 

This is a male with a history of Parkinson's disease, chronic low back pain and associated gait ataxia.  Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs).  Recent documentation from the patient's healthcare provider indicates that due to progressively worsening functional decline, the patient is currently max assist and dependent on full support for completion of his ADLs (activities of daily living), toileting, gait mobility and feeding.  Hence, the currently approved plan of Personal Assistance Services is insufficient to meet the patient's current needs.  For these reasons, the proposed treatment 168 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dizziness post cochlear implant
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male who underwent elective second stage or right cochlear implant surgery with tissue graft and suffered post-operative dizziness.  He was admitted post-operatively for this dizziness.  Management included antibiotics, fluids, anti-nausea medicines and radiological studies.  The patient was discharged on POD (postoperative day) #2 when the patient was stable enough for discharge.  The issue under review is the hospital admission for dizziness after the surgical procedure. 

Yes, the Inpatient Admission was medically necessary.

The medical records document the vertigo and nausea associated with the cochlear implant.  These are known risks for this surgery (1-3). When these occur, the individual requires inpatient supportive care including IV (intravenous) fluids as well as medicines to control the dizziness. In addition, the individual must be watched for signs of meningitis.

Admission should have been authorized. In the published MCG (Milliman Care Guidelines) 24th edition, Admission is authorized post-operatively after ambulatory surgery for inadequate phsyiologic recovery or inability to return to appropriate level of activity.  Both of these criteria were met in this patient's situation. Therefore, given the above, the Inpatient Admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vaginal laceration during hysteroscopy
Treatment: Laparoscopic Surgical Procedure 
The insurer denied the Laparoscopic Surgical Procedure. 
The denial is overturned. 

The patient is a female who underwent a hysteroscopy for a uterine polyp. The procedure was complicated by a posterior vaginal laceration that was repaired. However, because the laceration extended into the peritoneal cavity and because of concern about organ damage, the gynecologic oncologist was called and performed a laparoscopy. 

Yes, based on the submitted information, the proposed treatment was medically necessary.

The patient had a vaginal laceration that was repaired vaginally. However, evaluation revealed a large laceration from 3 o'clock to 8 o'clock with central communication to the peritoneal cavity and bowel and omentum visualized. In other words, there was significant concern about a bladder, bowel or ureteral injury and a diagnostic laparoscopy was medically necessary to ascertain the degree of damage and repair it if needed.

Therefore, based on the submitted information, the laparoscopy was medically necessary.

In addition, per the Plan language: 
Medically Necessary/Medical Necessity
Health care services that We determine a Provider exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an Illness, Injury, disease or its symptoms, and that We determine are:
- In accordance with generally accepted standards of medical practice MET. While a vaginal laceration or a colpotomy are usually repaired vaginally, there was concern since the laceration has entered the peritoneal cavity about a bowel, bladder or ureteral injury. 
- Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's Illness, Injury or disease MET.
- Not primarily for the convenience of the patient, Physician, or other health care Provider MET.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic procedure. 
The insurer denied braces and monthly visits. 
The denial is upheld in whole.

The patient is a female with Skeletal Class II malocclusion. There is moderate maxillary crowding and mild mandibular crowding. She has a mild overjet and mild overbite. The subject to be determined is the medical necessity for braces and monthly visits.

No, the requested treatment of braces and monthly visits is not medically necessary for this patient. Using the Handicapping Labio-Lingual Deviations (HLD) index, which is the standard of care scoring system to determine medical necessity for the treatment, the malocclusion in this case is a 22 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 malocclusion in question does not meet the standard of care criteria to be classified as handicapping and the requested treatment would not be considered medically necessary in this case.
Thus, braces and monthly visits are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory. 
Inpatient hospital. 

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

The patient is a woman with a history of uterine leiomyoma complicated by menorrhagia and iron deficiency anemia and chronic alcohol use who was brought by Emergency Medical Services (EMS) to the emergency department (ED) with syncopal episode. The patient's husband reported that she was cooking and then fell on the ground and moved her extremities spontaneously. 

The Inpatient Hospital Stay was not medically necessary for this patient. The patient presented with a syncopal episode. Her vital signs, labs and diagnostic tests were normal. She was monitored in the hospital and her condition remained stable. There were no cardiac arrhythmia, hemodynamic instability, neurological abnormalities or evidence of blood loss. The patient was discharged with diagnosis of vasovagal syncope.
The patient's condition and level of care provided to her did not meet inpatient admission level of care. A lower level of care would be more appropriate.