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

Diagnosis: Asthma; Upper Respiratory Infection.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld. 

This male patient has a history of asthma and presented to the Emergency Department (ED) with complaints of shortness of breath (SOB), cough and wheezing for about 2 days. The patient used albuterol at home but his symptoms were not responsive to treatment. In the ED, the patient denied fever, chills or chest pain. The patient's vital signs at presentation were: Temperature 98.3, Heart Rate 84, and Respiratory Rate 21, Blood Pressure 128/73, and Oxygen Saturation 97 % on Room Air. The patient was not in acute distress, non-toxic in appearing, and was not using accessory muscles. The patient did not appear to be in respiratory distress. The patient's lung exam revealed bilateral wheezing. Otherwise, the patient had a normal cardiovascular and neurological exam. The patient was alert and oriented. The patient was treated with bronchodilators via nebulizers, intravenous (IV) fluids, IV magnesium, and oral steroids. The patient's test for influenza was negative. The patient was admitted to the hospital with diagnosis of asthma exacerbation, and viral upper respiratory infection (URI). As per the History and Physical, the patient was still awake, alert, and not in acute distress. The patient remained afebrile with stable vital signs. The patient's oxygen saturation was 97% on room air and the patient was able to speak complete sentences without the use of accessory muscles or chest retractions. The patient's treatment was continued on oral steroids, bronchodilators via nebulizers, and he was started on inhaled corticosteroid (ICS) inhalers. The patient remained stable overnight after admission and was afebrile and hemodynamically stable the next day. The patient was not in acute distress and was tolerating oral medications. The patient was then discharged home.

Based on the review of the medical record and literature, this patient did not need acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatments initiated. This patient was afebrile and hemodynamically stable at initial presentation and throughout hospital stay. There is no documentation that this patient was in respiratory distress or was using accessory muscles to breath. The patient was not hypoxic and was saturating oxygen well on room air. The patient was able to speak in full sentences, and tolerate oral medication and treatments. This patient was stable for discharge after a period in observation status. The patient's symptoms were responsive to treatment and oral medications. The patient could have been discharged home after a period of observation on oral medications and inhalers, and with close follow-up in an outpatient setting.

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

Based on the above, the medical necessity for inpatient hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Stage IIIc T3 N1 M0 (stage 3 tumor, in lymph node - stage 1, not metastasized) Rectal Adenocarcinoma
Treatment: Proton Beam Radiation Therapy
The insurer denied the Proton Beam Radiation Therapy.
The denial is upheld. 

The patient is a male with a recent diagnosis of loco-regionally advanced rectal carcinoma.  Adjuvant chemotherapy and radiation therapy was recommended, and proton beam radiation therapy was requested.

No, the health plan should not cover the proposed treatment. 

No, there is insufficient clinical data from well conducted randomized trials showing that proton therapy is likely to be more beneficial than other standard treatment such as photon IMRT (Intensity-modulated radiotherapy).

In this case, the patient is male with a recent diagnosis of loco-regionally advanced rectal carcinoma.  Adjuvant chemotherapy and radiation therapy was recommended, and proton beam radiation therapy was requested.  

Proton beam radiation therapy is a type of very precise external radiation treatment in which protons are used to treat cancer and other conditions.  Compared to photon, a proton beam that is delivered with sufficient energy has a low "entrance dose."  A proton beam also has a high dose "Bragg peak" region, which is designed to cover the entire tumor and there is no "exit dose" beyond the tumor involved in proton radiation therapy.  Because of this unique property, proton beam therapy is highly successful in minimizing damage to normal tissue and surrounding organs, resulting in fewer side effects.  It is an FDA (Food and Drug Administration) approved procedure and it is not subject to IRB (Institutional Review Board) review.

Although proton beam radiation therapy has been shown to be safe and effective for certain tumors that are adjacent to critical structures such as CNS (central nervous system) lesion, there is insufficient clinical peer-review literature for supporting its use for the treatment of rectal carcinoma.  There are other established alternative available such as conventional conformal or IMRT (intensity-modulated radiotherapy) photon therapy that have been shown to be safe and effective for the adjuvant treatment of rectal cancers.  In this case, a proton/photon comparison plan was done.  The proton plan was able to reduce dose to the bowel, bladder and genitals, however, the doses to these structures were all within tolerance per Quantec limit and RTOG (Radiation Therapy Oncology Group) guideline for both the proton plan and photon plan.  In addition, according to the AP (attending physician), the requested regimen of 25 Gy (gray unit of radiation) in 5 fractions was based on the recommended regimen from RAPIDO (Rectal Cancer And Pre-operative Induction Therapy Followed by Dedicated Operation) trial.  However, proton therapy was not the radiation technique recommended in this trial.  Proton beam radiation therapy, therefore, has not been shown to be clinical superior compared to photon therapy in well conducted randomized trials.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Stage IIIc T3 N1 M0 (stage 3 tumor, in lymph node - stage 1, not metastasized) Rectal Adenocarcinoma
Treatment: Proton Beam Radiation Therapy
The insurer denied the Proton Beam Radiation Therapy.
The denial is upheld. 

The patient is a gentlemen with clinical Stage IIIC T3N1M0 (stage 3 tumor, in lymph node - stage 1, not metastasized) upper rectal adenocarcinoma. He was referred for neoadjuvant combined chemoradiotherapy.  

No, the health plan should not cover the proposed therapy. 

No, the proposed treatment would not be more beneficial than any standard treatment for this case.  

Even though proton therapy is technically superior than standard radiotherapy with IMRT (Intensity-modulated radiotherapy) or 3D (three dimensional) conformal therapy in terms of dose delivery and sparing of neighboring organs, this type of therapy has not been convincingly proven clinically to be more beneficial in terms of efficacy, toxicities and quality of life than the conventional radiotherapy. There is no scientific evidence to show that the recommended treatment will result in better health outcomes as compared to standard radiotherapy. There are retrospective reports on advantages of proton therapy in treating certain pelvic tumors, but the number of patients involved are small and most studies do not pertain to this case due to different type of cancer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee and Back Pain
Treatment: CDPAP services for a total amount of 56 hours per week
The insurer denied CDPAP services for a total amount of 56 hours per week.
The determination is upheld.

The patient has a past medical history significant for cervical disease, osteoarthritis, knee pain, lower back pain, migraines, hypertension and neuropathy.
Consumer Directed Personal Assistance Program (CDPAP) services 7 days a week 8 hours a day for a total of 56 hours a week. The patient has been approved for 28 hours a week.
At issue is the medical necessity of CDPAP services for a total of 56 hours per week.
The requested health service is not medically necessary for this patient. Additional CDPAP above 28 hours a week are not medically necessary. Her health plan denied services because the patient did not meet criteria. The patient requests an increase in CDPAP services secondary to chronic knee pain and needing assistance with personal needs including walking up and down stairs, transferring toileting. The patient complains of the following: She is independent for medication management. She requires set up for bed mobility and eating. She needs limited assistance for dressing upper and lower body, personal hygiene, bathing and toilet use. She requires extensive assistance for walking, locomotion and toilet transfer. However, she can complete most of the tasks herself. She needs maximal assistance for meal preparation. However, she can complete most of the task herself. She is totally dependent for housework. Time has been allotted for housework, laundry and meal preparation. She has a cane along with a walker and wheelchair to assist her with her needs. Based on a recent assessment 4 hours a day 7 days a week can safely meet her needs. Additionally an increase in service is not medically necessary.
The Uniform Assessment System (UAS) State of New York was reviewed. The tasking tool recommended 7 days a week of PCA services. A prior UAS State of New York was reviewed. The tasking tool recommended 5 days a week of PCA services. The physician progress note and the appeal from the patient was reviewed. The patient's functional needs did not change much from the initial evaluation compared to the evaluation done later in the year. The majority of the time allotted was for meal preparation and ordinary housework which did not change substantially. The patient needs limited assistance in other areas which also did not change. There were no other services noted which would necessitate additional medical need, noted in the appeal, uniform assessments (UAs) or physician progress notes.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Glaucoma. 
Treatment: Rhopressa. 

The insurer denied Rhopressa. The health plan's determination is overturned. 

The patient is a female with uncontrolled glaucoma of her right eye. She has been on more than three different classes of medications and is on three different medications at present with poor control. She has had eye pressure as high as 60 in her right eye. She already has visual field loss and thinning of her optic nerve. A sample of Rhopressa was used and noted to improve her intraocular pressure from 19 to 7 mmHg. Rhopressa is a Rho kinase inhibitor and is a newer class of medication for the treatment of glaucoma. 

A formulary exception is indicated in this case. 

The current formula medications helped to bring the intraocular pressure down from 60 to 19, however, the pressure needs to be lower to help prevent further visual field loss and optic nerve damage. The patient is already on three medications on formulary, but not under adequate control. A sample of Rhopressa was trialed and the pressure of the eye responded favorably by reducing her pressure from 19 to 7 mmHg. Rhopressa is a Food and Drug Administration (FDA) approved medication for the treatment of glaucoma and is a different class of medication that this patient was not on prior to a therapeutic trial. 

When multiple medications and three classes of drugs were used to help lower intraocular pressure are not enough to lower the intraocular pressure, then another class of drugs should be tried. Rhopressa is a newer class of medication to help lower intraocular pressure. It is reasonable to use this new class of drug when all others have been tried and the pressure is not down to target level. Rhopressa was shown to lower the pressure in this patient significantly and would help to reduce the risk of further visual loss.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Mental Health. 
Treatment: Pharmacy/Prescription Drugs. 

The insurer denied Vyvanse. 

The determination is overturned in whole. 

The patient is a male with history of attention deficit hyperactivity disorder (ADHD). The patient was initially diagnosed with ADHD following a comprehensive neuropsychological evaluation. He has had trials of multiple medications including Focalin extended release (XR), Strattera, and Adderall XR and has had found success with his current regimen of Vyvanse 20 milligrams (mg). The following review is evaluating whether formulary drugs of Adderall XR and methylphenidate ER would be as effective as the non-formulary drug Vyvanse. 

The patient has shown no benefit on methylphenidate extended release medications (Focalin XR) when he tried the medication. He had headaches and did not have improvement in focus and concentration. The patient has also had past trials of Adderall XR up to 10mg and had increased irritability, headaches and continued symptomatology. Given the above, the medical evidence supports the use of Vyvanse as he has failed methylphenidate based stimulant medications and has also failed a trial of Adderall XR. He has also failed trials of non-stimulant medications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dry Eyes
Treatment: Pharmacy/Prescription Drugs (Restasis)
The health plan denied the request for Restasis. 
The health plan's determination is overturned.

The patient is a female with a history of severe dry eyes. Exam demonstrates symblepharon, pannus, meibomian gland dysfunction and punctate epithelial erosions of the cornea. The patient is currently using preservative free artificial tears every five minutes. History of elevated intraocular pressure with use of topical steroids was a side effect in this patient. The request is for the use of Restasis for treatment of dry eye disease.

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

Yes. Restasis is used to treat chronic dry eye with decreased tear production due to inflammation. It can help increase the eyes' natural tear production with time. Patients using Restasis saw an increase in tear production. Because the patient has attempted aggressive artificial tear supplementation as well as topical steroids with suboptimal results, Restasis would be the next step in her treatment process.
This patient has severe dry eyes with damage noted to her cornea. She has punctate epithelial erosions and pannus formation on her cornea. The patient has been using artificial tears every five minutes with minimal effect. She was placed on topical steroids, however, she developed ocular hypertension due to steroid use. Because of the severity of her disease and risk of vision loss, Restasis would be the next logical step in treatment of her current dry eye disease. In this case Restasis would be medically necessary due to failed aggressive artificial tear supplementation as well as failed topical steroids due to unwanted side effects (ocular hypertension).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a past medical history significant for Hirschsprung's disease and past surgical history significant for a partial colectomy as well as ileostomy revision. The patient presented with abdominal pain, nausea, and hematochezia several days prior to admission. A computed tomography (CT) scan of the abdomen/pelvis demonstrated circumferential wall thickening from the transverse colon to rectum that was not seen on prior imaging. The patient was admitted to the hospital and hydrated; the diet was advanced as tolerated and the patient was stable for discharge to home later the same day with outpatient follow-up with his colorectal surgeon. At issue is whether an inpatient stay was medically necessary.

Inpatient care was not medically necessary.

The patient had abdominal pain with an abnormal CT scan and was appropriately watched to see if the symptoms worsened or improved. The symptoms improved and the patient's diet was advanced. The care provided (e.g. intravenous fluids, diet advancement) during this short period of time could have been provided at lower level of care. Therefore, an inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polyuria, polydisia, muscle cramps, and blurry vision
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with insulin-dependent diabetes, hypertension, and COPD (chronic obstructive pulmonary disease). He presented with polyuria, polydisia, muscle cramps, and blurry vision after not having taken insulin for two days.

The patient's glucose was 803 mg/dL (milligrams per deciliter), sodium 127, BUN (blood urea nitrogen) 34, creatinine 2.0, and venous pH (potential of hydrogen) 7.3. He was alert and oriented. His BP (blood pressure) was 102/57, and his heart rate was 65.

The patient was treated with intravenous fluids, potassium, and insulin. His creatinine improved to 1.3, CO2 (carbon dioxide) to 25, and glucose to 269 mg/dL (milligrams per deciliter).

The inpatient stay is the topic of this review.

No, the Inpatient admission was not medically necessary.

Patients with diabetic ketoacidosis can be safely managed in observation units unless they present with severe alteration of mental status or with critical illness such as sepsis [1], which is not documented in this case. This patient presented with hyperglycemia with known insulin-dependent diabetes. He had missed insulin therapy for two days. He presented with mild diabetic ketoacidosis with an initial pH (potential of hydrogen) of 7.3. His hyperglycemia quickly improved with intravenous hydration and insulin. He was hemodynamically stable. He had acute renal failure that quickly improved with hydration. This patient did not have alteration in his mental status, and the documentation does not support a diagnosis of hyperglycemic hyperosmolar syndrome. He was discharged the day after admission. Therefore, no, the proposed inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Kanjinti+Perjeta. 
The denial is overturned.

The patient is a female with a resected T2N1a, estrogen receptor (ER)+ (positive) breast cancer. By immunohistochemistry (IHC), the primary tumor was human epidermal growth factor receptor 2 (HER2)+ 3+. For reasons that are unclear, an OncotypeDX was sent that found the tumor to be HER2 negative. By fluorescence in situ hybridization (FISH), the HER2 was negative. The provider is concerned that the tumor is heterogeneous. Adjuvant trastuzumab (Kanjinti) and Perjeta has been recommended; this is under review for medical necessity.

The health plan's determination is overturned in whole.

Yes, the treatment of Kanjinti and Perjeta is medically necessary for this patient. This tumor may indeed be heterogeneous, but there is, at a minimum, a component that is HER2+ based on the IHC 3+ testing. American Society of Clinical Oncology (ASCO)/College of American Pathologists (CAP) guidelines, which are supported by the National Comprehensive Cancer Network (NCCN), and by the authors of UpToDate consider this tumor to be HER2+. In this clinical scenario, the NCCN recommends trastuzumab+Perjeta as an option for adjuvant therapy of breast cancer patients with resected node-positive disease. Given these factors, criteria for medical necessity of these agents have been satisfied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Allergic rhinitis with nasal polyps and severe persistent asthma.

Treatment: Dupixent.

The insurer denied coverage for Dupixent.

The denial is upheld. 

This is a female patient with a history of allergic rhinitis with nasal polyps and severe persistent asthma that has not been controlled despite treatment with Symbicort. She has also failed treatment with montelukast and fluticasone nasal spray for the rhinitis.  She has also had treatment with budesonide by nebulizer. She has required treatment with courses of oral corticosteroids.

"Current asthma guidelines recommend a control-based approach to management that involves assessment of impairment and risk followed by implementation of treatment strategies individualized according to the patient's needs and preferences. The fact that many patients still experience severe symptoms that negatively affect quality of life suggests that asthma control remains an objective to be achieved. Tools are available to help patients (and families) manage the day-to-day and short-term variability in asthma symptoms; however, when and how to implement a sustained step-up in therapy is less clear. The Asthma Yardstick is a comprehensive update on how to conduct a sustained step-up in asthma therapy for the patient with not well-controlled or poorly controlled asthma. Patient profiles and step-up strategies are based on current guidelines, newer data, and the authors' combined clinical experience and are intended to provide a practical and clinically meaningful guide toward the goal of well-controlled asthma for every patient. The development of this tool comes in response to the continued need to proactively address the sustained loss of asthma control at all levels of severity" (Chipps, B.E. et al. 2017).

"In patients with glucocorticoid-dependent severe asthma, dupilumab [Dupixent] treatment reduced oral glucocorticoid use while decreasing the rate of severe exacerbations and increasing the FEV1 [Forced expiratory volume in one second]. Transient eosinophilia was observed in approximately 1 in 7 dupilumab-treated patients" (Rabe, KF, et al. 2018).                                                       

Although the requested drug (Dupixent) has been effective, the preferred drugs have not been used with consistent compliance to base a determination that Dupixent is more effective. There is no evidence or documentation of adverse reaction to the preferred medications. The patient has used drugs similar preferred drugs without adverse reaction. 

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

The carrier's denial of Dupixent is upheld. The medical necessity is not substantiated.