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

Diagnosis: Type 2 diabetes mellitus, hyperlipidemia, prostate cancer, and acute hypoxic respiratory failure and encephalopathy, secondary to COVID19 (2019 Novel Coronavirus) pneumonia

Treatment: skilled nursing facility (SNF) long-term custodial care

The insurer denied coverage for skilled nursing facility (SNF) long-term custodial care

The denial is overturned.

The patient has multiple medical problems including diabetes mellitus and prostate cancer.  He developed acute respiratory failure and encephalopathy due to COVID pneumonia.  He received care at an SNF (including physical and occupational therapy).  Under review is the medical necessity of skilled nursing facility (SNF) long term custodial care.

The insurer indicated the criteria for approval were not met as they did not receive completed necessary forms indicating need for "permanent placement" at a nursing facility, or documentation indicating that the patient/family agreed to a permanent placement plan.  However, the generally accepted clinical criteria indicate patients require either hands on assistance with activities of daily living (ADLs)/mobility or cognitive deficits with supervision/cueing for ADLs.  His cognitive deficits had resolved prior to admission to the skilled nursing facility (SNF).  For the time under review, the patient required assistance for activities of daily living, including dressing and toileting.  He also required assistance for transfer activities and ambulation.  He made an excellent functional recovery and was appropriately discharged.    

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical probability, the skilled nursing facility (SNF) long term custodial care was medically necessary.

The insurer's denial of coverage for skilled nursing facility (SNF) long-term custodial care is reversed. Medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Multiple Relapsed Neuroblastoma
Treatment: Treatment Regimen (ifosfamide, carboplatin, etoposide, dinutuximab, and sargramostim) (Pre-Service)
The insurer denied the Treatment Regimen (ifosfamide, carboplatin, etoposide, dinutuximab, and sargramostim) (Pre-Service)
The denial is upheld.

The patient in this case is a male with relapsed neuroblastoma. He was initially diagnosed and has had multiple prior treatments since that time. These included combination chemotherapy regimens as well as experimental therapies. Most recently, he was treated with ifosfamide, carboplatin, etoposide, and dinutuximab along with sargramostim.

No, the health plan should not cover the proposed treatment with ifosfamide, carboplatin, etoposide, dinutuximab, and sargramostim.
The combination of ICE chemotherapy (ifosfamide, carboplatin, etoposide) with dinutuximab and sargramostim has not been reported as safe and effective in any published clinical trial. Dinutuximab is currently Food and Drug Administration (FDA) approved for use in the treatment of relapsed/refractory neuroblastoma in combination with sargramostim, interleukin-2 and 13-cis-retinoic acid.  It has been studied in combination with chemotherapy, notably with the combination of irinotecan and temozolomide.  However, there is no evidence supporting use in combination with ICE (ifosfamide, carboplatin, etoposide) chemotherapy.  Given the lack of any supporting evidence, this treatment should not be covered.

No, the requested treatment with ifosfamide, carboplatin, etoposide, dinutuximab, and sargramostim is not more beneficial than any standard treatment for the patient's condition.
As noted above, there is no evidence detailing the safety and efficacy of this specific treatment combination.  Therefore, it cannot be concluded that this requested health service is more beneficial than any standard treatment for this patient's condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Multiple Relapsed Neuroblastoma
Treatment: Treatment Regimen (ifosfamide, carboplatin, etoposide, dinutuximab, and sargramostim) (Pre-Service)
The insurer denied the Treatment Regimen (ifosfamide, carboplatin, etoposide, dinutuximab, and sargramostim) (Pre-Service)
The denial is overturned. 

The patient is a male who was diagnosed with metastatic neuroblastoma. He has been treated with multiple chemotherapy regimens including standard chemotherapy, humanized 3F8 monoclonal antibody (Hu3F8), vincristine, cyclophosphamide, irinotecan, low dose ifosfamide, toposide, carboplatin, Bivalent vaccine, and multiple other chemotherapy regimens. The provider is recommending treatment with dinutuximab, granulocyte-macrophage colony stimulating factor (GMCSF) and chemotherapy with ifosfamide, carboplatin and etoposide.

Yes, the health plan should cover the proposed treatment with ifosfamide, carboplatin, etoposide, dinutuximab, and sargramostim.
Most children with neuroblastoma present with metastatic disease and/or high-risk features. Despite multimodal intensive induction and consolidation therapy that provides responses for approximately 80% of patients, fewer than 40% of patients with high-risk disease are cured. The majority of responding patients eventually die from recurrent disease, indicating that they still harbor viable neuroblastoma after front-line therapy.  

Dinutuximab in combination with chemotherapy has been shown to be effective in the treatment of refractory neuroblastoma. Ifosfamide, etoposide and carboplatin is a known effective regimen and its combination with dinutuximab would be a reasonable treatment option for this patient that has failed all known effective chemotherapy for neuroblastoma.

Yes, the requested treatment with ifosfamide, carboplatin, etoposide, dinutuximab, and sargramostim is more beneficial as there is currently no standard of care as to the management of patients with relapsed neuroblastoma after this many regimens.
There are no other known curative regimens for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Herpes simplex viruses type 1 and type 2. 

Treatment: Zovirax 5% (present) ointment. 

The insurer denied coverage for Zovirax 5% ointment. 

The denial is upheld. 

The patient was prescribed Zovirax 5% ointment by her medical provider for long standing diagnosis of recurrent genital herpes simplex and recurrent oral herpes simplex. 

As per the patient's provider the patient has used Zovirax 5% in the past with success. The provider note also states that the patient experienced nausea, abdominal cramping and abdominal upset when she used the generic Acyclovir ointment. 

As per documentation provided the patient reported similar complaints while using any generic medication. She is on multiple medications and has the same reported side effects from use of all of these. 

There are multiple generic manufacturers who make Acyclovir 5% ointment. The patient can be prescribed any of them. There is no difference in efficacy between the generic and brand name product as they are the exact same medication and have the same formulation. 

Based on documentation provided denial of Zovirax 5% is not medically necessary. 

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

The insurer's denial of coverage for the medication Zovirax 5% ointment is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lung cancer
Treatment: Guardant 360 testing
The insurer denied Guardant 360 testing. The health plan's determination is upheld. 

The patient is a woman diagnosed with stage IV non-small cell lung cancer. She has metastases to brain, liver and left supraclavicular lymph nodes. The diagnosis was established via EBUS (endobronchial ultrasound) with + (positive) 4 lymph node for adenocarcinoma as well as level 7 at subcarina. Liver biopsy also confirmed the diagnosis. Treatment with carboplatin/alimta/Keytruda was started.

The Guardant360 laboratory testing is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The National Comprehensive Cancer Network (NCCN) guidelines recommend molecular testing for advanced cases of non-small cell lung cancer to assist in determining systemic therapy options. Tissue based testing is recommended.

The use of cell-free/circulating tumor deoxyribonucleic acid (DNA) testing should not be used in lieu of a tissue diagnosis. Studies have revealed false negative rates up to 30% with such assays. Standard of analytical performance characteristics of cell-free tumor DNA have not been established and no guidelines exist regarding the recommended performance characteristics of this type of testing. This sort of testing can identify alterations that are unrelated to a lesion of interest.

The use of this type of testing may be used if the patient is medically unfit for invasive tissue sampling or if there is insufficient material for molecular analysis. These scenarios are not present in this case.
There are no data from randomized, controlled clinical trials that demonstrate a survival benefit when such testing is used for selecting molecularly targeted agents based on such testing compared to the agents as recommended by NCCN by standard molecular markers outlined above.
Therefore, the use of this assay is not likely to be more beneficial than standard treatment in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lung cancer
Treatment: Guardant 360 testing
The insurer denied Guardant 360 testing. The health plan's determination is upheld. 

The patient is a female with diagnosis of stage IV Non-small cell lung cancer, adenocarcinoma, with brain, liver and left supraclavicular node metastasis. She has received therapy with Carboplatin, Pemetrexed and Pembrolizumab.

She has also received treatment with stereotactic brain radiation and palliative radiation therapy to mediastinum. After completion of three cycles of chemotherapy and immunotherapy, a computed tomography (CT) scan revealed progressive supraclavicular lymphadenopathy and new liver metastasis. Guardant 360 molecular profiling was ordered to identify targetable genomic alteration for potential treatment option.

The Guardant360 Laboratory Testing is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Guardant 360 testing is not indicated in this particular patient as she already has comprehensive profiling performed by FoundationOne (a tissue based test). The patient has no known targetable molecular alterations and therefore did not receive targeted therapy.

Although initial testing has now become standard practice and recommended by National Comprehensive Cancer Network (NCCN), American Society of Clinical oncology (ASCO) and European Society of Medical Oncology (ESMO) guidelines, repeat testing for comprehensive molecular profiling remains experimental (particularly patients who do not harbor known actionable mutations).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Lung cancer
Treatment: Guardant 360 testing
The insurer denied Guardant 360 testing. The health plan's determination is upheld. 

This is a female with metastatic non-small cell lung cancer. The patient has been treated with radiation, carboplatin+pemetrexed+pembrolizumab. Guardant360 Laboratory Testing was obtained at diagnosis. The Guardant360 Assay is under review.

The Guardant360 Laboratory Testing is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Complicating the role of liquid biopsies if that their results are limited in sensitivity to between 60 and 80 percent. The limited sensitivity of liquid biopsies is thought to reflect the biology that some cancers do not shed deoxyribonucleic acid (DNA) into the bloodstream rather than a feature of any given assay. However, mutation detection in blood has been associated with more advanced disease characteristics, including worsened performance status and prognosis and the presence of more metastatic sites. A second limitation of liquid biopsies is that the types of studies have a higher chance of being falsely negative compared with traditional biopsies, given the minuscule and variable amounts of DNA that tumors may shed into circulation. Finally, tests for programmed death-ligand 1 (PD-L1) expression cannot be conducted on liquid biopsies. For these reasons, the use of both tissue (FoundationOne) and liquid (Guardant360) is not known to be beneficial and is not recommended in national guideline nor by the authors of UpToDate.

Since there was an adequate specimen for tissue-based testing, there is a paucity of evidence that liquid biopsy testing (Guardant360) would provide additional information to improve this patient's care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: substantial functional impairment due to neurologic condition

Treatment: HHA (home health aide) services to 12 hours per day, 7 days per week

The insurer is denied coverage for HHA services to 12 hours per day, 7 days per week.

The denial is overturned. 

This female patient has a history of a cerebrovascular accident (CVA), ataxia related to CVA, general body weakness, right sided weakness, hypertension and depression.


Based on the information provided for review from the neurologist, UAS (Uniform Assessment System) nurse and patient's sister, it is apparent that the patient has substantial functional impairment for ADLs (Activities of daily living), including mobility (transfers and walking) and all toileting related tasks. The patient has had falls and episodes of incontinence when she is alone, as she cannot safely transfer and walk, and she cannot safely use the commode or toilet without assistance. If there is potential for improvement with rehabilitation services and adaptive equipment this would be beneficial for the patient. However, the recommendation of HHA hours for this external appeal is based on the patient's functional status as described in the records provided for review. It is medically necessary and in the patient's best interest to increase caregiver assistance for a longer period of time each day to help the patient with out-of-bed mobility and toileting related tasks later into the evening. 

The only informal caregiver identified in the UAS is the patient's sister. Her address on her letter indicates she does not live near the patient, and it is not known whether she could provide the level of care the patient needs, even if she were closer. As per NYS regulations for personal care services, assistance from informal caregivers is voluntary. Considering the patient is requesting HHA services 12 hours per day, 7 days per week, it is reasonable to conclude that there are no informal caregivers who can provide care for an additional 2 hours per day (current HHA services is 10 hours per day). When informal caregivers are unable to provide necessary care on a regular basis, then personal care services are indicated to provide assistance with ADLs and IADLs when needed throughout the day.

The additional hours of HHA services in the evening will give the patient the opportunity to safely participate in out-of-bed activity for a longer period of time each day with the assistance of the HHA; and provide assistance so that she can safely use the toilet or commode up until a later time in the evening before she goes to bed. 

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the  HHA services to 12 hours per day, 7 days per week is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary retention, status post hemorrhoidectomy
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient had under gone a hemorrhoidectomy. She presented to the emergency department the following day with suprapubic tenderness and the inability to urinate. Her vital signs demonstrated tachycardia. The white blood cell (WBC) count was 9.5. The hemoglobin (Hgb) was 8.0. A Foley catheter was placed, which returned 300 milliliters (ml) of urine. She was given a 1 liter (L) bolus. She was hospitalized for urinary retention, nausea, and vomiting. The next day, the patient was voiding on her own. She was complaining of pain at the surgical site. The surgical team felt she could likely go home that day, but she was kept an additional day. 

At issue is the medical necessity of an inpatient stay.

Inpatient hospital admission was not medically necessary for this patient. The patient had nausea, vomiting, and urinary retention, but did not have evidence of other complications. The patient did not have any evidence of active comorbidities requiring inpatient management or evidence of significant complications. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The patient did not have complex testing or therapy other than surgery that would have required an inpatient level of care. The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Kidney Stone.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a female with history of stones who presented with right sided abdominal pain, radiating diffusely to the groin, very severe with computed tomography (CT) of abdomen demonstrating right distal two millimeter (mm) stone. The patient had persistent nausea and pain; she received six intravenous (IV) doses of Dilaudid and two liters of normal saline and could not get comfortable (intractable pain) and felt nauseous. Creatinine was normal at 0.79.  Blood urea nitrogen (BUN) was 17. The patient did not have fever.  Her vital signs were stable. 

The patient was admitted for hydration and pain control, and was made nothing by mouth (NPO) after midnight. The patient has history of Hashimoto's thyroiditis and asthma.  During the admission, the patient passed the stone and resumed oral intake and was discharged to home.

Yes, the proposed inpatient admission was medically necessary.
This patient presented to the emergency department (ED) with severe pain that was refractory to six doses of intravenous Dilaudid.  She had persistent nausea and received two liters of intravenous fluids in the emergency department (ED) for an obstructing two millimeter distal ureteral stone. She met the clinical indications for admission to inpatient care as the patient was noted to have "severe pain requiring acute inpatient management" and the patient needed "IV hydration despite observational care treatment".  Severe pain is a recognized predictor of need for admission in the literature and thus admission for pain control would be considered standard of care.

This patient presented with severe renal colic and had a computed tomography (CT) scan demonstrating a two millimeter obstructing stone (hydronephrosis present).  She was unable to become comfortable in the emergency room despite six intravenous doses of Dilaudid and had persistent nausea despite receiving two liters of intravenous fluid. The patient's severe pain is a clinical indication for admission to inpatient care as well as the fact that the patient remained nauseous requiring acute inpatient management. The denial indicated that the patient did not meet the criteria due to the lack of hemodynamic instability, renal failure or bilateral obstruction but failed to note that to meet the criteria for admission to inpatient care one or more of the criteria must be met for which the patient is noted to have met two criteria. The appeal request notes that the patient met these criteria.  The literature supports that uncontrolled pain is a predictor of hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cirrhosis
Treatment inpatient hospital admission
The insurer denied coverage for inpatient hospital admission
The denial is upheld

The patient presented with abdominal pain and vomiting. He had a recent admission for acute pancreatitis. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. A computed axial tomography (CAT) scan showed cirrhosis, cholelithiasis, and a dilated common bile duct. He had a history of substance abuse and was on Methadone. There was also a history of drug seeking behavior. Intravenous (IV) hydration, proton pump inhibitor (PPI) therapy and pain medications were given. Labs were remarkable for pancytopenia. There was a plan to do a magnetic resonance cholangiopancreatography (MRCP). The patient eloped (left the hospital without having been discharged).

Milliman Care Guidelines Clinical indication for admission for Undiagnosed Abdominal Pain (M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

Clinical indication for admission for Gallbladder or Bile Duct Inflammation or Stone (M-555) include having acute cholecystitis or acute cholangitis. He did not have these conditions. He also did not have a calculus or duct obstruction causing hemodynamic instability, severe vomiting, severe dehydration, or severe pain not responding to analgesics.

The patient had cirrhosis and required a workup for bile duct dilatation. He did not have evidence of a severe acute infection. The MRCP could have been done on an outpatient basis. IV hydration, PPI therapy, and antiemetics could have been given in the emergency room (ER) as an outpatient. He did not meet MCG Criteria admission for either undiagnosed abdominal pain or bile duct inflammation or stone. 

The healthcare plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

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