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

Diagnosis: Periapical inflammatory disease
Treatment: D6010 Implant Placement for tooth #27
The insurer denied coverage for: D6010 Implant Placement for tooth #27
The denial is: Upheld
Based on review of the submitted documentation which includes copy of periapical radiographs, full mouth series radiographs, dental treatment/progress notes of varying dates with several doctors, periodontal charting, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment. The dentists recommended endosteal implant in area #27, having deemed #27 non maintainable due to caries and periapical inflammatory disease. The insurer has denied the aforementioned service stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants or that they meet other stipulated criteria. The insurer states that the medical records received do not demonstrate such conditions and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available. The insurer suggests that either removable partial dentures or conventional fixed bridge placement are covered and allowed alternative therapies. The patient is appealing the decision.

Upon review of the objective documentation consisting of the radiographic examinations and treatment notes, the patient exhibits significant caries and periapical inflammatory disease rendering #27 nonmaintainable. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable denture or a fixed denture prosthesis/bridge especially since the stability, maintainability, and dental health of #26 is also called into question based on the treatment notes. In this case a removable partial denture in the mandible would be entirely tooth borne, the most stable and retentive of all removable appliances. Further, as per portion of the attached signed treatment plan the patient was made aware of alternative therapies and chose endosteal implant in this site for their convenience. Therefore, as removable partial dentures or a fixed bridge remain standards of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures, the endosteal implants are considered elective and not medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for D6010 Implant Placement for tooth #27 is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Left neck vagal paraganglioma.
Treatment: Proton Beam radiation therapy.
The insurer denied the proton beam therapy.
The health plan's determination is upheld.

This is a female patient with a history of left vagal paraganglioma who was recommended to proceed with definitive radiotherapy. The request is for approval of 30 fractions of daily proton beam radiation therapy.

The requested proton radiation is not more likely to be beneficial than photon-based intensity modulated radiation therapy (IMRT) for the patient's vagal paraganglioma. Proton radiation is not proven to yield superior clinical outcomes in the patient's setting. The provided plan comparison shows that photon radiation can provide adequate safety and precision about target coverage and normal tissue avoidance. The patient has not received prior radiation to the head or neck region, nor does she have a genetic or comorbid condition that increases her risk for normal tissue toxicity.

I uphold the determination in whole, the health plan determination regarding the proposed treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Left neck vagal paraganglioma.
Treatment: Proton Beam radiation therapy.
The insurer denied the proton beam therapy.
The health plan's determination is upheld.

This is a female patient who presented with a left vagal tumor in her neck. The tumor has grown in size and is being evaluated for treatment using radiation using proton beam therapy (PBT). This is the subject of review.
The proposed health service or treatment of proton beam radiation therapy is not likely to be more beneficial than any standard treatment or treatment for the patient's life-threatening or disabling condition or disease.
The dose-volume histogram comparison of PBT and intensity-modulated radiation therapy (IMRT) showed that the dose of radiation to organs at risk (OAR) from IMRT is acceptable. The prescribed dose is not as high as for head and neck tumors which we treat with 70 grays (Gy) with IMRT. In this case, the prescribed dose is 60 Gy, which can be given with IMRT.
Pencil-beam scanning proton radiotherapy is highly feasible in the treatment of large glomus jugulare tumors with mild acute toxicity and promising short-term results. Longer follow-up and larger patient cohorts are required to further identify the role of pencil-beam scanning (PBS) for this indication.

I uphold in whole the health plan's determination regarding the proposed health service or treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Left neck vagal paraganglioma.
Treatment: Proton Beam radiation therapy.
The insurer denied the proton beam therapy.
The health plan's determination is upheld.

This is a female patient with a left neck vagal paraganglioma or schwannoma that has grown to 7 centimeters (cm) in size. It is not resectable. Radiation therapy is recommended to attempt to control its growth and a proton beam approach is requested to deliver 60 Gray (Gy).

The proposed treatment with proton beam radiation therapy is not more likely to be more beneficial than any standard treatment for the insured life-threatening or disabling disease.
There is a lack of significant clinical trials completed and published in peer-reviewed journals supporting the benefits and safety of proton beam radiation therapy over standard-of-care photon beam radiation therapy in this clinical scenario. The recommended proton beam radiation therapy for this patient is considered not medically necessary and should be denied.

I uphold in whole the health plan's determination regarding the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Inpatient hospital

Diagnosis: Cervical myelopathy
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

The patient is a male who presented with 2 months of progressive cervical myelopathy symptoms. His past medical history (PMH) is significant for diabetes, gastroesophageal reflux disease (GERD), high cholesterol, and hypertension. Physical exam was notable for some global weakness and abnormal reflexes signs consistent with the diagnosis of cervical myelopathy. The patient was admitted urgently with plans for operative intervention the following day. 

The inpatient hospital admission was medically necessary.

The patient presented with progressive cervical myelopathy and imaging demonstrating myelomalacia. He required urgent admission and surgery due to his progressive symptoms in the setting of spinal cord compression which is irreversible. Due to his underlying medical comorbidities and pre-existing neurologic dysfunction, he required post-operative care in excess of the standard care as well as for a prolonged period of time.
Ambulatory status criteria includes fusion at or below C3 in patients < (less than) 65 years old without myelopathy and without need for extended post-op observation. This patient had cervical myelopathy and need for extended post-op care as per above. Furthermore, the Milliman Care Guidelines (MCG) delineate the need for extended stay with significant neurologic compromise and need for extensive surgery (i.e. corpectomy). This patient meets criteria for extended stay and inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intellectual disabilities; status post cerebrovascular accident
Treatment: Increase Personal Care Aide (PCA) Services For 
24 Hours Per Day (live-in per diem), 7 Days A Week
The insurer denied: Increase Personal Care Aide (PCA) Services For 24 Hours Per Day (live-in per diem), 7 Days A Week
The denial is upheld.

This patient is an adult female with a history of intellectual disabilities since childhood. She also has epilepsy and is status post cerebrovascular accident (CVA). She is being cared for by her mother and personal care services for 70 hours a week. The request is for an increase to 24-hour live in services. 

The requested Increase Personal Care Aide (PCA) Services For 24 Hours Per Day (live -in per diem), 7 Days A Week is not medically necessary.

The patient does not have adequate activities of daily living (ADL) needs to qualify for 24-hour live in personal care assistant (PCA) services at this time. Therefore, 24-hour live in personal care assistant services is not medically necessary. The patient lives with her mother, who directs her care. The patient is able to take care of her toileting needs and transfer on and off the toilet with assistance. The patient is able to feed herself with assistance, once meals are prepared by the caregiver. The patient ambulates without an assistive device. Time has been allotted for meal preparation and light housekeeping. The patient is able to activate a personal emergency response system (PERS) in case of an emergency. The request for 24-hour live in personal care assistant (PCA) services does not meet the medical necessity criteria per current literature and standard of care for this specific clinical situation.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: Ulcerative Colitis.
Treatment: Zeposia.
The insurer has denied Zeposia.
The health plan's determination has been upheld.

This is a female patient with a history of ulcerative colitis. She has had recurrent left-sided colitis, with loose bowel movements and urgency requiring prednisone and Canasa suppositories. A colonoscopy showed congested mucosa in the rectum and otherwise an unremarkable ileum and colon. Biopsies showed normal ileal and colonic mucosa and mild congestion of the rectal mucosa. She has failed 5-aminosalicylate medications and prednisone. The coverage is requested for Zeposia for the treatment of ulcerative colitis. The request was not approved as there has been no attempt of or contraindication to Humira, Amjevita, Simponi, Stelara, Xeljanz, or Rinvoq.

The request for Zeposia is not supported as medically necessary based on the submitted information. Zeposia has proven safety and efficacy for the treatment of ulcerative colitis [1-3]. However, it is not recommended by the American College of Gastroenterology or American Gastroenterological Association guidelines as initial therapy for the treatment of ulcerative colitis after failure of 5-aminosalicylate therapy [4,5]. Zeposia is indicated and FDA-approved only for moderate to severe ulcerative colitis [6]. The American Gastroenterological Association for the Treatment of moderate to severe ulcerative colitis states, "In adult outpatients with moderate to severe ulcerative colitis who are naive to biologic agents, the AGA suggests using infliximab or vedolizumab for the induction of remission" [4]. The guidelines recommend avoiding various other therapies for the induction of remission [4]. The American Gastroenterological Association, for the treatment of mild to moderate ulcerative colitis, does not recommend Zeposia [7]. Zeposia has not proven safer or more effective than other guideline-recommended alternatives for the treatment of ulcerative colitis. For these reasons, the request for Zeposia is not supported as medically necessary over alternatives for the treatment of this patient's ulcerative colitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lichen Planus
Treatment: Xeljanz
The insurer denied coverage for: Xeljanz
The denial is: Overturned
 
The patient is an adult with a rash on her feet and hands.  A biopsy was performed and demonstrated a lichenoid dermatitis, compatible with lichen planus. The patient has failed therapy with topical Clobetasol, Triamcinolone, Tacrolimus, and Prednisone oral therapy. The request is for Xeljanz.    

Based on the submitted documentation, the use of Xeljanz is medically necessary. The patient has tried multiple topical therapies as well as oral Prednisone. There are no Food and Drug Administration (FDA) approved medications for the topical or systemic therapy of lichen planus.  Topical and oral steroids are considered first line therapies for lichen planus and the patient has failed therapy with these. Of note, the patient also has a positive anti-nuclear antibodies (ANA) as well as anti-double stranded DNA Antibody (dsDNA antibody) and is scheduled for a rheumatology work-up. Based on the submitted documentation, the use of Xeljanz is medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Xeljanz 10 mg tablet is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who was admitted for abdominal pain with nausea. She had history of colon cancer and required biliary drain exchange prior to admission. She was started on intravenous (IV) fluid and antibiotics. Blood cultures were negative. She was evaluated by the infectious disease service for management of antibiotics. She was also treated with pain medication. Paracentesis was attempted and peritoneal fluid was negative for infection. She was discharged in stable condition.

The inpatient hospital admission was not medically necessary. The patient was admitted for abdominal pain which improved with pain medication in 48 hours. She was also evaluated for sepsis from possible biliary drain infection; however, she remained hemodynamically stable, no recurrent fever and had negative blood cultures. She also underwent paracentesis which was negative for peritonitis and tolerated the procedure well without immediate complications.
When taking into account the patient's exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done and the availability of any additional diagnostic testing as an outpatient, she had no requirements for the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atypical chest and neck pain
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
This adult patient has a past medical history of Addison's disease, cervical spondylosis, diabetes mellitus and multiple previous admissions for neck pain and weakness who presented to the hospital complaining of neck pain radiating to the chest with accompanying lightheadedness and weakness. Symptoms were persistent for several days prior to presentation.  On arrival to the hospital, vital signs were stable (BP 112/57 millimeters of mercury [mmHg], Pulse 86 beats per minute [bpm]).  Physical examination revealed no major abnormality.  12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST or T wave abnormalities. Serum troponin levels were not elevated. The patient was admitted to the hospital and treated with analgesics for pain management. Echocardiogram demonstrated a normal left ventricular ejection fraction (LVEF) with no wall motion abnormalities. 

This patient presented with atypical chest and neck pain and a past history of multiple evaluations for the same set of symptoms. The patient pretest probability of coronary artery disease was low.(Reference 1)  Utilizing the History, electrocardiogram, age, risk factor, and troponin (HEART) score the patient was considered low risk.(Reference 2)  Utilizing the Thrombosis in Myocardial Infarction (TIMI) risk score the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days.  (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (Reference 3).  Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus
Treatment: Mounjaro
The insurer denied Mounjaro.
The determination is upheld.

The patient is a female with past medical history of hypothyroidism, asthma, migraine, hyperlipidemia, diabetes mellitus type 2, obesity, and hypertension who had been prescribed Mounjaro 5 milligrams (mg)/0.5 milliliters (ml) subcutaneously weekly for the treatment of diabetes mellitus type 2. The patient had been seen by her medical provider with an office visit note stating patient was treated with Farxiga, Actos, and Ozempic with a hemoglobin A1c result of 10.2. The provider switched Ozempic to Mounjaro 5 mg/0.5 ml subcutaneously weekly. The insurer sent a final adverse determination continuing to deny coverage of Mounjaro 5 mg/0.5 ml Pen injector as not medically necessary as the patient had not had serious side effects or drug failure with Trulicity or Victoza. The provider and patient appealed the denial decision.

No, the requested health service/treatment of Mounjaro is not medically necessary for this patient. The patient continued to have a high hemoglobin A1c on Ozempic and the patient's provider chose to change to Mounjaro. Plan guidelines for coverage of Mounjaro include 1) the patient must be 18 years or older and have diagnosis of diabetes 2) there must be documentation showing that the patient had serious side effects or drug failure to generic metformin and and 2 of the following: Ozempic, Trulicity, Victoza. There is no documentation that the patient had serious side effects or drug failure with Trulicity or Victoza. There is no clinical documentation of why Mounjaro would be more effective than Trulicity or Victoza. There is no clinical documentation from the patient's primary care provider (PCP) of medical necessity of Mounjaro. In summary, Mounjaro 5 mg / 0.5 mL pen injector is not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: hypertension
Treatment: Edarbi (azilsartan)
The insurer denied Edarbi (azilsartan)
The health plan's determination is upheld.

The patient is a woman with a history of hypertension. Per the physician's appeal letter, previous treatment regimens, including amlodipine 5 milligrams (mg) daily, amlodipine-olmesartan 5/40 mg daily and azilsartan 80 mg daily were ineffective in reducing her blood pressure to goal. She did not tolerate metoprolol due to fatigue. 

A formulary exception is not indicated in this case. The formulary alternatives include candesartan, irbesartan, losartan, olmesartan, telmisartan and valsartan. These agents, like Edarbi (azilsartan) are angiotensin receptor blockers (ARBs).
In the reports by White, et al, and Bakris, et al, blood pressure reductions seen with azilsartan 40 mg versus olmesartan 40 mg were not statistically different. Per the physician's appeal letter, this woman's blood pressure was not adequately controlled on a combination of olmesartan 40 mg and amlodipine. However, she is currently taking nebivolol in addition to amlodipine and Edarbi 40 mg. It is unclear whether this combination is more efficacious than a combination of nebivolol, amlodipine and olmesartan 40 mg would be.
Regarding the other formulary alternative, in the report by Naruse, et al, azilsartan and telmisartan were similarly efficacious in reducing blood pressure in hypertensive patients. While the data regarding the comparative efficacy of azilsartan versus the remaining ARBs are limited, there are reports that azilsartan is more efficacious than valsartan and candesartan. Likewise, in some studies, losartan has been found to be less effective than other ARB.
In summary, while azilsartan has been shown to be more effective than some other ARBs, its efficacy is similar to others, including formulary alternatives olmesartan 40 mg and telmisartan. The expected adverse effects are similar between different ARBs. Accordingly, one would not expect this woman to have more side effects with the formulary drugs than with Edarbi.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Transsexualism
Treatment: Delestrogen intramuscular injection (10 milligrams per milliliter)
The insurer denied: Delestrogen intramuscular injection (10 milligrams per milliliter)
The denial is upheld.

The patient is an adult with the diagnosis of Transsexualism. According to the provider, the patient is a male to female transgender. Hormonal treatments were started when the patient was about 16 to 17 years old. The most recent was the requested medication every 4 weeks (delestrogen intramuscular injection) and Lupron Depot 11.25 intramuscular (IM) every 3 months. The patient reported trying Estradiol by mouth (PO) in the past but feeling that the medication was not effective and caused headaches. The provider prescribed continuation of therapy of delestrogen intramuscular injection (10 milligrams per milliliter).

The health plan should not cover the requested therapy.

The patient reported trying Estradiol by mouth (PO) in the past but feeling that the medication was not effective and caused headaches. In this case there is no documentation that the patient has tried and failed all of the formulary medications including estradiol patch. There is no documentation that the other preferred formulary medication is ineffective for the patient. 
Transdermal estrogen has been associated with a lower risk of venous thromboembolism (VTE) and stroke than oral estrogens. Typical estradiol regimens include:
- Transdermal, 0.025 to 0.2 milligrams per 24 hours. The patch is changed once or twice a week, depending on the product.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic idiopathic constipation
Treatment: Formulary exception for Motegrity
The insurer denied: Formulary exception for Motegrity
The denial is overturned.

The patient is an adult female with chronic idiopathic constipation. She has failed bulk laxatives, stool softeners, Miralax, MOM (milk of magnesia), Dulcolax and magnesium citrate. She has also failed lubiprostone, Linzess and Trulance. She has done well on Motegrity. Her provider is requesting to continue treatment with Motegrity. The health plan denied coverage of the request as not meeting formulary requirements. The denial is being appealed.

The health plan should cover the Formulary exception for Motegrity.

The patient has failed both of the preferred formulary alternatives lubiprostone and Linzess. Therefore, the patient has satisfied the health plan's formulary requirements. As such, the health plan should cover formulary exception for Motegrity.