Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lymphedema. 
Treatment: Lymphangiotomy, free omental flap with microvascular anastomosis and 1 day hospital stay. 

The insurer denied the Lymphangiotomy, free omental flap with microvascular anastomosis and 1 day hospital stay. 

The health plan's determination is overturned. 

The patient is a female who has chronic vulvar and bilateral leg lymphedema with recurrent infections subsequent to an inguinal node dissection and hemi vulvovaginectomy for bartholin's squamous cell carcinoma. She has had at least 4 hospitalizations with intravenous (IV) antibiotics for vulvar infections despite prophylactic Keflex antibiotics. Compression garments, programmed segmental pneumatic compression and manual lymphatic drainage have not provided relief.
At the examination the lymphedema was primarily of the genitalia. The Indocyanine Green (ICG) lymphography showed single channel from the right foot terminating in the distal shin and 2 channels from the left foot merging and terminating in the mid-shin of the legs showed dermal back flow. Her surgeon is proposing vascularized omentum lymph node transfer to the groin to treat the vulvar lymphedema. 

It is clear that transfer of more nodes increases efficacy of vascularized lymph node transfer in treating lymphedema. Fan et al. reported 2 cases of laparoscopically harvested omentum placed through a longitudinal incision at the lymphedematous area, and anastomosed proximally, with additional distal venous outflow. Although this yielded 25 percent (%) and 28% reductions in extremity volume without recurrent cellulitis episodes the author concluded that long-term studies are required to prove efficacy. Taranto et al. reported on 10 patients with lymphedema and ulcers that significantly improved clinically and lymphoscintigraphy showed improvement of the lymphatic drainage and restoration of lymphatic network following omental free flap transfer.
A systematic review of vascularized omentum lymph node transfer (VOLT) in patients with lymphedema concluded that Overall, patients experienced successful lymphedema treatment with VOLT. All authors presented results with reduced circumferential size of the affected upper and lower limbs, as well as reduction of the infectious intercurrences, such as cellulitis, with a small incidence of associated complications. (Forte et al.) Therefore, the medical literature supports vascularized omental lymph node transfer in the treatment of this patient's lymphedema and recurrent infections.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: PCA (personal care assistant) service, split shift, 24 hours per day, 7 days per week

The insurer denied coverage for PCA (personal care assistant) service, split shift, 24 hours per day, 7 days per week

The denial is overturned

 
The patient has been diagnosed with dementia. The patient lives alone and has frequent urinary frequency and fecal incontinence, an unsteady gait, and is prescribed sleeping medications. It is noted the patient experiences sun downing and increased confusion in the evening hours. It is noted the patient wakes up several times per night with toileting needs and needs assistance. It is also noted there are concerns for skin issues due to the frequent incontinence. It is noted the patient has been found on the floor on some mornings, covered in feces, due to overflow of feces from briefs. The request is for PCA (personal care assistant) service, split shift, 24 hours per day, 7 days per week, which is under review.

It is noted the patient produces large amounts of feces, has overflow issues, instability issues, had had falls, and is at high risk for skin breakdown due to the frequent night time toileting needs. A 24 hour live in caregiver will not be able to get five hours of uninterrupted sleep, due to the patient's urinary and bowel incontinence/frequency. As such, split shift PCA is needed and should be approved as requested.

Based on the above, the insurer's denial must be overturned. 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 PCA (personal care assistant) service, split shift, 24 hours per day, 7 days per week is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Testicular Hypofunction
Treatment: Jatenzo (testosterone)
The health plan denied the requested prescription medication, Jatenzo. The health plan's determination is upheld.

This is a patient with a history of testicular cancer, having been on Testopel, tolerating Testopel pellets less than before, although specific side effects were not mentioned.

The health plan's determination is upheld, in whole.

No, the formulary drugs will not be and have not been ineffective, or would not be as effective as the non-formulary drug, or would have adverse effects. Formulary alternatives are Testosterone 1% gel (generic of Androgel 1% and generic of Testim 1%); Testosterone 2% gel (generic of Fortesta 2%), Testosterone solution, Testosterone Cypionate, Testosterone Enanthate. There are no head to head trials that support that conclusion.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: maxillary and moderate mandibular crowding.
Treatment; braces/monthly visits.
The insurer denied braces/monthly visits. 
The health plan's determination is upheld. 

The patient is a male with severe maxillary and moderate mandibular crowding. Tooth #11 is erupting labially in the dental arch. The patient has a Class I occlusion with 3 millimeter (mm) overjet and 3mm overbite. 

Braces and monthly visits are not medically necessary.
While the patient has crowded teeth, there is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. If his teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Braces are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Occipital neuralgia.
Treatment: Injections to block occipital nerve for pain.
The insurer denied Injections to block occipital nerve for pain.
The determination is overturned.

This is a female patient with occipital neuralgia. The patient has tried and failed acetaminophen, ibuprofen, various headache preventative medications, physical therapy, and massage. At issue is the medical necessity of injections to block occipital nerve for pain.

The requested treatment is medically necessary. The patient has tried and failed the recommended oral treatments for occipital neuralgia including analgesics and non-steroidal anti-inflammatory medications. The patient has also tried and failed other therapeutic measure such as massage and physical therapy. Nerve blocks targeting the greater occipital nerve can be used as the primary treatment of headaches but are more often used to treat intractable headaches when other methods have failed. The greater occipital nerve block can be an effective and safe treatment option for several headache disorders, including occipital neuralgia, migraine, post-dural puncture headache, cervicogenic headache, and cluster headache. The nerve block can also reduce associated symptoms resulting from nerve irritation, including tinnitus and otalgia. As the patient has failed first-line therapy and is known to respond to greater occipital nerve blocks, continuation of the injections is medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is overturned.

This case involves a child with a history of abnormal ambulatory EEG (electroencephalogram) demonstrating diffuse mild cerebral dysfunction as well as evidence of generalized epileptogenicity without definitive seizures. The last video EEG was years ago. The last seizure was months ago, and the patient's mother noticed him staring into space with possible arm twitching lasting approximately 10 minutes. Rescue medication was not administered. The patient was recommended for admission for video EEG with seizure precautions. Video Electroencephalogram (VEEG) was initiated and 50 mg (milligrams) of Keppra was administered. The patient continued to receive GT (gastrostomy tube) feedings. The EEG showed spikes and wave patterns localized to the left temporal region, but there were no full seizure events. Keppra was increased to 150 mg prior to the discharge home.  

Milliman Care Guidelines (MCG) state that the VEEG can be performed in an ambulatory setting in patients who have or are suspected of having frequent events (daily) and are unlikely to require an extended period of observed provocation (cessation of anticonvulsant medication) or medication adjustment. 

Inpatient status is supported in patients with less-frequent events, who require prolonged observed provocation, or who require medication adjustment under observation. In this case, the patient did not have a history of frequent events and required medication adjustment. Keppra was adjusted during the study. Therefore, the procedure could not have been completed at a lower level of care. 

Based on the above, the insurer's denial must be overturned. 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 the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Poor vision, cataracts, hypertension, difficulty walking, osteoarthritis, and hearing loss. 
Treatment: Consumer directed personal assistance services (CDPAS) 56 hours per week. 

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 56 hours per week. 

The denial is upheld. 

This is an elderly person with chronic medical problems including hypertension, cataracts and osteoarthritis. She lives alone in a studio apartment. The patient is approved for CDPAS 35 hours/week and is requesting 56 hours per week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is "modified independent." She is able to make her needs known to her caregiver and has access to a Personal Emergency Response System (PERS). Performing Instrumental Activities of Daily Living (IADL) tasks ranges from limited to maximal assistance. The patient requires extensive assistance for bathing, dressing, locomotion, ambulation and toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel. Limited assistance is needed for personal hygiene. She is independent with bed mobility and eating. 

The patient's functional ability has only modestly decreased when compared to the previous UAS report. The insurer responded appropriately by increasing CDPAS from 30 to 35 hours/week. However, there has been no change in ADL (Activities of Daily Living) status over the prior 90 days or reported falls. The patient's clinical condition and functional deficits are not at a level or unpredictable as to require CDPAS 56 hours/week. 

This physician would agree the patient may require additional monitoring; particularly due to her vision impairment and decreased balance. However, safety monitoring under PCS does not include monitoring an individual when no other Level I (1) or Level II (2) personal care services task is being provided. Based on the records reviewed, the patient's health and safety in the home can be appropriately provided and maintained by the currently approved CDPAS 35 hours/week. 

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 consumer directed personal assistance services (CDPAS) 56 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Colon Cancer/Colon cancer (stage IV mets to liver, pancreas and lungs)
Treatment: Hospice Care/transfer from Elmhurst Hospital to Calvary hospital for hospice
The health plan denied the requested transfer from Elmhurst Hospital to Calvary hospital for hospice as not medically necessary. The health plan's determination is overturned.

This is a case review for a male with a medical history notable for stage IV colon cancer with metastasis to the liver, pancreas, and lungs. The patient and his care team requested a transfer from Elmhurst hospital to Calvary hospital for hospice care, and this request was denied by the health plan. This denial is the subject under review.
The patient was admitted to the hospital with hypoxic respiratory failure. He was started on steroids and bronchoscopy was recommended. Ground glass opacities were noted on computed tomography (CT). He was empirically treated for community acquired pneumonia and pneumocystis pneumonia. His respiratory status was ultimately deemed to be secondary to his metastatic lung disease. He continued to decline from a respiratory standpoint. Given his overall prognosis, after a goals of care discussion the patient opted for comfort care. He initially expressed a desire to return home with hospice but did not appear clinically stable to do so, given his high-flow nasal cannula oxygen requirement. The attending attestation to the progress note states that they were attempting to wean his oxygen to allow him to potentially be discharged home, and that the patient's "most reasonable plan would be home hospice" if they could complete the wean.
The health plan denied the request for transfer. They state that the patient did not meet the criteria for transfer because he can get the care at the hospital he is at now and there is no medical need for transfer to another hospital. They also state that he can get the hospice care provided at a nursing home.
At issue is the medical necessity for the requested health service/treatment of transfer to Calvary hospital for hospice.

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

The requested health service/treatment of transfer to Calvary hospital for hospice is medically necessary for this patient.
The patient is terminally ill with advanced metastatic cancer. He has respiratory failure and is unable to wean off high flow oxygen. His first preference, to go home with hospice, is therefore not medically feasible. He will need hospice in an inpatient setting.
Transferring to a specialty hospice hospital is in the patient's best interest. Studies have demonstrated greater usage of palliative medications when patients are under hospice care compared to typical acute care facilities. Patient experience, pain control, and clinical outcomes have all been shown to be more favorable under inpatient hospital care. Although the patient could remain in the acute care hospital and receive hospice services there, he is not likely to experience the same level of specialized end-of-life care there that he would if was transferred to the specialty hospice facility.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer
Treatment: Ibrance
The insurer denied Ibrance. The health plan's determination is upheld. 

This is a female with metastatic osteosarcoma. The patient has previously undergone chemotherapy with doxorubicin+cisplatin. Despite an above knee amputation on the left, she received adjuvant ifosofamide+etoposide. She developed widespread metastatic disease. She resumed ifosfamide+etoposide but progressed and was started on cabozantinib which she continued until progression when she began docetaxel+gemcitabine. Next generation sequencing demonstrates MDM2 (mouse double minute homolog) and CDK4 (Cyclin-dependent kinase 4) amplification. Palbociclib (Ibrance) was recommended and is under review.

Ibrance is not medically necessary for this patient.
The use of Ibrance in this clinical scenario remains unproven. This approach remains the subject of at least two active clinical trials. There is a paucity of evidence that this agent provides outcomes benefit in this clinical scenario and, as a consequence, support in the peer-reviewed literature is lacking. Further, the authors of Up-To-Date do not recommend the use of this agent. For these reasons, medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Continuous Glucose Monitoring and Supplies 
The insurer denied Continuous Glucose Monitoring and Supplies. 
The health plan's determination is overturned. 

This is a female diagnosed with Type I Diabetes Mellitus with Hyperglycemia, and Diabetic Neuropathy. This request is for a continuous glucose monitor (CGM) and supplies. As reported, she has been on the pump and her diabetes improved. As per a recent visit note, she is on Dexcom G6; Omnipod 5 and Novolog. Her ICR (insulin to carb ratio) was 1:10 and ISF (Insulin Sensitivity Factor) was 1:40. The Hemoglobin (HGB) A1C on 1-2023 was 6.9 % (percent).

Continuous Glucose Monitoring and Supplies are medically necessary for this patient.
Continuous glucose monitoring systems including real-time systems have Food and Drug Administration (FDA) approval. They are not the subject of Phase I-III clinical trials. The peer reviewed literature supports the long-term use of CGMS in adult (>=25 year old) patients. The American Diabetes Association (ADA) position statement on standards of medical care in diabetes published in January 2011, states, "Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower HGB A1C in selected adults (age >=25 years) with type 1 diabetes." The ADA considers this to have a level of evidence of "A" which is "Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered."
This is based on a recent large scale trial published in the New England Journal of medicine in September 2008 that showed that CGMS (Continuous Glucose Monitoring System) is effective in reducing HGB A1c in adults with type 1 diabetes over a 6 month period.
The latest ADA statement on the standards of medical care in diabetes states the following regarding the use of CGM in children and adolescents: "Although the evidence for HGB A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device." This is based on a recent trial published in the New England Journal of Medicine showing benefit of CGMS in children and adolescents with type 1 diabetes who are not well controlled. In addition the peer reviewed literature supports the use of long-term CGMS in patients with type 1 diabetes with hypoglycemia unawareness and episodes of hypoglycemia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Disease
Treatment: Transplantation Procedure on Bone Marrow or Stem Cell (Allogeneic Stem Cell Transplant)
The insurer denied: Transplantation Procedure on Bone Marrow or Stem Cell (Allogeneic Stem Cell Transplant)
The denial is: Upheld

The patient is a male with sickle cell disease. He has a history of severe anemia with multiple hospitalizations for pain crisis. The patient is receiving hemodialysis for end stage renal disease due to focal segmental glomerular sclerosis (sickle nephropathy). He has sickle retinopathy. An allogeneic stem cell transplant (ASCT) has been recommended and this is under review for medical necessity.

The health plan's determination is upheld.

The requested transplantation procedure, allogeneic stem cell transplant is not medically necessary.
Data demonstrating an outcomes benefit to allogeneic stem cell transplant in this clinical scenario are sparse. Based on a 2017 retrospective series (Gluckman, et al.) of 1000 individuals with sickle cell disease (SCD) who underwent ASCT, the five-year overall survival for those transplanted when 16 years or older was 81 percent. For every one-year increment in age there was a 10 percent increase in the hazard ratio for death. Mortality from hematopoietic stem cell transplantation (HSCT) may be as high as 5 to 10 percent. Further, as noted by the authors of UpToDate, "Prognosis continues to improve for individuals who receive high-quality supportive care and hydroxyurea, and those with frequent vaso-occlusive episodes or episodes of acute chest syndrome do not have reduced mortality compared with other individuals with SCD....Compared with HSCT, long-term survival with hydroxyurea therapy may be superior...".
The greatest support for this therapeutic modality is in the pediatric literature, which is not applicable to this patient. This modality remains the subject of ongoing investigation. Lacking recommendations from national guidelines and the peer-reviewed literature, medical necessity cannot be established.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine. 
Treatment: Emgality 120mg/ml (milligrams per milliliter) Pen. 

The insurer denied: Emgality 120mg/ml (milligrams per milliliter) Pen. 
The denial is overturned. 

The patient is an adult female with migraine headache disorder. The provider has requested Emgality for migraine prevention. This was denied coverage as she has not tried and failed or does not have a contraindication to Aimovig. 

The health plan should cover the proposed treatment. 

The patient is an adult female with migraine headache disorder. The provider has requested Emgality for migraine prevention. This was denied coverage as she has not tried and failed or does not have a contraindication to Aimovig. According to the letter of medical necessity written by the patient's provider, "The patient has tried Aimovig, which caused side effects, and the patient has also tried Nurtec, Botox, Topamax, Amitriptyline and Depakote which were ineffective." Therefore, Emgality would be appropriate in this case. The health plan should cover the requested treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Muscoloskeletal/Other/s/p leg surgery
Treatment: Inpatient Stay
The health plan denied the requested inpatient stay as not medically necessary. The health plan's determination is overturned.

The patient is a girl with a 3-centimeter limb length inequality of unknown etiology. She is obese and has idiopathic scoliosis and thoracic back pain. The orthopaedic surgeon recommended and carried out an open shortening of the right femur, with internal fixation using a locked intramedullary nail to address the lower limb length inequality.
At issue is whether inpatient stay was medically necessary.

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

Yes. Femoral shortening is a well-known but infrequently done procedure used to address symptomatic limb length abnormality, usually used in a skeletally mature patient with discrepancies of moderate size. This is a major surgical procedure performed on the largest bone in the body, and can be associated with blood loss, nerve injury, compartment syndrome, fat embolism, and other complications. Significant pain may be present, and a period of monitoring for complications is advisable. This patient's obesity may raise the risk of complications. It would be unsafe to do this procedure on an outpatient or observation basis, and an inpatient admission should be considered medically necessary.