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

Diagnosis: pancreatic cancer
Treatment: Proton beam therapy
The insurer denied proton beam therapy. The health plan's determination is upheld.

This is the case of a patient who was treated with 4 cycles of chemotherapy followed by radiation therapy for pancreas versus (vs) stomach cancer. The patient then was treated with chemotherapy followed by immunotherapy. Recent magnetic resonance (MR) cholangiogram showed a 10 centimeter (cm) mass involving the head of pancreas. He is evaluated for palliative radiation therapy (RT) using Proton beam therapy. This is the subject of review.

The requested 20 Outpatient Proton Therapy Treatments (Proton Beam Therapy Visits) is not medically necessary for this patient.
This patient needs palliative RT which can be done using standard photon based intensity modulated radiation therapy (IMRT). There is no good, controlled research study to show that proton beam therapy offers benefit over standard photon IMRT.
The generally accepted treatment in the USA for this clinical scenario is IMRT. The National Comprehensive Cancer Network (NCCN) guidelines do not recommend Proton beam in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vision. 
Treatment: Pharmacy/Prescription Drugs -Zylet. 

The insurer denied Zylet 0.5-0.3% OP SUSP. 
The denial is upheld. 

The patient is a male with keratoconjunctivitis sicca for whom Zylet (loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension) has been recommended. The health plan initially denied as no rationale was provided as to why the formulary alternatives (Maxitrol, Tobradex suspension, Blephamide eye drops) would be inappropriate. Upon appeal, the provider stated that the patient had a corneal transplant which was failing, and that the patient needed Zylet. An exam note documented complaints of the left eye being irritated and red for the last three days. The patient was using Cequa (cyclosporine ophthalmic solution) 0.09%. The patient was identified as having 3 plus (+)  giant papillary conjunctivitis (GPC) left eye (OS). Zylet drops and Lotemax ointment were prescribed. 
At issue is the medical necessity of Zylet 0.5-0.3 percent (%) ophthalmic (OP) suspension (SUSP). 

The health plan's determination of medical necessity is upheld. 

The requested health service/treatment of Zylet 0.5-0.3% OP SUSP is not medically necessary for this patient. 

Based on the records provided for review, the requested Zylet is not established as medically necessary for this patient. In this case, the primary indication for treatment with Zylet remains unclear based on the documentation. Initially, Zylet was prescribed for keratoconjunctivitis. Subsequently, the patient was reported to have a failing corneal transplant. However, the medical records submitted do not report history of corneal transplant or corneal pathology. The patient is reported as having 3+ GPC (giant papillary conjunctivitis) OS. Loteprednol, a steroid with less anti-inflammatory efficacy than the formulary alternatives, is generally used in patients where there is concern for elevated intraocular pressures with chronic use. In this case, there is no documentation of the patient being a steroid responder, and no other rationale provided as to why formulary alternatives may be inappropriate. 

Therefore, the requested health service/treatment of Zylet 0.5-0.3% OP SUSP is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis; Lupus
Treatment: Home Health Care (HHC) - Level 2 Personal Care Services (PCS), per 15 minutes Increase to 163 Hours/Week
The insurer denied HHC - level 2 PCS, per 15 minutes increase to 163 hours/week.
The health plan's determination is upheld. 

This case involves a female with lupus and type 2 diabetes who is being evaluated for an increase in need for home health care (HHC) services. The insurance plan approved 150 hours/week in 15 minute increments of level 2 personal care services (PCS). The request was made to the insurance company for an increase in hours to 163 hours/week of level 2 PCS. 

The HHC at level 2 PCS, per 15 minutes increase to 163 hours/week is not medically necessary for this patient. The Uniform Assessment System tool did not demonstrate any changes in physical functioning since prior evaluation. The treating physician did not note any significant changes in physical functioning or demonstrate any particular medical need which would warrant an increase in service hours of an additional 13 hours/week. It is unlikely that the additional 13 hours would provide any meaningful impact in the quality of the patient's care. This equates to less than 2 hours per day, and given the patient's need for sleep, it is not unreasonable to have a brief period of respite overnight where toilet transfers would not be needed. The remainder of her needs for assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) should be sufficiently met with her current daytime coverage. Although her needs for toileting and toilet transfer are extensive, she has been managing this well in her current arrangement.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Major Depressive Disorder

Treatment: Prozac 20mg

The insurer denied coverage for Prozac.

The denial is overturned.

The case involves an adult female who is prescribed brand Prozac for treatment of recurrent major depressive disorder with moderate severity. The patient is being treated with brand Prozac with the current dose of 40 milligrams (mg) daily. The patient was unable to tolerate or benefit from treatment with the generic formulation of Prozac, as well as other antidepressant medications according to the prescribing clinician. 

A formulary exception is indicated in this case. In this case, the patient is diagnosed with recurrent and severe major depressive disorder, generalized anxiety disorder and panic disorder. Maintenance treatment with generic Prozac (fluoxetine) provided a clinical response or remission until the manufacturer, Sandoz discontinued manufacturing the generic formulation of Prozac. Attempts to use alternative formulations manufactured by others failed to provide benefit and resulted in a recrudescence of depressive symptoms including associated symptoms of anxiety. The alternative generic formulations were prescribed at higher dosages without benefit. And, when brand Prozac was prescribed and titrated to the usually effective dose of 40 mg daily, the patient enjoyed a robust clinical response and remission with improved functioning. The use of brand Prozac in this case has resulted in a clinical response in a patient with treatment failure with two of the currently available selective serotonin reuptake inhibitor (SSRI) generic formulations.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Sjogren's syndrome with pulmonary fibrosis
Treatment: Personal Care Aide (PCA): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week 
The insurer denied coverage for PCA: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week
The denial is overturned in part.

This patient is of advanced age and has Sjogren's syndrome with pulmonary fibrosis and requires portable home oxygen. She lives alone in a second-floor walk-up, 2-bedroom apartment. She is approved for 6 hours per day, 7 days per week for a total of 42 hours day. Under review is the requested increase PCA: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's decision-making ability is described as "modified independent." She is fully oriented and alert. She requires extensive assistance for personal hygiene. Maximal assistance is required for bathing, dressing, and toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel. She requires maximal assistance for ambulation. Her cognitive status, ability to use a Personal Emergency Response System (PERS), as well as "verbalize a plan of action in case of an emergency" do not support the requested increase PCA: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week. However, her progressive pulmonary fibrosis, requiring daily home oxygen, weakness and functional decline support an increase PCA to 12 hours/day, 7 days/week totaling 84 hours; allowing the patient the ability to continue living safely at home.
  
The insurer's denial of coverage for personal care aide (PCA): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week is modified as noted above. Medical necessity is not substantiated for 12 hour per day 7 days a week (split shifts) for total of 168 hours weekly. However, 12 hours per day 7 days a week for a total of 84 hours weekly is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with benign past medical history who presented to the emergency room with complaints of a two-week history of pain and swelling in the right thumb.

Vitals on presentation included: temperature 99.0 Fahrenheit, blood pressure-100/49, pulse -78, respiration rate - 18, oxygen saturation -100% on room air. Laboratory results included the following: white blood cell (WBC) -9.7, hemoglobin-14.7, hematocrit-46.7, creatinine-0.8, glucose-87.

The patient was started empirically on intravenous antibiotics (vancomycin and cefepime) for a right thumb cellulitis. The patient underwent incision and drainage of the thumb abscess by Plastic Surgery. Infectious Diseases also consulted for antibiotic management. Intra-operative cultures grew Staphylococcus aureus. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral antibiotics as an outpatient.

According to documentation, the patient was admitted with a right thumb paronychia. Otherwise, the patient was afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal WBC. The patient had no evidence of a systemic infection and no co-morbid conditions. Based on above findings, the patient met criteria for observation level of management.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epigastric Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female with history of schizophrenia and major depressive disorder (MDD) who presented to the hospital with epigastric pain. The patient was found to have acute cholecystitis with multiple stones in the gallbladder and a large stone in the neck of the gallbladder. Leukocytosis was noted on admission.

Yes, the proposed inpatient hospital admission was medically necessary. The patient was admitted with epigastric pain after eating a fatty meal. The patient was found to have a large gallstone with computed tomography (CT) scan findings of fluid indicative of acute cholecystitis. The patient's white blood cell (WBC) count was 13 and liver function tests (LFTs) were within normal limits. Inpatient cholecystectomy was indicated and medically appropriate as this is the standard of care for the diagnosis of acute cholecystitis rather than intravenous antibiotics and outpatient removal. The hospital admission was medically necessary for this diagnosis. Inpatient level of care was necessary given the elevated leukocytosis, large gallstone, and need for post operative pain control.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.

The patient had a prior ultrasound during a psychiatric admission demonstrating gallstones. In the emergency department, the patient was found to have a large gallstone at the neck of the gallbladder with fluid, pain, and leukocytosis. Inpatient admission with cholecystectomy is sound and reasonable. This follows the guidelines for acute cholecystitis which is intravenous antibiotics and early removal of gallbladder. The medical team acted appropriately especially given the patients lack of follow up for prior gallstones seen in 2020. The Tokyo Guidelines have been used as a guideline for the diagnosis and treatment for acute cholecystitis. The 2018 guidelines recommend urgent lap cholecystectomy for all grade I and II acute cholecystitis. This patient demonstrated Grade I and could withstand surgery. Therefore, removal of the gallbladder was indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epigastric Pain
Treatment: Inpatient admission 
The insurer denied the inpatient admission
The denial is overturned

The patient is a female with history of schizophrenia and major depressive disorder (MDD) who presented to the hospital with epigastric pain. The patient was found to have acute cholecystitis with multiple stones in the gallbladder and a large stone in the neck of the gallbladder. Leukocytosis was noted on admission.

Yes, the proposed inpatient hospital admission was medically necessary.
The patient was admitted with epigastric pain after eating a fatty meal. The patient was found to have a large gallstone with computed tomography (CT) scan findings of fluid indicative of acute cholecystitis. The patient's white blood cell (WBC) count was 13 and liver function tests (LFTs) were within normal limits. Inpatient cholecystectomy was indicated and medically appropriate as this is the standard of care for the diagnosis of acute cholecystitis rather than intravenous antibiotics and outpatient removal. The hospital admission was medically necessary for this diagnosis. Inpatient level of care was necessary given the elevated leukocytosis, large gallstone, and need for post operative pain control.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient had a prior ultrasound during a psychiatric admission demonstrating gallstones. In the emergency department, the patient was found to have a large gallstone at the neck of gallbladder neck with fluid, pain, and leukocytosis. Inpatient admission with cholecystectomy is sound and reasonable. This follows the guidelines for acute cholecystitis which is intravenous antibiotics and early removal of gallbladder. The medical team acted appropriately especially given the patient's lack of follow up for prior gallstones. The Tokyo Guidelines have been used as a guideline for the diagnosis and treatment for acute cholecystitis. The guidelines recommend urgent lap cholecystectomy for all grade I and II acute cholecystitis. This patient demonstrated Grade I and could withstand surgery, therefore, removal of the gallbladder was indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior cross-bite.

Treatment: D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visits.

The insurer denied coverage for D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visits.
The denial is upheld.

This case involves a female with review of medical necessity for a comprehensive orthodontic treatment and periodic orthodontic treatment visits.

The requested comprehensive orthodontic treatment of adolescent dentition (code D8080) and periodic orthodontic treatment visits (code D8670) are not considered medically necessary for this patient.

A review of the clinical information submitted does not indicate the patient has a handicapping malocclusion. The definition of medically necessary services as defined in the patient's health plan certificate as it relates to orthodontic treatment is specific in defining what constitutes a handicapping malocclusion and related treatment that is covered under the terms of the plan.

The criteria reviewed include, but is not limited to: Deep impinging overbite with palatal impingement causing tissue trauma; true anterior open bite, more than two teeth in anterior crossbite with gingival stripping; impacted incisors or canines that will not erupt into the arches without orthodontic or surgical intervention; overjet in excess of 9mm (millimeters) ; negative overjet greater than 3.5mm; cleft lip/palate deformities and other significant craniofacial anomalies; malocclusions requiring a combination of orthodontic and orthognathic surgery for correction. 

The handicapping labio-lingual deviation (HLD) Index is also used as a basis for determining whether a patient qualifies for orthodontic treatment. A patient must score a minimum of 26 points to qualify for coverage. The initial review gave a score of 6 points. In summary, based on the information in the appeal file, intraoral and facial photographs, case photographs, radiographic images and the description of medical necessity, the denial of coverage for comprehensive orthodontic treatment was appropriate. The provider indicated there is a crossbite of the mandibular right canine with attachment loss. Upon review of the photographs, there appears to be a very slight open bite between the right canines. In addition, there does not appear to be any appreciable clinical attachment loss noted on the photographs and there appears to be adequate keratinized attached gingiva. 

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

The insurer's denial of coverage for D8080 comprehensive orthodontic treatment of adolescent dentition and D8670 periodic orthodontic treatment visits is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: epilepsy
Treatment: Gammaked
The insurer denied Gammaked. 
The health plan's determination is overturned. 

The patient is a woman diagnosed with autoimmune epilepsy. Her provider has prescribed intravenous immunoglobulin. The provider's diagnosis has been established by new onset seizures. A hospital discharge is included indicated that the patient has pseudo seizures. The provider indicates that a normal routine and continuous electroencephalogram (EEG) does not rule out autoimmune seizures.

Gammaked is medically necessary for this patient.
There are no controlled studies of any form of immunotherapy in patients with paraneoplastic or autoimmune encephalitis. The best chance for symptom stabilization or improvement appears to be early identification and treatment of the tumor and the use of immunotherapy (glucocorticoids, intravenous immune globulin, plasma exchange, cyclophosphamide, or rituximab) in various combinations.
As the provider indicates that the member has a diagnosis of autoimmune encephalitis causing seizures, treatment with intravenous immunoglobulin (Gammaked) is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive/Gastrointestinal System. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Stelara. 
The denial is overturned.

The patient is a patient has severe Crohn's disease. She has tried and failed steroids, an immunomodulator (6-mercaptopurine), two anti-tumor necrosis factor (TNF) agents (adalimumab and infliximab). Most recently she has tried and failed an anti-intern agent (vedolizumab). Because of prior exposure to an anti-TNF agent and an anti-integrin the attending provider would like to start her on Stelara to treat her severe Crohn's disease since it has different mechanism of action. The subject under review is the medical necessity for the Stelara.

The health plan's determination is overturned.

The requested health service/treatment of Stelara is medically necessary for this patient. Since this patient has been treated with an anti TNF agent and an anti-intern in the past, it is appropriate to start her on a biological agent with a different mechanism of action. Therefore, Stelara is medically necessary to treat this patient's Crohn's disease. Crohn's disease results from a pathological immune response to luminal antigens in genetically predisposed individuals. Since the causes of Crohn's disease are complex and only partially understood, treatment is based on the empiric use of anti-inflammatory drugs. The use of Stelara to treat this patient's Crohn's disease is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer
Treatment: Radiation Therapy for Metastases Bone: 10 fractions of Tomotherapy Direct/3D Image Guided Radiation Therapy (IGRT)

The insurer denied Radiation Therapy for Metastases Bone: 10 fractions of Tomotherapy Direct/3D Image Guided Radiation Therapy (IGRT). 
The denial is upheld. 

This patient is a female with a history of a stage IIIB adenocarcinoma of the left lung post resection followed by adjuvant chemotherapy and immunotherapy. She had severe upper back pain near the left scapula. She had further evaluation with x-rays and computed tomography (CT) scans that revealed progression of disease in her mediastinum and lungs as well as bone metastases at the right 3rd rib, left post 5th rib and lumbar (L)1 vertebral body. Her pain is related to the left posterior 5th rib lesion so palliative radiation therapy is recommended to this area with 3 dimensional (D) conformal tomotherapy with image guidance (IGRT) is requested to deliver 3000 centigray (cGy) in 10 treatments.
At issue is Radiation Therapy for Metastases Bone: 10 fractions of Tomotherapy Direct/3D Image Guided Radiation Therapy (IGRT).

The health plans determination of medical necessity is upheld in whole.

The requested treatment of Radiation Therapy for Metastases Bone: 10 fractions of Tomotherapy Direct/3D Image Guided Radiation Therapy (IGRT) is not considered medically necessary for this patient.
This patient has widely metastatic adenocarcinoma of the lung with progressing disease at the left 5th rib with a lytic lesion. Palliative radiation therapy is recommended to deliver 3000 cGy in ten treatments to this metastasis of the 5th rib. This treatment can be safely delivered with complex treatments without 3D approach as well as daily imaging is not necessary as weekly ports can be used to appropriately set up the radiation fields. This is supported by the American Society for Radiation Oncology (ASTRO) clinical guidelines and is accepted as the standard approach of treatment for palliation recognized in the oncologic medical community.
Therefore, the requested treatment of Radiation Therapy for Metastases Bone: 10 fractions of Tomotherapy Direct/3D Image Guided Radiation Therapy (IGRT) is not considered medically necessary.