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

Diagnosis: Rectal adenocarcinoma
Treatment: Proton Beam Radiation
The insurer denied: Proton beam therapy
The denial is: Upheld

The patient is a male who presented with tumor (T)3 node (N)1 metastasis (M) 0 adenocarcinoma of rectum. The patient was treated with neoadjuvant chemotherapy with complete response. The patient is planned with radiation therapy (RT) using proton beam. The subject under review is the medical necessity for the proton beam therapy.

The requested treatment with proton beam therapy is not medically necessary for this patient. Medically necessary treatment is defined as those treatments which are In accordance with generally accepted standards of medical practice in the United States.
In this case, radiation treatments which are in accordance with generally accepted standards of medical practice in the United States for rectal cancer are three dimensional (3D) conformal radiation therapy (CRT) or intensity modulated radiation therapy (IMRT) using photon.
National Comprehensive Cancer Network (NCCN) guidelines do not recommend proton beam for this clinical scenario. There are no published data to support proton beam for curative intent without surgery.
Proton treatment is not in accordance with generally accepted standards of medical practice in the United States for treatment of rectal cancer.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes type II.
Treatment: Mounjaro.
The insurer denied Mounjaro. 
The health plan's determination is upheld. 

This is a male diagnosed with for T2DM (type II diabetes mellitus) with hyperglycemia. This request is for Mounjaro. As reported, his diabetes was poorly controlled. His hemoglobin A1C is close to 10. Per a letter from the treating provider, he has failed Victoza, Ozempic and Trulicity. In addition, per the provider's letter, he has tried metformin, Amaryl, Tresiba and Jardiance (which he is still taking).

A formulary exception is not indicated in this case.
The formulary drugs, Victoza and Trulicity will be as effective as the non-formulary drug. The patient has failed Ozempic. According to a letter from the treating provider, the patient has apparently has tried/failed Victoza, Ozempic and Trulicity. However, a letter is not sufficient documentation of trial/failure of the formulary drugs.
Medical records in the form of chart notes or paid claims showing the patient on all the formulary alternatives and hemoglobin A1c levels showing that the A1c level was not at goal despite being on these medications are not provided. There are no studies showing superiority of the requested medication over formulary alternatives.

Therefore, a formulary exception is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Breast Cancer that has traveled to the liver.
Treatment: Radiation Therapy/intra-hepatic brachytherapy using yttrium-90.
The health plan denied the requested intra-hepatic brachytherapy using yttrium-90. 
The health plan's determination is overturned.

This is a female patient with a history of breast cancer, currently with liver dominant metastatic disease.
Past medical history was reviewed. She has had side effects due to the chemotherapy. The pertinent past medical records note obesity. Past surgery history reviewed includes bilateral mastectomy and hysterectomy. Medications and lab work were noted. Internal medicine clearance has been given for the procedure, planned with general anesthesia.
At issue is the medical necessity for the requested intra-hepatic brachytherapy using yttrium-90.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, given the patient's diagnosis and current health status, the requested health service/treatment or procedure of intra-hepatic brachytherapy using yttrium-90 is medically necessary for this patient. This therapy is not experimental or investigational.
I overturn, on the whole, the health plan's determination of the medical necessity for treatment of Stage IV metastatic breast cancer to the liver.
The patient has a history of hepatic metastatic breast carcinoma that is chemotherapy refractive.
This patient is not a candidate for ablation or stereotactic body radiation (SBRT) external beam radiation due to the size, number, and location of the liver lesions. She is also not a surgical candidate for resection. Additional systemic chemotherapy could always be used in addition to the liver-directed therapy proposed.
The patent should undergo Y-90 therapy to preserve her quality of life.
The role of local therapies in metastatic breast cancer from Up-to-date is not relevant. Y-90 liver loco-regional therapy is, however, frequently used in the approach to metastatic breast cancer.
This patient meets the accepted criteria in the literature. The patient should have the procedure of intra-hepatic brachytherapy using yttrium-90 microspheres authorized for her as a treatment, also known as Selective Internal Radiation therapy.
The treatment goal is palliative and not curative and is to debulk and shrink the liver tumors present, prevent new lesions and stabilize against further progression in the liver. She has a liver dominant disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: selective antibody deficiency
Treatment: Outpatient intravenous (IV) therapy services
The insurer denied: Outpatient IV therapy services
The denial is: Upheld

The patient is a female with selective antibody deficiency who receives intravenous gammaglobulin replacement therapy in a hospital outpatient setting. She has difficulty with the first infusion but tolerated subsequent infusions without difficulty. The subject under review is the medical necessity for outpatient intravenous (IV) therapy services.

The health plan's determination is upheld.

Outpatient IV therapy services are not medically necessary for this patient. Intravenous gammaglobulin services are appropriate for this patient as she has a selective antibody deficiency and has benefited from replacement therapy. However, the documentation provided supports well tolerated infusions. Administration in lower level of care setting is appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute cholecystitis

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. [1] Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. [2, 4, 5] Factors that contribute to an admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. [3] In patients without abnormalities of the bile duct or abnormal liver function tests, ambulatory laparoscopic cholecystectomy is safe and feasible. [5] Ambulatory and/or outpatient laparoscopic cholecystectomies reduce hospital costs without compromising patient outcomes. [6]

Per clinical documentation, this patient presented to the ED (emergency department) with a three-day history of right upper quadrant abdominal pain. The patient has a history of a sleeve gastrectomy. Vital signs in the ED were within normal limits. A CT (computed tomography) scan demonstrated findings suggestive of acute cholecystitis. The total bilirubin was elevated at 4.8. Alkaline phosphatase, alanine transaminase, and aspartate aminotransferase were all elevated at 161, 195, and 145, respectively. The white blood cell (WBC) count was elevated at 13.8. An ultrasound indicated mild gallbladder wall thickening. An MRCP (Magnetic resonance cholangiopancreatography) was performed due to the elevated liver function tests and concerns for choledocholithiasis. There was no evidence of choledocholithiasis. The total bilirubin increased to 7.4. The patient was taken to the operating room for a laparoscopic cholecystectomy with intraoperative cholangiogram. There were no reported complications. The patient was discharged on postoperative day one. Per MCG (Milliman Care Guidelines) criteria, an admission is indicated when there are systemic signs of inflammation (i.e. WBC count greater than 10.0) and evidence of common bile duct disease (i.e. total serum bilirubin greater than or equal to 2mg (milligrams) /dL (deciliter). [7] Peer-reviewed literature and MCG criteria indicate that an inpatient admission is necessary in these circumstances. The health plan did not act reasonably. Per provided clinical documentation, the inpatient admission was medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spasticity at the ankle
Treatment: Durable Medical Equipment -flexion/extension device
The health plan denied the Durable Medical Equipment as not medically necessary. 
The health plan's determination is upheld. 

This is a male who is a partial spastic tetraplegic. He is status/post (s/p) C3-T1 decompression and fusion. He has spasticity and is requesting an Ankle Dorsiflexion Dynasplint for range of motion (ROM) and stretching.

The ankle Dynasplint is not medically necessary for this patient with spasticity at the ankle. 

Standard of care for spasticity in the spinal cord population includes toxin injection with aggressive range of motion and splinting. Treatment for this condition includes a toxin injection and an ankle-foot orthosis (AFO)/multipodus boot.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar radiculopathy and spinal stenosis

Treatment is for outpatient procedures (64483 x 1, 64484 x 1) pain management, pain injections in the spine 

The insurer denied coverage for outpatient procedures (64483 x 1, 64484 x 1) pain management, pain injections in the spine 
 
The denial is overturned

This patient has a history of lumbar radiculopathy and spinal stenosis.  He takes Mobic, Tylenol #3, and Gabapentin for pain. He presented to the Pain Management physician's office for a follow up for back pain. He tried to schedule a transforaminal epidural steroid injection (TFESI), but it was denied by his insurance. He had excellent pain relief with a previous lumbar TFESI for greater than 6 months. The patient recommended a TFESI to treat back pain. 

His MRI (magnetic resonance imaging) showed herniated discs at L (lumbar) 4-L5 and L5-S (sacral) 1 with multilevel nerve root impingement.

Clinical practice guidelines support (1) the use of Epidural Steroid Injection in cases where there is a clearly documented herniated disc and where past Epidural Steroid injections have provided sustained relief. The guidelines state: "Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness."
Similarly, a Cochrane review found:
"A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term." This is Level 1 evidence.

There is no evidence to support the statement that Epidural Steroids cannot be used effectively after one year.

The insurer's denial of coverage for outpatient procedures (64483 x 1, 64484 x 1) pain management, pain injections in the spine is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Graves Disease. 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. 
The denial is upheld. 

The patient is a female who presented to the emergency department with concerns of myalgias, emesis, and dizziness of one week duration. Pertinent history included Graves disease. 
Initial vital signs revealed a temperature of 37.1 Celsius (C), heart rate (HR) 118, blood pressure (BP) 141/84, respiratory rate (RR) 20, peripheral capillary oxygen saturation (SpO2) 94% on room air. Initial examination documented exophthalmos and a large goiter. Initial laboratory testing revealed a thyroid stimulating hormone (TSH) less than (<) 0.015 and a Free thyroxine (T4) 3.33. Additional tests noted a white blood cell (WBC) 11.1, hemoglobin (Hgb) 14.5, platelets (Plt) 424, sodium (Na) 135, potassium (K) 4.1, chloride (Cl) 100, carbon dioxide (CO2) 21, blood urea nitrogen (BUN) 12, creatinine (Cr) 0.4, international normalized ratio (INR) 1.3, Troponin negative, creatine kinase (CK) negative, Lactic acid 1.3. Chest radiograph was negative. Electrocardiogram (EKG) showed sinus tachycardia without acute ischemic changes. The patient placed in the hospital thereafter with an impression of severe hypothyroidism with a Burch-Wartofsky Scale Score of 30 points. The treatment plan included initiation of methimazole and atenolol. On the next day her vital signs were noted to be a temperature of 98.2 Fahrenheit (F), HR 81, BP 138/96, and RR 16. The patient left against medical advice. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is upheld. 

The treatment of inpatient stay is not medically necessary for this patient. 
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care. 
In this particular situation, the patient had a known history of Graves disease and documented non-compliance of medical treatment who presented with concerns for symptomatic hyperthyroidism. Initial evaluation an undetectable TSH level and a Free T4 of 3.33. The Burch-Wartofsky score was documented as 30. Treatment included re-initiation of previously prescribed methimazole and atenolol. The following day the patient was hemodynamically stable and left against medical advice. Although the patient left against medical advice, clinical indications for admission to inpatient care were not met. The patient did not have a Burch-Wartosky Point Scale score of 45 or more, severe or persistent altered mental status, cardiac arrhythmias of immediate concern, temperature of 103.0 F or more, pulmonary edema, or hemodynamic instability.[2]
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Congestive heart failure, atrial fibrillation and hypertension

Treatment: personal care assistance (PCA) services 24 hours per day 7 days per week (live-in)

The insurer denied coverage for personal care assistance services 24 hours per day 7 days per week (live-in)
 
The denial is modified.

This is a patient with chronic medical problems including congestive heart failure, atrial fibrillation and hypertension. She lives alone in a private home.    She is currently approved for PCA services totaling 56 hours/week. She is requesting an increase in Personal Care Assistance (PCA) services to 24 hours per day 7 days per week (live-in), which is currently under review.  

The Uniform Assessment System (UAS) report was reviewed. The evaluation was primarily performed when she was an inpatient at the hospital.  The patient's cognition is described as "modified independence." She is fully alert and oriented. She requires maximal assistance for bathing, lower body dressing and toilet transfers/use. She is frequently incontinent of bladder and occasionally incontinent of bowel. Extensive assistance is required for personal hygiene, upper body dressing and ambulation.  

The patient's significant functional impairments support the medical necessity of Personal Care Assistance (PCA) services.  However, her condition and functional needs are not at a level or unpredictable as to require the requested Personal Care Assistance (PCA) services 24 hours per day 7 days per week (live-in). This physician would agree the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by increasing the PCA services to 12 hours/day, 7 days/week (84 hours total). 

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 certainty, the requested personal care assistance (PCA) services 24 hours per day, 7 days per week (live-in) is not medically necessary.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the patient's health and safety can be appropriately provided and maintained by increasing the PCA services to 12 hours/day, 7 days/week (84 hours total).

The insurer's denial of coverage for personal care assistance services 24 hours per day 7 days per week (live-in) is modified. Medical Necessity is partially substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gynecological - Pelvic Pain/Varicosities. 
Treatment: Surgical Services. 
The insurer denied outpatient procedure (pelvic embolization). 
The denial is overturned.

The patient is a female with pelvic pain and varicosities which are consistent with venous insufficiency. Her symptoms have gotten worse in the last few months, with findings of May-Thurner syndrome. In February of this year had a computed tomography (CT) venogram. Previously this March she had an ovarian vein embolization on the right a left one and improvement.
The patient's treatment plan is for venography to be performed and right pelvic venous embolization.
The subject to be determined is whether a pelvic embolization is likely to be more beneficial than any standard treatment for the patient's condition.

The health plan's determination is overturned.

After reviewing the available information, it is reasonable to consider that pelvic venous embolization would be the next best step in the management of this patient's symptoms. Particularly since she received benefits after prior embolization therapies. Variceal recanalization after prior embolization therapies is a well-known phenomenon and should be addressed with repeat embolization, particularly in the setting where the patient experience benefit from prior embolization. This condition is difficult to medically manage. These patients can have significant declines in quality of life.

The proposed procedure is likely to be more beneficial for this patient than other treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gynecological - Pelvic Pain/Varicosities. 
Treatment: Surgical Services. 
The insurer denied outpatient procedure (pelvic embolization). 
The denial is overturned.

The patient is a female with prior history of pelvic congestion syndrome initially treated with embolization of the left ovarian vein. She had improvement in her pain and was able to resume her normal activities including exercise. Recently her symptoms recurred in the pelvis. Her additional symptoms include internal hemorrhoids and pain with intercourse. The patient also suffers from ambulation issues being described as 'leg heaviness'.

As described, a computed tomography (CT) venogram demonstrated that the prior embolization has been successful, however, a May-Thurner morphology was seen in which there is compression of the left common iliac vein. When attempts were made to treat this narrowing, the patient had significant pain resulting in the procedure being aborted.

The subject under review is pelvic embolization, and whether it is likely to be more beneficial for the patient than any other standard treatment.

The health plan's determination is overturned.

The proposed treatment is likely to be more beneficial for this patient. The patient has previously had relief of her symptoms from venous congestion by embolization of the left gonadal vein. Her current symptoms have returned likely due to her pelvic drainage being compromised, this time by compression of her left common iliac vein. Commonly known as May-Thurner Syndrome, it is increasingly recognized as a contributor to pelvic congestion syndrome (PCS). It is referred to as a secondary source of PCS.
The concurrent presence of both pathologies makes initial complete treatment difficult since the standard embolization of the gonadal vein usually suffices as it did for this case, at least temporarily. In this case, the patient's symptoms resurfaced, and the physician investigated the compression of the left common iliac vein narrowing by venography and, by measuring a pressure gradient further confirmed this as a likely source of venous congestion.

Pelvic embolization will likely result in a decrease in the patient's symptoms by allowing for better drainage of her pelvic vessels.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Gynecological - Pelvic Pain/Varicosities. 
Treatment: Surgical Services. 
The insurer denied outpatient procedure (pelvic embolization). 
The denial is overturned.

The patient is a female patient who presented with a history of pelvic pain and varicosities consistent with pelvic venous insufficiency. She has had a five-month history of worsening pelvic symptoms. There are findings of May-Thurner morphology/syndrome as well.
She had a right ovarian vein embolization performed. Requested treatment authorization for the embolization performed.
The patient's past medical history was reviewed. She has no leg swelling or deep vein thrombosis (DVT). Pertinent past medical records note imaging; a computed tomography (CT) venogram. There are prior ultrasound reports.
Past surgery/procedural history reviewed including a left ovarian vein embolization. At that time, she had improved her symptoms post-procedure.
Medications noted including analgesics. No lab work was noted.
The current treatment plan was the venography performed along with a right pelvic venous embolization.
The subject under review is whether the proposed procedure is likely to be more beneficial for this patient than any standard procedure. 

The health plan's determination is overturned.

The proposed health service/treatment outpatient procedure (pelvic embolization), is likely to be more beneficial than any standard treatment or treatments, for the insured's a life-threatening or disabling condition or disease, symptomatic pelvic venous abnormalities.
This denial refutes the potential of gonadal vein/pelvic embolization as a reasonable treatment option, that this treatment is 'experimental or investigational', 'unproven', or non-standard or of 'uncertain role'. This is unreasonable based on newer literature and opinions. The procedure is not experimental.
Pelvic congestion syndrome can be a disabling diagnosis and a medical problem that should not be ignored but rather requires meaningful treatment. Ovarian venous embolization may have solved this patient's symptoms and thereby improved her health with a minimally invasive technique.
This treatment, ovarian vein (pelvic) embolization, is the only reasonable option for this patient and will give her the best chance for significant symptom relief and obliteration/improvement of her pelvic varicosities. Additional veins in the deep pelvis may have needed to be targeted but were not abnormal per imaging reports.
Scholarly articles and scientific evidence in peer-reviewed literature continue to show excellent results from ovarian vein embolization with great safety.