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

Diagnosis: Porokeratosis.
Treatment: Acitretin 10mg Capsules. 
The insurer denied Acitretin 10mg Capsules. 
The determination is upheld.

The patient has porokeratosis of the arms and trunk. They have been treated with liquid nitrogen and topical steroids with insufficient results, however, as per a clinic note, the porokeratosis was reported to be better on topical halobetasol. There are concerns of precancerous and cancerous potential of the porokeratosis lesions. Acitretin 10 mg capsules is under review for medical necessity.
The Acitretin is not medically necessary. There is no standard or proven method of treating porokeratosis of any variant (including Disseminated Superficial Actinic Porokeratosis). Only case reports exist to confirm potential clinical benefit of any surgical, topical, oral (including Acitretin), or laser/procedural treatment for porokeratosis of any variant. Because there are no randomized, controlled trials for these treatments, the incidence of treatment failures are not balanced against those reported case reports or case series that report treatment success. While potentially helpful, the unconfirmed use of oral Acitretin to prevent malignant transformation of porokeratosis lesions, and the lack of significant history of skin cancer in this patient, preclude any conclusion that the side effects of oral Acitretin outweigh any benefits (which for this patient are entirely unknown and unconfirmed).
Therefore, Acitretin is not medically necessary to treat this patient's Disseminated Actinic Porokeratosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Medial Meniscus Tear

Treatment: Left arthroscopic knee surgery (procedure code 29881)

The insurer denied coverage for left arthroscopic knee surgery (procedure code 29881)

The denial is upheld

This is a male with a history of a left medial meniscus tear.  The treating practitioner reviewed the magnetic resonance imaging of the patient's left knee and determined that he had a medial meniscus tear.  The patient had a left knee arthroscopy with a partial medial meniscectomy to treat his condition. 

Surgical indications require identification of the pain generator and failure to improve with conservative treatment.  There should be consistency of subjective complaint, physical findings and imaging.  There should be functional limitation with likelihood of improvement. The records showed a visit to the physician, who reported imaging studies were positive for a tear to the meniscus.  There was no documentation of limitations, functional loss or physical examination.  There was no documentation that other treatments were provided before surgery. These findings do not substantiate necessity for surgery.  Imaging studies by themselves are not sufficient for operative intervention. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The arthroscopic knee surgery (procedure code 29881) performed is not considered medically necessary for this patient.

The insurer's denial of coverage for the arthroscopic knee surgery (procedure code 29881) performed is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 

The insurer denied proton beam therapy. 
The denial is upheld in whole. 

This patient is a female with a locally advanced invasive ductal carcinoma involving the right breast. She had neoadjuvant chemotherapy followed by bilateral mastectomies and tissue expander placement. Pathology revealed a complete response with only minimal ductal carcinoma in situ (DCIS) in the mastectomy specimen. Radiation therapy is recommended to the right chest and nodal regions to decrease her risk of recurrence and proton beam approach is requested. She has been entered on clinical registry trial for proton radiation. The subject under review is the medical necessity for the requested therapy. 

The health plan's determination is upheld in whole. 

The requested treatment of proton beam therapy is not medically necessary for this patient. The recommended proton beam radiation therapy for this patient is considered not medically necessary as there are lack of any significant clinical trials published in peer reviewed journals supporting the benefits and safety as compared to conventional photon beam radiation therapy. The small studies that are published such as Lou et al. state the need for further evaluation and clinical trials to be performed to make a determination on the benefits of proton beam radiation therapy for post mastectomy breast cancer patients. There are multiple ongoing clinical trials available after reviewing clinicaltrials.gov. Until these trials mature and evaluated and then published in peer reviewed journals showing the outcomes of proton beam radiation as compared to photon beam radiation, this approach of treatment for this clinical scenario is considered not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Crohn's Disease
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug, Entyvio as not medically necessary. 
The health plan's determination is overturned.

This is a review for the use of Entyvio (Vedolizumab) to treat Crohn's disease in a patient. This female patient has severe ileal Crohn's disease. She failed conventional therapy with 5-ASA agents (Pentasa) steroids and immunomodulators. She was previously treated with 3 anti-tumor necrosis factor (TNF) agents (Infliximab, Adalimumab and Certolizumab) but lost response or developed and adverse reaction to these agents. She was started on Ustekinumab but failed this medication despite a dose escalation to every 4 weeks and the addition of an immunomodulator. She was started on Entyvio and did well initially, but later she started losing response to every 8-week infusions. Therefore, the attending gastroenterologist escalated the dose to 300 milligrams (mg) every 4 weeks. Her Crohn's disease is in remission at the escalated dose. Hence the attending gastroenterologist would like to continue Entyvio at the escalated dose of 300 mg every 4 weeks.
At issue is the medical necessity of the requested prescription drug, Entyvio.

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

The standard of dose of Entyvio in both ulcerative colitis and Crohn's disease is 300 mg infused intravenously over approximately 30 minutes at zero, two and six weeks, then every eight weeks thereafter. The attending provider is requesting an Entyvio dose escalation with a shortened interval between infusions to every 4 weeks since the patient did not respond to Entyvio every 8 weeks. The patient's dose of Entyvio was escalated several months ago and the patient is stable on this dose. The concept of dose escalation is standard of care in the treatment of inflammatory bowel disease and has been done with Remicade, Humira, Stelara and Entyvio but not with Cimzia. Dose escalation in biological therapy used to treat inflammatory bowel disease is a well-accepted practice and supported by literature in patients who are not responding to standard dosing of the medication. This can be done by a dose increase or shortening the interval between infusions and sometimes a combination of both dose increase and shortening the interval between doses. Additionally, since this patient has already been on the medication for several years and her Crohn's disease is in remission, she should be continued on this dose. The only reasons to stop Vedolizumab or any other biologic agent used for treatment of inflammatory bowel disease are:
1) an adverse reaction or
2) a contraindication or
3) loss of response to the medication.

Based on the clinical data provided, the use of Entyvio at 300 mg intravenous (IV) every 4 weeks to treat this patient's medically refractory Crohn's disease is appropriate and medically necessary because she has tried and failed every FDA approved biological agent used to treat Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes 

Treatment: Inpatient Acute Rehabilitation Admission

The insurer denied coverage for inpatient acute rehabilitation admission. 

The denial is overturned.

The patient is a male with multiple medical problems including atrial fibrillation, diabetes mellitus, hypertension and stroke. He has a grade 4 sacral ulcer with a diverting colostomy to avoid contamination. His hospitalization has been complicated. However, he has improved and was referred for acute inpatient rehabilitation, which is currently under review.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the combination of the patient's medical, nursing and functional needs support the medical necessity of acute inpatient rehabilitation. The patient is an excellent candidate for acute inpatient rehabilitation. His functional deficits are best addressed in an acute rehabilitation setting with comprehensive physical and occupational therapy, as compared to skilled nursing facility (SNF). Nursing issues are also complicated, including grade 4 decubitus ulcers, which can be best treated in an acute rehabilitation facility while undergoing therapy. In addition, given his multiple medical problems, the need for ongoing physician supervision has also been established.  

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient in this particular case. Inpatient acute rehabilitation admission is medically necessary.

The insurer's denial of inpatient acute rehabilitation admission is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea/vomiting
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a male who was admitted to the hospital. He presented due to intractable nausea and vomiting and management of poor oral intake. He had a history of prostate cancer status post prostatectomy complicated by metastatic disease to the bone status post palliative radiation, and metastatic gastric cancer. He had developed back pain and jaundice and had a computed tomography (CT) scan demonstrating a pyloric tumor causing obstruction of the common bile duct. He underwent an attempted endoscopic retrograde cholangiopancreatography (ERCP) but gastroenterology was unable to traverse the pylorus due to gastric narrowing. He was taken to the post anesthesia care unit and had an uneventful course. However, due to his history of intractable nausea and vomiting, he was admitted with a plan to attempt a gastric stent placement. The plan of care included intravenous (IV) fluids, IV anti-emetics, no food by mouth, hold anticoagulation, and pain management. The gastroenterology service also followed the patient during the hospital stay.

The inpatient hospital admission was not medically necessary. The patient was noted to be stable and the indication for hospital level care of care was not provided in the progress notes. Although it was noted that he had intractable nausea and vomiting, there were no acute electrolyte abnormalities and he appeared to be able to tolerate a diet with antiemetics. The patient was described as being hemodynamically stable with no acute abnormalities during the interval of time while he awaited his interventional radiology procedure. The patient did need the gastric outlet procedure performed but it occurred after several days of hospitalization. During the time interval before the procedure, there were no acute medical needs. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and Monthly Visits
The insurer denied the Braces and Monthly Visits.
The determination is overturned.

The patient has a Class I malocclusion, moderate spacing of the upper and lower arches and anterior crossbite of teeth number (#) 7-#10. He is missing all four first premolars. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion. At issue is the medical necessity of braces and monthly visits.
The patient has significant spacing with #7-#10 in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. He is already severely damaging his upper incisors. Studies have shown that even the untreated dentition shows increased anterior irregularity with time (4), which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. 

For these reasons, the orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 

The insurer denied increase in personal care assistance hours to 84. 
The denial is overturned. 

The patient is a male with Lennox-Gastaut syndrome, medically refractory epilepsy, pervasive developmental disorder, and developmental delay. He is wheelchair bound, non-verbal, non-ambulatory, and requires complete assistance with activities of daily living (ADLs). The patient has incontinence, is able to walk only a couple steps with assistance and takes multiple anti-seizure medications daily. 

Letters from the patient's neurologist and from the primary care provider are included. A Uniform Assessment Report is also included. 

The health plan has previously approved a total of 26 hours per week of Personal Care Assistance. The patient's representative requested an increase to 84 hours per week. 
The subject under review is whether an increase from 26 hours to 84 hours per week is medically necessary for this patient. 

The health plan's determination is overturned. 

The requested service of 84 hours per week in Personal Care Assistance is considered medically necessary. This patient is incontinent, non-ambulatory, and non-verbal. He requires full support for all care. 

This is a patient with a permanent, severe medical condition that affects development and need for assistance with activities of daily living. This patient meets the threshold for personal care assistance, and 84 hours per week of this care is considered medically necessary. Based on this patient's medical condition and the information provided, this patient requires full support with all activities of daily living and cannot make decision for himself. While some of these cares were previously provided at the school, education has been only virtual during the coronavirus pandemic. This patient has medical conditions that make him completely dependent upon caregivers.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite.
Treatment: Braces.

The insurer denied braces. The health plan's determination is overturned. 

The patient in question is a male with an anterior crossbite on tooth 10. He presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. He is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite.

The braces are medically necessary for this patient. This patient presents with an anterior crossbite on tooth 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.

If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. Braces are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems/Stroke/CVA
Treatment: Home Health Care
The health plan denied the requested increase in personal care assistant hours due to the lack of medical necessity. 
The health plan's determination is overturned.

The patient is a female with past medical history of cerebrovascular accident (CVA), wheelchair dependence, osteoporosis, urinary incontinence, bowel incontinence, chronic kidney disease stage 3, congestive heart failure, hypothyroidism, and glaucoma who had been assigned personal care assistant (PCA) hours 10 hours/day, 7 days/week, to total 70 hours/week based on telephonic assessment tool performed. The patient was assessed at total assistance with tasks of ordinary housework and shopping while maximum assistance with tasks of meal preparation and stairs. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, transportation, bathing, personal hygiene, dressing upper/lower body, locomotion, transfer toilet, and toilet use while independent with tasks of bed mobility and eating. The activities of equipment management, walking, and stair use were noted as "activity did not occur". At issue is the medical necessity of the requested increase in personal care assistant hours.

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

Yes. The patient has documented chronic medical problems of CVA, bowel and urinary incontinence, pressure ulcer, and wheelchair dependence with documented worsening of functional status. The patient is dependent for all activities of daily living (ADLs) / instrumental activities of daily living (IADLs) as documented in the tasking tool/assessment. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The insurer also incorrectly utilized the tasking tool despite the patient's documented 24-hour care needs. The patient had progression of pressure ulcers due to lack of assistance with bed mobility, personal hygiene, transfer toilet, and toilet use in the overnight hours. The patient's daughter is no longer able to provide the same level of informal support and the patient has no other informal support. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Considering the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, live-in 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: abdominal pain
Treatment: inpatient admission
The insurer is denied coverage for inpatient admission
The denial is overturned. 

This female patient has a history of significant hypertension, irritable bowel syndrome (IBD), ruptured ovarian cyst, status post pancreatic cyst fluid drainage, Roux-en-Y cystojejunostomy and cystogastrostomy who presented to the Emergency Department (ED) with complaints of pelvic pain, vomiting, and diarrhea. The patient's vital signs on presentation included: Temperature 99 Fahrenheit, Blood Pressure 118/77, and Pulse 115, Respiratory Rate 18, and Oxygen (O2) Saturation 99% on Room Air. The patient's laboratory results included the following: white blood cell (WBC) count 18.4, hemoglobin 12.0, hematocrit 36.7, creatinine 0.93, glucose 123, amylase 153, lipase 193, and lactate 2.4. The patient was started on intravenous (IV) fluids and antibiotics (i.e., vancomycin and Zosyn) for possible intra-abdominal infection. The patient's computed tomography (CT) scan of the abdomen/pelvis showed inflammatory changes in the left upper quadrant, a 1.5 centimeter (cm) peripherally enhancing fluid filled structure, mural thickening of distal transverse colon.  Infectious Diseases consulted and adjusted the patient's antibiotic coverage. General Surgery also consulted for the patient's crampy abdominal pain.  Gynecological evaluation was negative. The patient improved clinically and was discharged to continue outpatient management.

Based on the review of the medical record and literature, full hospital admission was medically necessary for this patient. The patient presented with abdominal pain of unclear etiology as well as other non-specific gastrointestinal symptoms.  The patient was afebrile, but had tachycardia with heart rate up to 115. The patient's laboratory results showed numerous abnormalities including elevated white blood cell (WBC) count, lactate, lipase, and amylase. The patient's computed tomography (CT) scan of the abdomen/pelvis was worrisome for inflammatory changes and possibly an abscess.  Based on these clinical abnormalities in a high-risk patient with numerous co-morbid conditions, hospital admission was medically necessary for administration of intravenous antibiotics as well as specialty evaluation.   
	
The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alopecia Areata
Treatment: Xeljanz 
The insurer is denied coverage for Xeljanz
The denial is upheld. 

This female patient has a history of Alopecia Areata. She had a telehealth visit with the dermatologist for a follow up visit regarding alopecia treatment. The patient is currently taking 5 milligrams (mg) of oral Xeljanz twice a day (BID.) She has had regrowth over most of the scalp but there are still regions that have not regrown.  The physician recommended increasing the dosage to 10 mg of Xeljanz BID. 
Xeljanz is not medically necessary for the patient's condition, alopecia areata. The patient has not failed or has not shown to have a contraindication to numerous non-systemic therapies known to possibly improve alopecia areata, including light therapy, squaric acid, diphenylcyclopropenone (DPCP), calcipotriene, and anthralin (1-11).  Although case reports have demonstrated possible efficacy of Xeljanz for alopecia areata, further studies are needed to demonstrate the long term efficacy and safety of Xeljanz.  It is noted that the Food and Drug Administration (FDA) released a statement in early 2019 finding increased risk of deep vein thrombosis (DVT) and pulmonary embolism in patients enrolled in a phase 4 clinical trial of Xeljanz at a dosing of 10mg BID (1).   The standard of care for treatment of alopecia areata would necessitate an attempt to use the above mentioned non-systemic options for the treatment of alopecia areata.  

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for Xeljanz (Tiofacitinib) to treat Alopecia Areata is upheld.   The medical necessity is not substantiated.