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

Diagnosis: Breast Cancer
Treatment: Radiation Therapy (Initial Phase: 28 Fractions of 
Proton Beam Therapy with Image Guided Radiation Therapy [IGRT])
The insurer denied: Radiation Therapy (Initial Phase: 28 Fractions of Proton Beam Therapy with Image Guided Radiation Therapy [IGRT])
The denial is overturned.

The patient is an adult female with a history of stage I left breast cancer status post breast conserving surgery followed by adjuvant left breast radiation. She recently presented with a locoregional recurrence status post left mastectomy (stage pT3N1). Left chest wall and comprehensive nodal re-irradiation was recommended and proton therapy was requested.

The proposed treatment is medically necessary.

In this case, a dosimetric comparison with a photon-based plan was performed, and the proton therapy plan significantly reduces radiation dose to the heart and lung. Because of her prior radiation exposure to the heart and lung, it is crucial to minimize additional radiation exposure to her heart and lung to reduce the risk of heart and lung toxicity. 
A 2013 MD Anderson Cancer Center study evaluated 33 patients that underwent proton beam therapy (PBT) reirradiation for intrathoracic recurrent non-small cell lung cancer (NSCLC). The results showed that "Thirty-one patients (94%) completed reirradiation. At a median 11 months' follow-up, 1-year rates of overall survival, progression-free survival, locoregional control, and distant metastasis-free survival were 47%, 28%, 54%, and 39%", and the authors concluded that "PBT is an option for treating recurrent NSCLC". 
Another 2017 multi-institutional trial (including the University of Maryland) performed joint estimation of the risk of recurrence caused by inadequate radiation dose coverage of lymph node targets and the risk of cardiac toxicity caused by radiation exposure to the heart. Delivered photon plans are compared with realistic proton plans, thereby providing evidence-based estimates of the heterogeneity of treatment effects in consecutive cases for the two radiation treatment modalities. The authors concluded that "Modern photon therapy yields limited risk of cardiac toxicity in most patients, but proton therapy can reduce the predicted risk of cardiac toxicity by up to 2.9% and the risk of 
breast cancer recurrence by 0.9% in individual patients". 
Proton beam radiation is the best technique that can provide adequate tumor coverage and normal tissue sparing. There are several studies that have shown an advantage of proton beam radiation therapy over the conventional conformal radiation therapy, and especially in the setting of re-irradiation. The requested proton therapy, therefore, is medically necessary.
In addition, image-guided radiation therapy (IGRT) uses medical imaging to help provide precise and accurate radiation treatment. It is often considered a necessary addition to proton beam therapy. Since the requested proton therapy is considered medically necessary, image-guided radiation therapy is also medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, diabetes, and imbalance
Treatment: Consumer Directed Personal Care Aide for a Total of 168 Hours per Week
The insurer denied: Consumer Directed Personal Care Aide for a Total of 168 Hours per Week
The denial is overturned.

The patient is an elderly female. Her medical conditions include dementia, diabetes, and imbalance. She had a fall recently followed worsening of her conditions. Denial of consumer directed personal care aide for a total of 168 hours per week is being appealed. The health plan approved 56 hours per week.
The patient's Uniform Assessment System (UAS) evaluation completed eight months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances and medications, and shopping; maximal assistance with phone use, stairs, bathing, personal hygiene, dressing, and toileting; extensive assistance with walking, locomotion, and eating; and limited assistance with bed mobility. She has bladder incontinence.
A letter from the patient's provider notes that the patient has worsening dementia, diabetes and poor gait. She is unable to ambulate. She wears diapers. She would benefit from change in position every 2 hours to avoid bed sores.
A letter from another provider notes the patient has short-term memory loss and unsteady gait. She is unable to perform ADLs (activities of daily living), including moving her position every 2 hours.

The requested Consumer Directed Personal Care Aide for a Total of 168 Hours per Week is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split-shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of consumer directed personal care aide for a total of 168 hours per week is being appealed. The health plan approved 56 hours per week. This patient has multiple chronic conditions. The health plain denied the requested hours based on the patient not needing continuous care. Uniform Assessment System (UAS) evaluation completed eight months ago shows the patient requires assistance with all ADLs (activities of daily living). She has bladder incontinence. The appeal statements support progression with the patient's functioning, and she is dependent with all ADLs (activities of daily living) and requires frequent assistance turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested consumer directed personal care aide for a total of 168 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara SQ 90mg
The health plan denied: Stelara SQ 90mg
The determination is: Overturned 


The patient is a female with Crohn's disease status post ileocolic resection and small bowel resection for stricture. She failed Remicade and high-dose Humira. She was started on Stelara with infusion. She subsequently had some improvement in abdominal pain and bloody diarrhea. The erythrocyte sedimentation rate was elevated at 40 millimeters per hour (mm/hr) three weeks after Stelara infusion. She was given a Stelara subcutaneous (SQ) injection with increased erythrocyte sedimentation rate of 60 mm/hr. The coverage is requested for Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease. 
At issue is the medical necessity of Stelara SQ 90 mg every 4 weeks.
The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of Stelara SQ 90mg is medically necessary for this patient. Current medical literature supports the dose escalation of Stelara to 90 mg every 4 weeks as medically necessary in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al). Another study showed a 73 percent (%) response in patients with anti-TNF-resistant Crohn's disease, and 80% of responders maintained remission for 1 year (Kopylov, et al). The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor medications, which the patient has failed (Tuskey, et al). A study showed dosing at 90 mg every 4 weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every 4 weeks (Kopylov, et al). Multiple studies have shown that a majority of patients in whom Stelara dosing every 8 weeks failed to control symptoms responded to dosing every 4 weeks (Wils, et al; Battat, et al; Khorrami, et al; Ollech, et al; Fumery, et al; Haider, et al). In this case, the patient has had persistent disease symptoms and elevated inflammatory markers after Stelara infusion and an early Stelara injection (at 5 weeks). American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should...have their medication dose adjusted in order to attempt to optimize therapy" (Lichtenstein, et al). Use of Stelara every 8 weeks or discontinuation of Stelara (even if an alternative is attempted immediately) may result in loss of disease control, with complications such as stricture, fistula, bowel obstruction, flare, hospitalization, need for further surgery, or other complications in this patient with severe stricturing disease which has required surgery at a young age. For these reasons, the request for Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of this patient's Crohn's disease.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
pain management

Diagnosis: stiff person syndrome
Treatment: pain management
The insurer denied Therapeutic Apheresis or Plasmapheresis. The health plan's determination is upheld. 

The patient is a female diagnosed with possible stiff person syndrome (SPS). The patient has symptoms of a spastic paraparesis. The physician indicates that the patient is negative for antibodies typically associated with stiff person syndrome including glutamic acid decarboxylase and glycine receptor antibodies. Documentation indicates that the patient has tried and failed first line medication such as benzodiazepines and baclofen. 

Therapeutic Apheresis or Plasmapheresis is not medically necessary for this patient.
For stiff person syndrome, first-line therapy includes treatment with benzodiazepines. If a patient has tried and failed benzodiazepines, second line therapy includes baclofen. In this instance, the patient has tried and failed both benzodiazepines and baclofen. For stiff person syndrome that is resistant to oral medication, the next recommended line of treatment is intravenous immunoglobulin or intravenous immunoglobulin (IVIG). Evidence supporting the use of IVIG in patients with SPS includes a small randomized crossover trial and some case reports and case series; even severely affected patients may respond to this therapy The efficacy of IVIG was best shown in the randomized blinded crossover trial comparing IVIG with placebo. Eleven of 16 patients who received immune globulin were able to walk more easily or without assistance; their frequency of falls decreased, and they were able to perform work-related or household tasks. The duration of benefit ranged from six weeks to one year. Anti-GAD65 antibody titers declined after therapy with IVIG but not after the administration of placebo. In another study, functional status improved markedly in three bedridden patients with previously refractory disease. Plasma exchange is not recommended unless treatment with intravenous immunoglobulin has been ineffective. There is no documentation of this in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: exacerbation of asthma, shortness of breath, wheezing
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a female with hypertension (HTN), diabetes mellitus (DM), and asthma. The patient had a prior pulmonary embolism (PE), Parkinson's, and anxiety. The patient had a hospital admission a month prior but had no prior intubations. She presented with dyspnea, wheezing, coughing, and malaise after exposure to COVID.

In the emergency department (ED), the patient's temperature was 36.8 degrees Celsius, blood pressure (BP) was 138/76, heart rate (HR) was 88 beats per minute (bpm), respiratory rate (RR) was 16, and her peripheral capillary oxygen saturation (SpO2) was 93 percent (%) on room air (RA). She was in no distress, her heart was regular, she was breathing comfortably with wheezing, she had leg edema, and she was alert and oriented. The patient's white blood cell count (WBC) was 7.4, sodium (Na) was 136, bicarbonate was 25, blood urea nitrogen (BUN) was 10, and creatinine was 0.98. The Influenza, respiratory syncytial virus (RSV), and COVID tests were all negative. Her chest x-ray (CXR) was clear. A computed tomography pulmonary angiogram (CTPA) showed no pulmonary embolism (PE), pneumonia, or edema. She was diagnosed with an asthma exacerbation and was started on steroids and nebulized bronchodilators. The next day, she had improved with scattered wheezing. Treatments continued. The following day, she was feeling better, her lungs were clear, and she was continued on prednisone and nebulizers. The next day, she was doing well and was discharged on a course of prednisone.

At issue is the medical necessity for an inpatient hospital admission.
I uphold the health plan's determination, in whole.

An inpatient admission was not medically necessary.
The patient presented with dyspnea and wheezing with no other diagnoses. She was not severely ill, and she had no organ dysfunction, respiratory distress, or gas exchange abnormality. She was improving over an ED course of care and improved significantly over a short time frame. She had no history of prior intubation and had not failed outpatient treatment. Given all of this, I do not think she needed an inpatient admission, as she did not require inpatient only testing, monitoring, or treatment and did not need an inpatient admission for prolonged or poorly responsive symptoms. I think an alternate level of care would have been reasonable, but I do not think an inpatient admission was needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Miscarriage.
Treatment: Inpatient hospital admission.

The insurer denied Inpatient hospital admission.  The health plan's determination is upheld. 

The patient is a pregnant female with a spontaneous miscarriage of a fetus. She was admitted as an inpatient. Her vital signs were stable. She was discharged the following day.

At issue is the medical necessity of Inpatient hospital admission.

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

The requested health service/treatment of Inpatient hospital admission is not medically necessary for this patient.

The patient is a healthy female without significant comorbidities. She had vaginal bleeding however without severe anemia and the need for blood transfusion. Her vital signs were normal, and she had no hemodynamic instability. Her procedure (spontaneous miscarriage) was without complications, and her bleeding resolved. She had no pulmonary complications, hepatic or renal complications. Generally, she would have been observed after her miscarriage in the post anesthesia care unit (PACU). There was no need for acute, inpatient monitoring, as there were no complications after surgery. She had no hemorrhage, infection nor poor wound healing.
Therefore, the requested health service/treatment of Inpatient hospital admission is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right total knee arthroplasty
Treatment: Ambulance Services
The insurer denied Ambulance Services
The determination is upheld.

This is a female patient diagnosed with right knee arthritis. There is a request regarding ground ambulance transportation. An operative note from the physician documents that the patient underwent a right total knee arthroplasty. There is a nonemergent transport certification form stating that the patient required transportation as the patient was on continuous oxygen which cannot be self-administered as the patient has an illness preventing them from being able to self-administer oxygen, is unable to get up from a bed without assistance, and unable to sit safely in a chair or wheelchair. The patient has comorbid diabetes, obstructive sleep apnea, and cardiac history. A prior review indicates that the patient was transported from a hospital to a skilled nursing facility. A transport record indicated that the patient was alert and oriented, her vital signs were within normal limits, and she was on four liters of oxygen via nasal cannula. The patient was assisted out of the chair, able to stand and sit on a stretcher without incident, the vital signs were reviewed and normal during transportation, no incidents were reported, and the patient was brought to the room on a stretcher and transferred to a hospital bed upon arrival without incident. An appeal letter from the patient states that after a knee replacement surgery, the patient required a skilled nursing facility for recovery. The patient stated the need for oxygen following surgery above normal usage prior to surgery. At issue is the medical necessity of ambulance services.

The ambulance transportation was not medically necessary. The plan supports ambulance transportation services which are due to an emergency or in nonemergent cases based on medical necessity. In this circumstance, there was no documentation of an emergent condition that required it to be transportation. Additionally, there is no documentation that the care provided was most appropriate level of service or supply which can safely be provided. The documentation provided indicates that the patient utilizes oxygen prior to surgery and there is no indication the patient could not continue to self-administer oxygen or that the patient could have safely been transferred upright as the patient was able to sit safely in a chair and wheelchair.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multifocal motor neuropathy.
Treatment: Injection (rituximab -Q5115).

The insurer denied Injection (rituximab -Q5115).  The denial is overturned.

The patient is an adult male with multifocal motor neuropathy. He is currently on intravenous immunoglobulin (IVIG). He has weakness mostly in the arms. Prior electromyogram (EMG) showed active denervation in multiple nerve distribution. The provider wishes to prescribe rituximab. Initially intravenous immunoglobulin was effective, but the patient's condition has declined over the years. The request was previously denied coverage by the health plan, as the plan does not cover rituximab for non-covered indications (oncologic, multiple sclerosis). The denial is being appealed.

The requested health service is medically necessary.

The patient has tried and failed intravenous immunoglobulin, which is a standard therapy for multifocal motor neuropathy. There are case reports that rituximab may be effective in treating multifocal motor neuropathy, which is a chronic and progressive disease. Furthermore, there is emerging evidence that rituximab may be effective for chronic immune mediated neuropathies, which multifocal motor neuropathy is part of.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Hemorrhage.
Treatment: Inpatient admission.

The insurer denied Inpatient admission.  The denial is upheld.

This is an adult male, who presented to the emergency department with rectal hemorrhage. The patient reported fatigue, weakness, dizziness, dyspnea, and bloody diarrhea 8x/day. Bloody bowel movements started two to three months prior to admission. The patient stated he did not come to the emergency department because he did not have insurance. Emergency medical services administered intravenous normal saline (NS).

The patient's past medical history was significant for hypertension, hyperlipidemia, mitral valve prolapse, alcohol abuse, portal hypertension, alcoholic hepatic steatosis, diverticulitis, lower gastrointestinal bleeding, hemorrhoids, obesity (body mass index [BMI] 30.6), tobacco abuse, and depression. In the emergency department, the patient's hemoglobin was 6.1. The patient was initiated on treatment with intravenous fluids, pantoprazole intravenous, and one unit packed red blood cells. Repeat hemoglobin after the transfusion was 5.8. The patient received two more units of packed red blood cells. Repeat hemoglobin was 6.6. The patient was continued on intravenous fluids, pantoprazole intravenous, and Clinical Institute Withdrawal Assessment (CIWA) protocol.

On day #2, the patient denied chest pain or shortness of breath, denied nausea/vomiting. It was stated that esophagogastroduodenoscopy and colonoscopy would likely be performed on Monday. Esophagogastroduodenoscopy and colonoscopy were performed on day #5.  Esophagogastroduodenoscopy showed LA (Los Angeles) grade A esophagitis, gastritis, and duodenitis. Colonoscopy showed sigmoid diverticulosis, large hemorrhoids, liquid stool in the entire examined colon, and a fair bowel prep. 

The inpatient admission was not medically necessary.

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. A lower level of stay would have been more appropriate for this patient. A lower level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have active and ongoing rectal bleeding, did not have high risk endoscopic features, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Nausea.
Treatment: Inpatient admission.

The insurer denied: Inpatient admission.  The denial is upheld.

The patient is an adult male. An inpatient hospital admission is being reviewed. Coverage for inpatient hospital admission was denied by the health plan based on the MCG (Milliman care guidelines) 26th edition guideline in regard to "abdominal pain, undiagnosed." The appeal letter from facility notes that the patient has a history of diabetes and gastroparesis. The patient had presented to the emergency room with abdominal pain and nausea and then was discharged; he re-presented 10 hours later. The patient had a computed tomography (CT) scan of the abdomen/pelvis that showed concern for thickening in the right colon and rectum and no bowel obstruction. The patient was recommended admission for abdominal pain. The appeal letter notes that physical exam on admission revealed tenderness, but no rebound tenderness or guarding were reported. The patient had a leukocytosis and an elevated bicarbonate level. The patient was given lactated Ringer's, morphine, and intravenous famotidine and Zofran.

The inpatient admission was not medically necessary.

There is no evidence in the submitted documentation that the patient required a higher level of care than observation care. There is no evidence in the submitted documentation that the patient meets the criteria in the MCG (Milliman Care Guidelines) 26th edition guideline in regard to abdominal pain. Therefore, the inpatient admission was not medically necessary.