Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned


Diagnosis: Obesity/Diabetes.
Treatment: Mounjaro.
The insurer denied Mounjaro. 
The health plan's determination is overturned. 

This is a male with type 2 diabetes, obesity, prostate cancer, hypertension, hyperlipidemia, obstructive sleep apnea, non-alcoholic fatty liver disease, atrial fibrillation, and a history of stroke. He is on metformin extended release (XR) 500 milligrams (mg) twice daily. He is unable to tolerate higher doses. He has tried and failed Ozempic and Trulicity. He started Mounjaro with improved glycemic control. Hemoglobin A1C 6.8%.

A formulary exception is indicated.
The formulary alternatives include Ozempic, Trulicity, and Victoza. The patient has tried and failed Ozempic and Trulicity. The American Diabetes Association clinical guidelines recommend the use of Mounjaro or Ozempic for patients with type 2 diabetes and obesity when weight loss is desired, as in this clinical situation. Victoza is not recommended as an alternative in this clinical situation. In addition, Ozempic has been shown to be superior in lowering hemoglobin A1C as compared to Victoza. Victoza is not an appropriate alternative in this patient who has already failed Ozempic. Without Mounjaro, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the formulary drugs will be or have been ineffective as the requested non-formulary drug.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pituitary Adenoma. 
Treatment: Stereotactic body radiotherapy (SBRT); procedure codes 77373 and 77435. 

The insurer denied coverage for stereotactic body radiotherapy (SBRT); procedure codes 77373 and 77435. 

The denial is overturned. 

Radiation therapy (RT) in pituitary adenoma should be offered only to patients with residual, recurrent, progressive, or high-risk tumors with careful assessment of the benefit-risk ratio by an experienced multidisciplinary neuro-oncology team.
The choice of RT technique should be based on size, site, and availability of infrastructure and expertise, with no significant differences between fractionated approaches and stereotactic radiosurgery (SRS). 

This patient has a slowly growing pituitary tumor which can be treated with single shot Gamma knife, fractionated intensity modulated radiation therapy (IMRT) or fractionated stereotactic radiosurgery (SRS). Although the patient has no visual symptoms, it is better to treat now rather than waiting for symptoms as the tumor is in a critical location. 
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for stereotactic body radiotherapy (SBRT); procedure codes 77373 and 77435 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diffuse large B-cell lymphoma.

Treatment: Other Radiation Therapy (Proton Beam).

The insurer denied coverage for Other Radiation Therapy (Proton Beam).

The denial is upheld. 

This is the case of an adult patient who presented with stage 2 lymphoma and was treated with 6 cycles of chemotherapy. Positron emission tomography (PET) scan showed partial response. The patient is being evaluated for Chimeric antigen receptor (CAR-T) bridging Radiation Therapy (RT) using a Proton beam. 

This patient has unilateral neck disease and is being treated with a moderate dose of 30 Gray (Gy) (unit of ionizing radiation dose). The patient can be treated with Intensity modulated radiotherapy (IMRT) which is standard of care (SOC). The treating physician provided a dose-volume histogram (DVH) comparison of IMRT and proton beam; however, RT doses to organs at risk (OAR) are within acceptable range with IMRT. IMRT is SOC in such cases.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Other Radiation Therapy (Proton Beam) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, breast cancer, gastroesophageal reflux disease (GERD), thrombocytopenia, hyperlipidemia, hypertension, hypothyroidism, and osteoporosis

Treatment: personal care services (PCS) level 2; 12 hours per day, 7 days per week; total 84 hours per week

The insurer denied coverage for personal care services (PCS) level 2; 12 hours per day, 7 days per week; total 84 hours per week

The denial is overturned

This is a geriatric patient with chronic medical problems including arthritis, hypertension and osteoporosis.  The patient lives alone in a 1-bedroom apartment.  The insurer approved personal care services (PCS) level 2; 8 hours per day, 7 days per week, total 56 hours per week and the request is for PCS level 2; 12 hours per day, 7 days per week, total 84 hours per week.   

According to the Uniform Assessment System (UAS) report, the patient's cognition is modified independent.  The patient is able to independently direct care, has the capacity to properly activate a Personal Emergency Response System (PERS) unit and can call Emergency Medical Services (EMS) if necessary. The patient is reportedly totally dependent to maximal assistance for much of the Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient also reportedly requires extensive assistance for bathing, personal hygiene, dressing, locomotion, toilet transfer/use and ambulation. Limited assistance is reportedly needed for bed mobility and eating. The patient is frequently incontinent of bladder and continent of bowel.  

This physician would agree that given the patient's reported general weakness and debility and limitations in performing Activities of Daily Living (ADLs), the patient may benefit from additional hours. Based on the records reviewed, the patient's health and safety would be properly maintained with personal care services (PCS) level 2; 12 hours per day, 7 days per week; total 84 hours per week.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care services (PCS) level 2; 12 hours per day, 7 days per week; total 84 hours per week is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: epilepsy
Treatment: Inpatient Intercranial Laser Interstitial Thermotherapy (LITT-procedure of the brain) 
The insurer denied Inpatient Intercranial Laser Interstitial Thermotherapy (LITT-procedure of the brain). The health plan's determination is overturned. 

The patient is a male with a history of a motorcycle accident and who was treated for seizures for two years and was seizure free for two years and tapered of anti-seizure medications (ASMs). He then had a motor vehicle accident caused by a convulsive seizure and was put back on ASMs. The plan was for Laser Interstitial Thermotherapy (LITT) as test results show that the left Hippocampus was always the first to start the seizure off. 

The LITT procedure is likely to be more beneficial than any standard treatment as his medications do not control his significant seizures which are disabling. The area of his onset of seizures is not conducive to surgical treatment. 
LITT is a minimally invasive, cytoreductive surgical technique that can be used to make targeted and conformal lesions in the brain. Several critical advances in probe design and the development of MR thermometry have made LITT a more practical surgical technique. This recent interest in LITT has spurred numerous reports describing efforts to treat neurosurgical pathologies, including neoplasms and epileptogenic foci. The value of LITT for the treatment of certain pathologies such as recurrent glioblastoma multiforme (GBM) and epileptogenic foci has now become well established.  

LITT is increasingly being performed in favor of open surgical procedures. LITT is associated with a shorter length of stay (LOS), a higher likelihood of being discharged home, and lower index hospitalization charges compared to open procedures. LITT is a safe treatment modality in carefully selected patients with RE and offers an opportunity to increase the utilization of surgical treatment in patients who may be opposed to open surgery or have contraindications that preclude open surgery.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: epilepsy
Treatment: Inpatient Intercranial Laser Interstitial Thermotherapy (LITT-procedure of the brain) 
The insurer denied Inpatient Intercranial Laser Interstitial Thermotherapy (LITT-procedure of the brain). The health plan's determination is overturned. 

This is a male with a history of medication resistant temporal lobe epilepsy. He has had multiple medications without relief. The neurologic exam shows no motor, sensory or reflex abnormalities. The provider has recommended Inpatient Intercranial Laser Interstitial Thermotherapy (LITT-procedure of the brain).

The requested procedure is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The procedure is supported in the literature. Le et al cite "overall, Engel Class I outcome was achieved in 62% of patients with MTLE ((Mesial temporal lobe epilepsy)), and 97% of patients achieved > 50% seizure frequency reduction. Complications were largely temporary, though there was one persistent visual field deficit. Laser ablation is well-tolerated and offers marked seizure reduction for the majority of patients". Xue et al cite "meta-analysis of data from 16 studies that included 269 patients with treatment-resistant epilepsy showed that magnetic resonance imaging (MRI) -guided LITT significantly reduced the frequency of seizures and reduced postoperative complications, supporting the safety and effectiveness of MRI-guided LITT in the treatment of drug-resistant epilepsy". Lastly, Donos et al cite "seizure-free outcomes following LITT may be comparable in carefully selected patients with and without MTS (Mesial temporal sclerosis), and these outcomes are comparable with outcomes following microsurgical resection".
Appeal type: Experimental/Investigational
Decision: Overturned

Central Nervous System
surgical services

Diagnosis: epilepsy
Treatment: Inpatient Intercranial Laser Interstitial Thermotherapy (LITT-procedure of the brain) 
The insurer denied Inpatient Intercranial Laser Interstitial Thermotherapy (LITT-procedure of the brain). The health plan's determination is overturned. 

The patient is a male with Drug resistant post traumatic epilepsy. 

Inpatient Intercranial Laser Interstitial Thermotherapy (LITT-procedure of the brain) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
There are large long term studies showing clear benefit of this treatment in such cases.
Halpern et al noted "Overall, Engel Class I outcome was achieved in 62% of patients with MTLE (Mesial temporal lobe epilepsy), and 97% of patients achieved > (greater than) 50% seizure frequency reduction. Complications were largely temporary, though there was one persistent visual field deficit. Laser ablation is well-tolerated and offers marked seizure reduction for the majority of patients."
Jagid et al noted "LiTT appears to be a safe and effective surgical option for treatment-resistant MTLE, particularly among patients with MTS (Mesial temporal sclerosis). Remission of presurgical mood and anxiety disorders can also result from LiTT."
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post fall 
Treatment: Room and Board Custodial Care
The insurer denied the room and board custodial care.
The denial is overturned.

The patient is a female. She has a history diabetes, hyperlipidemia, coronary artery disease, hypertension, glaucoma, chronic obstructive pulmonary disease, hypothyroidism, atrial fibrillation, obesity, and varicose veins. She was admitted to the facility after a fall with debilitation and multiple fractures. She had poor participation with therapy and was discharged with total assistance for transfers and extensive assistance with toileting and hygiene.

The clinical notes a complaint of a new upper thigh wound. The patient was noted to be hemodynamically stable. The records show the patient refusing to participate with therapy. Reports show the patient is content to remain in bed and requires extensive encouragement to participate in therapy. She is unable to progress in functioning with bed exercises.

The room and board is medically necessary.

This is a review for a custodial level of care. The patient was discharged from therapy. Her cognition is modified independent and her physical functioning is total dependence with transfers and assistance with toileting and personal hygiene. She is incontinent of bowel and bladder. She requires assistance with medication administration and monitoring. Custodial care is care primarily for the purpose of assisting a patient in ADLs (activities of daily living) or in meeting personal rather than medical needs. This care is not expected to substantially improve a medical condition and has minimal therapeutic value. Such care includes assistance with walking, bathing or dressing; transfer or positioning in bed; normally self-administered medicine; meal preparation; feeding by utensil, tube or gastrotomy; oral hygiene; ordinary skin and nail care; catheter care; suctioning; using the toilet; enemas; or preparation of special diets and supervision over medical equipment or exercises or over self-administration of oral medicine. This patient has multiple chronic medical conditions and limited mobility with assistance. In addition, she requires assistance with medication administration, bathing, and toileting. The requested custodial level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's disease
treatment: Skyrizi
The insurer denied Skyrizi. 
The health plan's determination is upheld.

This patient is a young female with a history of Crohn's disease and psoriasis. She has tried and failed Stelara and Entyvio. Skyrizi (risankizumab) is being requested and is under review.

Skyrizi is not medically necessary for this patient.
Skyrizi is an interleukin-23 antagonist indicated and Food and Drug Administration (FDA) approved for the treatment of moderate-to-severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy or active psoriatic arthritis in adults OR moderately to severely active Crohn's disease in adults.
Skyrizi is not FDA approved in pediatric patients with Crohn's disease. The safety and efficacy of Skyrizi in treating pediatric Crohn's disease are not established.
There are no peer-reviewed literature reports supporting the proposed treatment. Furthermore, the patient has not tried and failed the FDA approved therapies for her age and condition, such as infliximab and adalimumab (Humira). The history of psoriasis is not considered a contraindication for using infliximab or Humira.
Therefore, Skyrizi is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Charcot Marie Tooth Disease
Treatment: Transport chair
The insurer denied the transport chair.
The determination is overturned.

The patient has a past medical history of Charcot Marie Tooth with degeneration and deformities in the bilateral ankles and feet. The rehabilitation notes indicate that the patient can only move around the house by crawling. It was also noted that they discussed bracing with their primary care physician (PCP) however this was contraindicated secondary to extensive damage in the legs. They are unable to stand for more than five seconds. Due to severe limitations in mobility the patient is bed bound. At issue is the medical necessity of the service/treatment of transport chair.

The requested health service/treatment of transport chair is medically necessary for this patient.

The wheelchair is a complex piece of equipment that has been extensively engineered and studied. They are indicated for patients with severe limitation in mobility, especially within the home. It should allow for increased independence in the activities of daily living. Most individuals with severe orthopedic or neurological issues become wheelchair experts because doing so increases their chances of getting a wheelchair that truly meets their needs. 

However, there are numerous options when considering a manual wheelchair including dimensions, tire type, cushion type and features including tilt and weight. The physician, patient and therapists will need to give input when prescribing a wheelchair. Considering this patient's chronic medical condition and documentation of severe mobility restrictions, the wheelchair appears appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colorectal Liver Cancer
Treatment: Liver Allotransplantation 
The insurer denied the Liver Allotransplantation.
The health plan's determination is overturned.

The patient is a male who is diagnosed with stage 4 colorectal cancer (CRC) status/post (s/p) neoadjuvant chemotherapy, right colon resection with pathology showing cancer where the tumor has grown into the outer lining of the bowel wall but has not grown through it with the involvement of 1-3 regional nodes and the cancer has spread to other parts of the body (T3N1M1) disease. He was evaluated and deemed a candidate for a living donor liver transplant meeting very strict criteria for consideration. He received additional chemotherapy and further extensive evaluation in a very specialized program and demonstrated stable to improving liver disease with no evidence of extrahepatic disease and maintained an excellent functional status, continuing to work throughout his evaluation and treatment. He meets the very strict criteria for consideration with an Oslo score of 1 with the only point given for the fact that it has been less than 2 years since diagnosis. He is an excellent candidate for this option with expected overall survival (OS) and disease-free survival (DFS) for this particular patient far and away improved over what would be expected with chemotherapy alone.
The medical reviewer within the organization cites the patient as not being a candidate because one of the criteria is that he has had malignant disease within 5 years. This contraindicating criterion is only cited for cadaveric donors and the plan for this patient is a living donor transplant of which there are many options available to him.

The requested allograft transplant for isolated unresectable hepatic metastatic CRC is medically necessary for the patient. Multiple highly specialized selected centers are now providing this option under rigorous protocols using strictly selected criteria which this patient fits extremely well and which will highly likely result in a much better outcome for this particular patient than chemotherapy/immunotherapy alone.
This patient meets the very strict criteria for consideration of a living donor liver transplant for unresectable CRC hepatic only metastatic disease. He is extremely high functioning despite the rigorous chemotherapy protocol he has. The existing data both domestic and international demonstrates the expected OS and DFS is far and away better than with adjuvant therapy alone and the patient is in the hands of a center which has rigorously studied and developed the program. The data shows that this is an excellent therapeutic option for this patient with a much better outcome more likely than not compared to adjuvant treatment alone. The outcomes in low risk patients, i.e., those that fit very strict criteria, is similar to those who undergo liver transplant for hepatocellular carcinoma for which it is acceptable and approved.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Duchenne Muscular Dystrophy
Treatment: Physical Therapy
The insurer denied Physical Therapy.
The determination is overturned.

The patient has a past medical history of Duchenne Muscular Dystrophy, cardiac transplant on immunosuppression and osteoporosis. They are wheelchair bound secondary to severe trunk weakness and contractures in all four limbs.

The requested health service/treatment of Physical therapy visits (26 home health visits) is medically necessary for this patient.
Duchenne Muscular Dystrophy is a progressive disorder. It is one of the most common and severe forms of muscular dystrophy and usually affects boys in early childhood; people with the condition will usually only live into their 20's or 30's. Mobility assistance including exercise, physiotherapy and physical aids are crucial to maintaining quality of life.
In this case, considering the patient's age, extensive medical issues and potential lifespan, continued therapy appears appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Ventilator dependent
Treatment:  Inpatient admission/continued long term acute care (LTACH)
The insurer denied coverage for inpatient admission/continued LTACH.
The denial is overturned.

The patient is an adult female with a history of polysubstance abuse, diabetes, Wolf-Parkinson White Syndrome, gastroesophageal reflux disease (GERD), hypothyroidism, asthma, hypertension, and antiphospholipid syndrome. 

She was admitted with shallow breathing, hypoglycemia, was in cardiogenic shock, and needed resuscitation with intravenous (IV) fluids and vasopressors. The patient was intubated and placed on ventilator. She went into cardiac arrest and underwent CPR (cardiopulmonary resuscitation) and was resuscitated. She required a prolonged hospital stay with Tracheostomy and percutaneous endoscopic gastrostomy (PEG) for feeding.

During the period denied by the insurer, this patient had severe Diabetes Mellitus with periods of Hyperglycemia and Hypoglycemia and was exhibiting dawn phenomenon, early-morning rise in blood glucose levels.

The patient also had a complex wound, which required daily dressing with Silver Alginate and Foam.

This patient had several referrals sent out to nearby Skilled Nursing Facilities (SNF) by the long term acute care (LTACH), but no facilities were available to accept this patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for continued LTACH is substantiated.