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

Diagnosis: Breast cancer. 
Treatment: Ibrance. 

The insurer denied Ibrance. The health plan's determination is upheld. 

This is a female with estrogen receptor (ER) +/ progesterone receptor (PR) +/HER2 (human epidermal growth factor receptor 2)- (IHC [Immunohistochemistry]) metastatic breast cancer. Fluorescence in situ hybridization (FISH) studies indicate a focal 1.5 millimeter (mm) area of carcinoma positive for HER2 amplification. HER2/CEP (chromosome enumeration probe) ratio is 2.35 with the HER2 average copy per cell of 5.05. Ibrance has been recommended as a component of treatment and is under review. 

Ibrance is not medically necessary for this patient. 

The submitted documentation indicated that the patient had a negative HER2 by IHC, but IHC is subject to variability that FISH is not. FISH has been demonstrated to be more accurate and reproducible. This patient has FISH testing that is positive (if only focally) for HER2 and in this setting, it is recommended the patient he treated as a HER2+ patient. This approach is supported by the peer-reviewed literature, national guidelines, and by the authors of UpToDate. 

Ibrance is not recommended for use in the treatment of patients with HER2 positive disease due to a lack of proven benefit. Therefore, Ibrance is not indicated for this patient. 

There are an array of National Comprehensive Cancer Network (NCCN) recommended treatment options available for this patient based on prior treatment history, patient goals, and the characteristics of the malignancy. Options include hormonal therapy such as selective estrogen receptor modulators, tamoxifen, and aromatase inhibitors. Additionally, HER2-directed therapy can be considered as a single modality or in combination with cytotoxic therapies.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Eating disorder
Treatment: Vyvanase
The insurer denied Vyvanase. 

The health plan's determination is overturned. 

This case involves a young adult female diagnosed with an eating disorder and mood disorder best characterized as bulimia nervosa and a single episode of major depressive disorder. She has a comorbid seizure disorder. She was initially evaluated and treated with a psychotropic medication regimen of Effexor and Vyvanse with the addition of as needed (prn) Xanax. The patient's symptoms include binge eating and bulimic behavior together with symptoms of depression. There is no documentation of the frequency of binge episodes or of any involvement with a mental health practitioner for psychotherapy. The patient lives alone and works and attends college. The patient's clinician and patient are requesting coverage for treatment with Vyvanse for treatment of the eating disorder indicating that this is the only medication that is effective and helps. 

The continued use of Vyvanse is backed by scientific evidence published in peer-reviewed, medical literature. Vyvanase for the diagnosis of an eating disorder with binge eating and bulimia is generally recognized by the relevant medical specialty community; and is consistent with prevailing medical standards and clinical guidelines including national consensus statements, nationally recognized clinical guidelines, and national specialty society guidelines. Vyvanse at a daily dosage of 20 milligrams (mg) daily for the treatment of binge eating is consistent with prevailing standards of medical practice, as well as the Food and Drug Administration (FDA) indicated use for the treatment of binge eating disorder.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Eating disorder
Treatment: Vyvanase
The insurer denied Vyvanase. The health plan's determination is overturned. 

This case involves a young adult female diagnosed with an eating disorder and mood disorder best characterized as bulimia nervosa and a single episode of major depressive disorder. She has a comorbid seizure disorder. She was initially evaluated in October of 2021 and treated with a psychotropic medication regimen of Effexor and Vyvanse with the addition of as needed (prn) Xanax in December of 2021. The patient's symptoms include binge eating and bulimic behavior together with symptoms of depression. There is no documentation of the frequency of binge episodes or of any involvement with a mental health practitioner for psychotherapy. The patient lives alone and works and attends college. The patient's clinician and patient are requesting coverage for treatment with Vyvanse for treatment of the eating disorder indicating that this is the only medication that is effective/helps. 

The continued use of Vyvanse is backed by scientific evidence published in peer-reviewed, medical literature. Vyvanase for the diagnosis of an eating disorder with binge eating and bulimia is generally recognized by the relevant medical specialty community; and is consistent with prevailing medical standards and clinical guidelines including national consensus statements, nationally recognized clinical guidelines, and national specialty society guidelines. Vyvanse at a daily dosage of 20 milligrams (mg) daily for the treatment of binge eating is consistent with prevailing standards of medical practice, as well as the Food and Drug Administration (FDA) indicated use for the treatment of binge eating disorder.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Open Angle Glaucoma.
Treatment: Formulary exception for Lumigan, Pre-service.
The insurer denied the Formulary exception for Lumigan, Pre-service.
The denial is overturned.

The patient is a male with open angle glaucoma, moderate stage, for whom coverage of Lumigan 0.1% (percent) is the subject of review. Coverage was previously denied per policy as it was not identified that the patient had tried and had an inadequate treatment response, intolerance or contraindication to the required number of formulary alternatives which include latanoprost and travoprost (generic Travatan Z).

Upon appeal, it is identified that the patient tried and had adverse reaction after using latanoprost. An exam documents vision as 20/25-2 OD (right eye) and 20/20 OS (left eye), and intraocular pressures of 24 millimeter of mercury (mmHg) OD (right eye) and 18 millimeters of mercury (mmHg) OS (left eye) by applanation. Cup/disc ratios were 0.8 OD (right eye) and 0.7 OS (left eye). The patient was instructed to switch from latanoprost to Lumigan.

Yes, the health plan should cover the Formulary exception for Lumigan.
In this case, the patient has tried and had adverse reaction to one formulary alternative, latanoprost. While the remaining formulary alternative, generic travoprost, has not found to be ineffective or have adverse effects for this patient, travoprost is not considered as effective as the requested non-formulary Lumigan (bimatoprost) at lowering intraocular pressures.


Li, T., et al assessed the comparative effectiveness of first-line medical treatments in patients with POAG (Primary open-angle glaucoma) or ocular hypertension through a systematic review and network meta-analysis, and to provide relative rankings of these treatments. "The mean reductions (95% credible intervals) in IOP in millimeters of mercury at 3 months ordered from the most to least effective drugs were as follows: bimatoprost 5.61 (4.94; 6.29), latanoprost 4.85 (4.24; 5.46), travoprost 4.83 (4.12; 5.54), levobunolol 4.51 (3.85; 5.24), tafluprost 4.37 (2.94; 5.83), timolol 3.70 (3.16; 4.24), brimonidine 3.59 (2.89; 4.29), carteolol 3.44 (2.42; 4.46), levobetaxolol 2.56 (1.52; 3.62), apraclonidine 2.52 (0.94; 4.11), dorzolamide 2.49 (1.85; 3.13), brinzolamide 2.42 (1.62; 3.23), betaxolol 2.24 (1.59; 2.88), and unoprostone 1.91 (1.15; 2.67)."

Myers et al found that reductions in intraocular pressure (IOP) from latanoprost baseline were larger with bimatoprost 0.01% than with bimatoprost 0.03%, and bimatoprost 0.01% had a more favorable tolerability profile.

Therefore, the health plan should cover the Formulary exception for Lumigan 0.1%.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Liver mass.
Treatment: Positron Emission Tomography (PET) scan.
The insurer denied the Positron Emission Tomography (PET) scan.
The denial is upheld.

The patient is a male. Abdominal ultrasound was done, which revealed a liver mass. This test was done to evaluate elevated liver enzymes.

MRI (magnetic resonance imaging) was done and revealed the same mass, felt to possibly represent malignancy.

Ultrasound guided biopsy was attempted but could not be completed due to lack of a viable path to biopsy.

PET/CT (positron emission tomography/computed tomography) was recommended for further evaluation. This test was done, and it reveled lack of significant hypermetaboilc uptake associated with this lesion.

No, the Positron Emission Tomography (PET) scan was not medically necessary.
This patient did not have an established diagnosis of cancer. He was found to have an indeterminate liver lesion and ultrasound guided biopsy was attempted but could not be done based on the location of this lesion. PET/CT (positron emission tomography/computed tomography) was done for further evaluation but there is no clear evidence showing that PET/CT (positron emission tomography/computed tomography) is a standard test for evaluation of indeterminate liver lesions.

The provided records indicate that the plan was that CT (computed tomography) guided biopsy would be considered based on the results of PET/CT (positron emission tomography/computed tomography) imaging. However, there is no information showing that this patient could not have undergone CT (computed tomography) guided biopsy, regardless. Given lack of evidence showing that PET/CT (positron emission tomography/computed tomography) is associated with improvement in health outcomes for patients being evaluated for indeterminate liver lesions, it cannot be concluded that this test was medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Respiratory Syncytial Virus/RSV.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient at the time of service presented to the Emergency Department (ED) with a three-day history of fever and increased work of breathing noted on presentation. The infant was born full term, did not have a significant past medical history, and had not received her two-month immunizations. The patient was initially placed on non-invasive support  but she was able to be weaned to a High Flow Nasal Cannula (HFNC) The patient remained in the ED awaiting a Pediatric Intensive Care Unit (PICU) bed, although the PICU team was seeing the patient and assisting in management. She was weaned to 2 liters/minute. After being admitted to the PICU, she continued to receive intravenous fluids had laboratory testing submitted/resulted and was on continuous cardio-respiratory monitoring. She received Tylenol per rectum for fever management and a single dose of Prevacid. Her diagnoses included: acute respiratory failure, dehydration, lactic acidosis, and Respiratory Syncytial Virus (RSV) Bronchiolitis. The patient's condition continued to improve, and she was weaned to unassisted room air and tolerating oral feedings. 
The requested health service/treatment of Inpatient Stay was not medically necessary for this patient. Published literature notes risk factors for hospital admission in infants with bronchiolitis. These include the following: Chronic lung disease, bronchopulmonary dysplasia, immunodeficiency, cerebral palsy, Down's syndrome, born prematurely, cystic fibrosis and congenital heart disease. The infant in this case did not have any of these diagnoses/conditions. The criteria in a bronchiolitis pathway from Children's Hospital of Philadelphia (CHOP) recommend beginning oxygen if the saturation is consistently < 91%, which it was not. The patient did not have apnea and was not noted to be in significant respiratory distress. The venous blood gas did not indicate respiratory failure. Therefore, a diagnosis of acute respiratory failure was not met. Regarding dehydration, the patient's serum electrolytes were within normal limits while her urine specific gravity was greater than (>)1.030, suggesting mild dehydration that could be managed with normal saline fluid bolus and a brief administration of intravenous fluids.
Per other published pathways, improvement in oxygenation (not a problem in the patient), and improvement in degrees of respiratory distress (noted to be mild retractions in this patient), and ability to take oral fluids following hydration with intravenous fluids (provided to this patient) are criteria for discharge to the care of competent care givers. Therefore, although this infant was felt to need observation in the hospital and intravenous hydration, the submitted documentation did not support the inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: GERD (gastroesophageal reflux disease).
Treatment:  LINX Procedure, Pre-service.
The insurer denied the  LINX Procedure, Pre-service.
The denial is overturned.

The patient is a female with history of reflux and hiatal hernia. She is on omeprazole 40mg (milligrams) daily, and was switched to pantoprazole with Pepcid or Gaviscon because of ongoing symptoms. She woke up with regurgitation and acid reflux up into her chest, which ultimately required vomiting. Also, she has dysphagia to solid foods. She had an abnormal esophageal pH monitor confirming GERD (gastroesophageal reflux disease).

The surgeon has requested Laparoscopic Linx procedure. The denial reason was experimental/investigational. The reason for appeal is that the procedure was FDA (United States Food and Drug Administration) approved, and supporting material support its appropriateness.

Yes, the health plan should cover the LINX procedure.
This patient suffers from GERD (gastroesophageal reflux disease) causing night time regurgitation, which wakes her up. Even with BID (twice daily) PPI (proton pump inhibitor) and H2 (histamine H2-receptor) blocker, there is refluxing gastric contents.

Yes, the LINX procedure is more beneficial than any standard treatment for the insured's condition.
Medical therapies have been exhausted for this patient, and are not working satisfactorily. Surgical therapies exist that resolve this very well. Without LINX procedure, a Laparoscopic Nissen Fundoplication (LNF) would have been recommended. Other techniques have been tried endoscopically and otherwise, but none have been able to demonstrate long term efficacy and safety. The side effects of LNF (Laparoscopic Nissen Fundoplication) make it a less than ideal operation. LINX is an operation that is less disruptive to the normal anatomy, has been shown to be effective at reducing reflux episodes to a physiologic level, and has been show to dramatically improve patient satisfaction long term. It is approved by the FDA (United States Food and Drug Administration). There is published data on patients who have had the device for 6 years, showing a very low complication rate and a high resolution of GERD (gastroesophageal reflux disease).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, left hip

Treatment:  Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is upheld. 

According to the documentation submitted, this is a patient with a history of gastroesophageal reflux disease (GERD), hypothyroidism, osteoarthritis, and polycystic ovarian syndrome (PCOS). She presented to the hospital for a scheduled left hip replacement surgery. 

The medical records demonstrate a non-complicated post-surgical course after Mako robotic hip arthroplasty. The procedure itself was approximately one hour with limited blood loss. The patient's vital signs were stable. There was no evidence of bleeding nor infection. Her wound was without problem. She was able to tolerate oral pain medication with chart noting pain level zero and she was awaiting physical therapy (PT). The attending record reported hemodynamically stable and for disposition planning after physical therapy/occupational therapy. She had been evaluated by PT and was instructed on the use of cane and rolling walker. Her discharge summary, completed later that evening, reported a non-complicated course. 

She did not require treatment for an underlying medical condition nor require additional imaging. Her body mass index (BMI) was taken into consideration (35.7).

These findings do not substantiate necessity of acute level admission. The services would be provided at a lower intensity. 

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cancer related pain. 
Treatment: Oxycontin (oxycodone ER). 

The insurer denied Oxycontin (oxycodone ER). 
The determination is upheld. 

This is a female with metastatic breast cancer. The patient is receiving palliative chemotherapy. She has severe pain due to bone metastases. The patient's pain has been controlled with oxycontin (oxycodone ER); this is under review. 

Equi-analgesic dosing can be achieved with dose conversions. Each opioid drug has a different potency, defined as the dose necessary to produce a given effect. When switching from one opioid to another, the starting dose of the new drug is informed by the difference in their relative potencies and there are guidelines to inform these decisions. There are long-standing guidelines to inform this.
Given the role of equi-analgesic dosing, there is a paucity of data indicating that formulary options are inferior to Oxycontin in any way. Neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate nor the peer-reviewed provide evidence of superiority of one opioid analgesic relative to the others with regard to efficacy. Similarly, there is a paucity of information indicating that this patient has tried and failed any of the formulary options. Therefore, a formulary exception is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epilepsy.
Treatment: oxcarbazepine 300mg #240/30 days .
The insurer denied oxcarbazepine 300mg #240/30 days. 
The health plan's determination is overturned. 

The patient is a man with medically refractory focal epilepsy. Treatment with oxcarbazepine is the subject of this review. The request is for 300 milligrams (mg) tablets #240 per month. The patient is also treated with Keppra and Vimpat. The dose of oxcarbazepine was recently increased after breakthrough seizures.

The requested oxcarbazepine 300mg #240/30 days medically necessary for this patient. The request is for 240 tablets per 30 days or 8 tablets per day. This is a total daily dose of 2400 mg (8 tablets x 300 mg each).
For patients 17 years of age and old, the daily maximum dose is 2500 mg/day. The drug is Food and Drug Administration (FDA) approved for both treatment of partial seizures and monotherapy for partial-onset seizures. The patient has partial seizures as demonstrated by an electroencephalogram that shows right temporal interictal slowing.
The drug and dose are medically necessary because it is for an FDA approved indication and within the dosing guidelines as established by the FDA and the manufacturer's guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Skyrizi Pen INJ 150mg/mL, Pre-service.
The insurer denied the Skyrizi Pen INJ 150mg/mL, Pre-service.
The denial is overturned.

The patient is a male with psoriasis to the trunk, extremities, face and nails, 30% body surface area (BSA), treated with multiple topicals.  The provider is requesting Skyrizi.  The health plan requires a trial and failure to methotrexate and formulary alternatives Humira, Enbrel, Cimzia, Ilumya and Cosentyx.  The patient has a strong family history of malignancy.

Yes, Skyrizi is medically necessary.
Skyrizi meets medical necessity as it is considered within good standards of acceptable medical practice.  Skyrizi is an approved, appropriate and effective medication for psoriasis.  A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. Skyrizi is among the most effective therapies for psoriasis according to current peer-reviewed literature and does not carry a risk of malignancy, making it a highly appropriate choice for this patient.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hyperlipidemia
Treatment: Livalo 2mg
The insurer denied Livalo 2mg.
The determination is overturned.

The patient's total cholesterol was 172, low density lipoprotein (LDL) was 81, glucose was 236, and hemoglobin A 1C was 7.1% (percent). The patient has a history of type I diabetes and hypercholesterolemia.  A letter of medical necessity reports that the patient has been intolerant of multiple statins in the past including Crestor, Lipitor, Zocor. It is reported that the patient should continue Livalo as it has been effective and well-tolerated. The  patient's dose is 2 milligrams (mg). The physician reports that Livalo was approved in the past and they are requesting continuation of coverage.
At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The patient has tried atorvastatin, rosuvastatin, simvastatin, and failed these due to side effects. The patient is on 2 mg of Livalo which is equivalent to the maximum dose of lovastatin and pravastatin and fluvastatin. The patient has not tried these formulary alternatives. They are expected to be equally effective. However, there is concern about the patient having side effects with these medications as she had side effects with multiple other medications in this class. Given the fact that the patient has had side effects with multiple other statins, the patient may be expected to have similar side effects with the remaining formulary alternatives which are all lower potency.
The patient has tried multiple statins and had side effects and this medication has worked for this patient. Discontinuation of the medication is not consistent with generally accepted standards of medical practice. Continuation of the medication is consistent with generally accepted standards of medical practice.