Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer
Treatment: Y-90 radioembolization 
The insurer denied Y-90 radioembolization 
The health plan's determination is overturned. 

This patient is a man with a history of stage IV colon adenocarcinoma with pelvic nodal and liver metastases. He was treated with chemotherapy with good response. On follow up imaging, he had stable small abdominal and pelvic lymph nodes visible as well as persistent multiple bilobed liver metastases present. Radioembolization with Y-90 selective internal radiation therapy is recommended to treat the liver metastases. 

Y-90 Radioembolization is likely to be more beneficial than standard treatment for the insured's life threatening disease.
There are excellent studies published in peer reviewed journals supporting the benefits and safety of Y-90 radioembolization for patients such as this scenario where there is controlled disease in the primary and other sites of metastases and persistent disease in the liver. These studies show excellent response and control rates as well as improved survival. This is also supported by National Comprehensive Cancer Network (NCCN) Guidelines with category 2A support.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer
Treatment: Y-90 radioembolization 
The insurer denied Y-90 radioembolization 
The health plan's determination is overturned. 

The patient is a male with history of stage IV colon cancer with nodal and liver metastasis presents to the IR (interventional radiology) clinic for Y90 Radioembolization. The patient's history dates back to earlier this year when he had worsening abdominal pain and was found to have a right sided colon mass with multiple metastasis in the liver. This was causing biliary obstruction and jaundice and hyperbilirubinemia. After liver and colon mass biopsy confirmed colorectal carcinoma, he began systemic therapy with chemotherapy. 

Y90 Radioembolization is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Based on review of literature, the requested treatment is considered an option for treatment for liver metastasis. There are studies showing that this can be an effective treatment for liver metastasis from colorectal cancer.
The National Comprehensive Cancer Network (NCCN) states yttrium 90 microsphere-selective internal radiation is an option and highly selected patients with chemotherapy resistant/refractory disease and with predominant hepatic metastasis.
In the literature there are articles addressing hepatic metastasis from colorectal carcinoma stating that it is an effective treatment in selected patients. A recent article published in May 2023 mentions that he yttrium-90 microspheres has involved his salvage therapy and surgically unresectable and chemo resistant metastasis.
Based on the review of the literature and the patient's medical records that are attached, Y90 radioembolization is indicated for the management of his liver metastasis. He is not a surgical candidate and has been on longstanding chemotherapy with limited response.
Appeal type: Experimental/Investigational
Decision: Overturned

Cancer
Radiation Therapy

Diagnosis: Cancer
Treatment: Y-90 radioembolization 
The insurer denied Y-90 radioembolization 
The health plan's determination is overturned. 

This is a male with history of stage IV colorectal cancer metastatic to his liver. He has been treated with systemic chemotherapy (FOLFOX/Avastin) since his original diagnosis in 1/2023. His liver disease has remained grossly stable. Under review it the use of Y-90 radioembolization (selective internal radiation therapy).

Y-90 radioembolization is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening condition. Radioembolization is the standard of care and supported by the National Comprehensive Cancer Network (NCCN) guidelines in this setting as it is proven to provide control of hepatic disease and limit the risk for hepatic tumor progression which would result in liver outlet obstruction and death due to hepatic failure. Radioembolization in this patient's situation is supported by numerous high quality prospective clinical outcomes reported in the peer reviewed medical literature. It is widely employed throughout the oncology community nationwide for similar patients with colorectal cancer.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Atopic Dermatitis

Treatment: Dupixent

The insurer denied coverage for Dupixent

The denial is overturned

The patient is a patient with a diagnosis of severe atopic dermatitis (AD).  The patient was previously treated and controlled with Dupixent but required spot treatment with Opzelura cream for breakthrough plaques.  The patient has previously failed topical therapy with steroids and Opzelura without Dupixent.  The request is for continuation of Dupixent with the concurrent use of Opzelura topical as needed.  

The patient has atopic dermatitis which requires systemic therapy given the extent of involvement. The use of Dupixent would appear to be reasonable given that it is a Food and Drug Administration (FDA) approved medication for the treatment of atopic dermatitis. Despite Dupixent therapy, the patient previously experienced episodic flares which necessitated topical therapy. The patient has failed topical therapy with steroids. The use of Opzelura topical is not contraindicated in patients on systemic Dupixent and would appear as a reasonable alternative to achieve enhanced disease control.  

The request for Dupixent is supported by the medical literature and specialty society guidelines.  Dupixent is an effective systemic therapy approved by the FDA for the management of atopic dermatitis. In early 2017, the FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments (1-3).  According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD .... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment ... with moderate-to-severe AD who are uncontrolled with topical therapies" (4).  The occasional use of Opzelura while on Dupixent is reasonable and within the standard of care.  

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

The medical necessity for Dupixent is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Live In). 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Live In). 
The determination is upheld.

This is a female patient with a medical history notable for dementia. The patient is approved for 36 hours per week of personal care services. The patient and her care team requested an increase to 24-hour per day live-in personal care, and this request was denied by the health plan. This denial is the subject under review. There were no medical records or letters of medical necessity provided as part of this appeal.
A Uniform Assessment System was completed and was available for review. The patient was alert and oriented to person and place only. She has poor insight into her medical problems and has frequent confusion. She requires prompting for daily tasks. She is able to call for help in an emergency. Her niece has been staying with her since discharge from a facility. For her Instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, and finances. She requires maximal assistance for medications and shopping. She requires extensive assistance for phone use, stairs, and transportation. For her activities of daily living (ADLs)s, she requires extensive assistance for bathing and dressing lower body. She requires limited assistance for hygiene, dressing upper body, toilet transfer, and toilet use. She walks with a slow unsteady gait using an assistive device or furniture. She attempts to toilet by herself but often requires checking to ensure proper hygiene. She is occasionally incontinent of urine and she is continent of stool. A task tool associated with the assessment recommended 36.75 hours per week to address her personal care needs. Compared to a prior assessment, the patient showed a decline in functional status. At issue is the medical necessity of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Live In). 

The requested health service of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Live In) has not been demonstrated to be medically necessary for this patient.
The patient requires personal care assistance for all IADLs and for some ADLs such as dressing and bathing. She is occasionally incontinent of urine. The health plan approved an increase to 36 hours which is commensurate with the recommendation from the task tool. There is no documentation regarding which personal care needs, if any, are not being met with this increased allotment of hours. Therefore, the requested increase has not been clearly demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Appendicitis. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is an adult female with human immunodeficiency virus (HIV) who was admitted to the hospital with acute appendicitis. She had a white blood cell (WBC) count of 12. 
Computed tomography (CT) showed appendicitis. The patient was treated conservatively and discharged the next day. 

The requested health service was not medically necessary. 

Inpatient admission was not indicated as the patient was admitted, received antibiotics, and got better quickly. Besides a white blood cell count of 12, the patient was hemodynamically stable and did not demonstrate any emergent need for an operation or complications. This patient's inpatient stay was not medically necessary. The presence of a mild leukocytosis without any other factors of sepsis, hemodynamic instability, or post-operative complications needing monitoring does not meet criteria for inpatient admission. This patient's vital signs were stable, she was treated conservatively without surgery, and was discharged. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary disease
Treatment: Inpatient admission
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult male. He underwent elective diagnostic cardiac catheterization. His past medical history includes known CAD (coronary artery disease) treated with three-vessel CABG (coronary artery bypass graft) surgery, multiple PCIs (percutaneous coronary interventions) with the last to the LAD (left anterior descending), hypertension, hyperlipidemia, diabetes, former smoking and anemia. He was found to have significant two-vessel CAD (coronary artery disease) with an 80-90% stenosis involving the distal left main and 80-90% in-stent restenosis of the proximal LAD (left anterior descending). There was total occlusion of the SVG (saphenous vein graft) to LAD-D1 (left anterior descending artery - first diagonal branch) proximal anastomosis and SVG (saphenous vein graft) to RCA (right coronary artery) RPDA (right posterior descending coronary artery)-proximal anastomosis. He required complex intervention with ICS (intracoronary stenting) and IVL (intravascular lithotripsy) to the distal left main, PTCA (Percutaneous Transluminal Coronary Angioplasty) to the proximal LAD (left anterior descending), atherectomy to the proximal LCx (left circumflex) and GP (glycoprotein) IIb/IIIa inhibitors on the same day. He was treated overnight and was discharged to home.
The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The inpatient admission was not medically necessary.

Based on the peer-reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of 
service for inpatient hospital stay. In this particular case, the patient underwent planned LHC (left heart catheterization) followed by successful and uncomplicated complex PCI (percutaneous coronary intervention) procedures on the same day. The information provided does not support the medical necessity for admission after his successful and uncomplicated coronary interventions. Even higher risk PCI (percutaneous coronary intervention) procedures like this patient had are routinely performed in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like ACS/AMI (acute coronary syndrome/acute myocardial infarction), CVA (cerebrovascular accident), contrast nephropathy, acutely decompensated CHF (congestive heart failure), life-threatening cardiac arrhythmia, procedural complications like acute coronary perforation or vascular access complication requiring surgery, or other medical instability or acute care needs that would require acute inpatient management. Therefore, based on the submitted information and the current published medical literature, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.

This is the case of a patient that presented to the hospital for elective cardiac catheterization. The patient reported symptoms of chest pain on exertion and cardiac computed tomography (CT) revealed significant calcification and atherosclerosis with a calcium score of 616. The patient's past medical history was significant for hypertension, hypercholesterolemia, and chronic obstructive pulmonary disease (COPD).  Cardiac catheterization was performed via a right radial approach.  The patient was noted to have heavily calcified lesions up to 80% (percent) in the proximal and mid left anterior descending artery and 70-80% (percent) in the proximal and distal right coronary artery. Left ventricular (LV) ejection fraction was 50% (percent).  Intravascular ultrasound (IVUS) guided atherectomy and drug eluting stents were placed in the left anterior descending (LAD) artery.  No perioperative complications were noted and the patient was discharged the following day with plans for staged revascularization of the right coronary artery.

This patient presented for elective percutaneous revascularization. The patient underwent an uncomplicated procedure and stents were placed in the proximal and mid LAD artery. He was discharged the following day. Several investigators have studied the safety and cost savings surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital (Reference1-4). Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a lower level of care  (Reference 4).  In conclusion, inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care.

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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Braces, monthly visit, and retainer

The insurer denied coverage for braces, monthly visit, and retainer

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 17 points by internal reviewers. The orthodontist is appealing on behalf of the patient.

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

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 braces, monthly visit, and retainer is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain/vomiting
Treatment: inpatient stay
The health plan denied the inpatient stay
The health plan's determination is upheld.

This case involves a man with diabetes, liver cirrhosis with thrombocytopenia varices, and splenomegaly; he was admitted to the hospital with generalized abdominal pain and vomiting. He described coffee-ground emesis but no diarrhea. He was evaluated in the emergency department (ED) and noted a hemoglobin of 12.4, with hemodynamic stability. A computed tomography (CT) abdomen pelvis showed no acute intra-abdominal pathology. 

The inpatient hospital admission was not medically necessary. Based on the provided documentation, the patient had less than 24 hours of nausea and vomiting, with questionable coffee grounds. The Hemoglobin is stable, hemodynamics are stable, abdomen is benign, without any clinical evidence of spontaneous bacterial peritonitis (SBP). Abdominal imaging is unremarkable. He was cleared for discharge by GI (Gastrointestinal) within hours of the decision to admit him to the hospital. He tolerated the diet but remained in the hospital until the following morning when he was promptly released. The final diagnosis was food-borne illness. He did not require any specialized endoscopic evaluations or treatments; there was no evidence of hemodynamic compromise, systemic infection, or uncontrolled bleeding. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain- cholelithiasis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld.
The patient had a history of a gastric bypass and biliary colic. She had planned to have a laparoscopic cholecystectomy but presented with right upper quadrant (RUQ) abdominal pain and vomiting. The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The white blood cell count (WBC) was 11.9k (thousand). An abdominal ultrasound showed cholelithiasis without evidence of acute cholecystitis and a common bile duct (CBD) which measured 1.1 centimeter (cm). A magnetic resonance cholangiopancreatography (MRCP) was negative for a CBD stone. It was believed that the patient may have passed a stone. The patient was able to tolerate a diet and there was a plan to follow-up in the Surgery clinic. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-555 for Gallbladder or Bile Duct Inflammation or Obstruction. Acute cholecystitis and acute cholangitis are indications for admission if there are systemic signs of inflammation. In this case the patient did not have acute cholecystitis or cholangitis. The sonogram showed gallstones but no evidence of acute cholecystitis. Other indications for admission include hemodynamic instability, common bile duct obstruction, severe vomiting that is not responsive to treatment, and bacteremia. The patient did not have these conditions. 

This patient had biliary colic and may have passed a stone. The MRCP was negative for any CBD stone at this time. The patient did not have acute cholecystitis or acute cholangitis. IV hydration, antiemetics, Pepcid, and pain medications could have been given in the Emergency Room (ER) with Observation care. The patient did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Obstruction. 

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 inpatient admission is not substantiated.