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

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care; 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week. 
The insurer denied Personal Care Assistance Service; 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week. 
The denial is upheld. 

The patient is a female with a past medical history significant for a fall. The patient is noted to have 2 separate falls in 8 days and found on the floor by her daughter. The patient is unable to get up on her own. She is unable to stand alone. The patient lives alone.
The patient is currently receiving 29 hours a week, and there is a request is for an increase to 12 hours a day times () 7 days a week for a total of 84 hours a week. This was denied by her health plan for medical necessity. Services were denied by her health plan stating the daughter asked for an increased due to a recent fall, as the patient may have tried to stand and lost her balance falling and sustained swelling and a bump on her forehead. The patient is more disoriented and does not follow directions, and her gait is unsteady. A review of her assessment and care plan resulted in a recommendation to continue the patient's current hours. The patient is appealing the decision.
At issue is the medical necessity of Personal Care Assistance Service; 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week.

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

The requested health service/treatment of Personal Care Assistance Service; 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week is not medically necessary for this patient.
New York state regulations do not require personal care assistant services for safety and supervision alone, such as may be clinically necessary for someone with cognitive dysfunction. Personal care assistant hours for companion care or for safety supervision, without the need for activity of daily living tasks, is not required to be covered. Cognitive and prompting is included as part of another task and is not a specific standalone task required to be performed by a personal care assistant. The patient is noted to have a stage I decubitus on her right buttock. The patient currently has a hospital bed with alternating pressure mattress. She is noted to be incontinent. The patient is requesting 7 days a week  24 hours a day as services. It was stated that the patient lives alone.   It is not clear from the patient's appeal letter that she does need 12 hours per day 2 split shift services and there is no documentation supporting this. There is no medical documentation noting the necessity for continuous care.
Therefore, the requested health service/treatment of Personal Care Assistance Service; 12 hours per day 7 days per week (Monday through Sunday), a total of 84 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Elective, staged percutaneous coronary intervention. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

This female patient presented for elective, staged percutaneous coronary intervention (PCI). Her past medical history (PMH) is pertinent for recent ST-elevated myocardial infarction (STEMI) with cerebral vascular accident (CVA) from subacute stent thrombosis due to medical noncompliance and catheter manipulation in the ascending aorta. She underwent percutaneous coronary intervention to the residual to the left anterior descending (LAD). There were no procedural complications and the patient was discharged to home the next day. The request for coverage for acute inpatient hospital stay was denied and the provider is appealing the decision.

No, the proposed inpatient admission was not medically necessary. 

In this particular case, the patient underwent elective, successful and uncomplicated staged percutaneous coronary intervention (PCI). The information provided does not support the medical necessity for admission after her coronary intervention. This procedure is routinely performed now in the ambulatory setting with overnight observation. There is no documentation of unstable medical conditions like acute myocardial infarction (AMI), contrast nephropathy, acutely decompensated congestive heart failure (CHF), life-threatening cardiac arrhythmia, procedural complications, or other medical instability or acute care needs that would require acute inpatient management. Since hospitalization for patient, physician or hospital convenience does not establish medical necessity, it is agreed to uphold the denial for care in the acute setting when the same care can be provided in a lesser intense setting. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endocrine disorder, unspecified. 
Treatment: Formulary exception for Testosterone 40.5MG / 2.5GM (1.62%) TD Gel, Pre-service. 

The insurer denied the Formulary exception for Testosterone 40.5MG / 2.5GM (1.62%) TD Gel, Pre-service. 

The denial is upheld. 

The patient is a male, noted to have hypogonadism. Coverage for a testosterone 1.62% gel has been requested. 

The patient's low serum testosterone levels included a value of 59 ng/dL (nanograms per deciliter) (normal 250-1100). 

No, the health plan should not cover the formulary exception for testosterone gel.
The patient did not have a specific pathologic cause of hypogonadism provided. The diagnosis of hypogonadism requires specific symptoms and two abnormally low morning serum testosterone levels. In this case, only one timed low morning testosterone level was provided. 

Therefore, given the above, the health plan should not cover the formulary exception for the requested testosterone gel.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Idiopathic Constipation. 
Treatment: Formulary exception for Motegrity. 

The insurer denied the Formulary exception for Motegrity. 
The denial is upheld. 

The patient is a female with chronic idiopathic constipation. She has failed OTC (over-the-counter) laxatives and Linzess. She has done well on Motegrity for approximately over a year. Her provider is requesting to continue Motegrity. 

No, the health plan should not cover the Formulary exception for Motegrity. 
The patient has chronic idiopathic constipation. She has failed the formulary preferred Linzess, but not the formulary preferred Amitiza. Linzess is a synthetic guanylyl cyclase C (GC-C) agonist, and the Amitiza a prostone analog, and work by different mechanisms. Amitiza may not be ineffective to treat the patient's constipation, and may be as effective as Motegrity to treat this patient's constipation. It also may or may not have side effects. There is no medical literature to support that Motegrity is more effective than Amitiza to treat chronic idiopathic constipation. Amitiza, the formulary alternative, may be effective. Therefore, the health plan should not cover the formulary exception for Motegrity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment:  Remicade 17mg/kg every 4 Weeks, Pre-service
The insurer denied the  Remicade 17mg/kg every 4 Weeks, Pre-service
The denial is overturned

The patient is a male with moderate to severe Crohn's of the duodenum, jejunum and ileum, status post resection. He has failed Humira and Stelara, as well as FDA approved dosing of Remicade. He has improved on titration of Remicade to 17 mg/kg every 4 weeks. His physician is requesting continuation of Remicade.

Yes, the proposed treatment is medically necessary.
Medical literature supports dose intensification of biologics in patients with Crohn's Disease (CD) who fail treatment with FDA approved dosing. Over 25% of patients with CD (Crohn's Disease) treated with biologics require dose intensification. Remicade has been found to be safe and effective at doses as high as 20 mg/kg every 4 weeks. Therefore, as this patient lost response to Remicade 5 mg/kg every 8 weeks, and was titrated up to and is doing well on Remicade 17 mg/kg every 4 weeks and is doing well, the requested dose and frequency is supported by current peer-reviewed medical literature, clinical practice guidelines, and is standard of care and medically necessary.

No.
As Remicade 17 mg/kg every 4 weeks is medically necessary in this patient, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient, by denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anxiety
Treatment: amounts above the health plan's quantity limit of alprazolam (2mg QID)
The insurer denied the amounts above the health plan's quantity limit of alprazolam (2mg QID)
The determination is overturned.

The patient has a diagnosis of generalized anxiety disorder, panic disorder and agoraphobia that has been effectively treated with alprazolam 2 milligrams (mg) four times daily with effective treatment since 2016. The patient has failed to respond to selective serotonin reuptake inhibitors (SSRIs) and quetiapine. Current medications also include Wellbutrin and Trintellix and trazodone. The patient also receives cognitive behavioral therapy (CBT) combined with medication management.
There is no other reported psychiatric co-morbidity or substance use, and the patient does have significant general medical conditions that impact his anxiety disorder. Moreover, the patient is monitored with regularly scheduled visits and laboratory assessments as clinically appropriate.
The health plan denied authorization for coverage of the alprazolam indicating that the request for alprazolam four times daily exceeds quantity limits of 90 pills per 30 days.
The health plan documents, appeal documents, letter from the prescribing physician, and the denial determination reference to quantity limits for alprazolam tabs, case summary and recent records were reviewed, as well as supporting documents indicating the Food and Drug Administration (FDA) indications and recommended dosages and dosage limits with alprazolam.
The issue under review is the medical necessity of alprazolam 2 mg tablets for a month supply at 120 tabs for 30 days.

Yes, the requested health service/treatment of amounts above the health plan's quantity limit of alprazolam (2 mg QID) is medically necessary for this patient.
The clinical response to the use of alprazolam in this case scenario is clinically appropriate and indicated for the conditions under treatment and the patient is stable and functioning well at the current dose of 2 mg four times daily. The prescribing clinician notes that the 2 mg tablet (tabs) is the highest dose available and that the patient has not responded to lower dosages in the past. Thus, the request for a quantity of 120 tabs/30 days is appropriate and medically necessary in this case. To stop a treatment that is effective would be detrimental to the patient.
This answer is consistent with prevailing standards of medical practice, and in keeping with the scientific literature referenced below, as well as FDA recommended use of the requested medication, alprazolam at 2 mg four times a day (QID).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hodgkins' Lymphoma
Treatment:  Proton Beam therapy.
The insurer denied Proton Beam therapy.
The determination is upheld.

The patient presented with mediastinal lymphoma. She was treated with chemotherapy. She had a recurrence and was treated with different chemotherapy. She is being evaluated for consolidation radiation therapy (RT) using proton beam and the medical necessity of the proton beam therapy is the subject of review.

No. the requested health service/treatment of proton beam radiation therapy is not medically necessary for this patient.
It is not in accordance with generally accepted standards of medical practice in the United States.
The generally accepted standards of medical practice in the United States for this clinical entity is intensity modulated radiation therapy (IMRT).
The attending provider (AP) has provided a dose volume histogram (DVH) comparison of intensity modulated radiation therapy (IMRT) and proton beam therapy and there is not a significant difference. The constraints of IMRT are acceptable. The National Comprehensive Cancer Network (NCCN) guidelines do not recommend proton beam for this entity. The prescribed dose of radiation is moderate 3000 centigray (cgy) which can be safely delivered with IMRT.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer 
Treatment: Proton Beam Radiation Therapy 
The insurer denied Proton Beam Radiation Therapy. 
The denial is overturned. 

This is a male patient with a medical history of Ewing sarcoma of his left nasal cavity status/post (s/p) resection. He has been recommended to proceed with postoperative systemic chemotherapy followed by consolidative external beam radiotherapy with curative intent.

At issue is the medical necessity of Proton Beam Radiation Therapy.

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

The requested health service of Proton Beam Radiation Therapy is medically necessary for this patient.

This is the standard of care in the patient's setting. Postoperative radiotherapy is proven to minimize the risk for tumor recurrence and improve survival for a patient with Ewing sarcoma of the nasal cavity. The treating provider has supplied a proton/photon plan comparison which shows that the photon-based treatment plan would result in an excessive risk for normal tissue toxicity. For example, the photon radiation plan would significantly increase the risk for permanent xerostomia and swallowing dysfunction secondary to higher parotid gland exposure. The proton radiation plan was able to significantly reduce this high dose parotid exposure to within known safe tolerance limits. It is critical to minimize the risk for permanent toxicity given the excellent prognosis and chances for long term survival given the patient's early-stage disease and highly curable situation. The American Society for Radiation Oncology (ASTRO) Model Policy for proton radiation supports its use for nasal cavity tumors. Proton radiation is supported by high quality prospective clinical outcomes reported in the peer reviewed medical literature.

Therefore, the requested health service of Proton Beam Radiation Therapy is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Pregnancy
Inpatient hospital

Diagnosis: ectopic pregnancy
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female who presented to the emergency room. She had complaints of vaginal bleeding and pain with a positive pregnancy test. An Ultrasound showed hemoperitoneum and an adnexal mass consistent with ruptured ectopic pregnancy. The patient was taken to the operating room just prior to midnight for a laparoscopic salpingectomy. The patient was discharged later without reported complication. 

The inpatient hospital admission was not medically necessary. The laparoscopic procedure was performed the day of admission and reported to have been performed as planned without intraoperative complication. That procedure is generally considered an outpatient procedure. There were no unexpected events, and she was discharged shortly after the surgery ended. She required no serial testing or observation, and her vital signs were never unstable (American College of Obstetricians and Gynecologists (ACOG) criteria reports vital signs within 20% of baseline to be stable for discharge). There is no report of hemorrhage after the surgery. There are no notes from the resident or attending physician suggesting there was a plan to escalate care, continue observation, monitor the patient further, or keep her in the hospital another night. The physician discharge summary was written just about 6 hours after she first presented to the emergency room. She was treated only with oral pain medication after leaving the recovery room (Percocet) and discharged after only one night in the hospital (the night included her ER stay). Her vital signs were within normal limits for her entire stay. This patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foreign Body Ingestion
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

The patient has a medical history of asthma and psoriasis/eczema. He presented to the emergency department with dysphagia, spitting, and drooling and a sensation of something stuck in his throat. A computed tomography scan of the neck at the referring hospital showed a foreign body in the upper esophagus, and he was transferred for removal. Vital signs were notable for an elevated blood pressure of 159/97 millimeters of mercury (mmHg). The physical examination was notable for normal breath sounds and a nontender abdomen. Lab results showed an elevated white blood cell count of 18.2 thousand per microliter (K/uL), elevated aspartate aminotransferase of 66 units per liter (U/L), and elevated alanine aminotransferase of 102 U/L. A chest x-ray showed no ingested foreign body. An x-ray of the abdomen showed no foreign body.
A gastroenterology consultation concluded that he had a foreign body, with swallowed dentures the prior evening and inability to tolerate secretions; the recommendation was nil per os (NPO) and emergent esophagogastroduodenoscopy. An oral maxillofacial surgery consultation concluded that he had a mobile tooth with facial gingival defect, and recommended outpatient follow-up. An esophagogastroduodenoscopy showed a 3.5-centimeter (cm) denture/retainer, which was just distal to the upper esophageal sphincter, and removed using a cold snare; there was evidence of erythema and inflammation in the esophagus, and the stomach and duodenum appeared normal. He was recovering well and in no acute distress; he was tolerating a diet. Lab results showed a low hematocrit of 39.4% (percent) and unremarkable basic metabolic panel. He was doing well, and tolerating a diet without pain or dysphagia. Lab results showed an elevated white blood cell count of 15.7 K/uL and unremarkable basic metabolic panel. An ultrasound of the abdomen showed increased hepatic parenchymal echogenicity consistent with steatosis. He was discharged with a plan for oral maxillofacial surgery and dermatology follow-up. At issue is the medical necessity for the inpatient level of care.

No,  the inpatient level of care was not medically necessary in this case. The most recent available American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the management of foreign body recommend emergent endoscopy for sharp-pointed objects in the esophagus and urgent endoscopy for objects located in the stomach or duodenum; in this case, it foreign body was appropriately removed from the esophagus [1]. Surgical intervention was not necessary [2]. The patient had appropriate conservative monitoring and did not need serial imaging; he was soon tolerating a diet and did not develop any instability to warrant intervention [1-5]. Oral maxillofacial surgery arranged outpatient follow-up. The care provided, including monitoring, esophagogastroduodenoscopy with uncomplicated foreign body removal, and specialist consultations, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female who presented to the emergency department (ED) with left sided chest pain radiating to left arm and back. She reported left sided tightness radiating to left back and left arm, numbness in left arm and cramping in left leg. The patient also was complaining of a bilateral frontal headache. 

The Inpatient Hospital Admission was not medically necessary for this patient. The patient presented with chest pain and headache. The patient's electrocardiogram was without changes, and the patient's troponin was normal. Her chest pain quickly resolved. The Cardiologist felt that no additional work up was necessary. Based on above, the inpatient level of care for chest pain was not indicated.
The patient presented with high blood pressure (BP), but it normalized within several hours with one Intravenous Labetalol injection and oral hydralazine. The patient did not have indications for inpatient hospital stay for elevated BP. Her potassium was corrected within 24 hours. 
Based on above, all her problems could have been addressed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Crohn's Disease.
Treatment: Stelara 90 mg every 6 weeks.
The insurer denied Stelara 90 mg every 6 weeks.
The determination is overturned.

The patient has Crohn's disease. She has failed 5-aminosalicylate therapy, infliximab, and vedolizumab. She had marked improvement on Stelara. However, she later developed active disease symptoms 6 weeks after Stelara injections. She has been on Stelara 90 mg every 6 weeks. Testing on showed a Stelara level of 2.7. Continuation of Stelara 90 mg every 6 weeks for the treatment of Crohn's disease is requested and is under review for medical necessity.

Yes, the request to continue Stelara to 90 mg every 6 weeks is medically necessary and supported by the current medical literature.
Stelara is Food and Drug Administration (FDA)-approved for the treatment of Crohn's disease, and a large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease [1-3]. Guidelines for the treatment of Crohn's disease recommend the use of Stelara [4]. A study showed dosing intensification (90 mg every 4 weeks) was used frequently to address loss of response, and a large proportion of patients were able to maintain response [5-7]. One study showed that dose escalation was required and approximately half of patients, and successful in 61.1% of dose escalation attempts [5]. Another study showed efficacy of dose escalation to recover lost response in 73% of patients in whom it was attempted [7]. Additionally, American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should be treated with an alternative therapy for mild to moderate disease, have their medication dose adjusted in order to attempt to optimize therapy" [4].
In this case, the patient has failed multiple other medications for the treatment of Crohn's disease, and failed Stelara every 8 weeks. She subsequently had improvement in Crohn's disease on Stelara 90 mg every 6 weeks. Discontinuation of dosing every 6 weeks (even if an alternative therapy is attempted immediately) may result in complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with limited available alternatives for the treatment of Crohn's disease. For all of these reasons, continuation of Stelara 90 mg every 6 weeks is supported as medically necessary for the treatment of Crohn's disease in this case.