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

Diagnosis: Decreased mobility
Treatment: Personal Care Services (PCS): 24 hours/day, 6 days/week (split shift) and Consumer and Self-Directed Personal Assistance Services: 24 hours/day, 1 day/week
The insurer denied PCS: 24 hours/day, 6 days/week (split shift) and Consumer and Self-Directed Personal Assistance Services: 24 hours/day, 1 day/week.
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, osteoporosis, urinary incontinence, hyperlipidemia, gastroesophageal reflux disease (GERD), anxiety, osteoarthritis, dementia, coronary artery disease, atrial fibrillation on chronic anticoagulation, and history of colon cancer who had been assigned home health services.

Personal Care Services (PCS): 24 hours/day, 6 days/week (split shift) and Consumer and Self-Directed Personal Assistance Services: 24 hours/day, 1 day/week are medically necessary for this patient.

There is documentation of cognitive and functional decline following hospitalization. The patient's medical provider documented the need for turning and repositioning overnight every two hours as well as frequent diaper changes. Overnight care logs document the patient has overnight care needs that would not allow a PCA (personal care assistant) 5 hours of uninterrupted sleep. The requested increase in services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The plan assumed the patient had informal help outside of currently assigned hours, which is not the case. The patient requires at least maximum assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services are medically necessary for this patient. PCS are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Formulary Exception
Decision: Overturned


Diagnosis: Attention deficit hyperactivity disorder (ADHD).

Treatment: Concerta (methylphenidate ER Osmotic Release).

The insurer denied coverage for Concerta (methylphenidate ER Osmotic Release).

The denial is overturned.

 
This case involves a young adult diagnosed with partial epilepsy and attention deficit hyperactivity disorder (ADHD) who is being considered for Concerta. When the patient was seen, the patient had a history of focal epilepsy and ADHD. Medications at that time included Lamictal XR, Concerta 27 milligrams (mg), sertraline 50 mg, and melatonin. Aside from an elevated heart rate of 107, her vital signs were stable, and examination was unremarkable. The treatment plan included continuing Lamictal. Records indicated the patient had done well with brand Concerta since 2015 and required continued treatment with the medication. She failed generic and brand dexmethylphenidate and generic methylphenidate as treatment for ADHD. 

There is always a chance that formulary drugs can cause the patient an adverse reaction.

The documentation provided for the review noted that the patient failed generic and brand dexmethylphenidate and generic methylphenidate as treatment for ADHD. 

The requested drug would be more effective than the formulary drugs given that the patient has already used this medication and is stable on her regimen. She already had documented failure of dexmethylphenidate and generic methylphenidate.

The Food and Drug Administration (FDA) states that Concerta is indicated for the treatment of attention deficit hyperactivity disorder (ADHD) in children 6 years of age and older, adolescents, and adults. The advanced control formulary provided for the review indicated that the patient did not satisfy the criteria for the use of Concerta. However, the documentation provided for the review noted that the patient had used this medication since years ago after failing to respond to other medications to include brand dexmethylphenidate and generic methylphenidate. Given the duration of the use of Concerta for treating ADHD, forcing the patient to try a formulary alternative would be inappropriate and not within the standard of care. The patient is stable on current medications with no need to switch to another drug in the formulary when she could have a potential adverse reaction from a new medication and has already trialed two of the medications in the formulary without success. 

The formulary drugs might cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The not formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Concerta (methylphenidate ER Osmotic Release) is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left mandibular cancer
Treatment: Proton radiation therapy
The insurer denied the proton radiation therapy.
The health plan's determination is overturned.

The patient is a female with history of grade 3 osteosarcoma of her left mandible status/post (s/p) resection with close margins. She has been recommended to proceed with a course of postoperative radiotherapy with curative intent.

The health plan did not act in the best interest of the patient. Proton radiation is medically necessary as discussed below.

The requested proton radiation therapy is medically necessary and standard of care in the patient's situation. The treating provider supplied a proton/photon plan comparison which showed that the photon-based intensity modulated radiation therapy (IMRT) plan is unable to provide adequate safety/precision. The IMRT plan resulted in excessive exposure to the patient's left parotid gland and oral cavity; if delivered, the IMRT plan would lead to an unacceptable and unnecessary risk for high grade toxicity (including xerostomia, swallowing dysfunction, and feeding tube dependence).
The proton radiation plan was able to significantly minimize the exposure to these critical normal tissues, thereby limiting the patient's risk for serious/life-threatening complications (e.g., aspiration pneumonia). Proton radiation is supported by high quality clinical outcomes reported in the medical literature as well as the American Society for Radiation Oncology (ASTRO) Model Policy because the provider has shown that photon radiation cannot be delivered safely/effectively. Proton radiation is routinely utilized throughout the oncology community nationwide for similar patients receiving unilateral radiation to the head/neck region.

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

Diagnosis: Peripheral vascular disease. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
 The health plan's determination is upheld. 

The patient is a man with a history of peripheral vascular disease. He initially presented with complaint of bilateral foot and shoulder pain. The patient has comorbid health conditions of coronary artery disease, and diabetes. He has bilateral heel ulcers. At the time of emergency department (ED) evaluation, he was reported to have bilateral infected foot wounds and an infected left shoulder wound. 

The inpatient hospital admission was not medically necessary. 
This patient presented with bilateral foot and shoulder pain in the setting of extensive coronary and peripheral vascular disease. He was appropriately evaluated as detailed in the cardiology consultation note. While he was anticipated to require several percutaneous coronary interventions, percutaneous vascular surgery assessment and treatment and treatment of a left shoulder wound, none of these interventions required an inpatient designation. Additionally, the submitted material does not include daily progress notes that provide ongoing justification of medical necessity for an inpatient level of care. The care and treatment provided could have been rendered with a lower level of care. The staged interventions did not mandate that the patient be kept in the hospital with an inpatient designation for the entirety of this prolonged hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath. 
Treatment: Inpatient admission. 
The insurer denied coverage for Inpatient admission. 
The denial is overturned. 
 
This is the case of an adult with a past medical history of hypertension (HTN), hyperlipidemia, lower extremity edema, metabolic syndrome, osteoarthritis, very recent uncomplicated sleeve gastrectomy who was discharged post-operative day 1.  As per the history and physical, she presented to another hospital with complaints of extremity weakness and shortness of breath (SOB) with notable tachycardia to 120's improved with intravenous (IV) fluid. Initial concern was for stroke; however, all work-up done was negative including computed tomography angiogram (CTA), brain, neck, brain perfusion. CT of the abdomen and chest was without pulmonary embolus (PE). Given recent surgery and persistent SOB she was transferred to this facility. On arrival she was afebrile, and hemodynamically stable. The abdomen was soft, non-distended, no guarding, incisions healing well, heart rate 90-100's with normal respirations. Exam revealed non labored breathing, abdomen was soft, non-distended. Hemoglobin (Hgb) was 12.6. As per the assessment the patient appeared to be with no evidence of leak. Patient remained stable and tachycardia improving. The plan was to continue Lovenox. 

Progress notes indicated the patient had stable vital signs, with CT unremarkable with some bilateral pleural effusions. The patient needs good pulmonary toilet and limit IV fluid. 

Progress notes indicated the pain was well controlled, breathing room air, ambulating and tolerating diet. Heart rate (HR) 69 with respirations of 19. Hematocrit (Hct) was 23.4. The plan was continued monitoring. The attending noted on exam that the flanks were mildly dull likely consistent with hemoperitoneum. Hgb was 8.0; she had a significant drop in Hgb noted and received 1-unit of blood with etiology of weakness and SOB from somewhat delayed intraperitoneal bleed. Currently entirely low level of suspicion for active bleeding. Will check Complete Blood Count (CBC) in AM and if stable will discharge. 

Acute inpatient admission was justified as this patient should not have been managed in an ambulatory/observation setting as she was transferred for SOB as well as evidence of intraperitoneal hemorrhage. Her Hgb was 12.6 and dropped to approximately 7. She needed to be monitored. She also needed to be transfused. In this setting acute inpatient admission was warranted. 

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 the inpatient hospital stay is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Atopic Dermatitis
Treatment: Pharmacy/Prescription Drugs/Cibinqo
The health plan denied the requested prescription medication, Cibinqo, as not medically necessary. The health plan's determination is upheld.

The patient is a female with severe atopic dermatitis (eczema area and severity index (EASI) score of 50) of the body and scalp (and associated with discrete areas of hair loss). The patient has alopecia areata. The patient has tried and failed topical Fluocinolone, Triamcinolone, and Opzelura, as well as intralesional Triamcinolone and oral Prednisone. The patient regularly drinks alcohol. A clinic note states that the patient was taking Olumiant dosed 4 milligrams/day, but has stopped.
At issue is the medical necessity for the requested health service/treatment of Cibinqo.

The health plan's determination of Cibinqo coverage is recommended to be upheld, in whole.

No. The patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil), or to biologic agents more newly-approved for this condition (Dupixent or Adbry). Cibinqo is not proven to be superior to all other formulary alternatives as per comparative, controlled studies, and is only Food and Drug Administration (FDA) approved for second-line systemic therapy behind the other, aforementioned systemic therapies. Furthermore, use of Opzelura cream (another Janus Kinase inhibitor) is not medically indicated or appropriate with systemic Janus Kinase therapy. Furthermore, if the patient has not sufficiently responded to Olumiant, another systemic Janus Kinase inhibitor, the consideration that Cibinqo will also result in treatment failure, must be strongly considered.
Therefore, as per the patient's health plan policy language, [1] and consistent with current medical literature, [2-6] the requested Cibinqo is not medically necessary and does not meet the health plan coverage requirements.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
treatment: Dupixent. 

The insurer denied Dupixent. The health plan's determination is overturned. 

The patient is a female with atopic dermatitis, that effects 15% body surface area (BSA) to the trunk and extremities. She was treated with topicals including intralesional Kenalog, triamcinolone, clobetasol and mometasone, methotrexate, and anti-histamines. 

Dupixent is medically necessary for this patient. 

This patient has a large body surface area for application of topical calcineurin inhibitors, and this is not practical. Topical calcineurin inhibitors are considered second line therapy for atopic dermatitis. In May 2020, the Food and Drug Administration (FDA) also approved dupilumab for the treatment of patients aged 6 years and older with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. This approval followed a phase 3, randomized, double blinded placebo controlled trial that enrolled 367 patients to evaluate the safety and efficacy of dupilumab in children (ages 6-11 years) for treatment of atopic dermatitis (Paller et al). Significantly and clinically meaningful improvements in patients signs and symptoms of atopic dermatitis as well as quality of life were reported. As seen in adults, treatment in pediatric population was reportedly well tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis. Therefore, in this case, Dupixent is indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mal positioned Teeth.
Treatment: Braces and monthly visits.
The health plan denied: Braces and monthly visits.
The determination is: Overturned.

The patient is a male with a Class I malocclusion and anterior crossbite of #7 and #10. Teeth 22 and 27 are labial in the mandibular arch. They are in danger of gingival recession if they are not moved into a more favorable position. He is treatment planned for 30-36 months of orthodontics with extraction of teeth 5, 12, 21, and 28 to correct his malocclusion.
At issue is the medical necessity of braces and monthly visits.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of braces and monthly visits is medically necessary for this patient. This patient presents with an anterior crossbite and significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. [1,2,3]
The patient has anterior crowding with #7 and #10 in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time [4], which will make treating this occlusion at a later time more difficult. Teeth #22 and #27 already have slight recession, and further movement of these teeth will likely lead to the need for future for periodontal grafting on one or both of these teeth. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: plantar fasciitis.
Treatment: custom shoe inserts.
The health plan denied the requested custom shoe inserts as not medically necessary. The heath plan's determination is upheld.

The patient is a male that was initially seen for complaints of flatfeet. He stated that his old orthotics are worn out. He has pain with prolonged walking and standing to both of his feet. His previous treatment was custom orthotics. On exam, he was noted to have flexible flatfeet with excessive pronation. There was no pain noted to his feet. He was diagnosed with flatfeet. He was recommended custom foot orthotics at that visit. He was then seen by another provider complaining of painful feet all of the time. The patient was noted to be wearing prefabricated orthotics for the previous 3 months but still had pain. On exam, the patient was noted to have pain on palpation of heels, medial central band plantar fascia bilaterally, medial ankle ligaments bilaterally. He was diagnosed with plantar fasciitis. He was recommended stretching, wearing supportive shoes and recommended custom foot orthotics.
Then, the patient presented for an orthotic consult. He was complaining of pain to both heels and arches. He stated he had old pair of custom foot orthotics (CFO) that had gotten worn out. He attempted switching to over-the-counter (OTC) inserts but did not get relief. On exam, there was tenderness noted to medial calcaneal tubercle. The patient was diagnosed with plantar fasciitis. The patient was recommended custom molded orthotics.
The issue is the medical necessity of the custom shoe inserts.

I uphold, in whole, the health plan's determination of medical necessity.

No, the requested health service/treatment of custom shoe insets are not medically necessary for this patient. 
The patient initially had foot pain and was diagnosed with plantar fasciitis. As part of the treatment plan, the patient was given custom molded orthotics. The patient appeared to have a flare up of his plantar fasciitis. This flare up should be treated similarly to the initial diagnosis with an appropriate amount of conservative care. There is insufficient documentation of an appropriate amount of conservative treatment before custom molded orthotics are recommended. Custom orthotics should not be first line treatment options. Thus, the requested custom shoe inserts are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Facial Heaviness, Slurred Speech.
Treatment:  Inpatient Hospital Stay.

The insurer denied the inpatient hospital stay.  The determination is upheld.

This is a female patient, who presented to the hospital with two episodes of "facial heaviness" and slurred speech. The symptoms occurred when she went out in the cold and then resolved when she returned home. She presented to the emergency room with normal vital signs, initial laboratory work, and computed tomography (CT) / computed tomography angiography (CTA) of the head and neck. The patient was admitted to the hospital for evaluation of a stroke. Neurology was consulted and recommended magnetic resonance imaging (MRI) of the brain, which was also negative for an acute stroke. The patient was treated with aspirin and a statin. The patient was discharged with outpatient follow-up. At issue is the medical necessity of an inpatient stay.

The acute inpatient stay was not medically necessary. The patient presented to the hospital with episodes of facial heaviness and slurred speech. These episodes were brief and self-resolving. The patient presented to the emergency room with no neurological deficit and initial vital signs, imaging, and labs were unremarkable. The patient was admitted to the hospital for evaluation of a stroke. MRI of the brain with and without contrast was also negative.

Inpatient admission is not the standard of care for evaluation of transient ischemic attack. The patient did not have any abnormal vital signs, diagnostic studies, or laboratory tests that required immediate intervention and stabilization. The patient did not receive thrombolytic therapy or thrombectomy. The patient did not undergo a vascular procedure. The patient did not have a disabling deficit that was persistent. The patient did not require skilled nursing or rehabilitation on discharge. The patient was treated with oral medications. All of these services do not require the intensity of an acute inpatient stay.