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

Diagnosis: Class III malocclusion. 
Treatment: D8080 braces, D8670 monthly visit. 
The insurer denied the D8080 braces, D8670 monthly visit. 
The health plan's determination is overturned. 

The patient in question is a male presenting with a skeletal Class III malocclusion. He has minor crowding in the maxilla and mandible. He has a significant open bite affecting teeth 5-7 and 10-12. He is treatment planned for Braces and Monthly Visit to address the Class III and open bite. 

Braces and monthly visits are medically necessary for this patient. Anterior open bite patients are among the most difficult patients to treat. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. 
Braces are medically necessary for this patient due to the side effect as noted, and the fact that this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: Class I occlusion with 2 millimeters (mm) overjet.
Treatment: Braces and Monthly Visits with a Retainer.
The insurer denied Braces and Monthly Visits with a Retainer. 
The health plan's determination is overturned. 

The patient in question is a female with a Class I occlusion with 2 millimeters (mm) overjet. She has a 100% overbite. The maxillary occlusal photograph shows that the incisal papilla has redness and swelling. She has minor maxillary spacing and moderate mandibular crowing. She has treatment planned for Braces and Monthly Visits with Retainer to correct her malocclusion. 

Braces and Monthly Visits with a Retainer are necessary for this patient.
The patient's overbite is deep, and the incisive papilla is red and swollen. It also appears to have a ridge in it where the lower incisors are contacting it in occlusion. There is scientific evidence correlating deep anterior overbite with gingival contact and periodontal disease.
The patient's occlusion is causing her lower incisors to contact right at the lingual gingival margin of the maxillary incisors. This is a traumatic occlusion. Not only does it have a positive correlation with periodontal disease, but studies also indicate an increased appearance of periodontal radiolucencies on the maxillary incisors. It is believed these periodontal lesions are related to gingival surface injury and food impaction due to the deep bite. Therefore, correcting the patient's malocclusion with orthodontic treatment will create a clinically significant improvement in the patient's periodontal health.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gallbladder disease
Treatment: Inpatient Admission
The insurer denied coverage for: Inpatient Admission
The denial is: Upheld
The patient presented with abdominal and chest pains. The electrocardiogram (EKG) and troponins were negative for Acute Coronary Syndrome (ACS). The patient was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. An abdominal ultrasound revealed multiple gallstones. A magnetic resonance cholangiopancreatography (MRCP) showed gallstones with wall edema and mild pericholecystic fluid. There was no common bile duct obstruction. Antibiotics were started and he was able to tolerate a diet. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-555 for Gallbladder or Bile Duct Inflammation or Obstruction. Clinical indications for admission include having upper abdominal pain along with systemic signs of inflammation. In this case, the patient did not have systemic signs of inflammation. The patient also did not have hemodynamic instability, common bile duct obstruction, severe vomiting, severe pain, or bacteremia. 

This patient has gallbladder disease but did not have systemic signs of infection. There was no recommendation that the patient needed a cholecystectomy at this time. The patient could have been treated with oral antibiotics as an outpatient and then referred for outpatient follow-up. The patient did not meet MCG criteria for admission for Gallbladder or Bile Duct Inflammation or Stone. 

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 the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Post-traumatic headache and migraine.
Treatment:  Injections to block the occipital nerve for pain.

The insurer denied injections to block the occipital nerve for pain.  The determination is overturned.

This is a male patient diagnosed with a post-traumatic headache and migraine. Treatment with occipital nerve injections was requested. The provider indicates that the patient suffers from bilateral occipital neuralgia and has tried and failed conservative treatments such as anti-inflammatory drugs, exercise, and chiropractic therapy. At issue is the medical necessity of injections to block the occipital nerve for pain.

Yes. The patient is diagnosed with bilateral occipital neuralgia. The patient has tried and failed first-line treatments such as anti-inflammatory drugs, chiropractic manipulation, and exercise. Occipital nerve blocks are requested. The use of these injections is appropriate for treatment of occipital neuralgia as these injections can be both diagnostic and therapeutic for this condition. There are no other treatments that are more appropriate for this patient given failure of first-line options and nerve blocks are widely regarded as the treatment of choice for occipital neuralgia. The peer reviewed literature clearly indicates that occipital nerve blocks are the treatment of choice for occipital neuralgia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Transradial amputation.
Treatment: Right Arm Prosthetic (new).
The insurer denied the right Arm Prosthetic (new).
The denial is overturned.

This patient is a teenage male with a history of transradial amputation. The child has been provided with several upper extremity prostheses, including a myoelectric hand and a passive hand. The patient experienced weight gain and prosthesis malfunction due to mechanical reasons. The request for new transradial prosthesis was denied coverage by the health plan due to medical policy limitations allowing only one prosthetic device per lifetime and lack of medical necessity for the new prosthesis. The denial is being appealed.

The requested health service is medically necessary.

Prescription of a new prosthetic device is medically appropriate. The documentation provided points out that passive prosthetic device for the upper extremity has been prescribed to address the emotional and psychosocial needs of this child. The prescription of a passive UE (upper extremity) prosthetic is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism
Treatment: Increase Consumer Direct Personal Care Aide to 80 Hours Per Week
The insurer denied: Increase Consumer Direct Personal Care Aide to 80 Hours Per Week
The denial is upheld.

The patient is an adult male. His medical conditions include autism. He lives with his parents and siblings. Denial of increase consumer direct personal care aide to 80 hours per week is being appealed. The health plan approved 26.25 hours per week. The records include a letter noting that while additional hours are requested, a total of 80 hours a week is not requested. The Life Plan assessment shows 58 hours per week provided to assist the patient. The patient's Uniform Assessment System evaluation completed 7 months ago shows moderately impaired cognition and functional status: total dependence with meal preparation, managing finances, and phone use; maximal assistance with housework, managing medications, and shopping; extensive assistance with bathing, personal hygiene, and dressing; and independent with stairs, walking, locomotion, toileting, and eating. He is infrequently incontinent of bladder. An appeal letter notes that the patient is nonverbal. The patient requires attention during waking hours and assistance with activities of daily living (ADLs). A letter from the patient's provider notes that the patient's parents provide 24/7 care for assistance with activities of daily living. The patient requires supervision in his home and community settings. He is unable to stay alone. His family provides a social life for him.

Te requested Increase Consumer Direct Personal Care Aide to 80 Hours Per Week is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase consumer direct personal care aide to 80 hours per week is being appealed. The health plan approved 26.25 hours per week. This patient has autism and is nonverbal. He lives with his parents and siblings. The patient's 
Uniform Assessment System (UAS) evaluation completed 7 months ago shows he requires assistance with meal preparation, managing finances, and phone use; maximal assistance with 
housework, managing medications, and shopping; extensive assistance with bathing, personal hygiene, and dressing. He is infrequently incontinent of bladder. Appeal statements note the 
patient needs constant supervision during awake hours. The information provided does not support that the patient has functional needs requiring an increase in consumer direct personal care aide hours. Consumer direct personal care services are not indicated for supervision or companionship. The approved consumer direct personal care aide 26.5 hours per week is sufficient to meet this patient's needs for assistance with activities of daily living. The requested increase consumer direct personal care aide to 80 hours per week is not medically indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Flank Pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a past medical history of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and dyslipidemia who presented to the emergency room (ER) with left flank pain of a month's duration and nausea. She was hemodynamically stable and was afebrile. She had left flank tenderness without rebound, guarding, or rigidity. Her labs were unremarkable. A right upper quadrant (RUQ) ultrasound showed intra and extra-hepatic biliary dilation. A computed tomography (CT) scan also showed intrahepatic biliary dilatation. She was admitted. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital services was not medically necessary for this patient. The patient could have been managed at a lower level of care.
The patient was admitted and treated with intravenous fluids, analgesics, and a proton pump inhibitor (PPI). She was evaluated by a gastroenterologist who recommended supportive care and an outpatient endoscopic ultrasound (EUS). Magnetic resonance imaging (MRI) / magnetic resonance cholangiopancreatography (MRCP) of the abdomen did not reveal biliary dilation. She improved clinically and her abdominal pain gradually resolved. She was discharged home with outpatient follow-up.  She patient did not have a fever or peritoneal signs or symptoms of cholangitis or pancreatitis or evidence of hemodynamic instability to warrant acute inpatient admission.
Inpatient admission for acute abdominal pain is medically necessary for one or more of the following:
-	Inability to maintain oral hydration.
-	Fever.
-	Severe pain (eg, not controllable with oral medication or oral medication not tolerated).
-	Hypoxemia.
-	Hemodynamic instability.
The patient had none of the above.
Appeal type: Step Therapy
Decision: Overturned

Diagnosis: Erectile Dysfunction/Impotence. 
Treatment: Muse 500MCG (micrograms) UR (urethral) PLLT (suppository pellet).  
The health plan denied Muse 500MCG UR PLLT. 
The determination is overturned. 

The patient is a male with a history of erectile dysfunction. His provider is requesting Muse and notes that the patient has failed sildenafil and tadalafil. However, no claims were noted for these medications. 
At issue is the medical necessity of Muse. 
The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of Muse is medically necessary for this patient. The pharmacy claim has not been filed for Viagra; however, that does not mean the patient has not already tried and failed it. The provider has documented that the patient has tried and failed Viagra, as well as Cialis. The patient has failed phosphodiesterase type 5 (PDE5) inhibitors. Because the patient has already tried and failed the required formulary prescription drugs while under this plan or a previous plan, it is reasonable to try the requested prescription drug Muse. The patient is not currently stable on a prescription drug selected by his health care provider for the medical condition under consideration.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine
Treatment: Diclofenac oral powder
The insurer denied coverage for Diclofenac oral powder.
The denial is upheld. 

The insurer has denied coverage for Diclofenac oral powder. In a Final Adverse Determination letter, they stated that the plan approved criteria covers this medication when the patient has tried and had an inadequate response or intolerance to the required number of formulary alternatives. The patient may have a documented clinical reason that prevents the patient from trying the required number of formulary alternatives. Formulary alternatives are diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam tablet, nabumetone, naproxen, naproxen sodium, oxaprozin, and sulindac. The requirement is trial and failure of all formulary alternatives but not more than three. 

This is a patient with the diagnosis of migraine headaches. The standard of care for the treatment of migraines is to prescribe preventative medications which are medication used to prevent or minimize migraine occurrences, and abortive therapies which are designed to stop the headaches. The reviewer did see that the patient was treated with Topamax at a dosage of 100 milligrams (mg) twice daily (bid) which progress note documents that the frequency of the headaches has decreased. For abortive therapies, the patient has tried Rizatriptan which is the only migraine medication as well as Fioricet, caffeine, and rizatriptan. The patient has been on Cambia - diclofenac potassium powder, a non-steroidal anti-inflammatory drug (NSAIDs). The Formulary of medications approved for this condition include: diclofenac sodium, diflunisal, etodolac, ibuprofen, meloxicam tablet, nabumetone, naproxen, naproxen sodium, oxaprozin, and sulindac. All are NSAIDs (Nonsteroidal anti-inflammatory drugs).

While the records show that the patient has been on Cambia, the fact is that the formulary included diclofenac and Cambia is diclofenac. No data are provided to indicate the patient would not benefit from the same medication in a different form or for that matter with any of the other formulary-approved NSAIDs (Nonsteroidal anti-inflammatory drugs). 

Based on the above indicated reason the decision to prescribe Diclofenac is denied. 

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

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

The carrier's denial of a request for a Formulary Exception for Diclofenac oral powder to treat migraine is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alzheimer's dementia
Treatment: home health care
The insurer denied Consumer and Self-Directed Personal Assistance Service, 24 Hours per Day, 7 Days per Week (Split-Shift). The health plan's determination is overturned in part.  

This is a case review for a female with medical history notable for Alzheimer's dementia, chronic kidney disease, heart failure, and osteoarthritis. The patient's physician provided a letter of support for this appeal. The letter states that the patient lives alone and that her multiple medical conditions have significantly worsened. She has advanced dementia and is unable to communicate her needs. She has advanced hypertensive heart and kidney disease. She is dependent on others for transfers, ambulation, and position changes. She is incontinent of bowel and bladder and requires frequent diaper changes. Her family has been privately paying to allow the patient to have 24-hour per day coverage, but they have run out of money and can no longer afford to continue to do so. The physician reports that it is necessary for 24-hour care to continue for the patient.

Consumer and Self-Directed Personal Assistance Service24-hour live-in care is medically necessary for this patient.
The physician notes and the Uniform Assessment System (UAS) both demonstrate that the patient requires hands-on assistance for all activities of daily living including eating, transfers and toileting. She is incontinent of both stool and urine with frequent episodes that will require assistance with changing. The patient's personal care needs are expected to be continuous and unscheduled throughout the day and occasionally at night as well. The task tool can be useful as a starting approximation for patient's personal care needs, but when care needs are expected to be continuous throughout the day and night, the task tool cannot be relied upon as the final determining factor in the number of hours awarded to the patient. The patient will require 24-hour care to address her personal care needs. Therefore, a 24-hour live-in personal care aide is medically necessary and appropriate for the patient.
The documentation provided does not demonstrate the medical necessity for split shift care. Split shift care is appropriate when a live-in personal care aide cannot receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. There are no overnight care logs provided for review, and no evidence that the patient has care needs that would preclude adequate rest for a live-in aide.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer - head and neck cancer
Treatment: Radiation Therapy - Proton Beam therapy
The health plan denied proton beam therapy as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

This is an adult male with history of lymph node positive invasive squamous cell carcinoma of his base of tongue. He has been recommended to proceed with a course of external beam radiotherapy with curative intent. Request is for approval of proton beam radiation therapy.

The requested proton radiation is not medically necessary for this patient. Proton radiation is not proven to yield superior clinical outcomes in the member's setting. The treating provider did not supply a proton/photon plan comparison to show that photon radiation cannot provide adequate safety/precision (the provided plan comparison was for a case control patient). The patient has not received prior radiation to his head/neck region, nor does he have a genetic/comorbid condition that increases his risk for normal tissue toxicity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Swelling in the Colon. 
Treatment: Entyvio. 
The insurer denied: Entyvio. 
The denial is overturned. 

The patient is an adolescent male. He has been diagnosed with severe inflammatory bowel disease, likely ulcerative colitis. He failed steroids and high dose infliximab 15 mg/kg (milligrams per kilogram) every 5 weeks. He still has symptoms. His doctor requested Entyvio. The health plan denied coverage of the request as not medically necessary, citing that the patient is under the plan-approved age for Entyvio. The denial is being appealed. 

The requested treatment with Entyvio is medically necessary. 

A multicenter retrospective study at three tertiary IBD (inflammatory bowel disease) centers showed that vedolizumab (Entyvio) is effective and safe in pediatric patients with IBD (inflammatory bowel disease) (Singh et al 2016). Another multicenter retrospective study in Europe also showed that Vedolizumab was safe and effective in this cohort of pediatric refractory IBD (inflammatory bowel disease), including ulcerative colitis (Ledder 2017). In this study, Entyvio was used in children as young as two years old that failed conventional therapy and at least one of the anti-TNF (tumor necrosis factor) agents. Most recent multi-center study showed that, "treatment with vedolizumab is a safe and effective option for achieving clinical remission in paediatric patients with inflammatory bowel disease with primary failure or loss of response to other treatments, especially in UC [ulcerative colitis]" (Garcia-Romero 2021). 
In summary, vedolizumab (Entyvio) has been shown to be safe and effective for children with ulcerative colitis who failed anti-TNF (tumor necrosis factor) drugs or other biological agents (1-4). This patient has been diagnosed with severe ulcerative colitis and failed an anti-TNF (tumor necrosis factor) agent, infliximab. Entyvio would be clinically indicated per current literature. The requested health service is medically necessary.