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

Cancer
Radiation Therapy

Diagnosis: cancer
Treatment: radiation therapy
The insurer denied Proton Beam Radiation Therapy (PBRT).
The health plan's determination is upheld.

This is the case of a male patient with multiply recurrent cervical myoepithelioma. The patient was treated with surgery and radiation in the past. The patient had surgery followed by SBRT (Stereotactic body radiation therapy). He had surgery followed by radiation therapy last year. The patient has recurrence of disease with symptoms recently and is being evaluated for proton beam radiation therapy (PBRT). This is the subject of review.

The requested Proton Beam Radiation Therapy (PBRT) is not medically necessary for this patient.
Medically necessary treatment is defined as one which is a commonly used and accepted treatment in the United States. PBRT is not a generally accepted treatment for this patient's clinical scenario.
This is rare condition for which there is no published data to support PBRT. This is palliative condition in this patient with 3 prior treatments of radiation therapy (RT) and role of further RT using PBRT is unclear. The clinical data from randomized or cohort trials is not adequate to conclude that PBRT is proven and preferential in all palliative re-irradiation scenarios.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis ADHD
Treatment: Vyvanse 40 milligrams (mg) capsule
The insurer denied Vyvanse 40 mg capsule.
The determination is upheld.

The patient is a male with attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). The requested medication is Vyvanse 40 milligrams (mg), which is a non-formulary drug. Per the medical letter from the treating physician, the patient has been treated with Vyvanse (lisdexamphetamine) for the past 6 years. A reduction from 60 mg daily to 40 mg daily is requested due to loss of appetite and sleep disturbance. Prior failed medications include Focalin (dexmethylphenidate), Clonidine, and a 3rd unknown medication.

Under review is whether the formulary drugs Amphetamine-Dextroamphetamine, Amphetamine-Dextroamphetamine extended release, Atomoxetine, Dexmethylphenidate, Dexmethylphenidate extended release capsule, Dextroamphetamine, Dextroamphetamine extended release, Guanfacine extended release, Methylphenidate extended release osmotic tablet (generic Concerta), Methylphenidate extended release capsule will be or have been ineffective or would have adverse effects.

Based on the medical documentation provided, the patient has previously tried and failed clonidine, Focalin, and another unknown ADHD medication. The patient is having unwanted side effects on Vyvanse 60 mg, so a reduction to Vyvanse 40 mg daily is requested. The covered formulary drugs Amphetamine-Dextroamphetamine, Amphetamine-Dextroamphetamine extended release, Atomoxetine, Dexmethylphenidate, Dexmethylphenidate extended release capsule, Dextroamphetamine, Dextroamphetamine extended release, Guanfacine extended release, Methylphenidate extended release osmotic tablet (generic Concerta), and Methylphenidate extended release capsule would not be ineffective, less effective, or have more adverse effects than Vyvanse 40 mg. Clinical practice guidelines for the treatment of ADHD list stimulant medications as first line; additionally, all stimulant medications can be expected to have side effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Encephalopathy and quadriparesis. 
Treatment: Long Term Acute Hospital Admission. 
The insurer denied the Long Term Acute Hospital Admission. 
The denial is overturned. 

The patient is an adult female with history of prior ischemic stroke. She was admitted for right STA-MCA (superficial temporal artery-middle cerebral artery) bypass 2 months ago. Post-operatively, she developed encephalopathy and quadriparesis along with status epilepticus associated with need for intubation. 
The patient was intubated 2 months ago, and she has had problem of being weaned off the ventilator. She also had dysphagia and was status post PEG (percutaneous endoscopic gastrostomy)-tube for feeding with transition to PEJ (percutaneous endoscopic jejunostomy) and to TPN (Total Parenteral Nutrition). The patient has relevant past medical history of Diabetes Mellitus, Hypertension, PCOS (polycystic ovarian syndrome), moyamoya arterial disease and multiple ischemic strokes. She was admitted for right ACA/MCA (anterior cerebral artery/middle cerebral artery) ischemic stroke and right ICA (internal carotid artery) stenosis. She is full code. The patient's timeline showed intubation 2 months ago, status post tracheostomy 2 months ago with ventilation. Attempts were made to wean her off ventilator each day for a week to no avail.
Ongoing medical issues include TPN (total parenteral nutrition) feeding, wound management, breathing issues status post tracheostomy with intermittent tachypnea due to storming and pneumonia, fever with tachycardia, persistent encephalopathy with quadriparesis, recurrent right subdural hygroma, uncontrolled Diabetes Mellitus, et cetera. 

The transfer to a Long-Term Acute Care Hospital (LTACH) is medically necessary. The patient has encephalopathy and quadriparesis, with multiple ongoing medical issues that include TPN (Total Parenteral Nutrition) feeding, wound management, breathing issues status post tracheostomy with intermittent tachypnea due to storming and pneumonia, fever with tachycardia, persistent encephalopathy with quadriparesis, recurrent right subdural hygroma, uncontrolled Diabetes Mellitus, et cetera. The patient's best care will be in an LTACH (long term acute care hospital), and not a Subacute Rehabilitation Facility.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Bipolar Disorder. 
Treatment: Lamictal XR 250 mg (milligrams) TAB (tablet) ER (extended release) 24. 
The insurer denied coverage for the Lamictal XR 250 mg TAB ER 24. 
The denial is overturned. 

The patient is an adult female. She has a mood disorder best characterized as unspecified bipolar disorder associated with dysphoric and irritable mood with episodes of depression, together with comorbid generalized anxiety disorder and associated impairments of functioning. The patient is treated for migraine headaches. She has no co-occurring substance use disorder or eating disorder. The patient is prescribed brand Lamictal (lamotrigine) at a dose of 250 mg (milligrams) extended-release formulation daily. The patient has been effectively treated with brand Lamictal for 8 years, which followed an adverse reaction to the generic formulation. The patient is prescribed Zoloft 100 mg (milligrams) daily. The combination therapy has resulted in improved mood, diminished anxiety, and better control of behavior, as well as improved functioning with 
tolerability and adherence. The health plan has denied coverage for brand Lamictal extended-release medication, indicating that a formulary exception is only granted in the case of an allergic reaction or adverse effect to the inactive ingredients of the generic formulation of lamotrigine including nausea, vomiting and dizziness as typical adverse reactions, or more severe reactions such as anaphylaxis or allergic response. The appeal is based on the clinical features of the case and medical necessity indicating that the patient has been on brand lamotrigine (Lamictal extended release) for over a decade with a positive therapeutic response and tolerability. The appeal asserts that the patient must continue to be treated with the brand Lamictal, which is considered crucial in this case based on clinical judgment with submitted documentation and case summary. The appeal indicates that switching medication would pose risk for a recrudescence of symptoms including suicidality, as well as having a negative impact on daily functioning. 

The health plan should cover the formulary exception for brand Lamotrigine extended-release formulation. 

The patient's continued treatment with brand Lamictal with a formulary exception is reasonable, and in the patient's best interest. A switch to a generic formulation of this medication is contraindicated in view of the clinical history, and a switch to an alternative generic medication, as suggested in the denial determination, would be detrimental to this patient with medical certainty, including risk for a recrudescence of symptoms and the associated behavioral disturbances that were outlined in the patient's clinical history and appeal and submitted documentation. The continued use of brand Lamictal extended-release tab is clinically appropriate and in keeping with prevailing standards of medical practice, as well as the scientific literature and published guidelines, referenced below, and consistent with New York State instruction for this binding review.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Growth Hormone Deficiency
Treatment: Humatrope
The insurer denied: Humatrope
The denial is overturned.

The patient is a teenage male. He is diagnosed with GHD (growth hormone deficiency). This request is for Humatrope. His GH (growth hormone) stimulation test last month peaked at 9.94. His bone age from 5 months ago was 13 years which was less than his CA (chronological age). His MRI (magnetic resonance imaging) was normal. Earlier this month his testes were 6 cubic centimeters at right and 9 cubic centimeters at left and pubic hair was at tanner 2. The patient's weight was 41.1 kilograms. His height was 148.8 centimeters (-2.43 SDS [standard deviation score]). His mid-parental height is 175.4 centimeters (-0.20 SDS [standard deviation score]).

The requested Humatrope is medically necessary.

The peer-reviewed literature, including consensus clinical guidelines and randomized controlled trials, are summarized below:
Classic GH (growth hormone) deficiency
Classic GH (growth hormone) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH (growth hormone) deficiency published by the GH (growth hormone) research society (1), the Lawson Wilkins Pediatric Endocrinology Society (2, 3), and the medical guidelines for GH (growth hormone) use provided by the American Association of Clinical Endocrinologists (4). The above-referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on auxological, biochemical and sometimes radiological findings.
The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are
1) Severe short stature, defined as a height of more than 3 SD (standard deviation) below the mean;
2) Height of more than 1.5 SD (standard deviation) below the midparental height;
3) Height of more than 2 SD (standard deviation) below the mean, and a height velocity over one year of more than 1 SD (standard deviation) below the mean for chronological age, or a decrease in height SD (standard deviation) of more than 0.5 over one year in children over two years of age;
4) In the absence of short stature, a height velocity of more than 2 SD (standard deviation) below the mean over one year, or more than 1.5 SD (standard deviation) sustained over two years.
The biochemical criteria include low IGF1 (insulin-like growth factor 1) or IGFBP3 (insulin-like growth factor binding protein 3) or GH (growth hormone) stimulation testing, with a peak GH (growth hormone) of less than 10 ng/ml (nanograms per milliliter).
This patient met biochemical criteria. GH (growth hormone) stimulation testing peaked at less than 10 ng/ml (nanograms per milliliter). His GH (growth hormone) stimulation test last month peaked at 9.94. The patient met height criterion 2, as his height is more than 1.5 SD (standard deviation) below target height SD (standard deviation). His height earlier this month was 148.8 centimeters (-2.43 SDS [standard deviation score]). GH (growth hormone) in the treatment of GH (growth hormone) deficiency is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, hyperlipidemia, muscle weakness, osteoarthritis, and diabetes.
Treatment: Increase Home/Personal Care, Level 2, 15 Minutes to 24 Hours Per Day (split shift)
The insurer denied: Increase Home/Personal Care, Level 2, 15 Minutes to 24 Hours Per Day (split shift)
The denial is overturned.

The patient is an elderly female. Her medical conditions include dementia, hyperlipidemia, muscle weakness, osteoarthritis, and diabetes. She lives with her husband, daughter, and son-in-law. Denial of increase home/personal care to 24 hours per day (split shift) is being appealed. The health plan approved 84 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 5 months ago shows moderately impaired cognition and functional status of maximal assistance to total dependence with all ADLs (activities of daily living). She is bedbound and has frequent bladder and bowel incontinence. She requires turning and repositioning every two hours and spoon feeding. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a significant decline in functional status. She had a fall out of a chair two months ago. She also had a fall out of bed 5 months ago that resulted in orbital fracture. She was hospitalized 5 months ago for nine days with urinary tract infection and pneumonia.

The requested Increase Home/Personal Care, Level 2, 15 Minutes to 24 Hours Per Day (split shift) is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous 
or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase home/personal care to 24 hours per day (split shift) is being appealed. The health plan approved 84 hours per week.
This patient has multiple chronic conditions, including recent hospitalization with orbital fracture after falling out of bed, urinary tract infection, and pneumonia. Uniform Assessment System 
(UAS) evaluation completed 5 months ago, shows the patient requires maximal assistance to total dependence with all ADLs (activities of daily living). She is incontinent of bowel and 
bladder. She is bedbound and requires turning and repositioning every two hours and spoon feeding. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a significant decline in functional status. This patient has continuous needs that include requires turning and repositioning every two hours. The requested increase home/personal care from 84 hours per week to 24 hours per day (split shift) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems.
Dental Disorder.

Diagnosis: Dental/Orthodontic Procedure.
Treatment: Scaling and root planning all quadrants.
The insurer denied Scaling and root planning all quadrants.
The determination is upheld.

The patient is a female who presented for the treatment of scaling and root planning. Provided for review are multiple panoramic periapical and bitewing radiographs, periodontal probing depths, health plan language, a letter from the provider's office, multiple American Dental Association (ADA) claim forms, and letters of appeal and denial. At issue is the medical necessity of the treatment of scaling and root planning.
The requested health service/treatment of Scaling and Root planning all quadrants is not medically necessary for this patient. s not medically necessary for this patient.
From the provided documentation there is no evidence of active periodontal disease. The bone levels around the teeth are all within 1-2 millimeters (mm) of the cementoenamel junction (CEJ) with intact lamina dura and without documentation of any attachment loss. From both dates of periodontal probing, there is documentation of a complete absence of bleeding on probing. Although there is radiographic calculus present on the teeth, the calculus is sitting on the enamel close to the contact points and not in any proximity to the CEJ. There is not horizontal nor vertical bone loss on any of the teeth and any differences in bone heights between teeth is a result of CEJ discrepancies and tooth malposition. Of note in the records is that there is no difference in the probing nor any periodontal indices when comparing the pre and post treatment indices, after the treatment delivered, all parameters are exactly the same. As there is no evidence of attachment loss provided in the documents for the patient, the periodontal pockets provided are more than likely pseudo pockets.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection
Treatment: Inpatient admission
The insurer denied coverage for Inpatient admission.
The denial is Upheld.

The patient was a teenage female admitted on for frequent urination. Urine analysis was consistent with urinary tract infection (UTI) and was started on intravenous (IV) antibiotics. The patient was also found to have elevated creatinine secondary to prerenal azotemia and was started on IV fluid. Creatinine improved and patient was discharged in stable condition the next day.

The patient was admitted for UTI and her condition responded to standard therapy in 24 hours. The patient remained hemodynamically stable without complications and discharged in stable condition. Per evidence-based literature, observation level of care is appropriate to treat this patient's condition.

A multiyear database analysis including a nationally weighted sample of over 1.9 million pediatric patients presenting to an Emergency Department (ED) with a UTI (urinary tract infection) found an admission rate of 25% (percent) for infants younger than 1 year, 3% (percent) for patients 1 to 5 years of age, 2% (percent) for patients 6 to 13 years of age, and 12% (percent) for those 14 to 17 years of age [1].

A multicenter study including 350 children presenting to an Emergency Department with a first febrile UTI found that 25% (percent) were admitted for inpatient care.[2]

Implementation of a day treatment center protocol for infants with a febrile urinary tract infection led to 57% (percent) of patients being given a trial of IV (intravenous) and oral antibiotics on an outpatient basis, with 88% (percent) of these infants avoiding hospital admission [3].

When taking into account the patient's exam, imaging, and lab findings as well as her lack of need for diagnostic testing beyond what was done under observation care and the availability of any additional diagnostic testing as an outpatient, there were no requirements for inpatient level of care. Observation was more appropriate.

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

Diagnosis: Heart disease, lymphoma, lumbar radiculopathy. 
Treatment: Increase in Personal Care Worker (PCW) Service to 7 Days per Week, 10 Hours per Day; 70 Hours per Week. 
The insurer denied: Increase in Personal Care Worker (PCW) Service to 7 Days per Week, 10 Hours per Day; 70 Hours per Week. 
The denial is upheld. 

This patient is an adult male with medical conditions that include heart disease, lymphoma, lumbar radiculopathy, and chronic pain. He underwent repair of ascending aortic aneurysm and aortic valve replacement 6 months ago. He had a complication of cellulitis treated with oral antibiotics 3 months ago. He lives alone. The denial of an increase in personal care worker (PCW) service from seven days per week, six hours per day; 42 hours per week to seven days per week, 10 hours per day; 70 hours per week is being appealed. The Uniform Assessment System (UAS) evaluation completed 2 months ago shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances, phone use, shopping, bathing, lower body dressing, and toilet use; extensive assistance with managing medications, personal hygiene, upper body dressing, walking, locomotion, toilet transfer, and eating; and limited assistance with bed mobility. The patient has bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed 6 months ago, there has been a decline with toilet use. A letter from his Provider notes the patient has rapidly deteriorating mental and physical health. He has limited range of motion and decreased mobility. The patient requires continuous supervision and assistance. He cannot independently perform activities of daily living (ADLs). Another letter notes the patient needs help with activities of daily living. He has urinary incontinence and cannot change his diaper himself. 

The proposed treatment 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. The denial of an increase in personal care worker (PCW) service from seven days per week, six hours per day; 42 hours per week to seven days per week, 10 hours per day; 70 hours per week is being appealed. Uniform Assessment System (UAS) evaluation completed 2 months ago shows the need for assistance with all activities of daily living. The patient has bowel and bladder incontinence. There has been no significant decline in his functional status compared to Uniform Assessment System evaluation completed 6 months ago. Appeal statements note the patient needs assistance with activities of daily living and supervision. The information provided does not support that the patient has functional limitations requiring an increase in personal care worker from 42 to 70 hours per week. Personal care worker is not indicated for supervision. The patient can split hours of service to meet needs. The proposed increase personal care worker to 70 hours per week is not medically necessary.