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

Diagnosis: Vision-Glaucoma.
Treatment: Pharmacy/Prescription Drugs-Vyzulta 0.024% Ophthalmic Solution.

The health plan denied the Vyzulta as not medically necessary. The reviewer has overturned the health plan determination as not medically necessary.

An exam documents the patient as a low risk glaucoma suspect following up for intraocular pressure check. Vision was 20/30 both eyes (OU). Intraocular pressures were 21 mm Hg OU. Cup/disc ratios were 0.2 the right eye (OD) and 0.25 left eye (OS). Cosopt and Vyzulta were prescribed. The next exam documents the patient using Cosopt and having stopped Vyzulta two weeks prior. Vision was 20/30 OU. Intraocular pressures were 18 mm Hg OD and 20 mm Hg OS. The patient was to take Cosopt and begin Lumigan drops (denied) and latanoprost drops.

An exam documents the patient as a low risk glaucoma suspect following up for an intraocular pressure check. The patient was taking Cosopt and latanoprost drops. It was noted that the patient was not taking Lumigan drops. Vision was 20/30 OU. Cup/disc ratios were 0.5 OU.

An exam documents the patient following up as a low risk glaucoma suspect. The patient was taking Cosopt and latanoprost but had ran out of the drops 3 days prior. Vision was 20/20- OD and 20/25- OS. Intraocular pressures were 26 mm Hg OU. An optical coherence tomography (OCT) scan found no significant change in retinal nerve fiber layers OU. The patient was instructed to use Cosopt and Vyzulta (sample was given).

An exam documents the patient following up as a low risk glaucoma suspect. Vision was best corrected to 20/25 OU. Intraocular pressures were 22 mm Hg OD and 21 mm Hg OS. The patient was placed on Cosopt, and a sample of Vyzulta was given.

The provider notes that the patient has tried Cosopt, Simbrinza, Alphagan P, and Travatan. No trial of bimatoprost is identified. The provider states that bimatoprost is not available on the market and the patient has tried alternatives including Travatan, latanoprost, and Lumigan (bimatoprost) without success.

The requested health service/treatment of Vyzulta 0.024% is medically necessary for this patient. The medication was previously denied as it was not established that the patient had tried and failed generic bimatoprost. However, as the provider states that the patient has tried and failed 3 prostaglandin analogues including latanoprost, Travatan, and Lumigan (branded bimatoprost), it would not be expected that generic bimatoprost would be sufficiently efficacious for this patient.

Additionally, Weinreb et al found that latanoprostene bunod 0.024% dosed once daily resulted in greater intraocular pressure (IOP) lowering and comparable side effects relative to latanoprost 0.005%, which the patient has already tried and failed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer 
Treatment: Radiation therapy. 
The insurer denied radiation therapy. 
The health plan's determination is upheld. 

This patient is a female with a stage IV ovarian serous carcinoma with retroperitoneal carcinomatosis with debunking surgery. She was treated with systemic therapy. Now the patient was found to have brain metastases and leptomeningeal carcinomatosis. Radiation therapy is recommended to the craniospinal axis and the proton beam approach is being requested. This is the subject of this review.

The radiation therapy is not medically necessary for this patient.
Leptomeningeal metastases (LM) are associated with limited survival and treatment options. While involved-field radiotherapy is effective for local palliation, it lacks durability. Standard therapy relies mainly on focal irradiation and intrathecal or systemic chemotherapy. Studies using other therapeutic approaches such as new biological or cytotoxic compounds are ongoing.
In this case, the recommended proton beam radiation therapy for this patient and her leptomeningeal carcinomatosis is not considered medically necessary as there are lack of any significant randomized trials published in the peer reviewed medical literature showing equivalent nor better results than conventional photon beam radiation. There are ongoing trials to determine its efficacy, as this patient is entered in.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cancer.
Treatment:  SIRT (Selective Internal Radiation Therapy) with Yttrium-90 Microspheres.

The insurer denied SIRT (Selective Internal Radiation Therapy) with Yttrium-90 Microspheres.  The health plan's determination is upheld. 

The patient is a woman who presented with stage IV presumed gallbladder adenocarcinoma (liver, peripancreatic, mediastinal and abdominal lymph nodes).  She is status/post (s/p) 4 months (9 cycles) of Gemcitabine + abraxane with progressive disease (ascites and growth of liver metastases and nodal disease restaging computed tomography (CT)).

Under review is the medical necessity of Selective Internal Radiation Therapy (SIRT) with Yttrium-90 Microspheres.

The Selective Internal Radiation Therapy (SIRT) with Yttrium-90 Microspheres is not medically necessary for this patient.  This patient has progressive liver metastases on chemotherapy.  Her lymph node metastases are also growing, and she still has her primary disease (presumed gall bladder).  The current guidelines clearly state that in order to benefit from SIRT, disease should be limited to the liver and should not progress on systemic therapy.  For patients with pain from liver metastases the standard treatment is either a different systemic therapy or external beam radiation to the liver.  

This patient is extremely unlikely to benefit from SIRT.  Occasionally, SIRT is reasonable for a patient like this with metastatic gall bladder or pancreatic cancer with chemo-responsive and liver only metastatic disease with long disease control time; however, she doesn't have liver only disease, and her disease has progressed on chemotherapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing Teeth.
Treatment: Maxillary partial denture (D5213) and Mandibular partial denture (D5214).
The insurer denied the Maxillary partial denture (D5213) and
Mandibular partial denture (D5214).
The denial is upheld. 

The patient is a male requesting dental benefits for maxillary and mandibular metal base partial dentures.

Clinical exam summary indicates that the patient is missing teeth #s 6, 7, 8, 9, 14, 15, 16, 29, 30, 31, and 32, with teeth #s 3 and 18 to be extracted. Several other teeth are in need of restoration. Radiographs (x-rays) images are not clear. 

No, the Maxillary partial denture (D5213) and Mandibular partial denture (D5214) are not medically necessary.

Given the condition of the patient's supporting teeth, a metal base removable denture is contra-indicated, because it requires healthy teeth and adequate bone level to provide stability to the denture. The patient's records indicate that the supporting teeth and bone levels are less than ideal.

This reviewer concurs with the health plan's final adverse determination summary, namely that a resin base removable denture may be considered due to the condition of the supporting teeth.
The resin base denture is more easily adaptable should it become necessary for additional teeth to be extracted in the future.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of hypertension, gastroesophageal reflux disease (GERD), anemia and chronic kidney disease.
Treatment: Increase Personal Care Services to 8 hours x 5 days, 7 hours x 1 day, and 5 hours x 1 day per week, for a total of 52 hours per week.
The insurer denied the Increase Personal Care Services to 8 hours x 5 days, 7 hours x 1 day, and 5 hours x 1 day per week, for a total of 52 hours per week.
The denial is overturned. 

The patient is a female with a history of hypertension, gastroesophageal reflux disease (GERD), anemia and chronic kidney disease. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 52 hours per week personal assistance services to offer increased activities of daily living (ADL) support.

Yes, the proposed treatment of 52 hours per week personal assistance services is deemed medically necessary. 

This is a female with a history of hypertension, gastroesophageal reflux disease (GERD), anemia and chronic kidney disease. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to progressively worsening weakness, fatigue, gait ataxia and increased fall risk, the currently approved plan of personal assistance services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 52 hours per week personal assistance services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Myocardial infarction.
Treatment:  Inpatient hospital services.

The insurer denied coverage for the inpatient hospital services.  The denial is upheld. 

This is a male patient, who presented to the Emergency Department (ED) after being instructed to do so by his cardiologist.  The patient had noted chest pain 1 week earlier and never followed instructions to go to the ED.  His relevant past medical history included nephrectomy and hypertension (HTN).  Upon presentation, he was free of chest pain; his vital signs were stable, and no significant abnormalities were noted on heart and lung examination.  Electrocardiogram (ECG) revealed normal sinus rhythm without acute ST or T wave changes.  His troponin was mildly elevated.  Cardiac catheterization was performed and revealed 20% left main eccentric lesion and 85% mid right coronary artery lesion that required percutaneous coronary intervention.  Echocardiography revealed a preserved left ventricular ejection fraction (LVEF) and no valvular abnormalities.  The patient's post-procedure course was without complication, and he was discharged home the following day.

This patient presented 1 week following myocardial infarction to the ED and underwent percutaneous coronary revascularization.  He underwent an uncomplicated procedure and was discharged the following day.  Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between low risk patients that are discharged on the same day as compared to patients admitted to the hospital.  Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care.  In conclusion, this patient could have been treated at a lower level of care.  The health plan acted reasonably and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Proton Beam Therapy, Pre-service
The insurer denied the Proton Beam Therapy, Pre-service.
The denial is upheld.

The patient is a female with history of T1N1 (Stage 1 tumor, cancer in lymph node, stage 1) right breast invasive ductal carcinoma. She is s/p (status post) neoadjuvant chemotherapy followed by mastectomy. She was referred for post mastectomy radiotherapy.    

No, the health plan should not cover the Proton beam therapy.

No, the Proton beam therapy is not likely to be more beneficial.

There is no clinical evidence to show that proton therapy is significantly superior in terms of efficacy and safety than photon therapy, such as 3D (three dimensional) conformal therapy or IMRT (intensity-modulated radiation therapy) for this type of case. The available medical literature applicable to this case is very limited.  

Clinical evidence to support the use of proton therapy in this case in terms of safety and efficacy has not been well established. Peer-reviewed medical articles pertaining to this case to justify the use of proton therapy are few and retrospective in nature. Standard radiotherapy with photon either 3D or IMRT for this case would still be considered the standard approach. Even though technically the proposed treatment is dosimetrically superior than photon therapy, this has not been shown to translate to a clinical advantage.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Proton Beam Therapy, Pre-service
The insurer denied the Proton Beam Therapy, Pre-service.
The denial is upheld.

The patient is a female with a recent diagnosis of loco-regionally advanced right
breast carcinoma. She is s/p (status post) neoadjuvant chemotherapy and bilateral
mastectomy with right axillary dissection and reconstruction. Adjuvant radiation
therapy was recommended, and proton beam radiation therapy was requested.

No, the health plan should not cover the Proton beam therapy.

No, there is insufficient clinical data in well conducted randomized trials showing
that this procedure is clinically superior to the standard photon-based radiation.

In this case, the patient is female with a recent diagnosis of loco-regionally
advanced right breast carcinoma. She is s/p neoadjuvant chemotherapy and
bilateral mastectomy with right axillary dissection and reconstruction. Adjuvant
radiation therapy was recommended, and proton beam radiation therapy was
requested. However, based upon and in conclusion of the review above, the
proposed treatment is not considered medically appropriate for this individual under
these unique circumstances. Proton beam radiation therapy is a type of very precise external radiation treatment in which protons are used to treat cancer and other conditions. Compared to photon, a proton beam that is delivered with sufficient energy has a low "entrance dose." A proton beam also has a high-dose "Bragg peak" region, which is designed to cover the entire tumor and there is no "exit dose" beyond the tumor involved in proton radiation therapy. Because of this unique property, proton beam therapy is highly successful in minimizing damage to normal tissue and surrounding organs, resulting in fewer side effects. It is an FDA (Food and Drug Administration)-approved procedure, and it is not subject to IRB (institutional review board) review.

Although proton beam radiation therapy has been shown to be safe and effective
for certain tumors that are adjacent to critical structures, such as CNS (central
nervous system) lesion, there is insufficient clinical peer-reviewed literature for
supporting its use for the treatment of breast carcinoma. There are other
established alternatives available such as conventional conformal or IMRT (intensitymodulated radiation therapy) photon therapy that have been shown to be safe and effective for the adjuvant treatment of breast cancers.

There are several phase I and II clinical trials still evaluating the role of proton
therapy for breast cancer. The report of ASTRO's (American Society for Radiation
Oncology) emerging technology committee also does not include proton therapy for
breast cancer. In this case, a proton/photon comparison plan was done, and the
proton plan was able to reduce dose to the right lung and heart. However, the
doses to those structures were within tolerance per Quantec limits for both the
photon and proton plans. The requested proton therapy, therefore, is not the
standard of medical practice and is not considered medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Substance abuse/Addiction. 
Inpatient Hospital. 

Diagnosis: Substance Abuse. 
Treatment: Inpatient hospital. 
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is an adult male who had completed detoxification treatment with admission for inpatient rehabilitation substance use disorder treatment to address substance use with stimulants (cocaine); alcohol; and opioids (heroin), as well as use of Xanax intermittently. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had a history of substance use disorder with multiple prior detoxification treatments with relapses and no substantial periods of sobriety in the past. He was using cocaine at approximately $30 per day up to 5 bags of heroin with injection, as well as one pint of vodka daily and intermittent use of 2 milligrams (mg) of Xanax. 

The Inpatient Hospital Stay is not medically necessary for this patient. The patient in this case scenario is not clinically appropriate for inpatient level of care during the time interval under review. The patient did not warrant 24-hour monitoring and did not need the structure of inpatient level treatment in order to address the substance use disorder with rehabilitation treatment. He had completed detoxification treatment and had engaged with treatment and was actively involved with peer supported recovery groups while receiving psychotropic medications for the co-occurring anxiety and depressive disorders. There were no complications or severe symptoms that warranted inpatient level treatment. The patient could have been safely and effectively treated with lower level services in a less restrictive treatment setting. 

The patient presented with substance use disorders with use of heroin, alcohol and cocaine on a daily continuous basis with intermittent use of Xanax. He received inpatient detoxification treatment prior to transitioning to inpatient level rehabilitation treatment. He readily engaged in treatment with vitamin and nicotine replacement therapy and medications to address mood and anxiety disorders with tolerability and adherence. During the time interval under review, the patient was noted to be in no apparent distress with improved/reasonable functioning and active participation in treatment including mostly positive interactions with staff and peers until the day of discharge. He was administratively discharged, as noted. The application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts. Thus, medical necessity for the admission and the continued Inpatient stay is not met in this case scenario consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neuromyelitis Optica with MOG-IgG Positive Disease
Treatment: Privigen 20 Grams
The health plan denied the requested prescription drug. 
The health plan's determination is upheld.

The patient is a male who has a past medical history notable for attention deficit hyperactivity disorder (ADHD), migraine headaches and seizures (secondary to concussions). The patient reported episodes of clumsiness for a 1-2-month period. He suffered partial right monocular vision loss. His vision gradually deteriorated to where he lost visual ability in the right eye. At that time, he presented to the hospital where on examination he was suspected of having optic neuritis. A magnetic resonance imaging (MRI) of the brain showed an enhancing lesion in the right inferior frontal gyrus. An MRI of the orbits revealed enhancement of the right prechiasmatic optic nerve. He was treated with intravenous (IV) steroids followed by an oral steroid taper. Cerebrospinal fluid (CSF) testing only showed 1 OCB (Oligoclonal Band) and a protein of 48. He was suspected of potentially having multiple sclerosis (MS). Laboratory testing was ordered to evaluate for possible NMOSD (Neuromyelitis Optica Spectrum Disorder) or other MS "mimics".

The laboratory testing ultimately returned positive for an elevated MOG (Myelin Oligo Dendrocyte Glycoprotein) - IgG (Immunoglobulins) titer. The patient was given a diagnosis of a MOG antibody related disease. A recommendation was made for treatment with intravenous immunoglobulin (IVIG).

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

No, the requested service would not be medically necessary. The plan's decision followed findings in current medical literature and the plan also offered alternative treatment options.

The efficacy of IVIG in the management of this condition has not been shown to be superior to that of corticosteroids or other oral immunosuppressive agents. Various studies have presented conflicting results with regards to the use of IVIG in MOG based diseases (e.g. Ramanthan et al 2018 versus Chen et al 2020). As noted by Hegen and Reindl: "However, a serious comparison of different therapies in terms of efficacy or even the estimation of the size of treatment effects is not feasible yet due to insufficient evidence"(2020).

In this setting it cannot be concluded that the requested drug would likely be more beneficial than other immunosuprresive agents either. Likewise, Cobo-Calvo et al have noted "MOG-antibodies-associated disease is a new entity in the spectrum of inflammatory demyelinating diseases, distinct from both MS and NMOSD. There is a crucial need to identify factors associated to the risk of relapse or poor outcome, to seek patient subgroups in which immunoactive treatments could be beneficial" (2019).

The plan in this case has otherwise made an appropriate determination on the body of available literature. There is not a sufficient body of literature available to suggest the superiority of the requested IVIG versus the formulary alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

The patient is a male who presented to the emergency department complaining of three days of intermittent left-sided chest pain with radiation to the left arm and back. The pain was pleuritic and reproducible with palpation. He also reported elevated blood pressure readings for several days and minor temperature elevations. His medical history was remarkable for non-Hodgkin's lymphoma, in remission. His blood pressure was 151/97 millimeters of mercury (mmHg) with a heart rate of 103 beats/minute. His respiratory rate was 26/minute with a room air oxygen saturation of 97-100%. He was afebrile. On physical exam the patient's pain could be reproduced with palpation of the left chest. An electrocardiogram showed sinus tachycardia without acute ischemic changes. His serum troponin level and D-dimer level were normal. Chest X-ray was unremarkable. He was treated with intravenous ketorolac and admitted to the hospital to rule out acute coronary syndrome (ACS). Repeat troponin levels were normal. An echocardiogram was normal. Chest computed tomography (CT) angiography showed no evidence of pulmonary embolism. The patient's pain was thought to be musculoskeletal in origin. He was discharged.

The health plan's determination is upheld in whole.

This patient, without known cardiac risk factors, presented with atypical symptoms that were thought to possibly represent ACS. Accordingly, monitoring until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. Based on his HEART (history, EKG, age, risk factors, and troponin) score, he was at low risk for major adverse cardiac events. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.