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

Diagnosis: Coronary heart disease, dementia, right arm fracture, hypertension, gastroesophageal reflux disease (GERD)
Treatment: PCA (personal care aide) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week
The insurer denied coverage for PCA level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week.
The denial is overturned.

This is an elderly female with multiple medical problems including coronary artery disease, osteoarthritis and progressive dementia. She lives alone in a 1-bedroom apartment. She recently fell out of bed and sustained a right forearm fracture. She is currently approved by the insurer for PCA level 2: 6 hours/day, 7 days/week, totaling 42 hours/week and requesting an increase of 12 hours/day, 7 days/week; 12 hours/day - 7 days/week (split shift) - a total of 168 hours/week; which is under review.  

According to the Uniform Assessment System (UAS) report, the patient's cognition is described "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times" and has "declined" over the prior 90 days. She requires maximal assistance for bathing and lower body dressing. Extensive assistance is needed for personal hygiene, upper body dressing, bed mobility, ambulation, and toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel. Her ability to perform activities of daily living (ADL) tasks has also "deteriorated" over the past 90 days. The doctor's letter states that due to the progression of her dementia, she does not sleep at night and wanders around. She has also taken her medicines unpredictably, confusing the dosing/timing resulting in overdose. As per her son, she also leaves stove turned on. The currently approved PCA level 2: 6 hours/day, 7 days/week, totaling 42 hours/week is insufficient to meet her daily/nightly functional needs, which along with her cognition continues to decline. Her condition and functional needs are at a level and unpredictable as to require the requested PCA 24 hours/day, 7 days/week (split shift). The patient's health and safety can be more appropriately provided and maintained at home with the requested PCA 24 hours/day, 7 days/week (split shift), and totaling 168 hours.

From a physical medicine and rehabilitation perspective, PCA level 2: 12 hours/day - 7 days/week; 12 hours/day - 7 days/week (split shift) is medically necessary.

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 personal care aide (PCA) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - a total of 168 hours per week services is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Central Nervous System/Neuromuscular Disorder/Migraine/Migraine without aura, intractable, without status migrainosus.
Treatment:  Pharmacy/Prescription Drugs/Nurtec ODT.

The health plan denied Pharmacy/Prescription Drugs/Nurtec ODT as not medically necessary. The health plan's determination is upheld.

The patient is a female who is prescribed treatment with Nurtec ODT 9 (oral disintegrating tablet). The diagnosis provided for review is migraine without aura, intractable, without status migrainosus. The provider submitted a letter of medical necessity indicating that the patient has chronic migraines and has failed preventative treatment such as tricyclic antidepressants. No other medical records are provided for review. The drug was denied because the patient had not tried and failed formulary alternatives. The provider appealed the determination.

The health plan's determination is upheld, in whole.

There is no documentation that the patient has tried and failed any of the formulary medications other than Zomig (zolmitriptan nasal spray) and ibuprofen.

Nurtec ODT has two Food and Drug Administration (FDA) approved indications: treatment of acute migraine and prevention of episodic migraine.

The provider has not indicated for which indication Nurtec ODT is prescribed.

For the treatment of acute migraine, the patient has only tried and failed one triptan and ibuprofen. The remaining formulary alternatives are appropriate including Aimotriptan tablet; Dihydroergotamine Mesylate injection; Eletriptan tablet; Ergotamine with Caffeine tablet; Frovatriptan tablet; Naratriptan tablet; Tizatriptan ODT/tablet; and Sumatriptan injection/nasal spray/tablet.

The letter of medical necessity suggests, however, that Nurtec ODT is prescribed for prevention of migraine, as the provider notes that the medication has "good results in reducing and/or stopping patient's headaches occurrences." However, the provider also notes that the patient has chronic migraine, and Nurtec ODT is not approved for prevention of chronic migraine, only prevention of episodic migraine. Furthermore, if the medication is being used for prevention of migraine, there is no documentation that the patient has used any of the plan's preventative therapies, which include Aimovig, Ajovy, and Emgality.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis.
Treatment: Dupixent.

The insurer denied the Dupixent.  The health plan's determination is upheld.

The patient is a female with moderate to severe atopic dermatitis with a large involved body surface area that includes the face, arms, neck, chest, thighs, and buttocks. The patient has and IGA (immunoglobulin A) of 3.0, and an Itch Numeric Rating Schedule of 8.0. The patient has tried and failed topical steroids, as well as topical nonsteroidal Eucrisa, tacrolimus, and Opzelura, and also oral hydroxyzine and other antihistamines.

Dupixent is not medically necessary for this patient.

The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, or standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Cyclosporine, Azathioprine, or Mycophenolate Mofetil). Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with standards of care based on modern dermatology literature reviews, the requested Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Newly Diagnosed Diabetes Mellitus. 
Treatment: Inpatient Level of Care. 

The insurer denied: Inpatient Level of Care.  The denial is upheld. 

The patient is a male with previously diagnosed and untreated diabetes who presented to the hospital with complaints of fatigue and weakness. The patient stated that he had been losing weight recently unintentionally. He denied changes in bowel habits, blood in stool, or dark stools. The patient reported increased urination without any pain. He also complained of increased thirst. The patient stated that he had been diagnosed with diabetes in the past but did not take any medications for that. The patient was admitted to the hospital with a diagnosis of newly diagnosed diabetes mellitus and no evidence of diabetic ketoacidosis (DKA). In the hospital, the patient was started on insulin as well as treatment with the oral agent Metformin. As a result of the treatment in the hospital, the patient's clinical condition improved. His blood sugars became better controlled, and he was transitioned to outpatient care. 

The health plan's determination is upheld. 

According to the nationally accepted standards of care, admission at the acute inpatient level of care is indicated in some cases of diabetic ketoacidosis, hyperglycemic hyperosmolar state, or hyperglycemia that is associated with hemodynamic instability, altered mental status, severe or persistent dehydration, severe or persistent vomiting, significant electrolyte abnormalities that persist despite observation care, or in cases when glucose levels are persistently too high for the next level of care.  Also, the inpatient level of care is recommended for patients with severe hyperglycemia when the treatment of the underlying etiology of hyperglycemia is needed, such as in cases of infection. 

The review of the medical records clearly demonstrated the patient had none of the circumstances listed above. His dehydration was very mild and was corrected within the first few hours of the hospitalization. 

The patient could have been safely managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic squamous cancer
Treatment: Proton Beam Therapy
The insurer denied: Proton Beam Therapy
The denial is upheld

The patient is an adult male with a history of skin cancer who has TxN2bM1 (primary tumor cannot be assessed, affected nodes are on the same side of the body as the primary tumor, all less than or equal to 6 centimeters in size, with distant metastasis) metastatic squamous cancer to the left neck nodes status post left parotidectomy and neck dissection. Pathology showed 3 positive nodes in the left parotidectomy and level I node of the left neck.

Proton beam therapy is being requested to deliver post-operative RT (radiotherapy) of 60 Gy (Gray) on 30 fractions to the left neck on prospective registry trial.

The requested proton beam therapy is not medically necessary.

Currently, there is no published long-term clinical outcome evidence of proton beam therapy relative to photon RT (radiotherapy) for treatment for post-operative treatment of metastatic cervical nodes. Most studies reporting on the benefits from proton therapy are derived from non-randomized studies and dosimetric and biological considerations, which are theoretic. These published studies suggest that proton beam radiation offers superior dosimetry to photon radiation treatment dosimetry, and side effects of proton beam therapy reportedly offer potentially less local side effects compared to photons in several types of malignancy. However, no clinical outcomes studies on proton versus photon (IMRT [intensity-modulated radiotherapy]) have been published to conclusively state any advantage of protons to the current standards IMRT (intensity-modulated radiotherapy) for head and neck cancer, such as larynx cancer in this case. It is, therefore, not possible to draw any conclusions on the benefits of proton beam therapy compared to photon IMRT (intensity-modulated radiotherapy) in this patient's case. Therefore, the requested proton beam therapy is not established as medically necessary.

The NCCN (National Comprehensive Cancer Network) guideline on Head and Neck Cancer states that IMRT (intensity modulated radiotherapy) or other conformal techniques, such as 3D (three dimensional) conformal RT (radiotherapy), helical tomotherapy, volume modulated arc therapy (VMAT), and proton beam therapy (PBT) may be used as appropriate depending on the stage, tumor location, physician training/experience, and available physics support.

IMRT (intensity-modulated radiotherapy) has been the standard treatment modality for adjuvant radiation treatment for stage TxN2bM1(primary tumor cannot be assessed, affected nodes are on the same side of the body as the primary tumor, all less than or equal to 6 centimeters in size, with distant metastasis) squamous cancer metastatic to neck nodes. IMRT (intensity-modulated radiotherapy has been demonstrated to be safe and effective treatment modality, and NCCN (National Comprehensive Cancer Network) guideline includes IMRT (intensity-modulated radiotherapy) as one of the standard modalities for this patient's clinical condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Pain.
Treatment: Pain injections (cervical intralaminar block) in spine.
The insurer denied: Pain injections (cervical intralaminar block) in spine.
The denial is: Upheld.

The patient is a female with complaints of neck pain which radiates into the right shoulder. Pain is increased in all positions. Magnetic resonance imaging (MRI) of the cervical spine reported stenosis at cervical (C)5-6 and C6-7. Medications include meloxicam and cyclobenzaprine. The patient has undergone a prior cervical epidural injection. Electrodiagnostic studies upper extremities demonstrated right C7 radiculopathy. Physical exam demonstrated 5 out of 5 muscle strength, 4 out of 5 dermatomes on the right, exquisite tenderness cervical spine. An appeal letter dated reported the patient gets 3-6 months of relief every time she gets a cervical epidural injection. The patient is noted to have severe pain, and there is a plan for cervical epidural injection.
The subject under review is the medical necessity for the injection (cervical intralaminar block).

The health plan's determination is upheld.

The pain injections (cervical intralaminar block) in the spine are not medically necessary for this patient from this patient from the attached documentation, the patient has undergone prior cervical epidural steroid injections.
However, the objective evidence of pain relief and improved function to determine objective efficacy from prior injections was not established to support continued injections. Furthermore, it appears the patient has had multiple injections, and there is no documentation of sustained relief. Overall, the request is not medically necessary.
The provider is requesting a repeat cervical epidural steroid injection. Cervical epidural steroid injections are generally recommended on a case-by-case basis as a short-term treatment for intervertebral disc herniation, degenerative changes, and/or spinal stenosis leading to radicular pain (defined as pain in a dermatomal distribution with corroborative findings of radiculopathy). From the attached documentation, the patient has undergone prior cervical epidural steroid injections. However, the objective evidence of pain relief and improved function to determine objective efficacy from prior injections was not established to support continued injections. Furthermore, it appears the patient has had multiple injections, and there is no documentation of sustained relief.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia. 
Treatment: Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week (Split-Shifts). 
The insurer denied Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week (Split-Shifts).
The health plan's determination is upheld. 

The patient is a female with past medical history of hypertension (HTN), hyperlipidemia, permanent pacemaker, stress urinary incontinence, atrial septal aneurysm, low back pain, depression, anxiety, recurrent urinary tract infection (UTI) with colovesicular fistula, Meniere's disease, glaucoma, dementia, osteoporosis with history of vertebral fracture, anemia, and tremor who had been assigned PCA (personal care assistance) services. 

Personal Care Assistance Services: 24 Hours per Day, 7 Days per Week (Split-Shifts) are not medically necessary for this patient. 

There is no documentation of overnight care needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. There is no documentation of the need to turn and reposition the patient every 2 hours. In addition, there are no overnight logs documenting care needs. Split-shift services are not medically necessary. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, 7 days/week, splits-shifts, are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Postoperative Infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a history of a lumbar discectomy. The patient presented to the emergency room (ER) with signs and symptoms of a post-operative infection. The erythrocyte sedimentation rate (ESR) was 30 and C-reactive protein (CRP) was 67. Lumbar magnetic resonance imaging (MRI) showed a seroma. Neurosurgery did not recommend surgical intervention. Serial C-reactive protein (CRP)/ erythrocyte sedimentation rate (ESR) was recommended. The patient was admitted for intravenous (IV) antibiotics. Infectious disease recommended 6 weeks of IV antibiotic therapy. A peripherally inserted central catheter (PICC) line was placed. The patient was discharged home. At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary. The patient was found to have a post-operative wound infection that did not require surgical intervention. It was determined that the patient should have 6 weeks of IV antibiotics and a PICC line was appropriately placed. The patient could have received care at a lower level to have a PICC line placed and antibiotic therapy started as an outpatient. He did not require inpatient admission for serial ESR/CRP levels, as these are slow to normalize and could have been monitored as an outpatient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma. 
Treatment: Inpatient admission. 
The insurer denied coverage for an inpatient admission. 
 The denial is overturned. 

This patient has a history of asthma and presented to the emergency room (ER) with complaints of shortness of breath (SOB) and chest tightness. Vital signs were Blood Pressure 129/82, Heart Rate, 90, Respiratory Rate 18 and Temperature 98 degrees F (Fahrenheit). The patient was on 2L (liters) oxygen via Nasal Cannula with oxygen saturations 93-94 % on room air. The patient was noted to have bilateral wheezing on the lung exam. The White Blood Cell (WBC) count was 9.9K (thousand) with increased Eosinophil's. Electrolytes were within normal limits and the Hemoglobin was 14.5. The patient was treated with IV (intravenous) steroids and bronchodilators via nebulizer. 

The patient was admitted to the hospital for acute exacerbation of asthma and was continued on IV steroids and bronchodilators. Breo Ellipta was added to the treatments. 

The patient had improved and was weaned off oxygen. She was maintaining adequate oxygen saturation at room air during ambulation and at rest. She was switched to oral medications and inhalers and was discharged home. 

This patient had an asthma exacerbation with hypoxemic respiratory failure and needed IV steroids and supplemental oxygen for more than 48 hours. An inpatient admission was appropriate. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Tooth implants
The insurer denied the Tooth implants.
The determination is upheld.


The patient has congenitally missing maxillary lateral incisors. The retained deciduous incisors were removed due to dental decay. The incisor areas were previously grafted on an unknown date. The provider is requesting approval for placement of osseointegrated dental implants. The procedure was denied due to lack of medical necessity. At issue is whether the tooth implants are medically necessary.

The requested health service / treatment of tooth implants is not medically necessary for this patient. The standard of care does not necessitate that implants be placed when maxillary lateral incisors are congenitally missing.  Current literature states that orthodontic movement is sufficient to close the space left by the congenitally missing teeth-see the reference by Naoum et al and Silveira et al cited in the references.  There are no national guidelines that require placement of dental implants to replace missing congenitally missing teeth. The patient does not have a condition that is causing acute suffering, endangering life, resulting in any illness or infirmity that will interfere with normal activity or result in some significant hardship. The congenitally missing lateral incisors are not a rare occurrence and not life threatening and can be treated in a variety of means. The placement of dental implants is an elective procedure. This patient, or any patient, can function normally including normal mastication without these teeth. The dental arch will not collapse because dental implants are not being placed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Taltz 80MG/ML (milligrams/milliliter) SC (subcutaneous) SOAJ (solution auto-injector).
The insurer denied: Taltz 80MG/ML (milligrams/milliliter) SC (subcutaneous) SOAJ (solution auto-injector).
The denial is upheld.

The patient is an adult male diagnosed with severe psoriasis, affecting 90% BSA (body surface area). He has tried and failed prednisone, and was then started on Taltz with improvement. The treating provider has requested coverage of Taltz. The request was denied coverage by the health plan, because the patient has not tried and failed the preferred alternatives: Cosentyx, Humira, Enbrel, Renflexis, Inflectra or Avsola.

The requested Taltz is not medically necessary.
There is insufficient documentation as to why the patient would not have a positive response to the health plan's preferred alternatives. The alternatives have demonstrated safety and efficacy in treating the patient's disease. The preferred alternative Cosentyx is in the same class as the requested Taltz, and there is no indication that the patient could not do well on this alternative.

Therefore, given the above, the requested Taltz is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: acute coronary syndrome (ACS)

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

The patient with a history of hypertension, hyperlipidemia, diabetes mellitus, and morbid obesity presented to the hospital with dyspnea on exertion and exertional chest pain X (times) 5 days. The pain was radiating to his shoulders. The patient was hypoxic on room air. Vital signs at presentation were Temperature 98 degrees F (Fahrenheit), Heart Rate 76, Respiratory Rate 20, Blood Pressure 158/87 mm Hg (millimeters of mercury).

The patient had decreased breath sounds on both lung fields and bilateral lower extremity edema was noted.

Laboratory results showed: WBC (white blood cell count) 9.5K (thousand), Hb (hemoglobin) 15, Arterial Blood Gas was 7.31/75/102/79 on FIO2 (fraction of inspired oxygen) 40% on 4L (liters) of oxygen via nasal cannula. EKG (electrocardiogram) HR (heart rate) 94 RBBB (Right bundle branch block). Chest X-ray showed no acute pathology. A CTPA (CT pulmonary angiogram) was negative for pulmonary embolus. Cardiac Enzymes were negative. BNP (B-type natriuretic peptide) was normal. A DVT (deep vein thrombosis) study was negative.

The patient was admitted to the intensive care unit (ICU) for acute coronary syndrome (ACS) / Hypoxic Resp Failure / rule out congestive heart failure (CHF).

The patient was placed on bilevel positive airway pressure (BiPAP). He was treated with Lasix, steroids and bronchodilators (BD). A repeat ABG (arterial blood gas) was 7.31/81/98/43 on BiPAP (bilevel positive airway pressure) 12/5 40 %. Weight decreased by 7 lbs. (pounds) after diuresis.

Myocardial Infarction was ruled out by Cardiology. Cardiac Catheterization revealed non-obstructive coronary artery disease (CAD).

This patient had multiple medical critical issues necessitating admission and length of stay.


The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the full hospital admission is overturned. Medical Necessity is substantiated.