Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Stage II Squamous Cell Carcinoma of the Vulva
Treatment: Keytruda
The insurer denied Keytruda.
The health plan's determination is overturned. 

The patient is a female with squamous cell cancer of vulva, stage IIIc, grade 2, status post 3 cycles of cisplatin concurrently given with radiation therapy. Initially she was diagnosed, underwent radical vulvectomy and sentinel node biopsy. A computed tomography (CT) scan showed metastatic cancer with multiple bone involvement.

A Biopsy of the bone confirmed the diagnosis of squamous cell cancer with metastasis. PDL-1 (Programmed death-ligand 1) test showed positive expression with CPS (combined positive score) above 1.

Keytruda is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Standard regimen for treatment for newly diagnosed metastatic advanced vulvar cancer per National Comprehensive Cancer Network (NCCN) is combination of Carboplatin and Paclitaxel with Bevacizumab. The NCCN recommends Keytruda as second line regimen. However, in his case, the patient has already received 3 cycles of Platinum based chemotherapy and she has PDL-1 positive cancer with CPS > 1: therefore, Pembrolizumab can be given in this particular case as second line treatment in combination with chemotherapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Stage II Squamous Cell Carcinoma of the Vulva
Treatment: Keytruda
The insurer denied Keytruda.
The health plan's determination is upheld. 

The patient is a female who is noted to have a history of stage IIIc squamous cell carcinoma of the vulva. She was admitted recently due to cellulitis of the mons pubis requiring intravenous (IV) antibiotics. She was additionally noted to have burns and scarring related to radiation.

There is no data to support that treatment with Keytruda in combination with cytotoxic chemotherapy is likely to be more beneficial than standard treatment for this patient's condition.

This patient is noted to have persistent, metastatic vulvar cancer. She has received no systemic chemotherapy other than the radiosensitizing doses of cisplatin. Currently, National Comprehensive Cancer Network (NCCN) guidelines would recommend as first line therapy platinum-based therapy with or without bevacizumab, however there is no mention in those guidelines of the use of Keytruda in combination with chemotherapy. Keytruda is supported only as a second line therapy, and then as monotherapy (not in combination with cytotoxic chemotherapy). Currently, there are no clinical trials supporting the use of Keytruda in combination with cytotoxic chemotherapy for patients with a diagnosis of vulvar cancer.

Given the lack of data comparing standard of care treatment (platinum-based therapy with or without bevacizumab) with the requested treatment (chemotherapy with Keytruda), there is no data upon which to base a recommendation regarding the requested regimen being any more efficacious than standard of care treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Stage II Squamous Cell Carcinoma of the Vulva
Treatment: Keytruda
The insurer denied Keytruda.
The health plan's determination is upheld. 

This is a female with recurrent, metastatic stage IIIc squamous cell carcinoma of the vulva. The patient has previously undergone a vulvectomy with left sentinel inguinal lymphadenectomy. She received chemo-radiation adjuvantly (with cisplatin). The patient has developed recurrent disease. Palliative therapy with carboplatin + (plus) paclitaxel + bevacizumab + pembrolizumab has been recommended.

Keytruda is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The benefit of adding Keytruda (pembrolizumab) to first line therapy of metastatic vulvar cancer has not been demonstrated. This approach remains the subject of ongoing investigation in a number of trials including, but not limited to, NCT05903833. The use of this agent in this scenario is not recommended by the authors of UpToDate nor by the National Comprehensive Cancer Network (NCCN) Guidelines due to the lack of outcomes data. The NCCN considers this agent to be indicated (as a single agent) only in the subsets of patients with certain vulvar cancers. This patient isn't documented to meet these criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back and arm injury.
Treatment: Outpatient Physical Therapy x 15 visits. 
The insurer denied coverage for Outpatient Physical Therapy x 15 visits. 
The denial is overturned.  

This is an adult male who sustained a right upper extremity injury after "A 20-foot metal bar fell onto his right arm/back." After acute hospitalization he received inpatient rehabilitation. Additional treatment included cervical spine surgery and right brachial plexus repair surgeries with a subsequent complicated post-surgical recovery. 

The physical therapy (PT) notes; while limited, are sufficient to support the medical necessity of the 15 PT visits under review. The patient sustained significant traumatic injuries involving the cervical spine and right upper extremity. He underwent cervical spine and brachial plexus surgeries with complicated post-surgical recoveries.  The physical therapy notes document significant cervical and right shoulder strength/range of motion deficits. Disability assessment; Disability of the Arm, Shoulder (and) Hand (DASH) ratings were also significant. The combination of the patient's documented cervical/right shoulder impairments status complicated post-surgical recovery and associated functional limitations support the medical necessity of the physical therapy (PT) treatment x 15 visits. 

Based on the above, the insurer's denial must be reversed. 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 Outpatient Physical Therapy x 15 visits is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and Monthly visits
The insurer denied Braces and Monthly visits.
The determination is overturned.

The patient is a male with impacted teeth number (#) 18 and #31. These teeth are unable to erupt due to crowding. He presents with a skeletal Class II malocclusion and minor crowding. He is treatment planned for 30-36 months of orthodontics to address the crowding and to create space to bring the impacted teeth into the arch, but treatment was denied due to lack of medical necessity. At issue is the medical necessity of braces and monthly visits.

The incidence of impacted mandibular second molars is approximately 1.32%. (2) Studies have shown almost 65 percent (%) of untreated impacted teeth will cause some kind of pathology. (3) The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. (3) Given the proximity of tooth 18 to tooth 19 there is already concern that tooth 19 may be damaged. If left untreated the damage that can occur to the patient's teeth will be more time consuming to correct than the patient's existing orthodontic problem. There are many studies illustrating the success of orthodontic-assisted eruption of impacted mandibular second molars. (4,5,6) Orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 Braces, D8670 monthly visits

The insurer denied coverage for D8080 Braces, D8670 monthly visits.

The denial is upheld.

This patient is under the care of an orthodontist to treat a malocclusion. The patient has some crowding in both arches as well as an increased overjet and overbite. The provider feels the Handicapping Labio-Lingual Deviation (HLD) is a score of 29 and the dental consultant felt the score was 22. The request is for D8080 Braces, D8670 monthly visits, which are under review.

The health care plan has acted reasonably and with sound medical judgment and in the best interest of the patient.      

D8080 Braces, D8670 monthly visits considered is not medically necessary for this patient.

The request doesn't meet the criteria. The HLD calculate is three for each overjet and overbite. There is crowding in both arches for 10 and four millimeters (mm) for labiolingual spread for 20 total. This falls short of the score of 26 needed for approval.

Therefore, the request for D8080 Braces, D8670 monthly visits are not medically necessary and is denied.

"There was a statistically significant decrease in the overall rate of approval in 2017 compared to 2016. No difference was found in the approval rate of Class I, II, or III subjects, but there was a significant decrease in the approval rate of subjects with impacted teeth" (Caplin, J., et al 2020).

"Maxillary incisor irregularity and its relapse in the non-extraction group were significantly greater at the long-term posttreatment stage and the long-term posttreatment period, respectively. Long-term posttreatment overjet changes were similar in the groups. Overbite and its relapse were significantly greater in the extraction group in the long-term posttreatment stage and period, respectively. There was a positive correlation of the relapse of mandibular incisor crowding with the relapse of overjet and overbite, and also a correlation of overjet and overbite relapses" (Francisconi, M. F., et al 2014). 

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 D8080 Braces, D8670 monthly visits is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD)
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of chronic obstructive pulmonary disease (COPD), hypertension, and substance abuse disorder. His presenting complaint was hypoxia in the setting of recent phencyclidine (PCP) inhalation.  The physical exam was notable for wheezing.  Radiology was notable for a chest x-ray without pulmonary opacity or effusion. The patient was admitted to an inpatient level of care for treatment of a chronic obstructive pulmonary disease (COPD) exacerbation and new onset tachyarrhythmias thought to be atrial fibrillation. At issue is the medical necessity of an inpatient stay.

The inpatient admission is not medically necessary for this patient.
The patient presented with hypoxia noted pre-hospitalization and wheezing in the setting of known COPD and PCP use. He had no respiratory complaints, respiratory distress, significant hypoxia, or hemodynamic instability. While in the emergency department, he was noted to have atrial fibrillation, which self resolved. A lower level of care would have been appropriate to start therapies for a COPD exacerbation and monitor the patient's atrial fibrillation which occurred in the setting of PCP use.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anoxic brain injury, hypertension, epilepsy, expressive language disorder, mild cognitive impairment, intellectual disability, scoliosis, generalized anxiety disorder, and Raynaud's syndrome
Treatment: Increase in Personal Care Aide (PCA) to 56 hours/week
The insurer denied the increase in PCA to 56 hours/week.
The denial is upheld.

The patient is an adult female. Her medical conditions include anoxic brain injury, hypertension, epilepsy, expressive language disorder, mild cognitive impairment, intellectual disability, scoliosis, generalized anxiety disorder, and Raynaud's syndrome. Denial of an increase in personal care aide (PCA) to 56 hours/week is being appealed. The health plan approved 28 hours/week.

The patient's Uniform Assessment System (UAS) evaluation completed 3 months ago shows modified independent cognition and functional status: extensive assistance with meal preparation, housework, managing finances and medications, and shopping; limited assistance with phone use, transportation, and bathing; independent with personal hygiene, upper body dressing, walking, locomotion, toileting, bed mobility, and eating; and supervision with lower body dressing. She requires supervision and cuing. She is continent of bowel and bladder. There has been no significant change in functioning when compared to UAS evaluation completed last year.

There are several appeal statements. The statements report the patient has mental retardation due to anoxic brain injury. She has involuntary head shaking. She is unable to follow a simple routine. She frequently becomes anxious and needs close supervision and assistance with activities of daily living (ADLs).

The increase in PCA to 56 hours/week is not medically necessary.

Personal assistance services provide hands-on assistance to individuals to include assistance with ADLs, health maintenance activities, and routine support services. Denial of an increase in PCA to 56 hours/week is being appealed. The health plan approved 28 hours/week.

This patient has a history of brain anoxia with residual conditions that include intellectual impairment. The health plan noted that UAS evaluation performed 3 months ago shows the patient requires assistance with meal preparation, housework, managing finances and medications, shopping, phone use, transportation, and bathing. She is independent with other ADLs. She is continent of bowel and bladder. There has been no significant change in functioning when compared to UAS evaluation completed last year. Appeal statements support that the patient needs supervision and assistance with ADLs. The information provided does not support that the patient has needs for PCA 56 hours/week. The currently approved 28 hours/week is adequate to meet this patient's needs for assistance with ADLs. The requested increase in PCA to 56 hours/week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment:  Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is upheld.

This patient is an adult male, who was hospitalized for chest pain. His past medical history is remarkable for known coronary artery disease, prior non-ST elevation myocardial infarction (NSTEMI) 2 years ago, multiple percutaneous coronary interventions (PCIs), hypertension, hyperlipidemia, and diabetes. The patient's vitals were stable. His exam was unremarkable. His electrocardiogram (EKG) showed sinus rhythm with old inferior myocardial infarction (MI), but without ischemia. His imaging was negative. The patient's cardiac catheterization with coronary angiography showed nonobstructive coronary artery disease (CAD). The patient was treated medically and discharged to outpatient care. The requested coverage for Inpatient Hospital Admission has been denied and the patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the peer-reviewed medical literature, including the Milliman Care Guideline criteria for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization, or any other medical condition, symptom, or finding for which inpatient hospitalization is considered appropriate. 
In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received, including urgent, uncomplicated cardiac catheterization, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis:  Niemann-Pick disease
Treatment: Consumer Directed Personal Assistance Program (CDPAP): 6 hours per day, 7 days a week, total 42 hours per week
The insurer denied Consumer Directed Personal Assistance Program (CDPAP): 6 hours per day, 7 days a week, total 42 hours per week.
The determination is overturned.

This is a female patient with a medical history notable for Niemann-Pick disease, major depressive disorder, hyperlipidemia, and urinary incontinence. The patient is approved for 3 hours per day, 5 days per week (15 hours per week) of consumer directed personal care assistance. The patient and her care team requested an increase to 6 hours per day, 7 days per week, and the request was denied by the health plan.
The patient's physician provided a letter of support. The letter states that the patient has had a rapid neurological decline with ataxia, impaired coordination, frequent falls, vision loss, dysarthria, and dysphagia from her Niemann-Pick disease. She requires assistance with toileting, dressing, bathing, hygiene, ambulation, medications, and housework. She lives with her father and brother, but they are not equipped to help her. The physician states that her current hours are inadequate for her personal care needs.
The patient's neurologist provided a letter of support.  The patient now requires assistance with all activities of daily living (ADLs) and is expected to continue to worsen. The neurologist certifies that the increase in home health aide hours is medically necessary for the patient.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in-person. The patient lives in an apartment with her father and brother. She was alert and oriented but showed cognitive decline. She is able to direct her own care. For her Instrumental activities of daily living (IADLs), she requires total dependence for housework. She requires maximal or extensive assistance for others. For her activities of daily living (ADLs), she requires extensive assistance for all (with the exception of eating and bed mobility). She is occasionally incontinent of urine, having episodes every 1-2 days when she cannot make it to the bathroom in time. She had a fall two weeks before the assessment when attempting to ambulate to the bathroom. At issue is the medical necessity of Consumer Directed Personal Assistance Program (CDPAP): 6 hours per day, 7 days a week, total 42 hours per week.

The requested health service of CDPAP: 6 hours per day, 7 days a week, total 42 hours per week is medically necessary for this patient.
The patient has a chronic and progressive disease which will continue to limit her ability to perform personal care tasks. Her physicians have attested that her current hours are insufficient to meet her needs. She had a fall just prior to the assessment when attempting personal care activities without assistance. Therefore, the requested increase to 42 hours per week is medically necessary and reasonable for the patient.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: appendicitis
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld.

The patient is a female who presented to the emergency department with right lower quadrant abdominal pain (the pain initially was epigastric pain). The pain was described as a constant dull non-radiating pain. She had history of Polycystic ovarian syndrome. Vital signs were without significant abnormality. She had right lower quadrant tenderness on exam. The white blood cell count (WBC) was 9.3. A computed tomography (CT) scan demonstrated appendiceal abnormalities and omental abnormalities. 

The  inpatient medical stay was not medically necessary, and the patient could have been safely managed at a lower level of care. The patient met discharge status criteria. The patient did not experience complicated appendicitis. The patient did not have clinically active comorbidities. The patient did not experience complications of wound dehiscence, wound infection, or enterocutaneous fistula. The patient did not experience an ileus. The patient did not experience postoperative bleeding. The patient did not experience complications or conditions such as anemia, arrhythmia, electrolyte disorder, fever, gastrointestinal (GI) bleed, hyperglycemia or complicated diabetes control, mental status change, psychiatric disorders, respiratory insufficiency, urinary complications, thrombotic complications or wound and skin care complications. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Bacterial Vaginosis.
Treatment Vaginal Panel of Test.
The health plan has denied the requested treatment, vaginal panel, as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with vaginal discharge. She had a multipathogen vaginal panel performed.

At issue is the medical necessity of a vaginal panel.
I uphold, in whole, the health plan's determination of medical necessity.

The requested health service/treatment of Vaginal panel is not medically necessary for this patient.
Vaginitis is diagnosed with a series of standardized clinical tests, such as bacterial culture, physical examination, microscopy and/or vaginal potential hydrogen (pH). In addition, direct deoxyribonucleic acid (DNA) probe assays to detect the DNA of candida, Gardnerella vaginalis, and Trichomonas vaginalis in vaginal fluid specimens may also be beneficial.
However, molecular diagnostic testing for vaginitis with nucleic acid amplification (NAAT) under current procedural terminology (CPT) 87481 or subsequent quantification testing for bacterial vaginosis (BV) or vaginal candidiasis are not medically necessary. These are considered experimental/investigational as they are not identified as widely used and generally accepted for any other proposed uses as reported in nationally recognized peer-reviewed medical literature in the English language. Mutipathogen panels are not currently recommended or under the patient's plan unless all pathogens tested in the panel meet requirement criteria. The testing listed under CPT 81513 would be considered experimental/investigational as they are not identified as widely used. The health plan's determination is upheld.