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


Diagnosis: Crohn's Disease
Treatment: Pharmacy/Prescription Drugs (Delzicol)
The health plan denied the request for Delzicol. 
The health plan's determination is upheld.

The patient is a male with a diagnosis of Crohn's Disease. The patient  had complicated perianal disease with an abscess that required antibiotics and incision and drainage. A colonoscopy revealed only active rectal disease. He was taking 6-MP, Canasa, and Lialda. Then later he was switched to Humira + Delzicol with the discontinuation of the previously mentioned drugs. He was then switched to citrate-free Humira . Due to recurrence of diarrhea he was placed additionally on Rowasa enemas which was then stopped and switched to Canasa. At some point, a course of Uceris was given for rectal active disease.  Medications were adjusted again and is now on Stelara + Delzicol and no other inflammatory bowel disease (IBD) meds.
The patient's provider recommended Delzicol 400 mg, 2 capsules twice daily (BID). This request was denied by the plan. The plan's preferred agents include Apriso, Sulfasalazine, Pentasa, Balsalazide, and generic Mesalamine.

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

The patient has active rectal disease in the setting of Crohn's. The patient experienced complications including complex fistulization with abscess formation. It is appropriate to treat the patient with a biologic such as Stelara. The benefit of Mesalamine in the setting of fistulizing Crohn's disease is no better than placebo. In this setting, after accounting for the benefit of the biologic, there is even less evidence to support the use of Delzicol. Most experts would simply recommend stopping the Delzicol. However, if the provider wished to give concurrent therapy with a Mesalamine preparation, any of the alternatives suggested by the plan are reasonable. Apriso is particularly attractive because it is once a day and delivers a high concentration of drug to the rectum. I agree with the denial put forth by the plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Petroclival grade 1 meningioma
Treatment: Proton Beam Radiation Therapy
The insurer denied Proton Beam Radiation Therapy.
The determination is overturned.

This is a patient with a large left petroclival grade 1 meningioma that had been subtotally resected. She has recurrent progression with disease involving the cavernous sinus and sixth cranial nerve palsy. Radiation therapy is recommended to treat this recurrent progressing base of skull meningioma and the proton beam approach is requested. At issue is the medical necessity of proton beam radiation therapy.
The requested health service of radiation therapy with proton beam radiation is considered medically necessary for this patient. The proton beam radiation therapy approach would be considered the best option to get the needed high doses of radiation to the meningioma resection region that are too dangerous to achieve with intensity modulated radiation therapy (IMRT) photons in this particularly eloquent area of the base of the skull and adjacent to extensive cranial nerves. The extremely tight margins needed to protect the normal brain while getting large doses of radiation to the tumor area are best obtained with the proton beam approach with its unique physical qualities. This approach of proton beam radiation therapy is used for uveal melanomas, clival tumors and other tumor areas that are very close to the optic apparatus. There are reports of the proton beam approach with meningiomas. With extrapolating from the clinical studies reported on the benefits of proton beam radiation therapy, this approach for this unique clinical situation would be considered the best and safest approach to decrease the risk of this meningioma from progressing. Comparison radiation plans have been performed between photons and protons which have been submitted and reviewed. These studies show the significant benefit of proton beam over photon beam radiation therapy to spare critical vital structures from receiving high doses of radiation including the left temporal brain, optic chiasm and left optic nerve. This in turn will decrease the risk of side effects including personality changes and vision loss. The recommended proton radiation therapy is considered medically necessary for this patient and her unique clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Home Health Care

Diagnosis: COPD/Hypertension/Dementia
Treatment: Personal Care Services: 24 Hours per Day, 7 Days per Week (Split-Shift)
The insurer denied the increase Personal Care Services: 24 Hours per Day, 7 Days per Week (Split-Shift) for Total of 168 Hours per Week. The health plan's determination is upheld. 

The patient is a female with past medical history of hypertension, chronic obstructive pulmonary disease (COPD), depression, urinary incontinence, amyloid angiopathy, and vascular dementia who lives alone and who had been assigned PCA (personal care assistant) services. The patient was assessed at limited assistance with tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use and supervision with task of eating. The patient was assessed as independent with bed mobility. 

The Increase in Personal Care Services: 24 Hours per Day, 7 Days per Week (Split-Shift) for Total of 168 Hours per Week is not medically necessary for this patient. 
The health plan has recommended PCA services 24 hours/day, live-in, 7 days/week which is appropriate to meet the needs of this patient. The night -time logs provided for review show the patient requires assistance with ADL tasks 1-2 times per night and the PCA would be able to obtain 5 hours of uninterrupted sleep. The patient does not require turning and repositioning every two hours. Therefore, the requested Increase in Personal Care Services: 24 Hours per Day, 7 Days per Week (Split-Shift) would not be indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease.
Treatment: Stelara.
The insurer denied the Stelara.
The determination is overturned.

This is a patient with moderate to severe Crohn's disease. She failed mesalamine and then Humira due to primary nonresponse. A colonoscopy  showed active colitis, ulcerated and narrowed ileum, and a colonic erosion. She has required hospitalization and corticosteroids for disease flare. She has had abdominal pain and diarrhea. The formulary alternatives are Entyvio, infliximab (Inflectra, Renflexis, or Avsola), and Cimzia. At issue is the medical necessity of Stelara for the treatment of Crohn's disease. 
The requested Stelara is medically necessary for this patient.
The patient has had symptoms consistent with active Crohn's disease, and has moderate to severe disease based on colonoscopy findings of ulceration and ileal stricture. Stelara is recommended by current guidelines for the treatment of Crohn's disease [1]. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohn's disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this enrollee has failed [2]. Another study showed a 73% response in patients with anti-TNF-resistant Crohn's disease, and 80% of responders maintained remission for 1 year [3]. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-TNF medications, which the enrollee has failed [4]. A recent study demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara [5]. In patients such as this patient with primary nonresponse to an anti-TNF medication, "switching to a medication in a different class is recommended" and "switching to a second anti-TNF agent has not been shown to be particularly beneficial", rendering infliximab and Cimzia (certolizumab) less appropriate than Stelara [6]. Compared with Entyvio, the other formulary alternative, Stelara is also significantly more likely to be effective. In patients with Crohn's disease who had failed anti-TNF therapy, Stelara "was associated with superior effectiveness outcomes when compared to Entyvio (vedolizumab), while safety outcomes were comparable after 52 weeks of treatment" [7]. Lack of effective therapy may result in complications such as fistula, stricture, and hospitalization or need for surgery. For these reasons, the request for Stelara is supported as medically necessary in this case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Adapalene-Benzoyl Peroxide Gel. 
The health plan's determination is upheld in whole.

The patient is a female with acne, for which Spironolactone was not tolerated, even at low doses.  The patient was on Tretinoin with good results, as well as Epiduo (Adapalene-Benzoyl Peroxide Gel). Oral Doxycycline was to be started at 100 milligrams (mg) twice-daily, and with a weaning dose as tolerated. The subject under review is whether the non-formulary drug Adapalene-Benzoyl Peroxide Gel is more effective than the formulary drugs.

The requested adapalene-benzoyl peroxide gel is somewhat superfluous for this patient, in that the patient is already on a retinoid (tretinoin) so that the use of an additional agent containing another retinoid (adapalene) is not indicated or consistent with standards of care and current literature [1-5]. Furthermore, the options of alternative topical agents with antibiotic effects (clindamycin-benzoyl peroxide, erythromycin-benzoyl peroxide, and over the counter benzoyl peroxide can and should be used either with the currently used topical tretinoin, or tazarotene should provide the benefits of both topical antibiotics and topical retinoids. Both adapalene and benzoyl peroxide that are within the requested medication are over the counter, and do not need prescriptions. 
With a variety of alternative topical retinoids and topical antibiotics covered for this patient [6], and with these formulary agents all well-tolerated in the majority of patients who use them, the requested adapalene-benzoyl peroxide gel is not likely to be more effective for this patient than the formulary agents.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Surgical Services. 
The insurer denied reduction mammoplasty. 
The health plan's determination is upheld in whole.

The patient is a female with large breasts and complaints of neck/back/shoulder pain. She also complains of shoulder grooving, rashes under the breasts, breast pain, and headaches. Conservative treatment includes supportive bras, physical therapy, powder, and ointment. Last recorded height was 5'2'', weight was 193 lbs., body mass index (BMI) 35.3, body surface area (BSA, Mosteller formula) was 1.957. The exam findings were reviewed and noted. The surgeon has requested breast reduction and plans at least 500 gram removal from each side. The enclosed photographs of the back and shoulders were reviewed.
The subject under review is the medical necessity for the requested breast reduction mammoplasty.

The health plan's determination is upheld in whole.

The requested breast reduction mammoplasty is not medically necessary for this patient.
Symptomatic breast hypertrophy is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and/or frequent episodes of headache, backache, and upper extremity peripheral neuropathies caused by an increase in the volume and weight of breast tissue beyond normal proportions (American Society of Plastic Surgeons [ASPS]). Since reported symptoms are subjective in nature, in order to prove medical necessity, objective findings such as a minimum reduction weight, demonstration of signs/symptoms of macromastia, standard photograph series of the breast profile, and a trial of conservative therapy are frequently recommended (Frey et al., Koltz et al.). According to ASPS guidelines, photographs demonstrating the patient's breast appearance, possible shoulder grooves, kyphosis, etc. should also be a part of the medical record to demonstrate medical necessity. The degree of symptomatology related to the macromastia has been shown to correlate to the post-operative satisfaction and outcome in a study by Radosa et al. Confirmatory evidence of symptoms, such as a history of conservative therapy, photographic evidence of severe breast hypertrophy and a history of frequent primary care physician visits for macromastia-caused symptoms is necessary to support the history provided by the plastic surgeon.
The medical documentation does not support a need for a functional reduction mammoplasty. There are no other provider's clinical progress notes submitted aside from the plastic surgeon to demonstrate this is a chronic problem requiring medical care. While photographs of the back and shoulders were provided, photographs of the breasts were not enclosed to confirm the clinical symptoms reported and examination documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Genitourinary/Kidney Disorder. 
Treatment:  Durable Medical Equipment (DME). 

The insurer denied a stair lift for medically necessity.  The denial was upheld.

The patient is a female with a past medical history significant for end stage renal disease (ESRD) on hemodialysis (HD) 3 times a week, who lives with her daughter.  The patient has a living area on the first floor of the home and a half bath.  The shower is on the second floor.  A request was made for a stair lift secondary to physical limitations.  
At issue is the medical necessity of the requested service/treatment of stair lift.

The health plan's determination of medical necessity is upheld in whole.

No, the requested service of stair lift is not medically necessary for this patient.

The patient lives with her daughter.  Documentation noted that she "sleeps, eats and watches TV in a recliner."  The first floor has a half bathroom.  Physical therapy noted that the patient ascended steps with handrail on right using 2 hands, leading with right leg and daughter standing behind for safety.  She needed to rest every 20 seconds.  Descending steps was described as "very unsafe."  While ascending/descending steps is not a safe option, the documentation stated that there is "a living space and half bathroom on the first floor," and it is noted that the patient "sleeps, eats and watches tv in a recliner."  Generally accepted standards of care do not include stair lifts, as this is considered a home modification.

Therefore, the requested health service of a stair lift is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  High Cholesterol.
Treatment:  Repatha (evolocumab).
The insurer denied the Repatha (evolocumab). 
The denial is upheld. 

The patient is a male with a past medical history of hypertension (HTN), dyslipidemia, coronary artery disease (CAD) / atherosclerotic cardiovascular disease (ASCD) status post (s/p) multiple coronary interventions. 

The patient is currently being managed with Pravastatin 80 milligrams (mg), with low-density lipoprotein-cholesterol (LDL-C) of 104 milligrams per deciliter (mg/dL).  Use of Repatha was requested for better control of low-density lipoprotein (LDL) with a goal of 70 mg/dL or less.  As per letter from the treating physician, the patient had prior adverse events (myalgia and hair loss) with high intensity statin.  As per Plan's pharmacy claim records going back to 2016, the patient has not previously been on rosuvastatin.  Trial of rosuvastatin, the Plan's preference, was recommended in the denial letter.

No, the proposed treatment with Repatha (evolocumab) is not medically necessary.

Repatha is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low-density lipoprotein cholesterol (LDL-C).  This patient has been treated with pravastatin, which he tolerated at 40 mg, and his low-density lipoprotein (LDL) is uncontrolled with this dose.  There is no record of intolerance to rosuvastatin or use of rosuvastatin, as per submitted records.  Therefore, the medical necessity of using Repatha over the health plan's preference (i.e. combination of Rosuvastatin and Zetia) has not been established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriatic arthritis.
Treatment: Rasuvo pen.
The insurer denied coverage for the Rasuvo pen.
The denial is overturned. 

This is a female patient with psoriatic arthritis. The patient's symptoms included joint pain and swelling, stiffness, and lower back pain. The patient is on Celebrex, upadacitinib and oral methotrexate which are not working adequately. The patient reported trying barcitnib and upadacitinib (Rinvoq) with no relief. The patient reports feeling uncomfortable with self-injection. Rasuvo was prescribed and on a follow-up visit it was documented that the patient was comfortable using the Rasuvo auto-injectors. 

As per review of the medical record, the patient tried and failed sulfasalazine and leflunomide, and has been clinically stable on the requested drug. The patient's treating rheumatologist requested consideration for an auto-injector or pen formulation because the patient has failed methotrexate sodium self-injection ordered by a previous physician due to a fear of self-injection. However, the insurer is declining coverage because the patient has not tried intramuscular methotrexate therapy.
	
As per UpToDate review on the use of methotrexate in the treatment of rheumatoid arthritis and the treatment of psoriatic arthritis, Rasuvo (methotrexate) administered via auto-injection subcutaneously works better and is far easier to administer, and there is no rationale for using intramuscular methotrexate instead, especially in this case where the patient has fear of needle and self-injection. As per medical record, the patient has tried methotrexate sodium self-injection but has not been able to tolerate its use. 

Rasuvo is an auto-injector, and the patient does not have to directly handle the needle and the syringe associated with self-injection route. As per medical record, this patient has tolerated the use of this auto-injector. Considering that this patient has tried and failed traditional self-injection, the Rasuvo pen is considered medically necessary for this patient. 

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

Based on the above, the medical necessity for the Rasuvo pen is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits x12. 
The denial is overturned in whole. 

The patient is a female with a Class II Division 2 malocclusion. She has significant crowding with #26 blocked out to the lingual and a 100 % deep bite occluding on her palate. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion but her health plan denied coverage on the basis that treatment is not medically necessary. 
The subject under review is the medical necessity for the requested treatment. 

The health plan's determination is overturned in whole. 

The requested treatment of braces is medically necessary for this patient and monthly visits is medically necessary for this patient. 
The documentation indicates that the patient is damaging the soft tissue of her palate due to her deep overbite. Her cephalometric radiograph indicates she is biting on her palate. Palatal tissue damage is a known side effect of deep bite malocclusions. [1] A deep bite on its own is not a reason to treat with orthodontics. However, she is already damaging the soft tissue of her palate. This will worsen with time if left untreated and can lead to periodontal problems in the future that will be more invasive and difficult to correct than the orthodontic problem she currently has. [2] Therefore, the requested treatment is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces and Monthly Visits
The insurer denied Braces and Monthly Visits.
The determination is upheld.

The patient has a diagnosis of Class II malocclusion, appropriate overjet and a slightly excessive overbite. The upper and lower arches are both moderately crowded. The treatment plan is for 18-24 months of braces with extraction of tooth number (#) 23 to correct the mandibular crowding. The provider is appealing noting that tooth 22 is in crossbite with gingival attachment loss. At issue is the medical necessity of braces and monthly visits.

The patient has an appropriate overbite and overjet. There is moderate crowding but that alone does not rise to the threshold of medically necessary. The photos do not support a diagnosis of a crossbite of tooth 22 with tooth 10. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. There does not appear to be any wear present on the teeth due to the occlusion. In the absence of a functional problem, orthodontic treatment would not be medically necessary to prevent future problems.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment: Braces and monthly visit. 
The insurer denied braces and monthly visit. 
The determination is overturned. 

The patient has a Class I malocclusion and anterior crossbite of tooth number (#) 7. Tooth #26 has significant wear as a result of this crossbite. He has severe crowding in the maxillary and mandible. He is in the mixed dentition. He is treatment planned for 30-36 months of orthodontics with extraction of the four first premolars to correct his malocclusion. At issue is the medical necessity of braces/monthly visit. 

This patient presented with an anterior crossbite and crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. [1,2,3] The patient has significant maxillary crowding with #7 in crossbite. This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time [4], which will make treating this occlusion at a later time more difficult. Tooth #26 already has significant wear, and further damage to #26 is likely without resolving the crossbite. Treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons orthodontic treatment is medically necessary.