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

Diagnosis: Invasive squamous cell carcinoma 

Treatment: Radiation therapy for head/neck cancer, Phase 1: 35 fractions (treatment sessions) of stereotactic body radiation therapy (SBRT) (using protons), image-guided radiation therapy (IGRT); proton beam therapy (PBT)

The insurer denied coverage for radiation therapy for head/neck cancer, Phase 1: 35 fractions (treatment sessions) of stereotactic body radiation therapy (SBRT) (using protons), image-guided radiation therapy (IGRT); proton beam therapy (PBT)
This is a male with a history of invasive squamous cell carcinoma of the right base of the tongue. The request is for approval of proton beam radiotherapy.

"The current standard of care using modern photon radiation technology has demonstrated excellent treatment outcomes, yet there are some situations where disease control remains suboptimal with the potential for detrimental acute and chronic toxicities. Due to the advantageous physical properties of the proton beam, proton beam therapy may be superior to photon therapy in some patient subsets for both disease control and patient quality of life. As enthusiasm and excitement for proton beam therapy continue to increase, clinical research and widespread adoption will elucidate the true value of proton beam therapy and give a greater understanding of the full risks and benefits of proton therapy in head and neck cancer." (Kim et al., 2018).

"At present, proton therapy is the predominant particle therapy under active clinical investigation in the United States.228-231...As described above, nonrandomized institutional reports and a small number of systematic reviews have shown that PBT is safe to use in a controlled setting. However, without high-quality prospective comparative data, it is premature to conclude that proton therapy has been established as superior to other modern radiation techniques such as IMRT (Intensity-modulated radiation therapy), particularly with regard to tumor control." (NCCN Version 2.2022).      


"Radiation therapy (RT) plays a key role in curative-intent treatments for head and neck cancers. Its use is indicated as a sole therapy in early-stage tumors or in combination with surgery or concurrent chemotherapy in advanced stages. Recent technologic advances have resulted in both improved oncologic results and expansion of the indications for RT in clinical practice." (Alterio et al., 2019).                                                         

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 radiation therapy for head/neck cancer, Phase 1: 35 fractions (treatment sessions) of stereotactic body radiation therapy (SBRT) (using protons), image-guided radiation therapy (IGRT); proton beam therapy (PBT) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis. 

Treatment: Dupixent Syringe 300 milligrams (mg). 

The insurer denied coverage for Dupixent Syringe 300 mg. 

The denial is overturned. 

The patient is a female with history of severe asthma and psoriasis who has atopic dermatitis affecting more than 40% total body surface area (TBSA), including the legs, trunks, and arms. The patient has failed therapy for the rash with numerous biologics, including humira, tremfya, cosentyx, and taltz. The requested medication is Dupixent. 

The patient has severe atopic dermatitis which would be amenable to systemic therapy.  The rash is unlikely psoriasis in nature as the patient has failed with numerous biologics known to improve psoriasis. The patient has concomitant asthma which would likely benefit from Dupixent, which is Food & Drug Administration (FDA) approved for atopic dermatitis and asthma. The use of Dupixent for this patient appears to be medically necessary based on the submitted documentation. 

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 Dupixent Syringe 300 mg is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypercarbic respiratory failure. 
Treatment: Airway clearance device. 

The insurer denied coverage for an airway clearance device. 
The denial is overturned. 

This is a female with Rett syndrome, epilepsy, microcephaly, central sleep apnea and global developmental delay. She requires BIPAP (bilevel positive airway pressure) respiratory support. She was hospitalized with hypercarbic respiratory failure and required endotracheal intubation and respiratory support. She had elevated pCO2 (partial pressure of carbon dioxide) on her blood gas and a chest x-ray demonstrated bilateral coarse opacities on her chest x-ray. It was documented that she had an ineffective cough to help keep her airways clear of secretions which predisposes her to atelectasis, recurrent pneumonia and episodes of respiratory failure. Her doctor ordered the cough assist device for use in the home to help with her ineffective cough which is secondary to her muscle weakness. 

An airway clearance device is considered medically necessary for this patient. 

The patient has chronic respiratory failure with elevation of her pCO2 and central apnea. She required a prolonged hospitalization for acute respiratory failure which resulted in the need for intubation and management with a ventilator. Her underlying disease results in muscle weakness and the inability to clear her airway secretions. This condition is known to result in recurrent respiratory infections due to inability to clear her airway secretions. It is the standard of care for pediatric pulmonologists to employ the cough assist device for children with chronic respiratory failure related to weakness of the respiratory muscles that are essential to clear airway secretions and prevent recurrent respiratory infections. 

As noted in Up to Date: "COUGH ASSISTANCE - An ineffective cough is common among patients who have respiratory muscle weakness due to neuromuscular disease. This predisposes such patients to aspiration, pneumonia, and respiratory failure. (See "Respiratory muscle weakness due to neuromuscular disease: Clinical manifestations and evaluation", section on 'Ineffective cough'.) 

Interventions that may be useful for improving cough and secretion clearance include mechanical insufflation-exsufflation, manually assisted coughing, hyperinflation maneuvers, and secretion mobilization techniques. Mechanical insufflation-exsufflation is generally the preferred intervention, although it has not been directly compared to the other interventions [15,27]." 

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 an airway clearance device is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer (of the parotid gland).
Treatment: Outpatient Proton Radiation Therapy, pre-service.
The insurer denied the Outpatient Proton Radiation Therapy, pre-service.
The denial is upheld.

The patient is a female with a diagnosis of locally advanced adenoid cystic carcinoma of the right parotid gland status post resection.  Adjuvant radiation therapy was recommended, and proton therapy was requested.

Coverage for the request of proton therapy was initially denied by the health plan, because it does not meet criteria for coverage and is not considered medically necessary. This denial is being appealed.

No, the requested proton beam therapy is not medically necessary.
Although there are single institutional trials and case series showing that proton therapy for head and neck cancer is safe and effective, there is insufficient clinical data in the medical literature showing that it is superior to photon IMRT (intensity-modulated radiation therapy) for the treatment of head and neck cancer in well-conducted randomized trials. There are ongoing clinical trials (including a phase III trial) still evaluating the role of proton therapy for head and neck cancer. IMRT (intensity-modulated radiation therapy) photon radiation therapy has been shown to be safe and effective for the treatment of head and neck cancer, and is currently the standard of care. Proton beam therapy is, therefore, not considered medically necessary because it is has not been shown in well-conducted randomized trials to be clinically superior to photon IMRT (intensity-modulated radiation therapy).

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
A proton/IMRT (intensity-modulated radiation therapy) comparison plan was provided. The proton plan was able to reduce dose to certain surrounding structures. However, the doses to those structures were all within tolerance per Quantec limits for both the proton plan and the IMRT (intensity-modulated radiation therapy) plan. Proton beam therapy is, therefore, not considered medically necessary because it has not been shown in well-conducted randomized trials to be clinically superior to photon IMRT (intensity-modulated radiation therapy).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I skeletal relationship, impacted third molars, blocked out mandibular second molars
Treatment: Braces and visits
The insurer denied the braces and visits.
The denial is overturned.

The patient is a female.  The request is for braces and monthly visits, pre-service.  The patient presents with class I skeletal relationship, class II canines, mild maxillary crowding, moderate mandibular crowding, left posterior crossbite, impacted third molars, blocked out mandibular second molars.

The health plan denied the claim because the patient did not score a 26 or meet any of the automatic qualifiers for the Handicapping Labio-Lingual Deviation (HLD) Index Report.  The provider appealed based on the diagnoses, particularly the blocked out second molars.

Yes, the proposed treatment of braces and monthly visits, pre-service is medically necessary.

As evident in the x-rays and photos, the patient has several factors contributing to the malalignment of her teeth.  The patient has crowding on the lower jaw that displaces the two anterior teeth.  She also has a left posterior crossbite, meaning her left maxillary posterior teeth from her canine to her first molar bites inside of her lower corresponding teeth.  Normally, they should bite just slightly outside of the bottom teeth.

If these conditions are left untreated, the complications of decreased proper function as it relates to chewing, speech, and compromised oral hygiene will only lead to greater problems with the patient's dentition long term.

No, the health plan did not act reasonably, with sound medical judgement, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Epigastric Pain.
Treatment:  Diagnostic Esophagogastroduodenoscopy (EGD). 

The insurer denied Diagnostic Esophagogastroduodenoscopy (EGD).  The denial is overturned. 

The patient is a female who underwent an upper endoscopy. The procedure was done for epigastric pain and bloating. There was no vomiting or melena. In addition, the patient was pre-operative for a sleeve gastrectomy. Upper endoscopy was performed and some small areas of nodularity in the stomach were identified and biopsied. Biopsies were positive for helicobacter (H) pylori.

The esophagogastroduodenoscopy (EGD) was denied by the plan because the patient did not meet criteria for approval as the patient did not have heartburn despite 2 months of treatment, persistent vomiting, dyspepsia at age greater than (>) 50, or gastrointestinal (GI) bleeding.

At issue is the medical necessity of EGD.

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

The requested health service/treatment of EGD is medically necessary for this patient.
This patient is going for bariatric surgery, which is an exception to the criteria for an EGD. The anatomy of the stomach must be assessed pre-operatively. H pylori status also must be clarified. In totally asymptomatic patients pre-operative (pre-op), an upper GI study is generally ordered and will perform non-invasive testing for H pylori (e.g., stool antigen testing). In a patient with upper tract symptoms the standard of care is to perform an upper endoscopy pre-operatively. If the patient has erosive esophagitis, peptic ulcer disease, or a malignancy pre-op, this is critical to know, and an EGD is the correct test for evaluation.

Therefore, the requested health service/treatment of EGD is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/ Gastrointestinal. 
Treatment: Surgical Services (All). 
The insurer denied EGD. 
The denial is overturned. 

The patient is a female who underwent an upper endoscopy. The procedure was done for epigastric pain and bloating. There was no vomiting or melena. In addition, the patient was pre-operative for a sleeve gastrectomy. Upper endoscopy was performed and some small areas of nodularity in the stomach were identified and biopsied. Biopsies were positive for helicobacter (H) pylori.
The esophagogastroduodenoscopy (EGD) was denied by the plan because the patient did not meet criteria for approval because the patient did not have heartburn despite 2 months of treatment, persistent vomiting, dyspepsia at age greater than (>) 50, or gastrointestinal (GI) bleeding.
At issue is the medical necessity of EGD.

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

The requested health service/treatment of EGD is medically necessary for this patient.
This patient is going for bariatric surgery which is an exception to the criteria for an EGD. The anatomy of the stomach must be assessed pre-operatively. H pylori status also must be clarified. In totally asymptomatic patients pre-operative (pre-op), an upper GI study is generally ordered and will perform non-invasive testing for H pylori (e.g., stool antigen testing). In a patient with upper tract symptoms the standard of care is to perform an upper endoscopy pre-operatively. If the patient has erosive esophagitis, peptic ulcer disease, or a malignancy pre-op this is critical to know and an EGD is the correct test for evaluation.
Therefore, the requested health service/treatment of EGD is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Recurrent oral aphthae.
Treatment:  Otezla Starter Pack + Otezla 30MG (milligrams).

The insurer denied the  Otezla Starter Pack + Otezla 30MG.  The denial is overturned.

The patient is a male. The patient has oral ulcers / Behcets syndrome. The patient has been prescribed Otezla.

Coverage for Otezla was denied by the health plan, because the patient does not meet criteria. The medicine was prescribed for oral ulcers. The denial is being appealed.

Yes, the requested Otezla is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.

The patient has the diagnosis of oral ulcers / Behcets syndrome. This condition can cause ulcers in many places, but many people will only have them over the oral mucosa, and recurrent apthous stomatitis is part of Behcets disease. This medicine is approved for Behcets.

Therefore, given the above, the requested Otezla is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD).
Treatment: Esophagogastroduodenoscopy (EGD) (43235).
The insurer denied the Esophagogastroduodenoscopy (EGD) (43235).
The denial is overturned.

The patient is a male with gastroesophageal reflux disease (GERD). His heartburn is well controlled with Dexilant. He does have dysphagia and regurgitation, as well as hoarseness and a bitter taste in his mouth. The attending physician (MD) is requesting esophagogastroduodenoscopy (EGD).

Yes, the requested esophagogastroduodenoscopy (EGD) is medically necessary.

The patient has gastroesophageal reflux disease (GERD), with dysphagia to solids and liquids. Esophagogastroduodenoscopy (EGD) is clinically appropriate, accepted standard of medical care, and medically necessary in the evaluation of alarm symptoms of gastroesophageal reflux disease (GERD), including dysphagia. Therefore, the requested esophagogastroduodenoscopy (EGD) is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient has gastroesophageal reflux disease (GERD), with dysphagia to solids and liquids. Esophagogastroduodenoscopy (EGD) is clinically appropriate, accepted standard of medical care, and medically necessary in the evaluation of alarm symptoms of gastroesophageal reflux disease (GERD), including dysphagia. Therefore, as the patient has alarm symptoms of gastroesophageal reflux disease (GERD), the requested esophagogastroduodenoscopy (EGD) is medically necessary, and the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atopic dermatitis.
Treatment:  Rinvoq.	

The insurer denied coverage for Rinvoq.  The denial is upheld.

The patient is a male with a diagnosis of pyoderma gangrenosum and atopic dermatitis. The patient's pyoderma gangrenosum appears to be well controlled on Remicade therapy. The atopic dermatitis has been treated with topicals, without any documentation of systemic therapies. The requested medication is Rinvoq tablets.

The documentation provided appears to indicate that Rinvoq is being used as an off-label treatment for atopic dermatitis. Furthermore, the documentation on this office visit indicates that the eczematous rash and pruritus may be a Remicade side effect, rather than atopic dermatitis. The patient is noted to have no prior history of eczema or atopy with suggestions of his eczema being "remicade induced."  

The insurer's denial of coverage for Rinvoq 15 milligrams (mg) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Home Health Care (HHC) - Level 2 Personal Care Services (PCS) per 15 minutes increase to 84 hours/week, pre-service
The insurer denied the HHC - Level 2 PCS per 15 minutes increase to 84 hours/week, pre-service.
The denial is overturned.

The patient is a male who is currently in a skilled nursing facility (SNF). He is appealing denial of increase home care personal care services (PCS) to 84 hours/week. The plan approved 56 hours/week. Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with meal preparation, housework, bathing, and locomotion; maximal assistance with managing finances and medications, shopping, lower body dressing, and toileting; extensive assistance with personal hygiene and bed mobility; and independent with eating. He has frequent bowel and bladder incontinence. He is wheelchair dependent.  Compared to UAS evaluation completed previously, there has been a decline in functional status with managing medications and finances, bathing, dressing, locomotion, toileting, and bed mobility.

Yes, the proposed treatment is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs), health maintenance activities, and routine support services care. This member is currently in a SNF and is appealing denial of increase home care PCS to 84 hours/week. The plan approved 56 hours/week. UAS evaluation completed shows he requires assistance with all ADLs, except eating. There is a significant decline in functional status compared to UAS evaluation completed previously. He has bowel and bladder incontinence. The information provided shows that the member is significantly impaired and requires significant assistance with ADLs. Based on the member's decline and level of functioning, the current Personal Assistance Services 56 hours/week is insufficient to meet the member's needs. The proposed increase in to 84 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

This is a patient with a history of endometrial cancer, who underwent a robotic-assisted total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, bilateral sentinel lymph node injection and bilateral pelvic lymph node dissection. There were no complications, though double vision, unsteady gait and decreasing blood pressure to 90s/40s was noted postoperatively. The patient was admitted for overnight monitoring. There were no acute events overnight and the patient was discharged.

There are many ways of doing a hysterectomy. The trend has been towards less invasive procedures. Conventional and robotic laparoscopy share similar advantages over laparotomy, including decreased morbidity, rapid recovery, and improved aesthetics of incisions.
Laparoscopic hysterectomies are outpatient procedures unless a complication arises. Admission becomes necessary if the patient is febrile, hypotensive, bleeding, has difficulty breathing or the severity of the pain is such that admission is necessary. According to Milliman Care Guidelines, Inpatient and Surgical Care 23 Edition, Laparoscopic hysterectomy, a laparoscopic hysterectomy is an ambulatory procedure. Inpatient stay may be needed for:
1) Surgical complications (bladder ureter or bowel injury or hemorrhage)
2) Conversion to abdominal hysterectomy
3) Complex surgery (staging of endometrial cancer)
4) Wound complications
5) Comorbidities.

This patient, because of her diagnosis of endometrial cancer, had complex surgery. Her surgery involved pelvic lymph node dissection. According to the scientific literature, the average length of stay for such patients is 48 hours in the hospital. In addition, this is an older patient with a history of comorbidities.

Based on the above, the inpatient admission was medically necessary for this patient. 

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

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