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

Diagnosis: Generalized fatigue, fevers, sore throat.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He presented to emergency room for evaluation of with generalized fatigue, fevers, sore throat. The patient was admitted to acute in-hospital level of care for viral illness.

The patient's condition improved significantly with emergency room care. He was afebrile, as well as not in any distress at the time of admission. The patient's vitals were stable. The patient was able to tolerate oral diet. Patient received IV (intravenous) antibiotics in the ER (emergency room). The patient was admitted for possible COPD (chronic obstructive pulmonary disease) exacerbation. The patient's condition improved within 24 hours.

No, the Inpatient admission was not medically necessary.

The patient's condition improved significantly with emergency room care. He was afebrile, as well as not in any distress at the time of admission. The patient's vitals were stable. The patient was able to tolerate oral diet. The patient received IV (intravenous) antibiotics in the ER (emergency room). The acute in-hospital level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries. 

Treatment: Air ambulance transport service.

The insurer denied coverage for the air ambulance transport service.

The denial is upheld. 

This patient is a female child who was involved in a small aircraft collision.  The documentation indicated that the patient was initially able to ambulate from the crash site prior to developing significant low back pain.  The documentation indicated that the patient did not lose consciousness during the accident.  The patient was initially transferred to the hospital where she was found to have a lumbar spine fracture.  The submitted documentation indicated the patient had a fracture at T12-L1 with a 3 column Chance fracture involving L1 vertebral body with surrounding paraspinal hematoma which was concerning for an unstable spinal column injury.  The documentation indicated that the patient was admitted to neurosurgical services.  Trauma was admitting the patient and the plan was for the patient to receive a magnetic resonance imaging (MRI) and the possibility of surgical services.  The patient's grandparents; however, requested that the patient be transferred to another hospital.  The documentation indicated neurosurgery and trauma did feel the patient was safe to be transferred as long as the lumbar and thoracic spinal precautions were maintained.  A physician at the hospital accepted the patient and arrangements were made for the transfer.  

Based on the review of the medical record and literature, the request for air ambulance transport service (codes A0431 and A0436) does not meet medical necessity.  There is no documentation of ongoing bleeding, cardiovascular instability or significant visceral damage.  There is no documentation of head injury or penetrating injury.  The patient had a normal neurologic exam and no neural compromise on imaging. While the patient had a documented L1 unstable fracture (Chance fracture), as long as the patient remained supine and immobilized with care to avoid pressure points, ground transport would have been safe for this patient. 

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

The carrier's denial of coverage for the air ambulance transport service should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple Sclerosis
Treatment: Avonex
The insurer denied the Avonex.
The denial is upheld. 

The patient is a female with multiple sclerosis. She has been treated with Avonex for many years. Her provider is requesting continuation of Avonex.

No, the treatment with Avonex is not medically necessary.

There is no documented reason as to why the patient cannot be treated with Rebif or the other formulary agents for her condition. All of the preferred agents are FDA (Food and Drug Administration)-approved for her condition, based on high-quality clinical trials published in the peer-reviewed medical literature (Rae-Grant et al.). There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Avonex relative to the preferred agents. In contrast, there are high quality clinical trials demonstrating that Rebif, Aubagio, Gilenya, dimethyl fumarate, Ocrevus, Tysabri and Mayzent are superior to Avonex in regards to clinical efficacy. There is no evidence that switching to a preferred agents would jeopardize her clinical stability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive non-small cell lung cancer. 
Treatment: Genetic Testing. 

The insurer denied Genetic Testing. 
The determination is overturned. 


The patient has progressive non-small cell lung cancer. The Guardant360 assay was obtained and is under review for medical necessity. 

The health plan, in its determination of medical necessity, has not acted reasonably, with sound medical judgement and in the best interest of the patient. The requested testing is medically necessary. The Guardant360 assay was obtained. The use of next generation sequencing gene panels to guide the treatment of patients with metastatic lung cancer is recommended by the National Comprehensive Cancer Network (NCCN) Guidelines, which state "...t is recommended at this time that when feasible, testing be performed via a broad, panel-based approach, most typically performed by next generation sequencing (NGS)....".  The assay in question is Food and Drug Administration (FDA) approved and evaluates the cancer for the recommended biomarkers - epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), c-ros oncogene (ROS) 1, mesenchymal epithelial transition factor (MET), rearranged during transfection (RET), and tropomyosin receptor kinase (TRK). 
The authors of UpToDate state "...GS overcomes many of the shortcomings of direct sequencing and allele-specific testing... It retains sensitivity even in specimens with low tumor cellularity, which is an improvement over direct sequencing, and can identify new abnormalities, which would not be detected by allele-specific testing. Moreover, NGS can often detect abnormalities that would historically be tested by fluorescence in situ hybridization (FISH) ...". The service under review is not the subject of ongoing investigation for these purposes.  For these reasons, the use of this assay in this scenario is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headaches, neck pain and occipital neuralgia
Treatment: Additional Trigger Point Injections for Pain
The insurer denied the Additional Trigger Point Injections for Pain.
The denial is overturned. 

The patient is a female.  A progress note reports headaches and treatment with trigger point injections for neck pain and occipital neuralgia.  Physical examination noted trigger points present in cervical and thoracic muscles.  The notes reports previous injections helped improve headache and pain.  Local twitch response was noted.

Yes, the proposed treatment with trigger point injections is medically necessary. 

While the health plan denied the repeat injections as there was no documentation of the original injections resulting in over 50% improvement for at least six weeks, this is not supported in the literature.  The literature supports repeat injections when the patient has shown benefit and improvement from the previous injection; however, does not specify a particular level that needs to be reached in order to justify repeat injections.

The records note positive response in regard to injections with reduction in headache and reduction in pain as result.  Given physical presence of trigger points identified on exam and positive response on functional ability, the injections are supported as medically necessary.

The treatment is being performed consistent with standard of care and in response to positive outcome for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Osteoarthritis.
Treatment:  Metal-on-metal resurfacing device/resurfacing surgery.

The insurer denied coverage for metal-on-metal resurfacing device/resurfacing surgery.  
The denial is upheld. 

This is a male patient with a medical history of gout, tendinitis in the right hip, right hip osteoarthritis, left knee arthritis and right knee and right hip/groin pain. The patient underwent right hip resurfacing by an Orthopedic Surgeon for the diagnosis of end-stage primary osteoarthritis. 

Surgical indications include required definition of a pain generator and lack of improvement with conservative treatment. There should be likelihood that operative intervention will provide benefit. 

The facts are the patient had not received conservative management. The patient received an injection in the past that was provided to the trochanteric area for bursitis. The records do not indicate that there had been a course of physical therapy (PT). The patient was evaluated and surgery was recommended. 

In addition, as summarized in Up to Date, there are issues with adverse tissue reactions associated with metal on metal bearings, questions regarding durability of joint resurfacing procedures and data indicating a greater rate of re-revision following resurfacing compared to total hip arthroplasty. The Food and Drug Administration (FDA) notes that patients with a body mass index (BMI) above 40 have "have an increased risk for greater wear of the device or for an adverse local tissue reaction (ALTR) and require closer follow-up."

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

The requested metal-on-metal resurfacing device/resurfacing surgery is not considered medically necessary for this patient.

The carrier's denial of coverage for metal-on-metal resurfacing device/resurfacing surgery is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrolithiasis.
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a male patient with a past medical history of diverticulosis, hyperlipidemia (HLD), and nephrolithiasis.  The patient presented to the Emergency Department (ED) with complaints of left lower quadrant (LLQ) pain and urinary urgency.  A computed tomography (CT) scan of the abdomen and pelvis (A/P) revealed a left ureteral stone.  White blood cell (WBC) count was 19,000.  The patient was admitted with nephrolithiasis.  The patient then underwent left ureteroscopy (URS) with laser lithotripsy and stent placement for an 8 millimeter stone.  The patient tolerated the procedure well and was able to get out-of-bed (OOB) and ambulate independently after the procedure.  Diet was advanced to a regular diet; pain was controlled with oral pain medications.  The patient was discharged home with outpatient urology follow-up.  

The insurer has denied coverage for the inpatient admission as not medically necessary.  They noted that the patient was stable, underwent an uncomplicated procedure, and went home the next day.  There was no unstable medical condition, no renal failure or bilateral obstruction, and the patient did not need intravenous (IV) fluids beyond the observation period.  

Per Milliman Care Guidelines (MCG) Health (24th Edition) Renal Colic and Kidney Stones, the patient fails to meet clinical indications for admission to inpatient care.  There was no hemodynamic instability, bilateral obstruction, acute renal failure, severe or persistent vomiting, urinary tract infection (UTI), severe pain requiring acute inpatient management, and no stone removal procedure needed requiring inpatient admission.

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

The inpatient hospital admission was not considered medically necessary.   

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung cancer
Treatment: Stereotactic Body Radiation Therapy
The insurer denied the Stereotactic Body Radiation Therapy.
The denial is overturned. 

The patient is a female. She has a diagnosis of stage IV rectal cancer status post chemotherapy and radiation therapy.  The patient had a near complete response with exception of two active oligometastatic lung lesions.  Definitive radiation to the lung lesions was recommended, and SBRT (stereotactic body radiation therapy) was requested.

Yes, the treatment with stereotactic body radiation therapy is medically necessary.

There is clinical evidence that showed that SBRT (stereotactic body radiation therapy) is safe and more effective than the standard radiation therapy for the treatment of lung lesions.

Uematsu et al. reported a three-year cause specific survival of 88% for patients receiving 50-60 Gy (Gray) in 5 to 10 fractions using stereotactic radiosurgery.  In a University of Miami study, the authors treated 95 patients with Cyberknife, and concluded that "Image-guided robotic stereotactic radiosurgery (IGR-SRS) of lung tumors with the CyberKnife achieves excellent rates of local disease control with limited toxicity to surrounding tissues, and in many cases may be curative for patients for whom surgery is not an option."

Another study from the University of Rochester evaluated 121 patients with five or fewer clinically detectable metastases, from any primary site, and treated with SBRT (stereotactic body radiation therapy) and the two-year OS (overall survival), FFDM (freedom from widespread distant metastasis), and LC (local control) rate was 39%, 28%, and 74%, respectively.  The authors stated, "Select patients with limited metastases treated with SBRT [stereotactic body radiation therapy] are long-term survivors."

SBRT (stereotactic body radiation therapy) has been shown to be safe and effective for the treatment of oligometastatic lung lesions.  Conventional radiation therapy may not be as safe and may not provide as good a local control compared to SBRT (stereotactic body radiation therapy).  The patient had oligometastatic lung lesions with no extra-pulmonary disease, and if her lung lesions could be adequately controlled with SBRT (stereotactic body radiation therapy), she might have a prolonged survival.  In this case, SBRT (stereotactic body radiation therapy) is an appropriate therapy for this patient.

Studies have shown that SBRT (stereotactic body radiation therapy) is safe and effective for the treatment of lung metastasis.  The SABR-COMET (Stereotactic Ablative Radiotherapy for the Comprehensive Treatment of Oligometastases) randomized trial showed that SBRT (stereotactic body radiation therapy) can improve local control as well as progression free survival for the treatment of oligometastatic disease, including lung oligometastasis.  This patient has two lung lesions without any active disease elsewhere, and if her lung lesions could be adequately controlled with SBRT (stereotactic body radiation therapy), she might have a prolonged survival.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's dementia
Treatment: Increase Personal Care Services To 24 Hours A Day 7 Days A Week (live-in), 91 hours/week
The insurer denied the Increase Personal Care Services To 24 Hours A Day 7 Days A Week (live-in), 91 hours/week.
The denial is overturned. 

The patient is a female with a history of severe Parkinson's dementia with associated hallucinations, cognitive impairment, muscle weakness and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 91 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the Increase in Personal Care Services To 24 Hours A Day 7 Days A Week (live-in), 91 hours/week is medically necessary.

The patient is a female with a history of severe Parkinson's dementia with associated hallucinations, cognitive impairment, muscle weakness and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).

Recent correspondence from the patient's medical provider indicates that due to significant worsening in the patient's cognitive function and physical mobility, she now requires total assist for completion of all ADLs (activities of daily living) and is a constant fall risk with recent hospitalization for fall injury. This correspondence revealed that the currently approved plan of 65 hours/week Personal Assistance Services is not sufficient to meet the patient's current needs. For these reasons, the proposed treatment of 91 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Dupixent. 
The health plan's denial is upheld.

The patient is a male with moderate to severe atopic dermatitis of the upper and lower extremities, as well as the back. The patient has tried and failed topical betamethasone dipropionate cream, clobetasol emollient cream, halobetasol cream, mometasone cream and ointment, and clindamycin gel. The provider reports that the patient used Protopic ointment a few years back for one year with treatment failure. The patient was put on Dupixent  with some response. Oral immunomodulatory agents have been avoided because of concerns about the COVID-19 pandemic.
Dupixent is under review for medical necessity.

The health plan's determination is upheld.

The requested treatment with Dupixent is not medically necessary for this patient. This patient has no prior systemic treatment prior to Dupixent, and it is not known if the patient would respond as well or better to the options of the plan-preferred medications such as cyclosporine capsules, azathioprine, or methotrexate. There is no documented treatment failure with, or true medical contraindication to, standard, first-line systemic and immunomodulatory therapies such as Methotrexate, Azathioprine, or Cyclosporine capsules. Therefore, the requested Dupixent is not medically necessary.
Modern dermatology literature [1-4] supports use of the health plan preferred medications as similarly efficacious to the requested Dupixent, particularly for a patient with a limited history of systemic atopic dermatitis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Constipation
Treatment: Movantik 12.5mg OR TABS, Pre-service
The insurer denied the Movantik 12.5mg OR TABS, Pre-service.
The denial is upheld. 

The patient is a female with opioid-induced constipation. Her provider is requesting treatment with Movantik.

No, the treatment with Movantik is not medically necessary.

There are no medical records provided. Pharmacy claims do not show that the patient has filled a prescription for narcotics for a few years. The appeal letter states that the patient is taking Movantik for opioid-induced constipation. Medical records documenting constipation, as well as what narcotics the patient is taking, would be helpful to make a determination. Based on a lack of medical records as well as a lack of documentation in the provider letter as to what narcotics the patient is taking, the proposed Movantik is not medically necessary.

Based on a lack of medical records as well as a lack of documentation in the provider letter as to what narcotics the patient is taking, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying Movantik.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cryopyrin-Associated Periodic Syndrome (CAPS).
Treatment: ILARIS dosed every 3 weeks Pre-service.
The insurer denied the ILARIS dosed every 3 weeks Pre-service.
The denial is upheld. 

The patient is a female with an undiagnosed autoinflammatory condition that features lung disease, abdominal pain/diarrhea, urticarial rashes, periorbital edema, and chronic anemia.  She has had gene testing done, which showed a variant of uncertain significance in the NLRP12 (Nucleotide-Binding Oligomerization Domain, Leucine Rich Repeat And Pyrin Domain Containing 12) gene, which has been associated with Familial Cold Autoinflammatory Syndrome.

The patient has been treated with multiple medications including NSAIDs (nonsteroidal anti-inflammatory drugs), systemic corticosteroids, colchicine, anakinra, IV (intravenous) and subcutaneous immunoglobulin, and most recently canakinumab (Ilaris) every four weeks without control of her disease.  Her pediatric rheumatology provider has asked to continue the use of Ilaris 100 mg (milligrams) every three weeks.

The pediatric rheumatologist has detailed the patient's evaluation to date, including the working diagnosis of undifferentiated autoinflammatory disease, as well as of all the treatment options that have been tried and failed to date.  The provider also notes, "the benefit of this has not been very clear except that some of her symptoms affecting her GI [gastrointestinal], skin and eyes seemed to improve while on canakinumab; actually lately we increased the frequency to every 3 weeks at a dose of 150 mg [milligrams]."

No, the treatment with ILARIS dosed every 3 weeks is not medically necessary.

Canakinumab (Ilaris) is a safe and effective therapy for several different autoinflammatory diseases, including Familial Cold Autoinflammatory syndrome.  It has been studied in clinical trials with these diseases.  There is no current evidence to suggest that canakinumab is effective at a dose of every three weeks. It has only been studied in a dosing frequency of every four to eight weeks.  Therefore, the proposed treatment frequency of canakinumab every three weeks is not medically necessary.

While canakinumab has been proven to be an effective and safe treatment option in several different autoinflammatory diseases, it has not been studied at a dosing frequency of every three weeks.  There is no evidence to suggest that if canakinumab is not effective at every four weeks, it will be effective at every three weeks.  Therefore, the increase of the dosing frequency to every three weeks is not medically necessary.