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

Diagnosis: Prostate Cancer
Treatment: Oncotype DX
The insurer denied the Oncotype DX.
The determination is upheld.

Reviewer 1

The patient is a male with prostate cancer who had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 3+3=6, adenocarcinoma in 3 of 12 cores. The clinical stage was tumor (T) 1c. The prostate-specific antigen (PSA) was less than (<) 10. At issue is whether the Oncotype DX gene expression testing likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The health plan's determination is upheld.
The Oncotype DX testing is not likely to be more beneficial than any standard treatment(s). The patient has a low-risk prostate cancer. Per the American Urological Association (AUA) Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)"
Guideline Statement 32: Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion)
Although results are promising, further validation is necessary to understand fully the potential clinical utility of this test. The National Comprehensive Cancer Network (NCCN) Guidelines state that "In summary, although molecular test results can provide additional guidance to patients, only limited data of prostate cancer specific-survival are available, and whether patient outcomes are improved with use of these tests is unclear." "...any of these tests may be considered to aid management decisions, but they are not required for standard of care at this time."
The 1.2017 NCCN Guidelines state that "Although full assessment of their clinical utility requires prospective randomized clinical trials, which are unlikely to be done, the panel believes that men with clinically localized disease may consider the use of tumor-based molecular assays at this time. Future comparative effectiveness research may allow these tests and others like them to gain additional evidence regarding their utility for better risk stratification of men with prostate cancer."
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient Hospital

Diagnosis: RSV
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female child with medical history significant for reactive airway disease who was referred to the emergency department (ED) for fever and respiratory symptoms. Symptoms of cough and nasal congestion began five days prior. 

The inpatient hospital stay was medically necessary. In this child's case, with strong family history of asthma and personal history of wheezing and albuterol use (reactive airway disease), it was not unreasonable to attempt treatment with bronchodilators and corticosteroids. She presented with signs and symptoms of significant respiratory distress, including nasal flaring and belly-breathing. She only improved upon initiation of high flow nasal cannula with supplemental oxygen, necessitating admission to the PICU. She improved relatively quickly over the course of the day, and was stable for transfer to the pediatric floor by the next day, with discharge the subsequent day. While her hospital stay was not prolonged, she had failed outpatient management (she was not known to be RSV positive) with bronchodilators, inhaled and enteral corticosteroids, and antibiotics. Acute inpatient management was medically necessary and appropriate. She could not have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac /Circulatory problems/Arrythmia  
Treatment: Inpatient Hospital 
The insurer denied the inpatient hospital stay. 
The denial is upheld in whole .

The patient has a history of systemic lupus erythematosus, chronic fatigue syndrome, fibromyalgia, bipolar disorder and anxiety disorder. The patient presented to the emergency department complaining of two days of worsening palpitations and exertional dyspnea.
Palpitations are a common complaint in patients presenting to the emergency department. The potential causes range from the benign to the potentially life-threatening. In this case, the patient's palpitations were attributed to sinus tachycardia, likely resulting from anxiety disorder. Inappropriate sinus tachycardia is not uncommon   with structurally normal hearts, particularly in those with psychiatric disease. It is a benign arrhythmia. While it can cause bothersome symptoms and negatively impact quality of life, it has not been shown to have serious adverse short- or long-term consequences. Treatment is based on symptoms and is aimed at reducing symptoms and increasing quality of life. Treatment options often include medications, such as beta-adrenergic blocking agents, calcium channel blockers and ivabradine. These drugs can be taken orally at a lower level of care,  and do not require electrocardiographic monitoring during therapy initiation or titration. Inpatient treatment of this hemodynamically stable patient with a benign arrhythmia was not medically necessary.  This is not an arrhythmia that would typically be considered an indication for hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. 
The denial is upheld. 

No, the Inpatient admission was not medically necessary.

The patient is a female with a past medical history significant for HTN (hypertension), dyslipidemia, CAD (coronary artery disease), s/p (status post) MI (myocardial infarction), PCI (percutaneous coronary intervention) of left circumflex artery in 2018, migraine headaches, and TIA (transient ischemic attack). She presented to the ER for evaluation of squeezing retrosternal chest pain, non-exertional, non-radiating, described as squeezing. 

The patient was hypertensive on admission, and she was treated with Labetalol. Her cardiac troponins were negative. ECG (electrocardiogram) revealed normal sinus rhythm with no acute ischemic changes. She was admitted to telemetry to rule out ACS (acute coronary syndrome). 

The patient's serial troponins were negative. An echocardiogram was obtained, revealing normal left ventricular wall motion with EF (ejection fraction) of 60-65% and LVH (left ventricular hypertrophy). A nuclear stress test was performed and was negative for ischemia. Neurology evaluation was obtained for the headache - it was felt to be cervical in nature, and PRN (as needed) pain medications were recommended.  

The patient was discharged home with a plan for outpatient follow-up.

The patient presented for evaluation of chest pain. The diagnosis of an acute MI was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test. Ischemia was ruled out by stress testing. 2D echocardiogram revealed normal LV (left ventricle) systolic function with normal wall motion. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. There was no evidence of acute neurological or cardiac pathology. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Worsening psychosis and aggression
Treatment: Continued Inpatient admission
The insurer denied the continued inpatient admission.
The denial is overturned. 

Yes, the Continued inpatient admission was medically necessary.

The patient is a female with a history of mental illness who received inpatient psychiatric treatment.

The patient has been diagnosed with schizophrenia.  She has a history of medication non-compliance, prior inpatient hospitalizations.  She lives in an independent living facility and is on SSI (supplemental security income).  She has hypertension, diabetes mellitus, and asthma.  She has a history of aggressive behavior.

The patient was brought into the hospital in the context of worsening psychosis and aggression.  She was making delusional and paranoid statements and was noted to be medication non-compliant.  She was medically cleared for psychiatric hospitalization and was hospitalized.  She was treated by a multidisciplinary team including psychiatry, nursing, and therapy staff.  She received group and individual treatment.  She received a psychopharmacology evaluation and was started on Risperidone, Depakote, and Cogentin.  Invega Sustenna was utilized during the hospitalization.

The patient represented an elevated risk of dangerous behaviors, including aggressive behaviors, self-injury, and suicide, and there was no less-restrictive treatment environment appropriate.  Therefore, the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained grossly psychotic.  The patient had multiple static risk factors for potentially dangerous behaviors, including prior aggression, medical comorbidities, and diagnosis with a severe mental illness.  Therefore, the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained psychotic was acute risk factor for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Upheld

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


The patient was brought to the emergency department (ED) with a two week history of intermittent fevers, sore throat, and aches. The day before, she was taken to an urgent care with a temperature of 103.5 degrees Fahrenheit; a throat swab was negative for strep and a urinalysis (UA) was negative. When she arrived in the ED, her temperature was 98.8 degrees Fahrenheit, respiratory rate (RR) 22, heart rate (HR) 142, blood pressure (BP) 110/68, and oxygen saturation of 98%. The emergency department (ED) physician documented that she was in no apparent distress, with clear lungs, normal breath sounds, and no respiratory distress. A chest x-ray (CXR) showed left lower lobe infiltrates. The white blood cell count (WBC) was 23.1 with 78% neutrophils. An Influenza swab was negative. Bicarbonate was 17. Blood urea nitrogen (BUN) and creatinine were normal. The urine specific gravity was 1.015. She was given intravenous (IV) fluid, IV ceftriaxone, and oral azithromycin in the ED and admitted to the hospital. The admission physical exam was normal as well. She was continued on IV antibiotics and remained afebrile and clinically well throughout. At issue is the medical necessity of an acute inpatient hospitalization.
The inpatient stay was not medically necessary. The patient presented with a history of fevers but was afebrile in the ED and throughout the hospitalization. The WBC was elevated and the CXR suggested a left lower lobe pneumonia, but the patient's respiratory status was normal-no tachypnea, retractions, hypoxemia; clear breath sounds. The patient did not have dehydration and was taking fluids. The diagnosis of community acquired pneumonia alone does not warrant hospitalization for intravenous antibiotics in a patient who is well appearing and has not had any failure of outpatient management. Empiric oral antibiotics for clinical pneumonia is standard of care. An inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis 
Treatment Otezla 

The insurer denied the Otezla. The determination is upheld.

The patient has psoriasis, which has been treated with topicals. The provider is requesting Otezla. The health plan has denied the Otezla as the the criteria of a trial of methotrexate, cyclosporine or acitretin was not met. At issue is the medical necessity of the Otezla. 

Otezla is not medically necessary for this patient. There are no studies to date comparing the efficacy of Otezla to other systemic medications for psoriasis. It is an oral therapy and requires less medication monitoring (current data do not indicate a need for laboratory monitoring) and is not immunosuppressive. Otezla is now among the growing number of systemic therapies for psoriasis. Currently there are no evidence based medical guidelines indicating which therapy is best or delineating a step-wise approach to psoriasis. The guidelines of care for the management of psoriasis state that each patient requires individual tailoring and a stepwise approach is not recommended.
However, this patient has no documented contraindications to the drug methotrexate, and this medication is still commonly used for psoriasis. Cyclosporine and acitretin are not used for plaque and guttate psoriasis. Therefore, given no documented contraindications to methotrexate, Otezla is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis.

Treatment: Inpatient admission.

The insurer denied the inpatient admission.

The denial was upheld.

This is a female patient with a history of cholecystitis, umbilical hernia and obesity. She presented to the hospital for a scheduled admission for a lap cholecystectomy with possible open umbilical hernia repair. It was reported that patient had been having severe abdominal pain. It was reported that the patient had had a magnetic resonance cholangiopancreatography (MRCP) had been done and an endoscopy where one gallstone was removed. The patient underwent a laparoscopic cholecystectomy with repair of umbilical hernia. The patient tolerated the procedure well and was able to tolerate a diet. The patient was medically stable and was discharged home with a Jackson Pratt drain in place.

According to the review of the MCG Health guidelines, the goal length of stay for this patient's procedure is ambulatory or 2 days and assumes optimal recovery, decision making, and care. The guideline indicates that patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. The clinical indications for admission to inpatient care includes acute cholangitis/cholecystitis with systemic signs of inflammation (e.g., fever, leukocytosis), and/or evidence of common bile duct disease noted by abnormal liver function tests/hepatobiliary imaging, and/or gallstone obstruction with hemodynamic instability, risk for dehydration due to persistent/severe vomiting. Bacteremia and/or severe pain requiring acute inpatient management are also considered for inpatient admission. However, in this case, this patient did not have sign and symptoms for acute cholecystitis as this was an apparent scheduled lap cholecystectomy. The patient also did not have findings consistent with acute cholangitis that would have necessitated an acute inpatient admission. The patient was admitted following her laparoscopic cholecystectomy and umbilical hernia repair with a JP drain placed. The patient could have been discharged after the surgery following a 23-hour observation stay. The patient was tolerating diet and ambulating and was kept in the hospital for observation. The patient did not need an acute admission as this was a scheduled ambulatory procedure. All that was required for this patient postoperative was observation level of care because the patient did not present with acute cholecystitis or cholangitis that required emergent surgical intervention. The patient's procedure was uncomplicated, and the patient did well post-operatively. Thus, inpatient admission was not medically necessary for this patient.

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

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal Bleeding 
Treatment: Inpatient Hospital Stay 

The insurer denied the inpatient hospital stay. The determination is upheld.

The patient presented to the emergency department on with a complaint of rectal bleeding and worsening pain. She had been noted to have thrombosed hemorrhoids on a colonoscopy two weeks ago and also said her hemorrhoids got worse after the prep for that procedure. She had been evaluated in the emergency department one week prior and sent home with conservative management. She was sent to the emergency department by surgery for admission. On physical exam, a digital rectal exam was refused due to severe pain. However, she was noted to have partial hemorrhoidal necrosis. She was taken to the operating room later the same day for a hemorrhoidectomy for prolapsing, thrombosed, and gangrenous hemorrhoid. She was noticed to have bleeding from the tissue proximal to this prolapsed hemorrhoid and the bleeding was controlled with suture ligation. At issue is whether an inpatient level of care was medically necessary. 

Inpatient stay was not medically necessary after a hemorrhoidectomy. The patient was young and without severe comorbidities that require an inpatient level of care. She tolerated the procedure well without complications and was felt to be stable for discharge to home the following day. A hemorrhoidectomy is traditionally an outpatient procedure. The care provided for this patient, such as pain control both before and after surgery and diet advancement could have been provided at a lower level of care than inpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial was upheld.

This is a female patient with history of asthma and hypertension. She presented to the Emergency Department (ED) with complaints of wheezing and cough. She reported that she had run out of her inhaled steroids and nebulizer medications. The patient was given Combivent on route to the hospital by the Emergency Medical Service (EMS). In the ED, the patient's vital signs were: temperature 97.3 F, heart rate 87, respiratory rate 17, blood pressure 164/98 mm Hg, oxygen (O2) saturation 100%, and peak expiratory flow (PEF) was 130 LPM. The patient was received bronchodilators via nebs, magnesium, steroids and doxycycline in the ED. On physical exam it was noted that the patient's lung exam revealed bilateral wheeze. Laboratory work up revealed white blood cell (WBC) count of 6.8K, and BUN/Creatinine and electrolytes within normal limits (WNL). The patient's venous blood gas (VBG) results showed pH 7.45, pCO2 28, pO2 61, oxygen saturation of 91%. The patient's urine toxicology was positive for cannabinoids. The patient's chest x-ray revealed no acute infiltrates; the patient had a bullous lung disease.

The patient was admitted for chronic obstructive pulmonary disease (COPD)/asthma exacerbation. As per the H&P, the patient was in no acute distress (NAD), afebrile and hemodynamically (HD). The patient was noted to be awake, alert and oriented. The patient's lung exam revealed bilateral wheezing but otherwise, the patient's cardiovascular and abdominal exams were unremarkable. The patient's peek expiratory flow (PEF) was 200 L/min. Further peak flow measurements were not done as there was a risk for pneumothorax. The patient remained stable after admission. The patient was on steroids, antibiotics, and Singulair. These could have been given orally. The patient was in no acute, respiratory distress and was tolerating oral intake.

This patient did not need acute hospitalization. This patient could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient could have been switched to oral medications with further follow up in outpatient setting. Thus, inpatient admission was not medically necessary.

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitation
Treatment: Inpatient admission 
The insurer is denied coverage for inpatient admission.
The denial is upheld.

This is a female patient with a medical history of asthma. She presented to the Emergency Department (ED) for assessment and management of palpitations in the setting of a couple of episodes of non-bloody, non-bilious vomiting and non-bloody diarrhea for the past couple of days. The patient's mother gave albuterol for the patient's palpitations thinking that it might be the patient's asthma. The patient's presenting vital signs were: heart rate 119, temperature 98 F, respiratory rate 18, blood pressure 124/76 and room air oxygen saturation of 99%. The patient's physical exam showed a well-developed, well-nourished patient. The patient's lungs were clear, and her cardiac exam was unremarkable. The patient's abdominal exam was noted to be soft with normal bowels sounds; there was no associated tenderness, guarding, organomegaly, distension, rebound, or palpable masses.
The patient's admitting laboratories were notable for white blood cell (WBC) count of 5.2 without a left shift (60 % neutrophils, no bands), hemoglobin of 14, platelets of 350, sodium of 141, potassium of 3.8, bicarbonate of 24, BUN of 12 and creatinine of 0.69.The patient's hemoglobin A1c was 5.7. The patient's influenza assay was negative. The patient's electrocardiogram (EKG) showed sinus tachycardia at 125 with normal axis/intervals and no acute ST/T wave changes. The patient's imaging included a chest x-ray that was unremarkable and an abdominal sonogram that showed a slightly echogenic liver. The patient received 10cc/kg normal saline bolus and a second 10cc/kg normal saline bolus. The patient had no further vomiting or diarrhea. Cardiology was consulted with recommendations for outpatient evaluation in two months. The patient was discharged home the same day for outpatient follow-up. 


In regard to this patient's volume status based on the review of dehydration in children from UptoDate, the patient's status was at best was minimal dehydration. The patient was noted to have tacky mucus membranes. Though patient received bolus fluids, the patient was not intolerant to oral hydration. After a brief period of observation and monitoring at the Observational level of care, the patient could have been safely discharged with outpatient follow-up. The patient received no acute level of care after admission that warranted inpatient level of care. Thus, inpatient admission was not medically necessary 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 inpatient admission should be upheld. The medical necessity is not substantiated.