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

Diagnosis: Eustachian tube dysfunction (ETD)
Treatment: Nasopharyngoscopy, Surgical, with Dilation of Eustachian Tube (i.e., Balloon Dilation)
The insurer denied Nasopharyngoscopy, Surgical, with Dilation of Eustachian Tube (i.e., Balloon Dilation). The health plan's determination is upheld. 

The patient is a woman with a history of suspected right sided Eustachian tube dysfunction based on symptoms of clogged sensation in her ears and popping. An audiogram demonstrated mild bilateral sensorineural hearing loss, with type A tympanograms bilaterally, but middle ear effusions were noted by the audiologist. The treating Otolaryngologist did not note middle ear effusions. She was then initiated on intranasal corticosteroids and oral corticosteroids.

Based on the patient's current clinical symptoms, the proposed health service is not likely to be more beneficial than standard treatment for the patient's condition.
In 2016, the United States Food and Drug Administration (FDA) approved endoscopic Eustachian tube dilation to treat persistent obstructive Eustachian tube dysfunction. This is well supported with randomized controlled clinical trials in patients with Eustachian tube dysfunction. In addition, the Clinical Consensus Statement: Balloon Dilation of the Eustachian Tube is supported by the American Academy of Otolaryngology-Head and Neck Surgery.
However, the patient has not been documented to have chronic Eustachian tube dysfunction, rather, acute symptoms without audiometric findings supporting middle ear effusions causing tympanogram or conductive hearing loss changes. In addition, tympanostomy tube placement would be considered standard, first line treatment prior to Eustachian tube dilation, which based on clinical documentation, the patient has never had performed previously.
Appeal type: Experimental/Investigational
Decision: Upheld

Ear Nose Throat
Surgical services

Diagnosis: Eustachian tube dysfunction (ETD)
Treatment: Nasopharyngoscopy, Surgical, with Dilation of Eustachian Tube (i.e., Balloon Dilation)
The insurer denied Nasopharyngoscopy, Surgical, with Dilation of Eustachian Tube (i.e., Balloon Dilation). The health plan's determination is upheld. 

The patient is a female diagnosed with Eustachian tube dysfunction (ETD). Symptoms included crackling and popping of the ear. In addition, she had bilateral tinnitus and blocked sensation; the Right was greater than the Left intermittently. Medical therapy (mometasone and gentamicin nasal rinses) showed no improvement. When the symptoms are severe, the patient does experience hearing loss. Preoperative assessment of the ETD related issues have been evaluated with tympanometry and audiogram. The patient also had computed tomography (CT) scan of the sinus and allergy testing.

Nasopharyngoscopy, Surgical, with Dilation of Eustachian Tube (i.e., Balloon Dilation) is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
On examination, the patient had a septal deviation to the RIGHT with a normal appearing tympanic membrane. Past medical history was significant for a history of bilateral middle ear effusion. Past surgical history was significant for in office balloon sinuplasty of the maxillary sinuses/endoscopic ethmoidectomy performed.
However, a tympanogram performed on 2/13/2023 was normal. Based on this assessment, the patient was recommended to undergo ET (eustachian tube) dilation (that was primarily affecting the RIGHT side) if the patient did not improve on mometasone nasal spray.
The patient was seen on 5/12/2023 with persistent symptoms involving the RIGHT ear. Based on the presentation, the provider was recommended to undergo RIGHT myringotomy and tube placement along with ET dilation.
The proposed therapy is not more likely to be more effective than the standard treatment. The patient fails to have sustained ET related symptoms (normal tympanogram, no evidence of fluid). The requirements for the requested procedure have not been met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: postpartum hypertension
Treatment: inpatient stay

The insurer denied the inpatient stay. The health plan's determination is upheld. 

In this case, the patient is a female who was postpartum day 5 status post SVD (spontaneous vaginal delivery) with pregnancy complicated by gestational hypertension with reported severe range blood pressures at home at 170/100. She had a headache with 3/10 pain. She had used the blood pressure (BP) cuff for the first time that evening and the BP was high. She had prior severe range blood pressures in the office. The patient was admitted with severe range blood pressures meeting criteria for preeclampsia with severe features on the fifth day postpartum. 

In this case, the patient presented with headache and postpartum severe range blood pressures supporting postpartum preeclampsia in need of magnesium sulfate. She was given magnesium sulfate and IV (4) hydralazine for control of blood pressure. Fetal status was not considered as she was day 5 postpartum. There was no acute range blood pressure ongoing. The patient was noted to have mild range blood pressures without any hypertensive emergency. There was no low platelet count. The liver enzymes were normal. There was no right upper quadrant (RUQ) or epigastric pain. There was no doubling of serum Cr (creatinine). There was no evidence of hemolysis. There was no evidence of end organ damage in this case. There was no evidence of cerebral infarction or intracerebral hemorrhage. There was no evidence of vision loss or unstable angina. The patient had no history or symptoms suggesting myocardial infarction, pulmonary edema, aortic dissection, seizures, or acute renal failure. The patient was noted to have normal renal function as measured by her creatinine and had a normal physical exam with normal neurologic exam. There is no evidence of intracranial abnormality or indication for imaging. In this case, a lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient with a past medical history including hypertension, hyperlipidemia, and schizoaffective disorder who presented to the emergency department with chest pain and right upper quadrant pain. The patient also complained of acid reflux and bright red blood per rectum. His vital signs demonstrated hypertension without another abnormality. The exam demonstrated tenderness in the right upper quadrant with a positive Murphy's sign. A digital rectal exam was negative. The white blood cell count (WBC) was 14.35. An ultrasound demonstrated a 1.2 centimeter (cm) gallstone lodged at the gallbladder neck with wall thickening and trace pericholecystic fluid and tumefactive sludge raising the possibility of acute cholecystitis. The patient was hospitalized. He was given cefoxitin as an antibiotic and was taken to surgery where a laparoscopic cholecystectomy was performed without complications. Later that day the patient was found to be doing well. An attempt was made to discharge the patient home but he could not get home due to a lack of transportation. The patient was discharged home on the next day. At issue is the medical necessity of an inpatient stay.

The patient's admission was not medically necessary at the inpatient level of care for the entire admission. Per the Milliman Care Guidelines (MCG) 26th edition ORG:M-555, inpatient admission is indicated for acute cholangitis, acute cholecystitis when cholecystectomy is not anticipated, and for calculous or obstruction of the gallbladder with certain complications. The patient does not meet criteria for acute cholangitis as this requires systemic signs of inflammation and evidence of common bile duct disease. The patient does not meet criteria for acute cholecystitis with signs of systemic inflammation or where cholecystectomy is not anticipated. The patient did not have a fever, C-reactive protein elevation. The patient did have white blood cell (WBC) elevation but did have anticipated gallbladder resection. The patient does not meet criteria for calculous or obstruction of the gallbladder or bile duct with hemodynamic instability, common bile duct obstruction, vomiting that is severe or persistent, severe pain requiring acute inpatient management, bacteremia. The documentation does not suggest that the patient's care could not have been performed at a lower level care. There is no evidence that additional complex testing or therapy other than the procedure was performed. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Services 12 hours a day, 7 days a week, totaling 84 hours. 

The insurer denied Personal Care Services 12 hours a day, 7 days a week, totaling 84 hours. 
The determination is overturned. 

This is a female patient with a medical history notable for dementia and heart disease. The patient is approved for 6 hours per day, 7 days per week (42 hours per week) of personal care services. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week) and the request was denied by the health plan. 

The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient is not able to care for herself independently due to deficits in mobility, function, and cognition. Her dementia and heart disease has been worsening and the provider requests additional assistance with her activities of daily living.
A Uniform Assessment System (UAS) was completed and was available for review. The patient's cognition was noted to have declined. She is frequently incontinent of urine and occasionally incontinent of stool. A task tool associated with the assessment recommended 47 hours per week to address her personal care needs. At issue is the medical necessity of Personal Care Services 12 hours a day, 7 days a week, totaling 84 hours. 

The requested health service of Personal Care Services 12 hours a day, 7 days a week, totaling 84 hours is medically necessary for this patient. 
The patient requires maximal assistance with toileting. She has dementia and incontinence of stool and urine. Her personal care needs are expected to be continuous and unscheduled throughout the day. She has forgotten that she has a bedside commode and will ambulate without assistance, which can lead to falls as she is known to require assistance with transfers. She will also require frequent help with changing after episodes of incontinence. If she does not have incontinence products changed in a timely manner, she could suffer adverse health consequences such as skin breakdown and/or infection. Therefore, the requested increase in personal care hours is medically necessary and reasonable for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient (body mass index (BMI) 30 kilograms per square meter (kg/m2)) who presented to the emergency department with abdominal pain and flank pain of 5-days duration. Comorbid health conditions included pre-diabetes and hypertension. Her evaluation included a physical exam, labs and an abdominal/pelvic computed tomography (CT) scan.  The computed tomography (CT) scan showed findings consistent with appendicitis. She was admitted to the hospital with the diagnosis of a appendicitis. The patient underwent surgery that included a laparoscopic appendectomy with findings of a retrocecal perforated appendicitis with a large associated phlegmon.
On the first post-surgical day, she was being treated with continued intravenous (IV) antibiotics (ancef/Flagyl) and she was kept nothing by mouth (NPO) status. The patient was afebrile, but had nausea and vomiting. Intravenous antibiotics were continued. The patient had normal vital signs, but the abdomen was mildly distended on physical exam. The WBC count was improved, but still elevated. Treatment was initiated for the new diagnosis of diabetes (Metformin). She was without a fever and was determined to be clinically stable for discharge. At issue is the medical necessity of an inpatient stay.

Based on this patient's presenting condition, diagnostic test results, and clinical status, an inpatient level of care during this time was medically necessary and appropriate.
The length of stay and the level of care were appropriate as supported by the submitted medical records. Uncomplicated laparoscopic appendectomy without abscess or peritonitis is typically an ambulatory procedure. However, in this case, the patient had a complicated presentation with ruptured acute appendicitis. The records state that she had sepsis at the time of presentation with tachycardia and leukocytosis. She required surgical treatment that included more extensive surgery than an uncomplicated appendectomy (appendectomy with piecemeal extraction of a perforated appendix in the setting of a large associated phlegmon).  Based on the surgery that was performed she had perioperative risks that were substantially different than those associated with straightforward appendectomy (staple line leak, post-surgical ileus, abscess, obstruction). The more extended inpatient stay was appropriate in this case due to advanced disease, need for more extensive surgical treatment, post-surgical leukocytosis and need for post-surgical parenteral antibiotics.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Breast Cancer
Treatment: Molecular Genomic Profiling Test
The insurer denied Molecular Genomic Profiling Test
The determination is upheld.

This is a female patient with metastatic triple negative breast cancer who is currently on Trodelvy. The Guardant 360 CDX was requested and at issue is whether it is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service, molecular genomic profiling test, or Guardant360 CDX assay is not more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
According to the National Comprehensive Cancer Network (NCCN) guidelines there are certain molecular markers to be tested to assist in the selection of systemic therapies for advanced cases of breast cancer. Those markers include the following: estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor (HER2neu), neurotropic tyrosine receptor kinase (NTRK), phosphoinositide 3-kinases (PIK3CA), estrogen receptor 1 (ESR1), microsatellite stability, tumor mutational burden, rearranged during transfection (RET), breast cancer antigen (BRCA) and partner and localizer of breast cancer antigen (BRCA) 2 [PALB2]. Any additional markers are not recommended by the National Comprehensive Cancer Network (NCCN) nor is there any data in randomized, controlled clinical trials that document a survival advantage over the standard of care therapies outlined by the NCCN according to the above mentioned molecular markers.
The health plan policy provided is in agreement with the National Comprehensive Cancer Network (NCCN) on the use of Guardant360 CDX assay in breast cancer. There are no data that support its use over tissue biopsy analysis for the markers outlined above.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Breast Cancer
Treatment: Molecular Genomic Profiling Test
The insurer denied Molecular Genomic Profiling Test
The determination is overturned.

This is a female with patient with triple negative breast cancer (estrogen receptor negative, progesterone receptor negative, and human epidermal growth factor receptor (her2/neu) negative) with metastatic disease to lymph-nodes in the neck, chest and abdomen (stage IV disease). Patient has undergone many lines of therapies including Adriyamycin, Cytoxan, Taxol, Xeloda, and Trodelvy.
Guardant 360 CDX, a Next Generation Sequencing (NGS) was ordered by the treating physician and is under review as to whether it is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The NexGen sequencing/molecular profiling is now a standard part of managing metastatic malignancies such as breast cancer.
Next generation sequencing (NGS) testing results will allow patients with metastatic breast cancer to receive Food and Drug Administration (FDA) approved therapies such as Alpelisib for phosphoinositide 3-kinases (PI3CK) mutation, Olaparib or Talazoparib for breast cancer antigen (BRCA) 1 and BRCA2 mutation, Larotrectinib or Entrectinib for neurotrophic tropomyosin receptor kinase (NTRK) fusion, Pembrolizumab for tumor mutational burden (TMB) more than 10, Pembrolizumab or Dostarlimab microsatellite instability high (MSI-H) or deficient mismatch repair (dMMR). These recommendations are based on National Comprehensive Cancer Network (NCCN) guidelines.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Breast Cancer
Treatment: Molecular Genomic Profiling Test
The insurer denied Molecular Genomic Profiling Test
The determination is overturned.

This is a female patient with recurrent metastatic breast cancer (estrogen receptor (ER) 1 positive (+), progesterone receptor (PR) 0, human epidermal growth factor receptor (HER2) negative (-); programmed death-ligand 1 (PD-L1) 0 percent (%)). In the metastatic setting, the patient has received capecitabine and Trodelvy. The Guardant360 CDX Assay was obtained and is under review.

This patient has refractory breast cancer. The American Society of Clinical Oncology (ASCO) has issued a provisional clinical opinion that supports somatic and germline genomic testing in patients with metastatic or advanced cancer when there are genomic biomarker-linked therapies approved by regulatory agencies for treatment of their cancer. Given the tissue-agnostic approvals for any advanced cancer with a high tumor mutational burden or deoxyribonucleic acid (DNA) mismatch repair deficiency (checkpoint inhibitor immunotherapy), BRAF [proto-oncogene B-Raf] V600E mutations (dabrafenib+trametinib), or neurotrophic tyrosine receptor kinase (NTRK) fusions (TRK inhibitors), this provides a rationale for testing for all solid tumors, if the patient would be a candidate for these treatments.
This patient has refractory disease and the documentation indicates she could be a candidate for one of these therapies pending biomarker testing. This approach is endorsed by the National Comprehensive Cancer Network (NCCN) Guidelines and by the authors of UpToDate. For these reasons, this service is considered a standard approach to determining treatment in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


Patient who has a history of Obesity and Bronchial Asthma presented to the emergency department (ED) with complaints of (C/O) shortness of breath (SOB) and Asthma Symptoms. The patient had run out of her Albuterol inhaler. The patient walked in by herself.

Vital signs in the emergency department (ED) were Temperature 96.8 degrees Fahrenheit, pulse 110 beats per minute, respiratory rate 22 breaths per minute, Blood Pressure 100/67 mm Hg.  Oxygen saturation was 95% (percent) on room air.  The patient was in no acute distress.
She was alert and oriented to person, place and time.  No accessory muscle use was noted while breathing.  Lungs were positive for bilateral wheezes.  Heart sounds were normal, neurologic exam was non-focal and the patient appeared non-toxic.

White blood cell count (WBC) was 14.2, electrolytes were within normal limits, D Dimer blood (test to determine the levels of D-dimer protein in the body) was negative, troponin was normal, COVID-19 and Influenza were Negative. The chest X-ray was normal.  Venous blood gas was 7.38/38/45.

The patient was treated with intravenous (IV) Steroids, bronchodilators, Magnesium and empiric antibiotics - Azithromycin and Rocephin were given.

This patient remained stable after admission and was discharged home after tapering steroids and switching to oral (PO) meds.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status which can be for up to 48 hours. She was stable to be kept in observation while diagnostic testing and treatment continued. She could have been kept in Observation until she started improving and at that time could have been switched to oral medications and discharged home.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back and lower extremity pain
Treatment: Pain injections (64483x1, 64484x1)
The insurer denied: Pain injections (64483x1, 64484x1)
The denial is overturned.

The patient is an adult male with low back and lower extremity pain. He underwent an L4 and L5 lumbar transforaminal epidural steroid injection that provided six months of pain relief. He returned five months ago with pain that was rated nine out of ten despite home exercises and oral medications. Magnetic resonance imaging (MRI) of the lumbar spine from two years ago shows history of L4 and L5 laminectomy, annular fissuring at the L3-L5 levels, and mild narrowing of the bilateral recesses at L3-L4. A request for repeat L4 and L5 lumbar transforaminal epidural steroid injection was denied as it has been more than 12 months or more than four injections since the first injection at this spine level.

The proposed treatment is medically necessary.

Subsequent transforaminal epidural steroid injections for recurrence of chronic pain that had improved from the first or second transforaminal epidural steroid injections are considered medically necessary with all of the following: The transforaminal epidural steroid injections are requested at a single level bilaterally or up to two levels unilaterally; if a cervical transforaminal epidural steroid injection (TFESI) is requested, non-particulate steroid must be used and the procedure must be conducted with real-time imaging, such as fluoroscopy; There was equal or greater to 50 percent relief and functional improvement for at least two months; at least two months have passed since the last transforaminal epidural steroid injection (TFESI); less than four injections have been given at the same site within 12 months; and less than 12 months have elapsed since the initial injection at the level requested (MET - it has been less than [<] 12 months when this was denied. In this case, the transforaminal epidural steroid injections are requested at a single level bilaterally or up to two levels unilaterally, there was equal or more than 50 percent relief and functional improvement for at least two months; at least two months have passed since the last transforaminal epidural injection, less than four injections have been given at the same site within 12 months, and less than 12 months have elapsed since the initial injection at the level requested (it was less than 12 months when this was denied from date of injection). As above, the procedure is considered medically necessary when it meets the clinical guidelines. In addition, a patient who received one epidural steroid injection that provided six months of pain relief meets reasonably accepted standard of care for repeat injection. This is consistent with cited literature and standard of care.