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

Diagnosis: Heartburn. 
Treatment: EGD (esophagogastroduodenoscopy). 

The insurer denied the EGD (esophagogastroduodenoscopy). 
The denial is upheld. 

The patient is a female. She presented with heartburn for the last year. 

Per clinic note, the patient tried OTC (over the counter) omperazole 20 mg (milligrams) QD (daily) with resolution of symptoms for 2 weeks. The patient stopped the medication. By the time of evaluation, she was off PPI (proton pump inhibitor) for 5 days, with breakthrough symptoms. She evidenced no alarming symptoms, such as pain, dysphagia, or weight loss documented. Her BMI (body mass index) was 27. 

The EGD (esophagogastroduodenoscopy) done showed gastritis and esophagitis. 

No, the EGD (esophagogastroduodenoscopy) was not medically necessary. 
Per the American College of Gastroenterology (ACG) Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease, 
"1. For patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms, we recommend an 8-week trial of empiric PPIs [proton pump inhibitors] once daily before a meal (strong recommendation, moderate level of evidence). 

2. We recommend attempting to discontinue the PPIs [proton pump inhibitors] in patients whose classic GERD [gastroesophageal reflux disease] symptoms respond to an 8-week empiric trial of PPIs [proton pump inhibitors] (conditional recommendation, low level of evidence). 

3. We recommend diagnostic endoscopy, ideally after PPIs [proton pump inhibitors] are stopped for 24 weeks, in patients whose classic GERD [gastroesophageal reflux disease] symptoms do not respond adequately to an 8-week empiric trial of PPIs [proton pump inhibitors] or whose symptoms return when PPIs [proton pump inhibitors] are discontinued (strong recommendation, low level of evidence)." 

The patient in this case was not put on an eight-week empiric trial of PPIs (proton pump inhibitors) prior to proceeding with upper endoscopy. Therefore, as the patient did not meet the current clinical guideline recommendations, the esophagogastroduodenoscopy was not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The esophagogastroduodenoscopy was not medically necessary per the current clinical guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries. 
Treatment: Inpatient Hospital. 
The insurer denied Inpatient Admission. 
The denial is upheld. 

This patient is a male who presented to the emergency department after sustaining a gunshot wound to the penis. The patient was able to urinate but had a significant amount of soft tissue injury to the penis and groin. He was taken to the operating room that day for cystoscopy, penile exploration, debridement, and a tissue transfer. The surgery went well, and the patient was discharged to home that same day with ambulatory surgery discharge instructions.
The issue is whether an inpatient admission was medically necessary.

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

The requested health service/treatment of Inpatient Admission was not medically necessary for this patient.
This is not a medically necessary inpatient admission. This patient had an isolated penile injury that was managed with an ambulatory surgery. He was discharged the same day as he presented. The patient was not unstable. There was no evidence of vascular injury. The injury was confined to the soft tissues and did not require inpatient management or monitoring. There is not a medical necessity documented to indicate an inpatient admission.
Therefore, the requested health service/treatment of Inpatient Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Arthrogryposis-renal dysfunction-cholestasis syndrome.
treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male who has multiple medical problems as a result of arthrogryposis-renal dysfunction-cholestasis syndrome. He had a number of prior hospitalizations for gastrointestinal and renal complications, including electrolyte derangements such as hypernatremia due to polyuria and hypocalcemia. He is on multiple medications. His nephrologist determined that he required a central venous catheter (port placement) due to poor intravenous (IV) access, need for frequent blood draws and prior hospitalizations for dehydration. The port placement was scheduled and he was pre-admitted to the nephrology service for IV hydration and calcium correction while nothing by mouth (NPO) awaiting surgery.

The inpatient hospital admission was not medically necessary. 

The patient was medically complex, but clinically stable when evaluated by nephrology prior to admission and when admitted pre-operatively. Labs showed some abnormalities. The nephrology note suggests that most of the abnormalities were stable, chronic issues (modest anemia, presumably due to renal disease, for which he was on Epogen; modest elevations of blood urea nitrogen (BUN) and creatinine consistent with chronic renal disease; mildly low albumin consistent with chronic gastrointestinal (GI) disease and failure to thrive; mild transaminitits consistent with chronic GI disease; and modestly low ionized calcium at 0.94 (consistent with chronic diseases). The only issues identified to manage pre-operatively were the need for intravenous fluids while NPO awaiting surgery and calcium correction. These two interventions can be performed at a lower level of care. There is no evidence that there were clinical issues that arose that would meet acute inpatient criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke with right sided weakness.
Treatment: Personal care aide 70 hours/week, consumer direct, 1 client.

The insurer denied personal care aide 70 hours/week, consumer direct, 1 client.  The determination is overturned.

The patient has a past medical history of a stroke with right sided weakness. This review is for the medical necessity of an increase in personal care assistant (PCA) to 70 hours/week, consumer direct, 1 client. The patient is currently approved for 35 hours/week.

He had been assigned services based on an assessment tool assessing the patient with modified independent cognition with no memory problems. He requires total dependence with task of ordinary housework while maximum assistance with the tasks of meal preparation, extensive assistance with managing medications and maximal assistance with shopping. The patient was assessed at extensive assistance with the task of bathing, limited assistance for personal hygiene, extensive assistance with dressing upper and maximal assistance for dressing lower body, extensive assistance with locomotion, maximal assistance with transfer toilet, extensive assistance toilet use, and independent with bed mobility and supervision with eating. He uses a wheelchair/scooter. He was noted with no change in activities of daily living (ADL) status in the last 90 days, and no change in self-sufficiency. He is bowel and bladder continent. He has no informal caregivers during the day.

The requested health service/treatment of personal care aide 70 hours/week, consumer direct, 1 client is medically necessary for this patient.

The patient requires assistance with activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). He has a history of a stroke with resultant weakness. He gets around with a wheelchair; however, he requires maximal assistance with transfer toilet, extensive assistance toilet use and lower body dressing and, thus, will require caregiver assistance for most of the day when no informal caregivers are available.
Therefore, the requested services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional/Obesity.
Treatment: Pharmacy/Prescription Drugs.
The health plan denied the requested prescription drug Saxenda as not medically. necessary. 
The health plan's determination is overturned.

The patient is a female with obesity. She has participated in a medical weight loss program and has lost 10% of her body weight over 9 months. She presented enrolled in Weight Watchers for a year and was exercising routinely. She presented later with a weight loss exceeding 5% within 3 months. She presented later with a loss of 22 pounds since starting Saxenda (210 pounds when starting Saxenda to 188 pounds); she had been exercising several days per week; her body mass index (BMI) was 31.9 kg/m2(kilograms is divided by height in meters squared). The patient's weight declined 12 pounds from 200 pounds to 188 pounds, or 6%. At issue is the medical necessity of the requested prescription medication Saxenda for the treatment of obesity.

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

Yes, the medical necessity of Saxenda is supported in this case. This patient with Class I obesity has had success with Saxenda for the treatment of obesity and risks the development of additional comorbidities such as hypertension, diabetes, obstructive sleep apnea, and joint disease with weight regain (Jensen, et al). Guidelines for pharmacological management of obesity released in 2015 by the Endocrine Society state that patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications (Apovian, et al). Specifically, pharmacotherapy is recommended in patients with a BMI higher than 30 kg/m2 (or 27 kg/m2 if comorbidities are present). Saxenda  is Food and Drug Administration (FDA)-approved for chronic weight management in patients with a BMI over 30 kg/m2 (Saxenda prescribing information). The medication proved effective in a randomized controlled trial with 63% of patients achieving weight loss of over 5% of body weight over 56 weeks (Pi-Sunyer, et al; Lundgren, et al; Mehta, et al). In this case, the patient has lost 10% of her weight over 9 months, including 6% of her weight in the last 6 recorded months. For these reasons, the request for Saxenda is supported as medically necessary for the treatment of this patient's Class I obesity.
Appeal type: Medical necessity
Decision: Upheld

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


The patient had an ovarian cyst and underwent a robotic assisted laparoscopic right salpingo-oophorectomy, requiring conversion to a laparotomy. The patient did not have a fever and her vital signs were stable. She tolerated oral intake and oral medications. The patient was discharged to home. At issue is the medical necessity of an inpatient stay. The requested health service/treatment of inpatient stay was not medically necessary for this patient. The patient was afebrile, with stable vital signs, she had a non focal exam and she was able to ambulate, void and take oral medications, as well as an oral diet. The patient did not have any conditions that required an inpatient level of care. This is consistent with peer-reviewed literature, consistent with standard of care and supported by professional organizations.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Guardant 360
The insurer denied the Guardant 360.
The determination is overturned.

This is a patient with hormone receptor positive, human epidermal growth factor receptor (HER2/neu) negative metastatic breast carcinoma stage IV (four). The patient had experienced disease progression on the standard antiestrogen therapy based on the recent radiological assessment by her treating oncologist. The NexGen sequencing test of Guardant 360 molecular profiling was requested by the treating oncologist to identify somatic mutation including phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha (PI3CK) mutation and other molecular abnormalities to direct future treatments. At issue is whether the Guardant 360 is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes. NexGen sequencing (NGS)/molecular profiling is now a standard part of management of metastatic malignancy such as breast cancer. For metastatic estrogen receptor positive breast cancer, testing for NexGen sequencing such as guardant 360 will provide molecular targets such as PI3CK mutation.
NGS testing results will allow patient to receive Food and Drug Administration (FDA) approved therapies such as Alpelisib for PI3CK mutation, Olaparib or Talazoparib for breast cancer antigen (BRCA) 1 and BRCA2 mutation, Larotrectinib or Entrectinib for neurotrophic receptor tyrosine 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. [NCCN guidelines version 3.2022 for invasive breast cancer treatment, page 87]. Therefore, the Guardant 360 is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Guardant 360
The insurer denied the Guardant 360.
The determination is upheld.

The patient has Stage IV (four), hormone receptor positive and human epidermal growth factor receptor 2 (Her2neu) negative breast cancer who progressed via recent positron emission tomography (PET) scan. At issue is whether Guardant360 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, Guardant360 is not likely to be 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, the following markers are recommended to be tested to assist in the selection of systemic therapy options in advanced cases of breast cancer: estrogen receptor (ER), progesterone receptor (PR), Her2neu, breast cancer antigen (BRCA), phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha (PIK3CA), programmed death ligand 1 (PD-L1), neurotrophic receptor tyrosine kinase (NTRK), microsatellite stability and tumor mutational burden. Any additional markers are not recommended as there are no randomized, controlled clinical trials demonstrating a survival benefit over standard of care guidelines as per NCCN.
Therefore, the Guardant360 is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Inpatient Hospital Admission.

The insurer denied inpatient hospital admission.  The denial is upheld.

The patient is a female with a history of diabetes, gastroesophageal reflux disease (GERD), Helicobacter (H.) pylori, and thyroid disease. She presented to the emergency room with left shoulder pain, along with left facial and left arm numbness. The vital signs were normal. She was alert and oriented and in no apparent distress. Physical exam was unremarkable. Labs were non-contributory. The head computed tomography (CT) scan and CT angiogram were essentially normal. There were no infiltrates, effusions, or pneumothorax on the chest x-ray. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.

Upon admission, the patient was treated with oral clopidogrel, "high-intensity" statin, and her usual home medications. Only one examiner noted mild left weakness, but several other examiners found no neurologic findings. The following day, a magnetic resonance imaging (MRI) of the brain was negative for acute infarct. The remainder of the stay was clinically uneventful, and the patient was discharged.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The requested inpatient hospital admission was not medically necessary for this patient. Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The services provided - imaging, labs, consultations, and oral medications - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebral vascular accident (CVA)
Treatment: home health care
The insurer denied Personal Care Services per 15 Minutes: 38 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, diabetes mellitus type 2, morbid obesity, deep vein thrombosis (DVT) / pulmonary embolism (PE) with chronic anticoagulation, cerebrovascular accident (CVA) with left-sided weakness, and legal blindness who had been assigned PCA (personal care assistant) services 38 hours/week. The patient's primary care physician (or provider) (PCP) provided form M11-Q stating the patient was legally blind, her care provider helped her with medications, and the patient needed all services continued due to the patient's poor health and legal blindness. The patient underwent an assessment via video teleconference assessing the patient at total assistance with ordinary housework while maximum assistance with tasks of meal preparation and shopping. With tasks of managing finances, managing medication, stairs, transportation, bathing, and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene and dressing upper body. The patient was assessed at supervision with tasks of walking, locomotion, transfer toilet, and toilet use while independent with tasks of bed mobility and eating. 

Personal Care Services per 15 Minutes: 38 Hours per Week are medically necessary for this patient.
The patient had previously assigned PCA services 38 hours/week. The patient had no improvement in her functional status yet her hours were reduced by 16 hours/week. The initial and final adverse determination denial notices failed to document a reason for this reduction other than noting tasking tool calculated 22 hours of care needed per week. On the previous assessment there was no documentation that the patient had improvement in her clinical status. The patient has legal blindness and left-sided weakness from a CVA and requires assistance with all activities of daily living (ADL) except for bed mobility and eating. The assessment and subsequent client task sheet underestimated the patient's assistance needs with ADL / Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 38 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Calculus of the right ureter.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This case involves a woman with hypertension and asthma, and chronic kidney disease due to minimal-change disease, who presented to the emergency department (ED) with right-sided abdominal pain. She described the pain as sharp, shooting, and constant, with associated bloating, gassiness, and nausea. She reports poor oral intake of food and liquids. Before hospitalization, she was assessed at urgent care with ultrasound and was prescribed Linzess, prune juice and MiraLAX for constipation. This produced multiple bowel movements but no improvement in the pain. The ultrasound revealed uterine fibroids and an ovarian cyst. A computed tomography (CT) scan of the abdomen and pelvis revealed diverticulosis without diverticulitis, normal appendix, right perinephric stranding, and mild hydroureteronephrosis with a 5 millimeter (mm) distal stone. The patient was admitted to the hospital with calculus of the right ureter, acute kidney injury (AKI), and a questionable urinary tract infection. 

The inpatient hospital admission was not medically necessary. Kidney stone evaluation and treatment are usually appropriately managed under a lower level of care. This patient's course was fairly unremarkable, with appropriate treatment of IV fluids, empiric antibiotics, a urologic procedure for removal of the stone, and subsequent discharge home.

The patient was experiencing several days of right lower quadrant pain and was found to have an obstructing ureteral stone on admission. She has chronic kidney disease (CKD) due to minimal-change disease and has primarily experienced an acute kidney injury due to prerenal etiology. The patient received IV hydration and urology and removed the stone without complications. Once this was accomplished, the renal function improved, and the patient was safely released home. Evaluation of the urinalysis revealed only nine white blood cells, with many bacteria, negative leukocyte Estrace and nitrites. Clinically, there is no evidence of sepsis, no evidence of profound hypotension, and refractory to IV fluids to suggest a life-threatening infection. There is no clear, convincing evidence of persistent nausea and vomiting and ongoing inability to tolerate food and liquids.
The patient has experienced an AKI and had a rapidly improved renal function once she was rehydrated, and the obstruction was relieved. The creatinine is less than 4 and improved from 2.5-1.8. There were no complications of the AKI, including hyperkalemia, severe acidosis, or hypoxemia, to warrant more extensive evaluation and treatments, i.e., inpatient level of care. All of the patient's symptoms improved with the urologic intervention. A lower level of care was appropriate.