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

Diagnosis: Prostate Cancer. 
Treatment: Oncotype DX Prostate Cancer Assay. 

The insurer is denied coverage for the Oncotype DX Prostate Cancer Assay. The denial is upheld. 

This patient is a male who was diagnosed with prostate cancer. A prostate biopsy revealed Gleason 3+3 adenocarcinoma in 1/12 cores. The patient's urologist ordered an Oncotype DX Prostate Cancer Assay for further evaluation. The genomic prostate score (GPS) revealed a risk score of 19. 

While the 2019 National Comprehensive Cancer Network (NCCN) guidelines state that men with low risk or favorable risk intermediate Prostate Cancer Assay (PCA) may consider the usage of Oncotype diagnosis PCA test, they also note the absence of randomized prospective trials. The American Urological Association (AUA) guidelines are not as optimistic about the usage of this test stating that the "tissue based genomic biomarker (such as Oncotype diagnosis PCA) has not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up." The impact of tissue based gene expression tests such as Oncotype diagnosis PCA on clinical practice and long term patient outcomes needs to be empirically demonstrated. Prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking. This patient clinically has low risk prostate cancer, and these patients do not always need additional confirmation of low risk status via gene expression tests. Although these tests have been studied at different institutions, it is not yet clear where these tests fit into the algorithm of the diagnosis or management of prostate cancer. 

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

The Oncotype diagnosis PCA test this patient is not considered medically necessary for this patient. 

Based on the above, the medical necessity for the Oncotype DX Prostate Cancer Assay is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Iron deficient anemia 
Treatment: Full hospital admission 

The insurer denied coverage for full hospital admission. The denial is upheld. 

This patient is a male with a history of iron deficient anemia and gastrointestinal (GI) bleeding. He had a previous gastric sleeve operation. He had received 5 units of PRBC prior to being transferred to this hospital. During this hospitalization there was no report of active bleeding. He remained hemodynamically stable. The plan was for a double balloon enteroscopy. The hemoglobin was 9.2. The double balloon enteroscopy did not reveal a source of the bleeding in the small intestine but showed blood in the cecum. A colonoscopy was then performed and no evidence of bleeding was found. The hemoglobin remained stable. 

Clinical indications for admission for iron deficient anemia (M-35) include hemodynamic instability, active bleeding, altered mental status, syncope, cardiac arrhythmia, severe thrombocyctopenia, acute renal failure and cardiac ischemia. The patient did not have these conditions. 

This patient had iron deficient anemia and now required further workup including a double balloon enteroscopy and colonoscopy. He was not actively bleeding at this time and the workup did not find a source for the bleeding. He remained stable to have had both procedures performed on an outpatient basis. No further transfusions were needed during this hospitalization. He did not meet MCG criteria for admission for anemia and he was not having active bleeding. The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld. 

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

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

The patient is a female. She has a past medical history significant for HTN (hypertension), breast CA (cancer), s/p (status post) surgical resection, dyslipidemia, CAD (coronary artery disease), s/p PCI (percutaneous coronary intervention), and Barrett's. She presented to the ER with complaints of intermittent non-exertional chest pain, radiating to left jaw and back, no associated dyspnea, palpitations or diaphoresis. 

No, the Inpatient admission was not medically necessary.

The patient was hypertensive on admission to 173/87 BP (blood pressure), subsequently improving to 121/60, afebrile. The ECG (electrocardiogram) revealed normal sinus rhythm with no ischemic changes. Cardiac troponin was negative. The patient was admitted for evaluation of chest pain. Repeat troponin was negative as well. A nuclear stress test was obtained and was negative for ischemia. She was discharged home with a plan for outpatient follow-up.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) 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. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. 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: Upheld

Diagnosis: suspected hereditary spastic paraplegia.
Treatment: Genetic testing.
The insurer denied the genetic testing. The health plan's determination is upheld. 

The patient is a boy with suspected hereditary spastic paraplegia. He was healthy as a newborn, but was noted to be developmentally delayed by an early age. In addition to developmental delay in both motor and cognitive spheres, he has developed spasticity and hypertonicity in his legs bilaterally. For this spasticity, he is treated with baclofen, with some improvement. The cause of his neurologic problems is unknown. Magnetic resonance imaging (MRI) scan of brain and spinal cord have been normal, as have serum lactate and ammonia levels. Because of the spasticity in his legs, in association with the developmental delay, the neurologist suspects that the patient may have a form of hereditary spastic paraplegia. To confirm this diagnosis and to potentially identify the specific gene defect underlying it, the provider has ordered a hereditary spastic paraplegia comprehensive gene panel. This was denied by the health plan as not medically necessary.

The Genetic Test: Invitae Hereditary Spastic Paraplegia Comprehensive Panel is not medically necessary for this patient.
The patient is suspected of having hereditary spastic paraplegia, which is a group of inherited disorders characterized by progressive weakness and spasticity of the legs. Complicated forms of hereditary spastic paraplegia may also include other neurologic symptoms. The disorder is due to inheritance of a defective gene in an autosomal recessive or dominant pattern, depending upon the specific form of the disorder. There is no specific treatment for hereditary spastic paraplegia.
The hereditary spastic paraplegia comprehensive gene panel is a molecular test that analyzes up to 65 genes associated with hereditary spastic paraplegia. It is possible that completion of this test would identify the genetic defect responsible for the patient's neurologic problems. In addition, the results could possibly provide information that would be valuable to other family members regarding genetic counseling. However, the information generated by this test would not directly impact this patient treatment. The test results would not be of any direct clinical value. Therefore, the requested testing is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Prostate Cancer.
Treatment:  Gene based test (Oncotype DX Genomic Prostate Score).

The insurer denied the for gene based test (Oncotype DX Genomic Prostate Score).  The denial was upheld.   

This is a male patient with past medical history of asthma, elevated prostate-specific antigen (PSA), C-spine injury, joint replacement prostate biopsy and subsequent prostate cancer diagnosis.  The patient's PSA was 4.2, and his biopsy revealed Gleason grade 3+4, 4+ core biopsies for cancer out of 12.  The patient's Oncotype DX PCA test showed a Genomic Prostate Score (GPS) score indicated intermediated risk. 

While it is true that National Comprehensive Cancer Network (NCCN) guidelines state that molecular testing, including the Oncotype DX PCA test be considered for men with NCCN low or favorable intermediate risk prostate cancer and at least a 10-year life expectancy, they also note the absence of randomized prospective trials.  The American Urological Association (AUA) guidelines are not as enthusiastic regarding the usage of Oncotype DX PCA or other similar tests, stating that "tissue based genomic biomarkers have not shown a clear role in Active surveillance for localized prostate cancer and are not necessary for follow-up".  The impact of tissue based gene expression tests, such as Oncotype DX PCA, on clinical practice and long term patient outcomes remains to be empirically demonstrated.  Prospective studies of these moleculars tests yielding a true clinical benefit when implemented in clinical practice are still lacking.  It is not yet clear where this test fits into the algorithm of the management of prostate cancer.  Not every case of low risk or favorable intermediate risk prostate cancer requires additional confirmation by the usage genomic biomarker testing.  There is no medical evidence at this time, that usage of this type of test improves health outcomes in patients with prostate cancer or is more likely to be more beneficial to the patient than any other available standard health service or treatment.
	
Oncotype Dx PCA is not considered medically necessary.  As stated above, further studies are needed to evaluate the efficacy of these genomic biomarker assays.  Prospective studies of Oncotype Dx PCA and other similar tests yielding a true clinical benefit when implemented in clinical practice are still lacking in peer-reviewed literature. 

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 gene based test (Oncotype DX Genomic Prostate Score) is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who presented to the emergency ward via EMS after an episode of loss of consciousness. 

No, the acute inpatient admission was not medically necessary. 

The patient presented after an episode of loss of consciousness. At presentation, her neurological examination, vital signs and neuroimaging were normal. The diagnostic studies, neurological consultation, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gynecological 
Treatment: Inpatient Hospital 

The insurer denied the inpatient stay. The denial is overturned, in whole.

The patient is a female, one month after a Cesarean delivery, who presented for a scheduled exploratory laparotomy for removal of a left ovarian cyst. The patient had an ovarian cyst noted during her Cesarean delivery, but by one month out her cyst had grown to a massive 25 centimeters in size. She was symptomatic with pain and pressure, and surgery was recommended. She underwent an exploratory laparotomy through a midline incision for left ovarian cystectomy. The subject under review is the medical necessity for the inpatient stay. 

The health plan's determination is overturned in whole. 

This is a major surgical procedure, arguably generating a more intense recovery component than a Cesarean delivery or even hysterectomy because of the midline incision. A midline abdominal incision generates more pain and morbidity that used for Cesarean delivery. The patient requires parenteral pain medication usually for at least 24 hours, along with Foley catheter drainage usually until the morning after surgery (with subsequent observation for proper voiding after that). Although early feeding is the contemporary routine, most patients are not actually tolerating any kind of diet for at least 24 hours. Recovery is usually 6 weeks after the surgery. The potential for complications, including bleeding, infection, bladder issues, and ileus, is robust in the first 48 hours after surgery. 

The inpatient stay is medically necessary. The cyst in this case was massive at 25 centimeter (cm), with over 4 liters of fluid aspirated from the cyst before it was removed. In the context of gynecologic procedures, this case represents a very significant and risky surgery. The level of care required is very high - intravenous (IV) hydration, parenteral analgesics, indwelling Foley bladder drainage, and a high level of nursing assistance since the patient may not be ambulatory for 24 hours or more. Additionally, a high level of monitoring including vital signs, urine output, and usually postoperative laboratories, is required to assess for the many possible complications after such a major surgery. This patient received serial laboratories during her entire stay. Unlike laparoscopy, where the incisions themselves are small and likely contribute little to the patient's pain level, the large incision in a midline laparotomy generates a massive inflammatory response and imposes major restrictions on the patient. 

The inpatient stay for this major surgery was medically necessary. Inpatient management is completely reasonable and expected after the procedure reported in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Inpatient Hospital 

The insurer denied the inpatient stay. The denial is upheld in whole. 

The patient is a male with a history of hypertension, hyperlipidemia, diabetes, coronary artery disease, myocardial infarction, and cardiac arrest. He presented to the emergency department complaining of left-sided chest pain that worsened with movement and radiated to the left hip. He had had these symptoms intermittently for three years, but they had worsened since his myocardial infarction one month prior. His blood pressure was 156/81 millimeters of mercury (mmHg) with a heart rate of 80 beats/minute. His room air oxygen saturation was 99%. His physical exam was unremarkable. His serum troponin level was normal. His electrocardiogram showed sinus rhythm with no acute ischemic changes. Chest x-ray showed no acute pathology. The patient was admitted to the hospital to rule out acute coronary syndrome. A second troponin level was normal. The patient had no further complaints. He was discharged. Medical necessity for an inpatient stay is at issue. 

The health plan's determination is upheld in whole. 

This patient with known coronary artery disease, presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was reasonable and prudent. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. Based on his HEART score, he was at low risk for major adverse cardiac events. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient stay and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Gynecological 
Inpatient hospital 

Diagnosis: Ovarian Cyst 
Treatment: Inpatient stay 

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

The patient is a female presented to the emergency room with left lower quadrant pain. She was found to have a left ovarian cyst on imaging with suspected torsion. Her history was remarkable for a prior surgery for ovarian torsion two years prior. 

The Inpatient admission in this case was not medically necessary. 

The patient was in the hospital less than 24 hours (discharged at 13:25 the day after her surgery). The laparoscopic surgery she underwent is routinely performed as an outpatient. Observation after the procedure was reasonable, since the procedure ended late at night with discharge from the post-anesthesia care unit (PACU) not occurring until 2243. However, there was no need for serial labs, multiple physician evaluations, or further interventions. She was voiding, ambulating, and taking oral pain medications by the morning after her surgery - therefore meeting discharge criteria. The patient displayed a routine postoperative course, and observation would be an appropriate level of care. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Pregnancy/Childbirth 
Inpatient hospital 

Diagnosis: Premature rupture of membranes 
Treatment: Inpatient stay 

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

This patient is a pregnant female who presented to the hospital with a chief complaint of rupture of membranes. The patient reported no fetal anomalies complicating her pregnancy. She was currently taking a prenatal vitamin. The pregnancy had been uncomplicated throughout the prenatal course and the estimated fetal weight was 3400 g (grams). The patient was group B strep negative. Her obstetric history was noted for this current pregnancy. She had no other prior pregnancy history. 

The inpatient hospital stay was medically necessary. The patient had premature rupture of membranes at 40-5/7 weeks gestation and induction of labor. In this case, the fetus was noted to have developed fetal distress with recurrent variable decelerations and was not responsive to intrapartum resuscitation with amnioinfusion or position change with maternal oxygen administration. Thus, the patient underwent a cesarean delivery due to fetal distress. This was an indicated admission for labor and then cesarean due to fetal distress in the course of labor. Given the patient had ruptured membranes at admission to the hospital, a plan of induction was appropriate and supported. 

Per the Milliman Care Guidelines (MCG), the admission was determined to be medically necessary. In this case, the cesarean was indicated for fetal distress. This was present in this case with recurrent variable decelerations. The patient had failed conservative attempts to improve fetal status. She was delivered by cesarean. 

In this case, the delivery was indicated by premature rupture of membranes at 40-5/7 weeks which would have been beyond the 39-0/7 weeks gestation. The cesarean was also indicated for fetal distress.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Osteomyelitis . 
Treatment: Radiology Services(MRI). 
The insurer denied Magnetic Resonance Imaging (MRI) of Chest. 
The denial is overturned in whole. 

The patient has a diagnosis of chronic recurrent multifocal osteomyelitis (CRMO) /Chronic non-bacterial osteomyelitis(CNO). The patient was also diagnosed with celiac, mild Crohn's, ulcerative colitis, and gastroesophageal reflux disease (GERD). The patient has a magnetic resonance imaging (MRI) of the chest ordered.
Yes, the requested MRI of the chest is medically necessary. This is considered standard of care for diagnosing and evaluating response to treatment in CRMO. Plain x-rays and even a full body bone scan will not show CRMO lesions in some patients. Therefore, the MRI is appropriate and a medically necessary imaging study for this patient.

This is the standard of care to determine if there are CRMO lesions. This condition can be managed with non-steroidal anti-inflammatory drugs (NSAIDs) and biologics; however, these medications should only be given if a diagnosis is made. The majority of patients with this condition require a full-body MRI in order to find all the lesions.
Therefore, the MRI of the chest is medically necessary in this particular case.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Chronic recurrent multifocal osteomyelitis.
Treatment: MRI.
The insurer denied the MRI abdomen. 
The health plan's determination is overturned.

The patient is a male who has a history of CRMO (Chronic recurrent multifocal osteomyelitis)/ CNO (Chronic non-bacterial osteomyelitis), which is an inflammatory disease causing bone inflammation. The patient has a history of a sacroiliac (SI) joint lesion and has been having years of leg pain. A magnetic resonance imaging (MRI) of the stomach area without contrast (dye) was ordered to evaluate for CRMO lesions; however, this was denied by the health plan and is under review.

Yes. The requested Magnetic Resonance Imaging (MRI) is medically necessary for this patient. This is considered standard of care for diagnosing and evaluating response to treatment in CRMO. This condition can be managed with non-steroidal anti-inflammatory drugs (NSAIDs) and biologics; however, these medications should only be given if a diagnosis is made. Plain x-ray and even full-body bone scan will not show CRMO lesions in some patients. Therefore, the MRI is the appropriate and acceptable imaging study for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Alzheimer's dementia, stroke, anemia, chronic low back pain and diabetes mellitus.
Treatment:  Increase Personal Care Service (PCS) to 24 hours  per day 7 days per week(live-in) for a total of 91 hours.

The insurer denied the Increase in Personal Care Service (PCS) to 24 hours  per day 7 days per week(live-in) for a total of 91 hours.  The denial is overturned. 

The patient is a female with a history of Alzheimer's dementia, stroke, anemia, chronic low back pain and diabetes mellitus.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of 24 hours seven days per week (live-in) Personal Assistance Services to offer increased ADL support.

Yes, the proposed treatment of 24 hours, seven days per week (live-in) Personal Assistance Services is deemed medically necessary. 

This is a female with a history of Alzheimer's dementia, stroke, anemia, chronic low back pain and diabetes mellitus.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  Recent documentation from the patient's provider indicates that due to progressively worsening functional decline, including worsening dementia and physical impairments, the patient is requiring 24/7 assistance for all of her ADLs including transfers, ambulation, toileting, feeding and clothing.  Hence, the currently approved plan of nine hours per day, seven days per week, for a total of 63 hours is insufficient to meet the patient's current needs.  Therefore, the proposed treatment of 24 hours, seven days per week (live-in) Personal Assistance Services is deemed medically necessary.