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

Diagnosis: Ovarian cancer

Treatment: code 0037U genetic testing

The insurer denied coverage for code 0037U genetic testing. The denial is overturned.

The patient is an adult female with an ovarian cancer tumor who underwent FoundationOne CDx testing. Pathology from the patient's tumor showed minimal response to treatment. The patient was treated with chemotherapy. Fluorodeoxyglucose (FDG) imaging showed evidence of recurring tumor and Carcinoembryonic Antigen (CEA) increasing. The request is for FoundationOne CDx testing, which is under review.

The scientific evidence in peer-reviewed literature does support a result of improvement in health outcomes.

Given that the patient's pathology showed minimal response to treatment, the recommended tumor testing is supported by National Comprehensive Cancer Network (NCCN) guidelines, it is standard of care, and supported by peer-reviewed literature.      

The code 0037U genetic testing does have final approval from the appropriate regulatory bodies for this diagnosis.     

This patient is a good candidate for code 0037U genetic testing. The patient's tumor has shown minimal response to treatment on pathology review.     

The code 0037U genetic testing is the best available treatment for this patient at this time.     

The use of this test has been shown to improve outcomes in patients with little or poor response to standard-of-care treatment as in this case.      

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of code 0037U genetic testing and coverage for the requested service should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Positional Plagiocephaly

Treatment: Medical equipment (S1040 x [times] 1)

The insurer denied coverage for medical equipment (S1040 x 1).

The denial is overturned.

This child presented with a diagnosis of positional plagiocephaly. At that point, the child had received physical therapy for two weeks. According to a study by Hauc et al: "Although helmet therapy is widely used, the factors that predict poor outcomes are not well characterized. In this study of over 140,000 patients who received helmet therapy, older age and greater severity at presentation, and noncompliance with treatment were each independently associated with worse craniometric and provider-reported outcomes. Each additional point of cranial vault asymmetry index or cephalic index at a presentation is associated with an increased likelihood of residual brachycephaly at completion [odds ratio (OR): 1.067; 95% (percent) confidence interval (Cl): 1.058-1.075; P <0.0001 and OR: 2.043; 95% (percent) CI: 2.021-2.065; P <0.0001, respectively], whereas each additional point of cranial vault asymmetry index at a presentation associated with increased likelihood of residual asymmetry at completion (OR: 2.148; 95% (percent)  Cl: 2.118-2.179; P <0.0001). Patients were more likely to have residual brachycephaly or asymmetry with increasing age at treatment initiation (OR: 1.562; 95% (percent) CI: 1.524-1.600; P <0.0001 and OR: 1.673; 95% (percent) Cl: 1.634-1.713; P <0.0001, respectively, for each additional month of age at initiation). These results highlight a need for prompt referral for helmeting, especially in cases with severe features or when patients present late to care."  

The child was already several months of age at presentation, and delaying intervention for another two months would have made helmet therapy significantly less effective. Multiple studies show that helmet therapy is superior to repositioning and therapy for the management of positional plagiocephaly. An excellent study by Noto et al using 3D (three-dimensional) scanning of head shapes concluded; "Severe plagiocephaly did not improve naturally in 66% (percent) of the cases."  Because of this child's late presentation, delaying helmet therapy for two months for a trial of medical management would have been unsafe and likely would have resulted in a worse outcome for the child. 

The request is medically necessary. Multiple studies show improved head shape outcome with helmet therapy compared to physiotherapy. Because of this child's late presentation, delaying helmet therapy for two months for a trial of medical management would have been unsafe and likely would have resulted in a worse outcome for the child.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for medical equipment (S1040 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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


This is a female patient who presented to the emergency department (ED) with the complaint of abdominal pain of 1-day's duration. Her past medical history included no chronic health conditions. She was evaluated with a surgical consultation that identified right lower abdominal tenderness. The white blood cell count (WBC) was elevated at 13.5 thousand (K). A computed tomography (CT) scan was completed showing findings of acute appendicitis. The patient was admitted to the hospital and started on intravenous (IV) antibiotics. The patient underwent laparoscopy with appendectomy for acute appendicitis. The records indicate that the operation was completed without complication.
Following surgery, the patient was treated with intravenous (IV) fluids, antibiotics, and analgesia. She was discharged from the hospital following a period of recovery.
At issue is the medical necessity of an inpatient stay.
Acute inpatient hospitalization was not medically necessary for this patient. The medical records support that this patient could have been reasonably and safely monitored and treated at a lower level of care without the need for a full inpatient admission.
This patient presented with abdominal pain. The evaluation with examination, lab data, and a computed tomography (CT) scan supported the diagnosis of acute appendicitis. The diagnosis and indication for surgery was established. She underwent an uncomplicated appendectomy. Following surgery, she was clinically stable, with a down trending WBC count and was started on a diet. Pain medications were transitioned to oral medications. She was discharged from the hospital.
The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have provided for presurgical assessment, operative treatment and post-surgical monitoring and antibiotics. This lower level of care would have also allowed for overnight monitoring.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male patient who initially presented to the emergency department with concerns for intermittent bright blood per rectum. Pertinent history included chronic anemia (baseline hemoglobin (Hgb) 7-8s), prostate cancer status/post (s/p) radiation, end stage renal disease on hemodialysis, coronary artery disease, congestive heart failure, and diabetes mellitus. 
The patient was admitted to the hospital with an impression of acute on chronic anemia with concern for a lower gastrointestinal bleed in the setting of dual anti-platelet (aspirin and Plavix) use. The treatment plan included transfusion of packed red blood cells, withholding Plavix, monitoring bleeding signs / hemoglobin levels, and obtaining consultations. Packed red blood cells (PRBCs) were transfused. Continued rectal bleeding was noted. Gastroenterology consulted and recommended conservative medical management with a bowel regimen and continued serial hemoglobin checks. Gastroenterology recommended a colonoscopy for ongoing bleeding. The bowel preparation was complicated by anginal type pain. A colonoscopy was performed which revealed findings consistent with radiation proctitis with evidence of active bleeding requiring argon plasma coagulation. Thereafter, the course was complicated by presumed pneumonia with empiric antibiotic initiation. The patient continued to have the recurrence of bleeding requiring additional transfusions of packed red blood cells. At issue is the medical necessity of an inpatient hospital stay.
Based on the clinical documentation provided, evidence-based literature and standards of care, acute inpatient level of care was medically necessary for the entire admission.

The patient had a history of end stage renal disease, coronary artery disease, chronic anemia, and prostate cancer treated with radiation therapy and presented with rectal bleeding. Initial evaluation was concerning for acute on chronic blood anemia with a Hgb of 6.2 grams per deciliter (g/dL). The treatment plan included a transfusion of packed red blood cells and conservative measures. Despite such, rectal bleeding persisted. Additional transfusions of packed red blood cells were required well beyond the observation care time frame due to persistent bleeding. A colonoscopy was performed which revealed findings consistent with radiation proctitis with evidence of active bleeding sites treated with argon plasma coagulation. Despite such, bleeding continued requiring additional transfusions of packed red bloods. A flexible sigmoidoscopy was then performed which also revealed additional active bleeding sites treated with argon plasma coagulation. Once the bleeding had resolved and Hgb remained stable, the patient was discharged.
The clinical indications for admission to inpatient care were met. The patient had ongoing active rectal bleeding that could not be controlled at a lower level of care or with an initial colonoscopy and required multiple transfusions of packed red blood cells.[2][3]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with a history of laparoscopic sleeve gastrectomy who was admitted to the hospital for nausea and vomiting. She was hemodynamically stable during her admission. Computed tomography (CT) showed likely residual post-operative air around the surgical site. She was advanced to a full liquid diet. She was then discharged. The denial was for the full inpatient admission.

The requested health service was not medically necessary.

Inpatient admission was not medically necessary as the patient was admitted for intravenous hydration, her nausea improved with medications quickly, and she was advanced to a liquid diet quickly. She had a computed tomography (CT) scan that demonstrated post-surgical changes with no evidence of sepsis. In addition. this admission does not meet Milliman Care Guidelines (MCG) criteria for abdominal pain admission. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multisystem sarcoidosis
Treatment: Acthar Gel 400 unit/5 milliliter (ml) vial
The insurer denied coverage for Acthar Gel 400 unit/5 milliliter (ml) vial.
The denial is Upheld.

This patient is an adult with a history of multisystem sarcoidosis involving the lungs, eyes, and liver. The patient had been treated with systemic Prednisone. The patient's physician is requesting Acthar Gel.

In a note, patient's physician states that the patient has a history of hypertension. Also noted that this patient had failed a course of steroids. No details were provided.

There is no documentation as to why this patient could not take Prednisone. Nor is there any documentation that states that this patient had been on alternate steroid sparing agents such as Methotrexate, Azathioprine or Leflunomide. Based on the documentation provided Acthar Gel cannot be approved as it is not the first line of therapy and not the standard of care.

The insurer's denial is 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 Acthar gel 400 unit/5 milliliter (ml) vial is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left common iliac artery aneurysm

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned.


The patient is an adult male who presented for a planned procedure.  The patient was seen approximately 10 days prior for incidental finding of left common iliac artery aneurysm that measured 3.2 cm (centimeters) on pelvic non-contrast computerized tomography (CT) for prostate cancer screening.  The patient underwent computed tomography angiography of the abdomen and pelvis as well as the chest.  This showed 3.2 cm isolated left common Akari aneurysm that was amenable to endovascular repair with iliac branch device.  The patient was asymptomatic.  Vital signs of the patient included temperature of 98.4 degrees Fahrenheit, heart rate of 67 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 142/92, and oxygen saturation of 100% (percent) on room air.  The patient underwent endovascular repair with an iliac branch device and recovered well postoperatively.  The patient's pain was controlled.  The patient was voiding without difficulty and tolerated oral intake.  The patient was able to ambulate without assistance.

The provided medical record and Milliman Care Guidelines (MCG) guidelines were referenced.  The patient had a complex medical history and presented with severe signs and symptoms which required medical care and services of such intensity that could only be furnished on an inpatient basis.  The patient had an incidental finding of left common iliac artery aneurysm and due to the size of the lesion, operative intervention was indicated.  The patient had endovascular repair of the aneurysm.  The procedure was on centers for Medicare and Medicaid services inpatient only list.  It was stated that the patient met inpatient criteria as the patient required vital signs, neurologic signs, neurovascular checks more frequently than every 4 hours.  Given that the surgical procedure was on the inpatient only list, this made the inpatient setting the only safe improvement setting in which the medical condition, safety, and health would not be significantly indirectly threatened.

Per the sited references, admission to the hospital is indicated when inpatient monitoring is needed such as with vital signs, neurological signs, neurovascular checks more frequently than every 4 hours.  Three-to-four-millimeter iliac aneurysms are appropriate for repair.  Given the aneurysm size and the need for frequent monitoring, admission to the hospital was medically necessary for the patient.  

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted tooth
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is overturned.

The patient is an adolescent male with no known medical or psychological conditions. The patient has a Class I skeletal and soft tissue profile and mixed dentition. The maxillary arch form is ovoid; the mandibular arch form is square. There is moderate maxillary and mild mandibular crowding present. There is no cross bite or open bite. The patient has a deep bite, and overjet of approximately 2 millimeters. The maxillary right canine is impacted and blocked out of the arch by more than 50% (percent).

The D8080 Braces, D8670 Monthly Visit are medically necessary.

The patient's maxillary right canine is impacted and blocked out of the arch by more than 50%. This meets the Auto-Qualifier criteria of "Impacted permanent anterior where extraction is not indicated." Since the patient has an Auto-Qualifier for Orthodontic Treatment, the requested services are considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: legally blind, diabetes, hypertension and chronic obstructive pulmonary disease 
Treatment: PCA level II service: 56 hours per week, 8 hours per day, 7 days per week
The insurer denied coverage for: PCA level II service: 56 hours per week, 8 hours per day, 7 days per week
The denial is: Overturned    
This is an adult legally-blind patient with chronic medical problems including diabetes, hypertension and chronic obstructive pulmonary disease (COPD).  The patient lives with spouse in a private residence. The insurer approved personal care aide (PCA) services 42 hours/week and the request is for PCA level II service: 56 hours per week, 8 hours per day, 7 days per week ; leading to an external review.  

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as modified independent. The patient requires maximal assistance to total dependence for completing Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient requires maximal assistance for bathing, lower body dressing and toilet use. Extensive assistance is needed for personal hygiene, upper body dressing and bed mobility. Limited assistance is reportedly needed for eating. The patient is non-ambulatory and described as "bed bound."  The patient is frequently incontinent of bladder and bowel. There have been no falls over the prior 90 days.  

Submitted for review are clinical records from a previous admission; which are not current and of marginal benefit for the purposes of this assessment. A more recent treatment note was submitted, from the patient's treating physician, documenting his underlying medical condition which was also reviewed. A physical examination is not documented as performed and there is no specific functional assessment.  

Based on the records reviewed, the patient's functional ability has declined. Furthermore, the patient's medical condition and physical limitations are at a level or unpredictable as to require PCA services 56 hours/week.  

The healthcare plan did not act reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based).   

From a physical medicine and rehabilitation perspective, PCA level II service: 56 hours per week, 8 hours per day, 7 days per week are medically necessary.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care aide (PCA) level II service: 56 hours per week, 8 hours per day, 7 days per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: lower extremity claudication
treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This woman presented to the hospital for scheduled lower extremity angiography and intervention, if indicated, for worsening claudication. Her medical history was remarkable for diabetes, Crohn's disease, hypertension, hyperlipidemia, coronary artery disease, coronary artery bypass graft surgery and obesity. Angiography showed significant stenoses in the left superficial femoral (SFA) and common femoral (CFA) arteries. The CFA lesion was treated with intravascular lithotripsy and a drug-coated balloon. The SFA was treated with mechanical thrombectomy and a drug-coated balloon. The procedure was uncomplicated. Post-procedure, the patient had urinary retention that required straight catheterization once. Her systolic blood pressure was elevated at 190-230. She refused medication and repeated measurements; she also refused continuous electrocardiographic monitoring. She was discharged.

Based on the documentation provided, an inpatient level of care was not medically necessary.
Peripheral arterial interventions in stable patients with claudication are increasingly being performed in the outpatient setting, including office-based centers, without an increase in complications as compared to patients who are admitted to the hospital overnight. This woman had an uncomplicated procedure. While she was markedly hypertensive post-procedure, there was no evidence of acute ischemia, decompensated heart failure or other end-organ damage. If it was deemed necessary to monitor her overnight, this could have been accomplished at a lower. An inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a young boy who presented with a first time seizure. He was well until naptime at school, when he began to flatten his back, foam at the mouths, and his eyes rolled back. He was unresponsive during the episode and it lasted from several seconds to a few minutes. An ambulance was called and he was noted to be 'spaced out' with a 'dead stare' for 10 minutes during transport. There were no other associated symptoms. He had no fever or recent trauma. He did have a runny nose for the past few days with a cough. He has a history of speech delay and is receiving speech therapy. His family history is significant for a seizure disorder in his sister.

Inpatient Hospital Admission was medically necessary for this patient.
This is a young boy who presented with a new onset, afebrile seizure. He was unresponsive during the event, and continued to have a 'dead stare' for 10 minutes while in transit. Therefore the event required evaluation for a potential etiology and to rule out non-convulsive status epilepticus. An appropriate work up was done in the emergency department, and additional monitoring and testing, including an overnight electroencephalogram (EEG), were needed, which requires an inpatient setting of care.
According to the MCG (Milliman Care Guidelines) Health Inpatient and Surgical Care Guidelines, 27th Edition, Seizure, Pediatric; hospitalization is indicated for patients with an etiology that requires inpatient level of care. This patient required hospital admission for evaluation of potentially dangerous etiologies for a first time afebrile seizure with loss of consciousness and continued unresponsiveness during transport.
He required hospital admission for careful monitoring with continuous oximetry and frequent neurology checks, and required additional evaluation with specialist consultation and an inpatient overnight EEG. Children with an unexplained seizure should have an EEG awake and while sleeping, and the EEG should be obtained as soon as possible after a seizure.