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

Diagnosis: Gastric ulcer.

Treatment: Procedure code 43239, esophagogastroduodenoscopy (EGD).

The insurer denied coverage for procedure code 43239, esophagogastroduodenoscopy (EGD).

The denial is overturned

The patient was previously found to have a gastric ulcer. She had been treated with a PPI (proton pump inhibitor) and her symptoms had improved. She was scheduled for an endoscopy to evaluate for healing of the gastric ulcer. The endoscopy showed that the ulcer had healed, and that mild gastritis was present. 

MCG (Milliman Care Guidelines) A-0203 describes indications for an upper GI (gastrointestinal) endoscopy. Peptic ulcer disease is a category that is listed in this guideline. If a patient has a gastric ulcer that is not clearly due to NSAID (non-steroidal anti-inflammatory drug) use, then a follow up endoscopy is indicated. 

This patient had a previous gastric ulcer. The submitted papers do not indicate that the ulcer was due to NSAID use. Therefore, the endoscopy met MCG guidelines for follow up of healing of a gastric ulcer. The health care plan did not act reasonably or with sound medical judgment. The endoscopy was medically necessary. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for procedure code 43239, esophagogastroduodenoscopy (EGD), is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thoracic fracture
Treatment: continued subacute rehab
The insurer denied continued subacute rehab. The health plan's determination is upheld. 

The patient is a male who has diagnoses of wedge compression fracture of first thoracic vertebra, initial encounter for closed fracture, malignant neoplasm of meninges, benign neoplasm of meninges. His past medical history also includes hypertension, seizure disorder on Keppra, meningioma. 

Continued Subacute Rehabilitation Service is not medically necessary.
Occupational therapy (OT) documents the patient's initial evaluation for lower body (LB) dressing, lower body bathing, toileting as total dependence without attempts to initiate. Upper body (UB) bathing, and UB dressing was max assist. Hygiene/grooming was moderate assist. OT documents that the patient's only change in these ratings is that he did have an attempt to initiate toileting, LB (lower body) dressing and LB bathing but was still max assist. Other domains were unchanged.
Physical therapy documents the patient's initial evaluation for bed mobility as max assistance. Transfers were total dependence without attempts to initiate. The patient was non-ambulatory. Functional transfers were total dependence without attempts to initiate. As of the dates under review, the patient had progressed to mod assistance for functional transfers, 50 feet with two-wheeled walker with contact guard assist (CGA) with mod assistance x 2. Other domains were unchanged.
Criteria for continued Subacute Rehabilitation includes that a patient must have medical necessity for physical, occupational, or speech therapy for a minimum of 1 hour per day and 5 days per week. In addition, documentation must demonstrate sustained gains, progress towards pre-established goals, improvement in function and reduction in limitations. For the time period in question, the patient did not meet these criteria. The patient did not have complex skilled nursing needs, did not require intravenous (iv) or IM (intramuscular) medication management, was not dependent on parenteral nutrition, and did not have complex wound care needs. The patient had made minimal gains in a month of therapy and would not be projected to make substantive further gains that would make continued services medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal - gastroesophageal reflux disease (GERD). 
Treatment: Diagnostic Testing. 
The insurer denied gastric services esophagogastroduodenoscopy (EGD). 
The denial is upheld.

The patient is a female with gastroesophageal reflux disease (GERD). She has occasional heart burn and takes over the counter medications as needed. She was scheduled for a surveillance colonoscopy. Therefore, the attending provider did an esophagogastroduodenoscopy (EGD) at the same time to evaluate her GERD. The subject under review is the medical necessity for the EGD. 

The health plan's determination is upheld.

The requested gastric services (EGD) is not medically necessary for this patient.
According to the current American College of Gastroenterology Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease, patients presenting with typical symptoms of heartburn and regurgitation should be given empiric medical therapy with a proton pump inhibitor. The diagnosis of gastroesophageal reflux disease is made using some combination of symptom presentation, objective testing with endoscopy, ambulatory reflux monitoring, and response to antisecretory therapy. Empiric proton pump inhibitor therapy (trial) is a reasonable approach to confirm gastroesophageal reflux disease when it is suspected in patients with typical symptoms. There is no indication that the patient has had an appropriate trial and failure of proton pump inhibitor therapy for 4-8 weeks to manage her symptoms.
Therefore, esophagogastroduodenoscopy for this patient would not be in accordance with generally accepted standards of medical practice or clinically appropriate, in terms of type, frequency, extent, site and duration for the patient's illness.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer - Prostate. 
Treatment: Lab Work/Blood Tests. 
The insurer denied Oncotype DX Prostate.
The denial is upheld. 

The patient is a male with low volume low risk prostate cancer. His prostate-specific antigen (PSA) is less than 1.0. His clinical stage is T1c. Gleason Grade Group 1 cancer was found in a very small number of tissue cores.  Oncotype Dx prostate testing was performed.
At issue is the medical necessity of Oncotype DX Prostate.

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

No, the requested health service/treatment of Oncotype DX Prostate is not medically necessary for this patient.
Current Guidelines of the American Urological Association (AUA) note that this testing is not appropriate for patients who may be considered candidates for active surveillance. The National Comprehensive Cancer Network (NCCN) notes the test is one of several biomarkers marketed with significant industry influence and not subjected to randomized controlled studies. It is not established as standard of care for this volume and type of prostate cancer.
Guidelines of American Society of Clinical Oncology (ASCO) do not endorse the use of this test, noting, "Tissue-based molecular biomarkers (evaluating the sample with the highest volume of the highest Gleason pattern) may improve risk stratification when added to standard clinical parameters, but the Expert Panel endorses their use only in situations in which the assay results, when considered as a whole with routine clinical factors, are likely to affect a clinical decision. These assays are not recommended for routine use as they have not been prospectively tested or shown to improve long-term outcomes-for example, quality of life, need for treatment, or survival."
Therefore, the requested health service/treatment of Oncotype DX Prostate is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke
Treatment: Personal Care Aide (PCA) Level 2: 6 hours/day, 7 days/week, a total of 42 hours/week
The insurer denied PCA Level 2: 6 hours/day, 7 days/week, a total of 42 hours/week.
The denial is overturned. 

The patient is a male with a past medical history of stroke, hypertension, and osteoarthritis.

The patient was assigned services based on assessment assessing the patient as minimally impaired with memory problems, moderate hearing difficulty, and no vision difficulties. The patient was assessed to require maximal assistance with task of meal preparation and shopping, total dependence for housework, and supervision with medications. The patient was assessed at extensive assistance with task of bathing, dressing lower body, walking, and toilet transfers, limited assistance for personal hygiene, dressing upper body, toilet use, and bed mobility, and set up with eating. The patient is frequently bladder incontinent and bowel continent.

Increase in services was requested and he underwent assessment assessing the patient at minimally impaired with memory problems, moderate hearing difficulty, and minimal vision difficulties. The patient was assessed to require maximal assistance with task of meal preparation, medications, and shopping and total dependence for housework. The patient was assessed at extensive assistance with task of bathing, personal hygiene, dressing upper body, dressing lower body, walking, toilet use, toilet transfers, and bed mobility and set up with eating. The patient is frequently bladder incontinent and occasionally bowel incontinent.

The patient's primary care provider wrote a letter of medical necessity. The physician noted that the patient has multiple medical problems and has gait abnormalities since his stroke with recent decline due to joint pain and requires assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

At issue is the medical necessity of Personal Care Aide (PCA) Level 2: 6 hours/day, 7 days/week, a total of 42 hours/week.

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

Yes, the requested health service/treatment of PCA Level 2: 6 hours/day, 7 days/week, a total of 42 hours/week is medically necessary for this patient.

The patient has had a documented functional decline from the initial assessment, now requiring more assistance for his ADLs. He was assessed as limited assistance for dressing upper body, personal hygiene, toilet use, and bed mobility, but he now requires extensive assistance. Thus, additional hours are medically necessary for safe completion of ADLs and IADLs.

Therefore, the requested health service/treatment of PCA Level 2: 6 hours/day, 7 days/week, a total of 42 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee pain

Treatment: Inpatient admission 

The insurer denied coverage for an inpatient admission 
The denial is upheld

The patient is a male with a past medical history significant for hypertension, chronic back pain due to lumbar spinal fusion (L3-5), GERD (gastroesophageal reflux disease), s/p (status post) right knee replacement and osteoarthritis who presented to the emergency room with complaints of right knee pain.  

Vitals on presentation included: Temperature 98.2 F (farenheit), Blood Pressure 149/84, Pulse 77, Respiratory Rate 18, oxygen (O2) saturation 99%. Laboratory results showed: white blood cell count (WBC) 7.4, Hgb (hemoglobin)-12.1, Hct (hematocrit) -38.1, crreatine-0.9, glucose-131. 

The patient was empirically started on intravenous antibiotics (vancomycin and cefepime) for possible right knee cellulitis. X-ray of the knee showed an implant in place, otherwise no fracture or dislocation. Orthopedics was consulted to rule out a septic joint. It was determined that the patient's presentation was "not a cellulitis process and was more likely a frostnip from cold therapy and physical therapy." The patient remained afebrile, hemodynamically stable, and was discharged to continue outpatient management on oral antibiotics.

According to documentation, the patient was admitted to the hospital for worsening right knee pain. Otherwise, he was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal WBC. It was determined that findings were consistent with cold treatments received during physical therapy rather than infectious. Based on above findings, the patient met criteria for observation level of management. He did not meet criteria for acute hospitalization.

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Inpatient Rehabilitation Admission
The insurer denied the Inpatient Rehabilitation Admission
The denial is upheld

The patient is a male, unemployed, living with his girlfriend, who presented for inpatient substance-abuse rehab admission with the primary diagnoses of amphetamine/stimulant use severe, cannabis use, moderate and tobacco use, moderate. The patient presented to the hospital with the chief complaints of I don't know how to deal with my emotions. The patient states that he went on a bad binge that even his mother did not want him in her house. 

The patient reports using one to three grams of crystal meth daily by injection. The patient reports daily cannabis use, smoking two joints daily with the last use on day of admission. He has had one treatment episode in the past which is described as several years ago. The patient reports inability to stop substance use on his own. He reports not having used in the last several days as family had locked him up to prevent use. No withdrawal symptoms are noted. No Clinical Opiate Withdrawal Scale (COWS) scores or Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scores are provided for review. No current withdrawal symptoms are noted. The patient's past withdrawal symptoms include agitation and lethargy. 

Medically, the patient has a history of hypertension and asthma. He denied any mental health issues. Blood pressure was elevated on admission. Urine drug screen (UDS) was positive for cannabis. Mental status exam, mood and affect were appropriate. No hallucinations, suicidal ideations or homicidal ideations are noted. There was no history of self injurious behavior.

No, the proposed inpatient rehabilitation admission was not medically necessary. On presentation, the patient did not present with acute or life-threatening withdrawal symptoms. On presentation, the patient did not have any withdrawal symptoms. His mood and affect were appropriate. He did not have any psychotic symptoms. He did not have any suicidal or homicidal ideation. His vital signs showed elevated blood pressure but the patient was noted to have a history of hypertension.

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

The patient did not present with acute withdrawal or life-threatening withdrawal symptoms or a history of complicated withdrawal symptoms or multiple past treatment failures to warrant inpatient rehabilitation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea, abdominal pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This patient is a male with Down's syndrome who presented with nausea, regurgitation and abdominal pain. His blood pressure (BP) was 97/65 and heart rate was 91. The patient's labs revealed normal white blood cell (WBC) count and electrolytes. A computed tomography revealed a thickened esophagus and no obstruction. The patient was hydrated and treated with intravenous Pepcid and Zofran. He was seen by gastroenterology (GI) who noted that the symptoms were longstanding, dating back several years. A previous esophagram was unremarkable. Day two, there was no further vomiting. The patient was discharged day three with plan for outpatient esophagogastroduodenoscopy (EGD).

No, the proposed inpatient hospital admission was not medically necessary.

The patient was hemodynamically stable, without ongoing vomiting or ongoing dehydration.  As the patient did not have obstruction, bleeding, sepsis or a need for further testing including endoscopic intervention, observation status was medically appropriate, with discharge to outpatient care. Acute inpatient hospital stay was not medically necessary.

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

As observation status was medically appropriate; the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying acute inpatient hospital stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endometriosis
Treatment: Orilissa
The insurer denied Orilissa. The health plan's determination is upheld. 

The patient is a female with endometriosis. She had a previous hysterectomy for her endometriosis and was recently seen by her provider. She had no hormonal medication since surgery, but did have progesterone at home that she could take while awaiting Orilissa approval. There is a "predisposition to blood clots" noted in her chart with a contraindication to estrogen because of that. There is an indication that she has "taken non-steroidal anti-inflammatory drugs (NSAIDs) -no benefit". There is also a note that she manages her pain with Tylenol prior to surgery. Her physician has prescribed Orilissa Tablets 150 milligrams (mg) for the treatment of her endometriosis related pain. Her plan requires that she has tried and failed two analgesics (ibuprofen, meloxicam, naproxen) after a three month trial.

The Orilissa Tab 150 mg (30 per Month) is not medically necessary for this patient.
The patient has had recent surgery for her endometriosis related pain and her physician has opted for Orilissa for post-surgical management of endometriosis. She has tried progesterone only medications in the past; however, she feels that this did not help. She has a "contraindication" to estrogen only medications secondary to a predisposition to endovascular clots; however, this cannot be supported by the medical documentation. Her plan requires that she has tried at least two analgesics like ibuprofen, meloxicam or naproxen for at least three months prior to Orilissa. There is no documentation, per the medical record, that this has occurred. There is only a line that she has taken "NSAIDs, no benefit" however, no documentation as to the dosage, use nor duration of treatment is provided. In addition, there is documentation that Tylenol controlled her pain prior to surgery which would negate the need for Orilissa. Therefore, it is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: AR2036054 New Century Health Regimen [regimen containing cyclophosphamide, fluorouracil hormone receptor positive breast cancer]
The insurer denied AR2036054 New Century Health Regimen [regimen containing cyclophosphamide, fluorouracil hormone receptor positive breast cancer]
The determination is upheld.

This is a patient with estrogen receptor positive (+) metastatic breast cancer. The disease was previously human epidermal growth factor receptor 2 (HER2)+ but is now HER2 negative (-). She has had multiple lines of therapy including TCH [Taxotere or Taxol, carboplatin and Herceptin], Zoladex plus (+) an aromatase inhibitor (AI)+everolimus, Faslodex+Ibrance, Kadcyla, Xeloda, carboplatin, eribulin, CMF [cyclophosphamide, methotrexate, fluorouracil], paclitaxel, Trodelvy, and gemcitabine. Due to a rising tumor marker (with stable radiographic disease), cyclophosphamide+5- fluorouracil (FU) +carboplatin+irinotecan+bevacizumab was started. AR2036054 New Century Health Regimen [regimen containing cyclophosphamide, fluorouracil hormone receptor positive breast cancer] was denied by the health plan and is under review for medical necessity.

No. In patients with metastatic HER2- breast cancer, there is a paucity of evidence that combination chemotherapy improves outcomes. Neither the National Comprehensive Cancer Network (NCCN), nor the authors of UpToDate, nor the peer-reviewed literature recommend this approach. Further, some of the drugs in this regimen have previously been administered with progression. Evidence is lacking that repeat exposure in a different combination re-establishes drug sensitivity; it is only clear that it increases toxicity, which has been experienced (treatment-limiting cytopenias).
For these reasons, medical necessity cannot be established for this combination in this clinical scenario.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia - Gastrointestinal bleed.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, asthma, hypothyroidism, and neurogenic bladder, who presented with reports of black stools and Hgb (hemoglobin) of 6.6 noted. The review of system was negative for additional clinical symptoms.
The patient was afebrile and was described as alert and in no acute distress. The patient was admitted for anemia. The patient was treated with 2 units of blood transfusions. 

The inpatient hospital admission was medically necessary.
The patient was admitted for severe symptomatic anemia with hemoglobin level of 6.0. The overall morbidity in an elderly patient is high. Although there was no hemodynamic instability, the patient required inpatient admission for blood transfusion, expert consultation with gastroenterologist for inpatient endoscopic intervention. Additionally, the patient has hypertension and advanced age. These are clinical predictors of increase in mortality and chance of adverse outcomes.
While the evaluation of anemia is often straightforward in an otherwise healthy individual, in many cases the cause may not be readily apparent, and treatment depends on the patient's age and etiology of the anemia. Anemia, especially in the older adult (age>65) population, has been associated with substantial morbidity and mortality. Many of the studies show an association between anemia and morbidity and/or mortality which replicates a reversed J-shaped curve, with worse outcomes at Hgb< 12. Additionally, the risk of mortality is also related to the etiology of the anemia. Small bowel vascular lesions are the most common cause of obscure gastrointestinal bleeding. They usually manifest as chronic, well compensated bleeding. This means that a patient may not necessarily demonstrate hemodynamic instability or gross bloody bowel movements. The clinical presentation is varied, ranging from hematochezia or melena to iron-deficiency anemia (with findings of low blood count on routine lab work) resulting from long-term blood loss. The management plan is individualized for each patient depending on severity, rate of rebleeding, and issues of comorbidity. Although the patient did not have hemodynamic instability, an acute drop in hemoglobin increases the overall morbidity and warranted evaluation for endoscopic intervention.