Showing 21 of 21 decisions
Transient Ischaemic Attack
MRI Brain with DWI
CT head rules out haemorrhage but cannot detect early ischaemic infarction. Resolved symptoms do not exclude stroke — up to 30% of clinical TIAs show DWI-positive infarction on MRI. Without MRI, the patient may be undertreated for a minor stroke, missing the window for optimal secondary prevention and recurrence risk stratification.
Community-Acquired Pneumonia
CT Pulmonary Angiography
Patient findings remain shared between pneumonia and pulmonary embolism even after a chest X-ray shows consolidation. The graph distinction shows PE is not excluded by the current work-up. Denying CTPA leaves a potentially fatal competing diagnosis untreated and preserves the wrong management path.
Haemorrhoids
Colonoscopy
Rectal bleeding is shared between haemorrhoids and colorectal cancer, but change in bowel habit, weight loss, and anaemia move this patient across the cancer threshold. Colonoscopy is the graph-backed discriminator. Delaying it prolongs diagnostic uncertainty in a potentially progressive malignancy.
Primary Headache Disorder
MRI Brain
Headache, nausea, vomiting, and visual change are shared between primary headache disorders and brain tumours. New behavioural change and seizures are the discriminators, and MRI is the graph-linked investigation that separates benign headache from intracranial mass effect.
Intervertebral Disc Prolapse
Urgent MRI Spine
Back pain, altered sensation, weakness, and urinary symptoms sit in the overlap between disc prolapse and cauda equina syndrome. MRI is the one discriminating investigation in the graph. Delaying it when bladder symptoms are already present risks irreversible neurological injury.
Pulmonary Tuberculosis
Standard 6-month RIPE regimen
This approval follows the guideline pathway. The diagnosis is confirmed, the isolate is drug-sensitive, and early standard therapy is the correct public-health and patient-level intervention.
Encephalitis
IV aciclovir with ICU monitoring
This is exactly the kind of emergency escalation insurers should not block. Falling consciousness, fever, seizures, and acute confusion justify immediate antiviral treatment and close monitoring while the diagnostic pathway proceeds.
Lymphoma
R-CHOP chemotherapy
This approval is clinically aligned. Tissue diagnosis is complete, staging is documented, and the treatment request follows the standard first-line haematology pathway rather than jumping ahead of diagnostic certainty.
Mild Intermittent Asthma
Biologic therapy (omalizumab)
This denial is consistent with stepwise asthma care. The patient is still near the entry point of the ladder, so moving directly to omalizumab skips multiple safer and evidence-backed controller steps.
Obstructive Sleep Apnoea
Second polysomnography
The patient is improving, not drifting. Repeating polysomnography without weight change, symptom recurrence, or equipment concern does not alter management.
Hypothyroidism
Repeat thyroid ultrasound
This request would add noise, not clarity. Stable hypothyroidism with normalised TSH and no new palpable abnormality does not justify repeat imaging.
Knee Osteoarthritis
Total knee replacement
This denial is clinically aligned. The patient is symptomatic but the conservative pathway has barely started, so replacement is ahead of the evidence and ahead of usual orthopaedic thresholds.
Major Depressive Episode
Inpatient psychiatric admission
This is deliberately borderline: no active plan, but the rest of the picture is worsening. Recent self-harm, failed medication, increasing isolation, and living alone make outpatient containment fragile. The denial is unsafe because the patient is already beyond a routine community-management threshold.
Knee Osteoarthritis
Knee arthroscopy
This is a classic borderline spending decision that is clinically wrong rather than dangerous. Mild-moderate osteoarthritis without locking or a failed conservative programme should not jump straight to arthroscopy because evidence does not show meaningful added benefit over physiotherapy and weight-focused care.
Chronic Lower Back Pain and Sciatica
Codeine prescription
This is not a catastrophic misstep, but it is the wrong one. With no NSAID trial, no physiotherapy, and no opioid-risk screening, jumping straight to codeine bypasses the conservative first-line pathway and adds avoidable dependence risk to a borderline chronic pain presentation.
Chronic Kidney Disease Stage G4
Nephrology referral
This patient sits right on the referral boundary but is over it: eGFR 28 means stage G4 CKD, not stage 3b. Progressive decline, anaemia, oedema, and heavy albuminuria justify specialist input before an avoidable crash into end-stage disease.
Breast Abscess / Mastitis
Core Needle Biopsy
Breast lump and tenderness are shared between mastitis and breast cancer. Persistence after antibiotics, absence of lactation, and nodal features all shift concern toward malignancy. Biopsy is the graph discriminator and delaying it risks stage migration behind an inflammatory explanation.
Coeliac Disease
Upper Endoscopy with Duodenal Biopsy
Abdominal pain, diarrhoea, fatigue, and rash are shared between coeliac disease and inflammatory bowel disease. Biopsy is the graph-linked discriminator. Starting a gluten-free diet before tissue diagnosis blunts the test and may delay recognition of an inflammatory bowel disease pathway that requires a different escalation strategy.
Community-Acquired Pneumonia
Inpatient admission
CURB-65 score of 2 is the decision boundary. This patient is elderly and newly confused, so an apparently ambulatory plan underestimates aspiration risk and the chance of rapid deterioration.
Infectious Mononucleosis
Lymph Node Biopsy
Fatigue, fever, lymphadenopathy, and organomegaly are shared between infectious mononucleosis and lymphoma. Persistent nodes, night sweats, and weight loss move the probability toward lymphoma. Biopsy is the discriminating investigation and delay prolongs a potentially treatable haematological malignancy.
Pulmonary Hypertension
Echocardiography
Breathlessness, chest pain, syncope, and oedema are shared between pulmonary hypertension and aortic valve disease. The discriminator is valve-focused structural assessment, and echocardiography is the graph-linked investigation that resolves that uncertainty. Deferring it risks missing severe valve disease at a decompensating boundary.