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

Breathing Problem
Inpatient Hospital

The patient has prior/recent history of myocardial infarction (MI) / coronary artery disease (CAD) status/post (s/p) stenting, insulin requiring Diabetes who is a smoker of 1 PPD (pack per day) who presented to the emergency department (ED) with complaints of shortness of breath, cough, difficulty to catch air producing yellow phlegm.  In the ED, he was noted to have wheezing.  Vitals signs were stable except mildly elevated blood pressure (BP) and Heart rate.  Oxygen saturation on room air was normal.  Lab work showed normal complete blood count (CBC) and chem panel, minimally elevated troponin and pro-BNP.  An electrocardiogram (EKG) had some changes, which were not deemed acute and the CxR (chest x-ray) also had clinically insignificant findings.  BS (blood sugar) was elevated at 479.  The patient was admitted.  The inpatient stay is under review. 

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  The patient had no prior history of asthma and as a smoker presented with bronchitis like symptoms.  There is no evidence of failed outpatient management, Peak expiratory flow (PEF) < (less than) 40% at any point, PEF < 80% and lack of response to three doses of inhaled short-acting beta-agonist, Room air pO2 less than 60 mm Hg or pulse oximetry less than 90%.  In addition, there was no Arterial blood gas (ABG) showing pCO2 greater than 50 mm Hg and/or pH less than 7.30.  The patient did not require bronchodilators more frequently or every 4 hours.  Troponins were mildly elevated but were deemed related to demand ischemia and not consistent with non-ST elevation myocardial infarction (NSTEMI).  Blood sugars were uncontrolled, but there was no ketoacidosis or anion gap noted.  Mild tachycardia on presentation resolved in ED prior to admission.  Observation at a lower level of care would have been appropriate treatment for this patient.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female, with a history of hypertension, hyperlipidemia, and tobacco dependence, who presented to the emergency department with a 5-day history of persistent dizziness, ataxia, and blurred vision.  Symptoms seemed to start after a cervical epidural injection.  The patient also had chronic neck and shoulder pain for at least 1 month in duration.  She was evaluated in the emergency department and was noted to be free of headaches, changes in speech or vision changes, and there was no focal weakness or numbness.  Nevertheless, the stroke team was alerted in the emergency department, and the patient had a computed tomography (CT) scan of the head, which was negative for an intracranial hemorrhage.  The computed tomography angiography (CTA) scan of the head and neck showed stenosis of the right vertebral artery, suspected to be congenital.  The patient was admitted to the hospital, for stroke rule out.  The calculated National Institute of Health (NIH) stroke scale was 0. 

The brain magnetic resonance imaging (MRI) scan and cervical spine MRI were ordered, along with a transthoracic echo without bubble study.  Brain MRI showed no evidence of acute infarction or intracranial hemorrhage.  An incidental meningioma was identified overlying the right frontal operculum without mass-effect.  There was also mild chronic microvascular ischemic disease.  The patient also underwent an MRI of the cervical spine, which showed multilevel cervical spondylosis with mild canal stenosis at C4-C5.  Neurosurgery was asked to evaluate the patient, and they recommended conservative management and physical therapy.

The health plan denied the inpatient admission as not medically necessary.  The health plan's determination is upheld.  This patient presented to the hospital with dizziness, gait ataxia, and blurry vision; the goal was to rule out an acute stroke.  This was effectively ruled out within 24 hours of admission with a brain MRI.  The patient has mild spinal stenosis and moderate foraminal stenosis at multiple cervical spinal levels.  This typically does not require an inpatient admission for evaluation or treatment, unless the patient requires surgery.  Typically severe spinal stenosis at the cervical level would require an inpatient admission, which the patient did not demonstrate.  In addition, the patient reported rectal bleeding, remained hemodynamically stable, and had no significant blood losses, as evidenced by stable hemoglobins.  The patient did not require an endoscopic or surgical procedure to further evaluate this.  There was no indication for inpatient hospitalization for either of these conditions.  As a result, the patient could have been evaluated and treated under a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary embolism and deep venous thrombosis
 
Treatment: Inpatient admission, medication, monitoring

The insurer denied the inpatient admission. The denial was upheld.

The patient is a female who presented to the emergency department with a complaint of cramping pain and swelling in her right lower extremity for one day, and dull, sub-sternal chest pain and dyspnea that began acutely overnight.  She has a past medical history of a pulmonary embolism (PE) in 2012, pulmonary nodule, diabetes mellitus type 2, and diabetic neuropathy.  The patient was no longer on anticoagulation.  The physical examination revealed tenderness (crampy feeling when palpated right calf, lateral, right thigh, right neck, shoulder, and upper arm).  A CT angiography of the chest and duplex ultrasound of the bilateral lower extremities were completed, and the patient was noted to have a deep venous thrombosis (DVT) and mainstem pulmonary embolism.  She was hemodynamically stable.  The patient was started on heparin and admitted to the hospital. She was seen by Hematology, and they started the patient on Xarelto and sent a hypercoagulation work-up. The patient was stabilized and discharged.  

MCG indicates that admission for a pulmonary embolism (PE) and/or deep venous thrombosis would be appropriate for a patient with a personal or family history of significant bleeding tendency or bleeding disorder that required monitoring beyond observation care, such as when continued monitoring of their response to anticoagulation is needed.  The records failed to support the patient had a necessity for continued monitoring of her response to anticoagulation beyond observation care. The patient was hemodynamically stable. The patient had a strong family history of deep venous thrombosis/pulmonary embolism, however, the records failed to support the patient could not be monitored at a lower level of care, such as observation status.    

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

Diagnosis:Major depressive disorder
Treatment: Inpatient admission
The Inpatient admission was medically necessary.

Summary:
The patient has a history of psychiatric illness as has been diagnosed with major depressive disorder.  There is a history of multiple prior hospitalizations for suicide attempts including intentional overdoses.  There is a medical history of chronic back pain, Factor V Leiden, hypertension, and DVT (deep venous thrombosis) with left lower extremity amputation.  He is homeless and lives in a motel.  He is divorced and has a prior history of DUI and ongoing alcohol abuse.  There is a prior history of inpatient substance abuse treatment.

The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of depression and substance abuse with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were he to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Headache and Anemia
Treatment:  Inpatient admission
The proposed treatment of inpatient hospital admission is deemed medically necessary. 

This is a female with a history of chronic anemia who presented to the ER for further evaluation/management of a severe, debilitating headache for three days, which remained refractory to over the counter migraine medications, along with worsening fatigue and dyspnea.  Intake vitals were afebrile and hemodynamically stable. Examination was non-focal.  However, laboratory testing was notable for profound anemia with hemoglobin of 6.1 mg/dL and hematocrit of 21.8.  Head CT, EKG and chest x-ray were without significant abnormalities.  The patient was admitted to the inpatient medical service where she received a transfusion with one unit of packed red blood cells.  Her post-transfusion hemoglobin initially improved to 7.2 but on subsequent testing dropped to 6.7, so an additional one unit of packed red blood cells needed to be transfused.  She eventually improved with the prescribed therapies and was subsequently discharged in stable condition.  The evidence of dropping hemoglobin/hematocrit values despite recent blood transfusion indicating requirement for ongoing/additional blood transfusions represents intensification of services during the course of this patient's hospital stay.  Hence, the patient's care could not have been safely furnished in a less intensive setting without adversely affecting the patient's safety or outcome.  For these reasons, the proposed treatment of inpatient hospital admission is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

 The insurer denied coverage for Inpatient admission. The denial was upheld.

This patient is a female with a past medical history notable for hypertension and hyperlipidemia, who presented to the ER with complaints of chest pain. Vital signs were stable. The pain presented and lasted 20-30 minutes. It was not associated with any other symptoms. The patient ruled out for myocardial infarction and was evaluated with a normal stress test. She was discharged home.

The patient presented with chest pain, however the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Further evaluation was warranted, however inpatient admission criteria were not met. There were no other high-risk co-morbidities. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: Fever, cough
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

Pneumonia occurs as a result of inflammation of lung tissue from either infectious or non-infectious causes. Infectious causes include bacteria, viruses, and fungi. Non-infectious causes include aspiration, hypersensitivity reactions, and drug- or radiation-induced pneumonitis. Streptococcal pneumoniae is the most common bacterial pathogen of infants and young children, while Mycoplasma pneumoniae and Chlamydophile pneumoniae are the most common bacterial pathogens of children and adolescents. Other bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Viral pathogens include RSV and influenza, as well as rhinovirus, human metapneumovirus, parainfluenza, and adenovirus. 

Bacterial pneumonia typically occurs when organisms from the respiratory tract colonize the trachea and then gain access to the lungs, although hematogenous spread is also possible. Different bacterial pathogens invade according to their own specific pathogenic processes. Viral pneumonia occurs from viral spread along the airways accompanied by direct injury to the tissues with subsequent airway obstruction. 

Pneumonia is typically preceded by upper respiratory tract infection symptoms, including cough and runny nose. The type and degree of symptoms of lower respiratory tract infection depend upon the organisms and stage of illness. Tachypnea, fever, cough, and chest pain may all be present. Physical examination findings may include decreased breath sounds, crackles, tachypnea, and shortness of breath. Infiltrate on chest x-ray is supportive of the diagnosis, and there may be accompanying effusion. There may be laboratory indicators of infection, including leukocytosis and elevated inflammatory markers. 

Treatment is based on the suspected cause. Hospitalization may be warranted in the very young, patients with concurrent serious chronic medical conditions, moderate to severe respiratory distress, need for supplemental oxygen, dehydration, inadequate response to outpatient therapy, and complications such as empyema or abscess.

This young female child with history of wheezing and frequent respiratory infection presented with four-day history of fevers and cough. Her examination was concerning for bronchospasm, and diagnostic studies confirmed pneumonia. Acute inpatient admission was medically necessary and appropriate in this case because of the combination of lower respiratory tract infection and asthma exacerbation in a young child with high fever and poor oral intake. She was at risk for respiratory decompensation and worsening dehydration. She could not have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cough and shortness of breath
Treatment:  Inpatient admission
The inpatient hospital admission was not medically necessary.

This patient with a history of asthma was admitted on with asthma exacerbation.  Evaluation in the ED showed the patient to be hemodynamically stable.  The patient was treated with three nebs and steroids in the ER with improvement in PEFR from 200 to 290, as well as improvement in O2 saturation.  The patient did not require ventilatory support or have hypoxia.  There were no comorbidities that required inpatient admission.  Based on the patient's response to treatment in the ER, inpatient admission was not medically necessary.  The patient remained stable the next day with additional improvement in PEFR and was discharged.  Inpatient hospital admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a history of hypertension, hyperlipidemia and smoking who was admitted to the hospital.  She presented with abdominal pain that started earlier that morning.  She described the pain as sharp and moderate in intensity.  She reported that it radiated to the right side of her back.  She denied shortness of breath, chest pain, fevers, chills and dizziness.  She stated that the symptoms were also associated with nausea and vomiting.  Vital signs showed temperature 36.9 Celsius, heart rate 96, respiratory rate 18, oxygen saturation 99%, and blood pressure 134/86.  On physical examination, she was in mild distress, heart was regular, breath sounds were normal, abdomen was soft and tender in the epigastric region with no rebound or guarding.  Labs showed white blood cell (WBC) count 10.6, hemoglobin 14.1, platelets 236, sodium 142, potassium 4.1, and creatinine 0.8. Imaging of the abdomen was negative for bowel obstruction.  The patient was admitted for abdominal pain and suspected gastritis versus peptic ulcer disease.  The plan of care included intravenous (IV) fluids, proton pump inhibitor, pain management, hypertension management, iron studies, and monitoring of electrolytes.  She was seen by gastroenterology, and they had suspicion for viral gastroenteritis and agreed with supportive care.  She was also diagnosed with low vitamin B 12 levels and received B 12 supplementation.  During the hospital stay she developed fever to 38.4 Celsius, and blood cultures were ordered. These cultures remained negative and symptoms improved.  She was discharged.

The health plan's determination is upheld.  The reason is that the patient did need medical care for her nausea and vomiting, but she had no acutely abnormal laboratory abnormalities with the exception of mildly elevated lipase, her physical exam was not acutely concerning, there was no evidence of acute bacterial infection at the time of admission, and there was no evidence of other acute abnormalities, such as acute pancreatitis, acute bowel ischemia, bowel obstruction, appendicitis, or cholecystitis.  In addition, she was not hemodynamically unstable, and there was no suspicion for an acute surgical abdomen or significant electrolyte abnormalities.

The patient did not have intra-abdominal abscess or evidence of systemic toxicity or end organ injury.  Symptoms responded to supportive care, and the leading diagnosis was viral gastroenteritis according to the gastrointestinal (GI) service.  In addition, she had no evidence of an acute abdomen or intra-abdominal abscess/infection, no acute ulcerative disease, no ileus, no hemodynamic instability, and no acute cholecystitis/biliary disease.  The patient could have been treated at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Pregnancy/Childbirth
Inpatient Hospital

This patient is a female who had abdominal pain for the past 4 days. The abdominal pain was noted to be on the right lower abdomen. The pain was off and on and was not severe otherwise she felt comfortable. The patient had no significant medical history. The past surgical history was noted for 2 prior cesarean deliveries. On examination, the vital signs were reported as stable. The abdomen was noted to be soft with mild pain on the lower right side of the abdomen. On palpation there is no rebound tenderness. A normal hemoglobin of 12 was noted and a positive pregnancy test of 6650 was noted on blood examination. The patient was given a diagnosis of possible early pregnancy with rule out ectopic pregnancy. There is a plan to monitor her human chorionic gonadotropin prove (hCG), complete blood count, and progesterone and a repeat vaginal sonogram was to be planned. There was also consideration of treatment with methotrexate if needed for ectopic. The patient underwent an ultrasound of the abdomen which noted a liver that was normal in size and echogenicity and a well-seen pancreas that was unremarkable. There were no gallstones in the gallbladder was normal in size. The gallbladder wall is normal in thickness. A sonographic Murphy sign was negative. There is no intrahepatic or extrahepatic biliary duct dilatation. The kidneys were noted to be normal. The spleen and peritoneum were normal. There is no acute sonographic abnormality demonstrated in the abdomen. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient admission was not medically necessary at the acute inpatient level of care status for this patient given the diagnosis of right sided, non-acute abdominal pain in pregnancy with stable vital signs and labs. In this case, the patient was noted to have normal vital signs and normal hemoglobin. There was no free fluid in the abdomen on ultrasound by trans abdominal approach. In fact, there was an intrauterine pregnancy present on transvaginal ultrasound. There was no evidence of dehydration requiring massive fluid resuscitation and this was also not supported by the labs or vital signs. The patient received standard intravenous (IV) fluid with D5LR at a normal, physiologic rate.
Based on review of the medical documentation and the Milliman Care Guidelines (MCG) , there was no medical necessity for acute inpatient admission as the patient had no evidence of acute bleeding or worsening abdominal exam. In fact, the patient was noted to have normal vitals with a stable hemoglobin and hematocrit with a stable exam during hospitalization. There was no acute abdomen requiring surgical intervention. Given the stable vitals and afebrile status, this patient was not noted to have any source of infection. Thus, in conclusion, this patient was found to lack medical necessity for acute inpatient hospitalization. The care could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Abdominal/Stomach Pain
Inpatient hospital

The patient is a woman who presented to the emergency department (ED) with a compliant of abdominal pain. Of note, the patient has undergone laparoscopic cholecystectomy 2-days prior. At the time of presentation, the patient had normal temperature and heart rate. The white blood cell (WBC) count was 8.0 K. Her evaluation in the ED included lab data that identified elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase with normal bilirubin. Ultrasound showed anatomic changes of prior cholecystectomy. The patient was admitted to the hospital and was treated with intravenous (IV) fluid and antibiotics. An magnetic resonance cholangiopancreatography (MRCP) was performed and did not identify a stone or obstruction within the common bile duct. The patient was advanced on her diet and was discharged from the hospital. The inpatient stay is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient presented to the ED with abdominal pain and elevated transaminases status/post (s/p) laparoscopic cholecystectomy 2-days prior. She was appropriately evaluated in the ED with lab data and imaging studies. Further imaging with MRCP was performed. The patient was clinically stable at the time of presentation and remained so during hospitalization. In this case, the intensity of service does not support the need for inpatient care.

In this case, the patient presented with an early post-surgical condition (abdominal pain and elevated transminases) following cholecystectomy. She was stable at the time of presentation and remained stable throughout the period of monitoring. A lower level of care would have been appropriate in this case. An inpatient level of care was not required for provision of IV fluid, imaging or follow up labs. The Inpatient care was not medically necessary.