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

Diagnosis: Wheezing, labored breathing
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a male child with medical history significant for eczema and one prior episode of wheezing that presented to the ED with one-day history of tactile fever and cough, and same-day history of increased work of breathing and worsening cough. Ibuprofen was ineffective. He had two episodes of vomiting, no diarrhea. Multiple family members were sick with respiratory symptoms. 

Vital signs included temperature 36.8, heart rate 135, and respiratory rate 32 with 95% saturation in room air. Examination was significant for moist mucous membranes, increased work of breathing, scattered wheezes, decreased air entry bilateral lung bases, subcostal retractions, benign abdomen, and non-focal neurologic exam. He was treated with three DuoNeb treatments back to back as well as a dose of prednisolone. Upon re-evaluation, exam was significant for decreased air entry bilaterally, with tachypnea, increased work of breathing, and retractions. He was given a fourth albuterol treatment, after which he was still retracting even in the absence of wheezing. An IV was placed and the patient was given a dose of Solumedrol. After a fifth dose of albuterol, with persistent distress, he was referred for admission for management of moderate asthma with status asthmaticus. 

Admission orders included nebulized albuterol every two hours, continued course of prednisolone, regular Halal diet for age, anti-pyretics as needed, and close monitoring with vital signs per protocol. The patient did well overnight, was able to tolerate nebulized albuterol weaned to every four hours. He was active and tolerating his diet. He was transitioned from nebulized albuterol to metered dose inhaler (MDI) and his family was taught how to administer it. He continued to do well, and was deemed stable for discharge the next day to complete a course of corticosteroids and use the inhaler every four hours weaning slowly to use as needed.

This young male child with history of atopic disease (eczema, one episode of wheezing) presented to the ED with increased work of breathing and wheezing consistent with an acute asthma exacerbation. He was treated appropriately in the ED with frequent bronchodilators and corticosteroids. Despite multiple doses, he continued to have difficulty breathing and evidence of bronchospasm, so was admitted for further care. While it was reasonable and appropriate to continue treatments in the hospital, monitoring for improvement, he was hemodynamically stable, with no oxygen requirement, no evidence of impending respiratory failure, able to tolerate his diet with no concern for dehydration. Acute inpatient admission was not medically necessary; he could have been safely and appropriately managed at a lower level of care such as observation with the same attention to interventions and response to treatment.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of chronic obstructive pulmonary disease (COPD), Rheumatoid arthritis, hypertension, and locally advanced gastric cancer.  The patient presented to the emergency department (ED) on with a complaint of abdominal pain and multiple episodes of nausea and vomiting. A computed tomography (CT) scan supported the diagnosis of gastric outlet obstruction due to malignancy (marked gastric distention). The white blood cell count was elevated at 12.3 K. Patient was initially treated with (NPO) status and a nasogastric tube was placed. The NG tube output was initially 700-cc of bilious return. Patient was treated with intravenous (IV) fluids, nausea medications and analgesic medications. Surgical, oncology, and gastroenterology consultations were obtained. The surgical recommendation was for resection of the gastric malignancy. The patient refused surgical intervention. The gastroenterology service planned for endoluminal stent placement. The patient left the hospital against medical advice.
The health plan determination was overturned in whole, the inpatient stay was medically necessary for this patient. This patient has a locally advanced gastric malignancy and required the coordinated care of multiple medical and surgical disciplines. Management of a nasogastric tube, provision of IV fluid, and preparation for endoscopic or surgical intervention is most appropriately provided with an inpatient designation. The clinical suspicion was that this patient's gastric obstruction was due to the locally advanced cancer. This diagnosis carries the potential for significant and rapid clinical deterioration and supported the need for inpatient care, provision of parenteral fluid, NPO status, intravenous antiemetic medications, and gastroenterology or surgical intervention as planned. The patient left the hospital against medical advice however, this does not detract from the appropriate care that was provided and planned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Febrile seizure, flu

Treatment: Inpatient admission, monitoring, hydration and medication management

The insurer denied inpatient admission. That denial was upheld.

This infant had reported temperature max of 103F at home, for two days.  He was also noted to have upper respiratory infection (URI) symptoms for one day.  The patient was at the pediatrician's office and had a witnessed Generalized Tonic -Clonic seizure.  The child was brought to the Emergency Department (ED) by Emergency Medical Services (EMS).  The child had positive ill contacts at home.  He is noted to be Influenza A positive.

Review of records shows that presentation at 11:51am, the emergency department (ED) vitals showed a Temperature of 103.9F, pulse was 156 (crying), respirations were 32.  ED exam at 17:24 noted a well nourished, well developed, active, child in no distress, with an unremarkable physical exam.  The pediatric early warning score (PEWS) at 11:56 was 0, at 20:05 was 0. ED treatment was Motrin, intravenous fluids (IVF) and Tamiflu.  ED Vitals at 20:05 hours were temperature 99.0F, pulse 151 (crying), blood pressure (BP) 109/67.  

The patient was reported as not drinking orally. The notes state will 'admit' for "dehydration."   The Physician Progress Note at 20:41 states this was a well looking child, *No Signs of dehydration*, normal neurologic exam, temperature 100.8F.  Admiting diagnosis: Simple Febrile Seizures associated with Influenza infection.  No intravenous (IV) antibiotic was ever instituted both in the ED and rest of the hospital note.  The next day notes document well looking child, no signs of dehydration, no focal neurologic deficits.  Temperature 103.2, continued on Tamiflu. This was the 1st febrile seizure in this child, it was simple, non-focal (had GTC), lasted less than one minute, back to base line by 5 minutes and on arrival to the ED, had a source for the Fever (Influenza A positive) and was well within the window to initiate anti-viral therapy (which was instituted in the ED with Tamiflu orally).  The services could have been delivered at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood in Urine
 
Treatment: Inpatient admission, diagnostic evaluation and medication management

The insurer denied inpatient admission. That denial was upheld

This patient presented to the Emergency Room (ER) complaining of gross hematuria with clots.  The patient was status post transurethral resection of a bladder tumor (TURBT) earlier that day at another facility.  In the Emergency Department (ED) a Foley catheter was placed, and the patient was started on continuous bladder irrigation (CBI).  The patient was admitted to Urology with the bladder irrigation continued.  The irrigation was held the following day, and the urine remained clear in color.  The patient was discharged home later that day and instructed to return to his urologist as soon as possible.  

The patient presented to the ER with a chief complaint of abdominal pain/urine retention both of which improved after placement of the Foley catheter.  Per MCG Health Urologic Disease GRG he patient fails to meet clinical indications for admission to inpatient care under two separate subsections.  These include: 

1)	Gross hematuria requiring inpatient care (no renal obstruction, decreased urine output, clot retention, severe anemia)
2)	Acute urinary retention requiring inpatient care (no hemodynamic instability, acute kidney injury (AKI), acute neurologic etiology)  

The inpatient admission was not considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lower extremity rash
Issue under review: Inpatient admission

Determination:
The inpatient admission was medicall necessary.

The patient meets the initial criteria for IV treatment and admission for cellulitis/abscess given by the Infectious Diseases Society of America, as he had systemic signs of infection (fever and elevated WBC count), suspicion of infection of deeper structures, and failure of outpatient therapy (1). There was a concern that he may have had a resistant bacteria (MRSA), with the history of such an infection, and thus admission was warranted and standard of care. Thus, this admission was warranted, supported by IDSA guidelines, as well as standard of care. Failure to admit such as a patient can lead to loss of function, sepsis, deep abscess, or death.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department with complaints of severe anxiety and transient thoughts of hurting herself. The patient was brought by Emergency Medical Services (EMS) for evaluation. The patient denied active suicidal or homicidal ideation, auditory or visual hallucinations, but was admitted for further evaluation of safety. The initial diagnosis was major depressive disorder, recurrent, with psychotic features, which was later modified to bipolar affective disorder, most recent episode mixed.

The health plan's determination is upheld. The The Psychiatric Inpatient Admission was not medically necessary for this patient.The patient was not actively suicidal, homicidal, or gravely disabled. The patient was stable and could have been treated at a lower level of care. The patient had safe living arrangements, and demonstrated an ability to care for herself, as well as an understanding of her illness. The least restrictive level of care is always appropriate for good mental health recovery. This patient did not require the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain, past medical history of hypertension, dyslipidemia, coronary artery disease with coronary artery bypass graft with a triple bypass and percutaneous coronary interventionx4, cerebral vascular accident, polysubstance abuse, chronic alcoholism.
 
Treatment: Inpatient admission, diagnostic testing and medication management

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

The patient presented with a complaint of chest pain. He reported partying the previous night and snorted and smoked cocaine prior to developing chest pain. The pain was worse on his left side, was described as tightening, radiating to his left arm and 10/10 in severity. He had vomiting X3 and diaphoresis. He noted shortness of breath and non-productive cough. His home medications included aspirin, atorvastatin, Coreg, Plavix, hydralazine and multivitamins. He did not take any medication on the day of admission. On physical exam it was noted that he appeared to be in moderate distress and appeared anxious. An EKG showed normal sinus rhythm with possible old inferior wall infarction and also evidence of left atrial enlargement. An EKG Day two, at 13:45, shows normal sinus rhythm at 66 bpm with ventricular premature beat noted. An EKG done on day three showed sinus bradycardia at 58 bpm and is similar to the previous EKGs. His initial troponin was within normal limits. Urine toxicology screen was positive for opiates, benzodiazepines, cocaine and cannabinoids. Additional troponins were also within normal limits. Chest x-ray was negative. Examination of previous records indicated that he had a left heart catheterization and coronary angiogram on approximately two years prior found three vessel disease. An echocardiogram done about a year and a half ago showed left ventricular hypertrophy (LVH) with mild systolic dysfunction within ejection fraction of 45% and grade 1 diastolic dysfunction. The assessment and plan stated that the patient had cocaine induced chest pain and they planned to rule out acute coronary syndrome (ACS). 

The risk of acute myocardial infarction is increased by a factor of 24 during the 60 minutes after the use of cocaine in persons who are otherwise at relatively low risk. The serum half-life of cocaine is 45 to 90 minutes; only 1 percent of the parent drug can be recovered in the urine after it is ingested. Thus, cocaine can be detected in blood or urine for only several hours after its use. (1) Two-thirds of patients had their myocardial infarction within 3 hours of the use of cocaine. (2) 

This patient noted the onset of left-sided chest pain following a night in which he used cocaine. He was asymptomatic once he was in the hospital, had negative troponin levels and he did not have any changes suggesting acute myocardial injury or ischemia on serial EKGs. The monitoring that this patient required could have been done in a less acute care setting
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain status post fall, history of hypertension, hyperlipidemia, irregular heart beat and a myocardial infarction and stroke

Treatment: Inpatient admission, diagnostic evaluation, medication management.

The insurer denied inpatient admission. That denial was upheld.

This patient reported that on the day prior to presentation, he fell 10 to 15 feet onto his back while doing construction work, followed by fatigue, dyspnea and chest discomfort.  An EKG was reported as normal sinus rhythm early repolarization and no ST segment depression.  Laboratory test included a creatinine of 1.01, a white blood cell (WBC) count of 7.4, a hemoglobin of 12.6, a brain natriuretic peptide (BNP) of 23.4, and a troponin of 0.00 with subsequent troponin levels also 0.00 at 05:15 and 08:20.  X-rays of the lumbar spine, chest, pelvis and hip were unremarkable, as was a CT scan of the brain.  A CT scan of the cervical spine did not reveal acute fracture, but did show a large Schmorl's node in the superior endplate of C-7 with associated degenerative disc disease in C5-C6-C7. A CT scan of the chest without contrast revealed dependent consolidation in both lung bases which was treated as likely pneumonia with intravenous Rocephin and azithromycin.  Echocardiography was normal.  He was discharged to home on aspirin, atorvastatin, azithromycin and ibuprofen for follow-up in the cardiology clinic.  

There is no evidence that this patient required an acute inpatient level of care to determine that his chest discomfort was not related to acute coronary syndrome.  There is no evidence that this patient was at increased risk for short-term adverse cardiovascular events requiring inpatient monitoring and management based on his clinical presentation and results of testing performed in the Emergency Department.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decompensated CHF with ongoing cardiac ischemia.
 
Treatment: Admission inpatient to Telemetry

The insurer denied the coverage. The denial was reversed.

This is a female patient with history of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), Hypertension (HTN), Wolff-Parkinson-White (WPW) syndrome, Long QT syndrome, Asthma and Polysubstance Abuse, who presented to the Emergency Department (ED) with increasing lower extremity swelling for about two weeks and facial swelling for one day.  The patient had been actively using drugs.  She last used Heroin two days prior.  The patient denied chest pain but complained of some shortness of breath and decreased exercise tolerance. Vital signs at presentation were Temperature (T) 97.7 F, Respiratory Rate (RR) 20, Heart Rate (HR) 88, Blood Pressure and (BP) 150/100 mm Hg.  Oxygen (O2) saturations were 93%.  The patient had some elevated jugular venous distention.  Lungs were clear.  CVS S1 S2 +.  Edema, feet +. The patient had a CT Chest which revealed Atelectasis/Infiltrate on the left side, and right sided Atelectasis.  Due to the possibility of Pneumonia, Doxycycline was started. The patient was admitted to Telemetry with diagnosis of decompensated CHF with ongoing cardiac ischemia.

This patent had a complicated presentation with decompensated heart failure (HF) with possible ongoing ischemia in the setting of multiple other co-morbidities.  The patient was actively using Heroin and Cocaine.  Possible Pneumonia was present for which the patient received intravenous (IV) antibiotics.  In addition the patient developed some worsening of renal function due to diuresis and this needed close monitoring due to the patient's underlying congestive heart failure (CHF).The patient lacked mental capacity so was deemed incompetent by Psychiatry and needed 1:1.

This patient was not stable to be placed on Observation or discharged from the Emergency Department (ED).  She needed admission for treatment and close monitoring of her clinical status.  Myocardial Infarction (MI) needed to be ruled out and Cardiac arrhythmia was a possibility given her WPW and Long QT Syndrome.  The carrier's denial of coverage for the inpatient is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This patient presented with hyperglycemia and dehydration in the setting of nonadherence to his glucose lowering medications. The documentation does not support that he was hemodynamically unstable. He did not have acidosis or elevated ketones to support a diagnosis of diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. He was tachycardiac and had an elevated creatinine level consistent with dehydration. The documentation does not support that he had severe dehydration that failed management under observation status. Therefore, no, the proposed inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The clinical documentation provided did not suggest that the patient was in acute respiratory failure. The patient presented with acute bronchitis leading to acute COPD exacerbation.  The laboratory data performed on admission did not suggest that patient had any pneumonia defined as severe pneumonia. The patient was not in respiratory distress defined by respiratory rate more than 30 and oxygen saturation less than 88% on room air at rest. There was not any increase in acute partial pressure of arterial carbon dioxide defining the patient as having acute hypercarbic respiratory failure.  There was no issue with the sensorium. The patient presented with normal sensorium. She was alert and orient x3. She had no speech defects. Her strength was good. She was ambulatory. She tolerated oral feeding throughout the hospitalization.  

In patients with acute COPD exacerbation, the following would justify acute in hospital stay due to acute COPD exacerbation if documented:
- Acute hypercarbic respiratory failure requiring noninvasive ventilation;
- Acute respiratory failure requiring invasive mechanical ventilation such as intubation with mechanical ventilation and ICU stay;
- Acute respiratory failure with hemodynamic compromise;
- Acute respiratory failure with  altered level of consciousness;
- Acute respiratory failure requiring high-flow oxygen;
- Acute respiratory failure with severe pneumonia;
- Acute respiratory failure with septic shock;
- Acute respiratory failure / acute COPD exacerbation with hypertension requiring volume resuscitation or vasopressor agents;
- Acute respiratory failure due to pulmonary embolism with Cor pulmonale /with hypotension

The patient's clinical history does not document any of the above complications of acute COPD exacerbation to warrant inpatient admission .
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain

Treatment: Inpatient stay 

Summary:
This patient presented with chest pain and a productive cough.  Although high sensitivity serum troponin was elevated, the history and physical along with the ECG and echocardiogram were not consistent with a diagnosis of acute coronary syndrome. This was noted in by the cardiology consultant.  The patient was afebrile and no infiltrate was noted on the chest X-ray. This patient presented with atypical chest pain. Physical examination was unremarkable and ECG failed to reveal specific findings consistent with an acute coronary syndrome. Admission to the hospital to treat an acute cardiac event was not medically necessary.  In conclusion, this patient could have been managed at a lower level of care.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Melanoma
Issue under review: DecisionDX-Melanoma test 

Determination:
The health plan should not cover the DecisionDX-Melanoma test.

The NCCN Guidelines for Melanoma version 2.2019 do not recommend Decision-Dx Melanoma in the work up of any stage of cutaneous melanoma. Per the guidelines, "While there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low- versus high-risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas (before or following SLNB) is not recommended outside of a clinical study (trial)." Gene expression profile signature (DecisionDx-Melanoma) to predict visceral metastatic risk in patients with stage I and stage II cutaneous melanoma is currently not standard of care in the management of cutaneous melanoma and is therefore not considered medically appropriate. 

DecisionDX-Melanoma test is not likely to be beneficial for the patient, as additional study is required to further validate if gene expression profiling of cutaneous melanoma will accurately identify which individuals are likely to have aggressive disease and how the results of testing would alter treatment plans and improve health outcomes in the surveillance and treatment of high-risk cutaneous melanoma.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Melanoma
Issue under review: DecisionDX-Melanoma test 

Determination:
The health plan should not cover the DecisionDX-Melanoma test.

This test is experimental.  Stage 1A is only separated from Stage 1B by a 3% survival from melanoma, and stage 2 A is 4%. Even stage 2B is only 14% from stage 1A and 11 % from Stage 1B.  This test shows minor differences in survival, but not significant enough to change therapy based upon the test.

The paper by Berger (provided in the Bibliography by the company) clearly states that there is insufficient data to propose changes in follow up based upon this test.