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

Diagnosis: alcohol withdrawal
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

This case involves a man with alcoholism admitted to the hospital with dizziness. Concurrent symptoms included shortness of breath. The last alcoholic beverage was the day before. He was drinking 1 L (liter) of whiskey. He denied any chest pain or anxiety fever. Vital signs on arrival included elevated blood pressure of 190/115, temperature of 97.9 degrees Fahrenheit, and heart rate of 54, with sinus bradycardia on electrocardiogram (EKG). On exam, the patient appeared alert-oriented with no distress. Cardiac exam showed normal heart rhythm, with no murmurs or thrills. The pulmonary exam was unremarkable, as were the gastrointestinal (GI) and neurologic exams.

Based on the provided documentation, the inpatient hospital admission was not medically necessary. The patient had mild alcohol withdrawal symptoms, and after the initial score of 16 on the Clinical Institute Withdrawal Assessment (CIWA) scale, there was a significant downtrend in the subsequent scores. The patient experienced no hallucinations, tolerated a diet, and had stable vital signs. There is no documentation of seizure activity. The physical exam shows an alert and oriented individual, with resolution of most symptoms. He was released within 48 hours of arrival. The rhabdomyolysis was mild and did not affect kidney function. It was treated supportively with intravenous (IV) fluids, which can be accomplished at a lower level of care. There were no other destabilizing factors.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:	shortness of breath.	

Treatment: hospital admission/evaluation.

The insurer denied inpatient care.

The denial is upheld.

The patient presented to the emergency room (ER) complaining of shortness of breath (SOB) and fatigue. The patient was not taking medications and had no significant past medical history. Vital signs were stable on arrival with a blood pressure of 105/63 and heart rate was 78 beats per minute. The physical examination upon arrival was benign and no abnormalities were reported.  An EKG(electrocardiogram) revealed normal sinus rhythm and no evidence of ischemic changes.  Serum blood testing revealed an elevated creatinine level of 1.5 milligram / deciliter (mg/dl) and an elevated troponin of 0.5 nanogram / milliliter (ng/ml). A CT(computed tomography) of the chest demonstrated no evidence of pulmonary embolism. A cardiac catheterization was performed revealing a left ventricular ejection fraction (LVEF) of 55% without obstructive coronary disease.  The patient was discharged home with follow up.

Full hospital admission was not necessary for this patient that presented with chest pain.  The pretest probability of coronary artery was low. (Reference 1)  

Utilizing the HEART (History, Electrocardiogram, Age, Risk factors, and Troponin) score the patient was considered intermediate risk. (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3).  Using the History, EKG, Age, Risk Factors, and Troponin (HEART) score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. However, numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (References 4,5) They found no significant difference in outcome at 30 days between the two groups.  Fernando Bellolio et al. noted that patients presenting with chest pain, which were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital. (Reference 5) In conclusion, this patient could have been managed at a lower level of care.

Based on the above, the insurer's denial must be 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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ventral hernia repair
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This patient is a man who presented to the emergency department (ED) with complaints of vomiting and abdominal pain. He had undergone laparoscopic hernia repair. He had no chronic health conditions. Vital signs at the time of ED presentation identified a normal heart rate and blood pressure of 147/99. The abdomen was reported to be soft with normally healing incisions. Lab data identified a normal complete blood count (CBC) and complete metabolic panel. He was admitted to the hospital.

The inpatient admission was not medically necessary for this patient. This patient presented one-day following a ventral hernia repair with intractable vomiting. He was clinically stable with normal vital signs and normal lab data at the time of presentation. He was admitted to the hospital and was treated with intravenous (IV) fluid and antiemetic medications. While he continued to have episodic emesis during the day, he left the hospital against medical advice in the evening. This patient may have had a post-surgical ileus or an adverse reaction to anesthetic or analgesic medications or other etiology of the emesis that prompted his presentation to the ED. However, a lower level of care would have allowed for provision of IV fluid, lab data and follow up assessment including overnight monitoring if needed. Short term monitoring (without full hospital admission) not expected to exceed 24-48 hours would have allowed for acute treatment and reassessment as provided in this case and would have been consistent with medical standards.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: non-ST elevation myocardial infarction (NSTEMI)/drug overdose
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a female who was brought by ambulance after she was found unresponsive outside a motel. The patient had a pipe next to her. Emergency Medical Services (EMS) administered Narcan. Previously, the patient was hospitalized in the Intensive Care Unit (ICU) on a Narcan drip due to an Opioid Overdose.
Her past medical history was significant for Hepatitis C, seizure disorder, Underweight (body mass index (BMI) 18.8), Tobacco Abuse, Polysubstance abuse, Multiple Drug Overdoses, Possible Bipolar Disorder, Depression and Anxiety. Her PSH (past surgical history) and Social history are unknown.

The Inpatient Hospital Stay was not medically necessary for this patient.
The patient presented with lethargy due to drug effect. Her lethargy resolved after effect of drugs subsided. She did not have stroke or any other neurologic diagnosis which would support inpatient admission. The patient was hospitalized multiple times previously for the same problem, that was not new. She did not have major withdrawal syndrome.
Based on the above, the inpatient level of care was not indicated.
The patient did not have cardiac complaints, she had troponin elevation which was due, most likely, to demand ischemia. The patient's vital signs were abnormal for sinus bradycardia, but it was not clinically relevant (she did not have symptoms caused by sinus bradycardia). The patient did not have evidence of unstable blood pressure, she did not have symptoms of heart failure or arrhythmia.
Based on the above, from a cardiovascular standpoint, the inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Agoraphobia with panic disorder and generalized social anxiety.
Treatment: virtual psychiatric intensive outpatient program treatment.
The insurer denied virtual psychiatric intensive outpatient program treatment.
The determination is overturned.

The patient is a female with a history of agoraphobia with panic disorder, generalized social anxiety, mood disorder, generalized anxiety disorder, and oppositional defiant disorder. The patient has a history of avoidance, violent behaviors, and safety concerns. She has been enrolled in weekly psychotherapy. She has been noted to engage in extreme and unsafe behaviors to avoid going to school. She has an individualized education program at school but has failed to progress. She was admitted to a virtual intensive outpatient treatment program. At issue is the medical necessity of the virtual psychiatric intensive outpatient program treatment.
The requested virtual intensive outpatient treatment is medically necessary. The patient failed the outpatient level of care. She was struggling in both the home and school environment and had safety concerns regarding transportation to appointments/treatments as evidenced by her self-harm behaviors that escalated during transportation.
The patient has failed lower levels of care, and the treatment is not solely for the comfort /convenience of the patient/family or treating provider. The patient's therapist, school officials, and psychiatrist were all in support of virtual intensive outpatient treatment and this is the standard of care for a child who is failing to progress with traditional outpatient treatment and has significant impairment in activities of daily living.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: 24 hours per day - split shift - consumer directed personal assistance services (CDPAS). 
The insurer denied coverage for 24 hours per day - split shift - consumer directed personal assistance services (CDPAS). 
The denial is overturned. 

According to the New York Medicaid Guidelines for personal care in the home, Personal Care Services are provided in the amount and quantity required to meet care plan needs. New York State Medicaid regulations state that 24 hours/day split-shift services are covered when the provision of uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for patients who need assistance with activities of daily living (ADLs) tasks such as toileting, walking, transferring, turning, or positioning because of their medical condition, with such frequency that an in-living 24-hour personal care aide would not be able to obtain on a regular basis 5 hours daily of uninterrupted sleep during the 8-hour sleep. 

The insurer has partially denied coverage for 24 hours per day - split shift - consumer directed personal assistance services (CDPAS), as not medically necessary. In a Final Adverse Determination letter, they stated that the plan initially approved 84 hours per week of CDPAS. The plan approval increased to live-in services. The nursing assessments were reviewed. There was a decline in the patient's ability to perform activities of daily living (ADL's). The patient is wheelchair bound. 

This case involves an adult who lives alone on the 2nd floor 2-bedroom apartment; the building has no elevator. In the most recent assessment, it was noted that the patient is totally dependent on most of their instrumental activities of daily living (IADLs) and ADLs. Based on the medical records submitted the patient exhibits deficits of judgment and insight. The patient's orientation to time, place, and person is impaired. The patient's thought process is not coherent and there are noted deficits in recent or remote memory. The patient needs maximum/extensive to total assistance with all of their daily activities. The patient had multiple falls in the past 12 months due to impaired cognition that resulted in emergency room (ER) visits. The patient is taking multiple medications for cognitive and behavioral diagnoses. The patient requires assistance to ensure that medications are being taken as prescribed. The clinical records showed that the patient's cognitive skills for daily decision making are impaired. Thus, the patient requires constant cues and supervision to ensure the safety of the patient and the community. Given the medical history, cognitive/behavioral impairment and the level of assistance required, this patient meets the criteria for continuous CDPAS. 

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 24 hours per day - split shift - consumer directed personal assistance services (CDPAS) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a girl with a history of asthma who presented with shortness of breath. She was well until the day prior to presentation, when after playing outside all day she developed a dry cough. She then developed sneezing and nasal congestion. By the following morning, she also had shortness of breath. She was given albuterol both from her inhaler and by nebulizer, but had no response. She was therefore brought to the emergency department for further care.

Inpatient Hospital Admission was medically necessary for this patient.
This is a young girl who presented with status asthmaticus. She had tachypnea and retractions upon arrival despite having received treatments at home. She received intensive and appropriate treatment in the emergency department with bronchodilators and corticosteroids, but she continued to have significant symptoms of tachypnea and wheezing. Upon admission, she was still requiring bronchodilator treatments every 3 hours. She therefore required hospital admission for continued frequent treatments, intravenous corticosteroids, and close monitoring with additional treatments as needed.
Children with asthma who have continued significant respiratory symptoms after emergency treatment and who require bronchodilators more than every 4 hours need hospital admission for continued frequent treatments along with close monitoring for potential deterioration of clinical status. This patient also had a history of intensive care unit admissions, raising her risk for morbidity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebral infarction/decreased mobility
Treatment: Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hours per Day (Split Shift) 
The insurer denied Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hours per Day (Split Shift) 
The health plan's determination is overturned. 

The patient is a female with past medical history of cerebral infarction, diabetes mellitus type 2 with neuropathy, osteoporosis, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, obesity, iron deficiency anemia, chronic pain syndrome, osteoarthritis, coronary artery disease, chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, depression, dementia, urinary incontinence, and bowel incontinence who had been assigned personal care services based on assessment assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with task of stairs, transportation, bathing, and dressing lower body. With tasks of managing finances, managing medication, phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at limited assistance while supervision with tasks of bed mobility and eating. 

Home Care / Personal Care Level 2 Personal Care Services Increase to 24 Hours per Day (Split Shift) are medically necessary for this patient.
There is documentation from the patient's medical provider of the medical necessity of split shift-services. Specifically, the patient's medical provider documents the medical necessity of turning and repositioning every 2 hours including the overnight hours. The patient's care needs would not allow a PCA (personal care aide) 5 hours of uninterrupted sleep and therefore split-shift services are medically necessary. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's dementia is of such severity that she would not be able to summon help via PERS (personal emergency response system) in the event of an emergency.
Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
Treatment: inpatient stay
The insurer denied
The determination is upheld.

This is a male patient with a history of insulin-dependent diabetes mellitus (IDDM), which is well controlled with an insulin pump, who presented to the emergency department (ED)with a history of vomiting for several hours at home. On the day of admission, the patient was previously well and went to school. He ate dinner and reportedly began with emesis and was brought to the ED after having had approximately 10 episodes of emesis.  Though it is documented in his physical exam that the patient is "alert and oriented for age" and "active," it is documented elsewhere that the patient was not acting normally or at his neurologic baseline. The patient had labs done in the emergency department (ED). 
He was given an appropriate bolus of normal saline (20 millilters per kilogram (mL/kg)) and ondansetron. It is recorded that the patient was still not at his neurologic baseline, so a decision was made to admit him. At some point, the patient reported to his mother that he had ingested a "gold coin," so an x-ray of the chest and abdomen were performed and reportedly normal with no evidence of a foreign body. On the day of admission, the patient was ordered maintenance intravenous (IV) fluids and a regular diet was ordered. No labs were repeated during admission, and there is a discharge order written. In the patient's discharge summary, it is documented that his last episode of emesis was in the ED . At the time of discharge, he is documented as being "active," with "no sign of dehydration," and "alert and oriented for age." It is also important to note that though the patient does have a chronic medical condition (IDDM), it is documented that his condition is well controlled with an insulin pump, and he was never hypoglycemic nor significantly hyperglycemic nor ketotic, which could require inpatient hospitalization. At issue is the medical necessity of an inpatient stay.

At the time of presentation, the patient had signs of mild (possibly moderate) dehydration. He had a HR and BP within normal limits for age. In the admission note, he is documented as being thirsty, which is a sign of mild dehydration. While in the ED, the patient is documented as not being at his neurologic baseline, which could be a sign of moderate dehydration. The patient is documented as having his last episode of emesis prior to administration of ondansetron in the ED. This reviewer is unable to find documentation of an oral (PO) challenge in the ED, however, upon admission, the patient was ordered a regular diet, with no documentation of further emesis. While it is appropriate to administer intravenous (IV) hydration in a setting of dehydration with intractable vomiting or inability to maintain hydration, the patient returned to his baseline and was able to maintain hydration by oral means within 12 hours of admission. As such, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever.

Treatment: Inpatient admission.

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

The patient has a history of peripheral neuropathy, right jugular vein occlusive thrombus, and esophageal cancer. The patient has undergone multiple lines of treatment including radiation therapy and chemotherapy with FOLFOX. A scan showed disease progression. The patient was started on Cisplatin/Nivolumab and Capecitabine and is currently on Carbo/Taxol/Nivolumab. He last received Carbo/Taxol and Nivolumab followed by Filgrastim. The patient's most recent dose of Nivolumab was held due to transaminitis.

The patient was admitted to the hospital after presenting with non-neutropenic fever post chemotherapy. The patient's temperature while at home was 101.8 degrees Fahrenheit (F), which persisted despite two (2) Tylenol tablets. The patient was admitted for fever and issues with their feeding tube. A chest x-ray did not show pneumonia and the patient was afebrile while in the Emergency Room (ER) with a temperature of 98.8 F.

The request for approval of the inpatient admission is the topic of this review.

The inpatient hospital admission is not considered medically necessary for this patient. 

Aside from a history of fever at home, which was not responsive to Tylenol, there is no suggestion of acute sepsis. There was no increased temperature in the Emergency Room (ER) and no indications of a focal infection or pneumonia, nor was the patient neutropenic. He was not in acute distress and had a normal examination. The fever may have been due to home medications to treat his cancer. 

The patient's vital signs were blood pressure of 103/73, pulse of 111, respirations of 19, temperature of 98.8 Fahrenheit (F) and oxygen level of 98% (percent). Therefore, the inpatient admission was not medically necessary for this patient. 

Based on the above, the insurer's denial must be 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 inpatient hospital admission is not substantiated.