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

Substance Abuse/Addiction
Substance Abuse Inpatient

The patient is a male who was admitted due to opioid dependence, cocaine use disorder, moderate, dependence, benzodiazepine abuse, Obesity, Pre-diabetes and chronic bilateral low back pain. The patient has history of hypertension (HTN) and dyslipidemia. On admission, the patient's urine toxicology screen was positive for cocaine, benzodiazepines, methadone, opiates and cannabinoids.
The patient had been admitted to detox originally, completed methadone tapering, and then was admitted in step down to inpatient rehabilitation. The patient had lower back pain rated as an 8/10. He had no other withdrawal symptoms, medical concerns or hallucinations. The patient was not suicidal or homicidal. In the 6 months prior to admission, the patient had been in 5 days of detox and had one emergency room (ER) visit. There were no other non-detox services. The patient had no significant medical instabilities or withdrawal concerns. He was not suicidal or homicidal. The patient had management of his chronic pain and HTN. He had no distress throughout, and he participated in care. At issue is the inpatient substance abuse rehabilitation. The health plan's determination is upheld in whole. The requested treatment of inpatient substance abuse rehabilitation was not medically necessary. The patient had completed detox with no complications. The patient was not suicidal, homicidal, psychotic, aggressive or threatening. The patient had chronic medical concerns, but no acute medical concerns that required around the clock monitoring. The patient was participating in care and had social supports. The patient had no severe post-acute withdrawal symptoms. Treatment could have been addressed at a lower level of care. Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) tool was utilized, and the result was consistent with treatment at a lower level of care based on the information in the medical record.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, cough 
Treatment: Inpatient admission 

The Inpatient admission was not medically necessary. 

The patient is a male infant. He presented to the ED in the evening with one-day history of fever to 101 treated with Tylenol and two-day history of dry cough. He had one episode of post-tussive emesis and one episode of diarrhea, but was otherwise feeding normally. 

The patient's vital signs included temperature 102.6, heart rate 170, respiratory rate 38, and 100% saturation in room air. Examination was significant for no acute distress, non-toxic appearance, mildly erythematous right tympanic membrane, moist mucous membranes, regular heart rate and rhythm, clear lungs, benign abdomen, brisk capillary refill, and non-focal neurologic exam. A partial septic work-up was undertaken, revealing the following: urinalysis with specific gravity 1.020, 100 protein, moderate blood, moderate leukocytes, 25-50 WBCs (white blood cells), and 6-10 RBCs (red blood cells); mild metabolic acidosis with CO2 (carbon dioxide) 20; mildly elevated CRP (C-reactive protein) 1.4; negative rapid influenza and RSV (respiratory syncytial virus); and leukocytosis with WBC count 14.1K, normal differential. 

The patient was treated with a normal saline bolus and a dose of ceftriaxone (after urine and blood cultures were obtained). He was admitted for management of urinary tract infection with possible pyelonephritis. Admission orders included continuation of ceftriaxone, IV fluids, diet for age, and follow-up of cultures. He had several episodes of fever overnight with maximum 102.9. He was active and feeding well, and his cough had resolved. The following day, he continued to do well, with maximum temperature the afternoon before (101.7). Urine culture was reported positive with gram negative rods, and the following day identification and sensitivities had been completed. He was at his baseline with no fevers. He was deemed stable for discharge, to complete a course of antibiotics with cefdinir and obtain a renal ultrasound as an outpatient. 

This male infant presented with fever and dry cough. Work-up in the ED was suspicious for urinary tract infection, with positive findings on urinalysis as well as elevated CRP and leukocytosis. He was given a dose of parenteral antibiotic prior to admission. Urine culture was ultimately positive for UTI (urinary tract infection) with E. coli sensitive to most antibiotics. For the duration of his hospital stay, including presentation to the ED, he was alert, hemodynamically stable, with no signs of dehydration or impending sepsis. While it was not unreasonable to monitor him in the hospital for deterioration or progression of illness, he did not require acute inpatient admission. He could have been safely managed at lower level of care such as observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiovascular/Chest pain  
Treatment: Inpatient hospital stay  

The patient presented to the emergency department by ambulance with chest pain and dizziness.  Patient has a past history of pericarditis, hypertension, diabetes, anxiety and asthma.  The patient was on aspirin at home and other meds.  An electrocardiogram (ECG) showed significant ST elevation in leads 3, AVF, V2-4 and ST depression in I and AVL.  The initial troponin was negative.  The health plan's determination of medical necessity is overturned in whole.   This patient had a thrombolysis in myocardial infarction (TIMI) score of 3 based on risk factors, aspirin use, and ECG findings.  This put the patient at higher risk for death or cardiac complications and made the admission appropriate.  

TIMI risk score - Analysis of data from the TIMI 11B and ESSENCE trials found seven variables to be independently predictive of outcome in patients with unstable angina (UA) or a non-ST elevation myocardial infarction (NSTEMI).  These criteria were defined as the TIMI risk score.  Normally a TIMI score of 2 or greater indicates higher risk and that the patient should be admitted.  This patient's admission was both appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular Accident 
 Treatment: Home Care/ Personal Care Home Health Care (HHC). 

The insurer denied the Home Care/ Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes increase to 72 hour(s) per week. The denial was reversed. 

This is a male patient with a medical history of stroke/cerebrovascular accident, chronic pulmonary obstructive disease, essential hypertension, edema, unspecified, shortness of breath, incontinence, and falls. He receives 37 hours per week personal care services (PCS) and is requesting an increase of PCS to 72 hours per week. It is reported that the patient's wife recently died and his daughter now lives with him. He is dependent on his caregivers for all of his activities of daily living (ADLs) (extensive or maximal assistance, or total dependence) with the exception of eating and bed mobility. The patient's son expressed safety concerns due to his father's recent fall and his unstable mobility. As per the patient's daughter she had medical issues that limit her ability to help her father. 

Multiple co-morbidities in the very old can result in significant burden with daily activities. Although the UAS describes patient as needing limited assistance with walking, it appears that the patient has multiple factors adversely affecting his ability to walk, including, dyspnea with exertion, arthritis, pain, edema, muscle rigidity. He had a fall the day before the UAS was done. The patient's son describes his father's mobility as unstable and is concerned for recurrent falls. The patient is at high risk for falls. Fall prevention is a priority for this patient. Falls in the elderly are associated with serious injury (e.g. fractures, head trauma), increased morbidity and increased risk of death. With h/o chronic lung disease and recurrent pneumonia, a serious injury resulting in hospitalization and prolonged immobility could be critical. 

Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. The patient's daughter is not able to provide much assistance due to her own health problems. The son requested 72 hours PCS services per week. It is reasonable to conclude that there are no informal caregivers who can provide the care the patient needs on a regular basis during daytime hours when he needs the most frequent attention for his ADL needs. 

Without informal caregiver support to provide the necessary care, then personal care services are indicated to provide assistance with ADLs. 

Level 2 Personal Care Services 72 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for Home Care/ Personal Care Home Health Care (HHC) - Level 2 Personal Care Services, per 15 minutes increase to 72 hour(s) per week is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Abdominal pain
Inpatient hospital stay

Treatment: Inpatient hospital stay
The patient has a past medical history of poorly controlled diabetes mellitus, asthma, diabetic gastroparesis, and chronic abdominal pain who presented to the emergency department with complaints of worsening abdominal pain.
It was reported that in the last 6 months preceding this admission the patient had multiple hospitalizations primarily because of the abdominal pain. The patient underwent a gastric emptying study and was diagnosed with gastroparesis. At that time the patient was discharged with a prescription for Reglan and Gabapentin. In the last 3 days before the day of admission, the patient noticed progressively worsening abdominal pain and a new bulging sensation in the right upper quadrant. The abdominal pain was aggravated by meals and alleviated by vomiting. The review of systems was positive for low-grade fever that the patient noticed 1 day before the day of admission, poor appetite, abdominal pain, nausea, vomiting, diarrhea. The rest of the review of systems was unremarkable.
The patient was admitted to the hospital with abdominal pain, nausea, and vomiting, which were attributed to gastroparesis. The patient continued to receive Reglan and Gabapentin. For the treatment of diabetes mellitus, the patient received a combination of long-acting and short-acting insulins.
During the hospital stay the patient was seen by an endocrinologist who diagnosed the patient with type 2 uncontrolled diabetes mellitus with hyperglycemia. The endocrinologist adjusted the insulin regimen and provided extensive counseling on medication adherence, also on complications of uncontrolled diabetes such as neuropathy, retinopathy, cardiovascular disorders, stroke.
The health plan's determination of medical necessity is upheld in whole. 
This patient presented to the emergency department with complaints of abdominal pain, nausea, and vomiting that occurred in the setting of already diagnosed gastroparesis due to uncontrolled type 2 diabetes mellitus. It was reported that the patient had a worsening of the chronic abdominal pain for which she had been hospitalized on multiple occasions. Apparently, the patient reported some bulging in the right upper quadrant/periumbilical area, which was associated with abdominal pain. It was specifically mentioned that there was a low concern for possible hernia. Even though the patient had uncontrolled diabetes, there was no mention that the patient had any of the glycemic emergencies including diabetes ketoacidosis or Hyperosmolar hyperglycemic state.
The patient's symptoms responded fast to treatment that was initiated in the emergency department and subsequently after the admission to the hospital.During the hospitalization, the patient did not require any diagnostic tests or procedures justifying admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Substance Abuse/Addictions
Substance Abuse: Inpatient

The patient is a male who presented for detoxification and substance-related services. The patient has an 18 year history of severe substance use disorders with opioid (heroin and methadone), stimulants (cocaine), other substance of abuse (PCP), and cannabis (marijuana) class substances of abuse. He had a history of multiple substance use disorder treatment episodes, but relapsed and was using a up to 10 bags of cocaine and up to 10 bags of heroin with intravenous (IV) administration, two bags of hallucinogens (phencyclidine) and one marijuana blunt, as well as tobacco (12 pack per day). Again, he had multiple prior substance use disorder treatments including a rehabilitation treatment episode with a chronic relapsing course since adolescence.

The health plan's determination is overturned. The inpatient detoxification is clinically appropriate, and medically necessary in this case scenario. The requested medical services could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of heroin together with cocaine, as well as PCP and marijuana that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, nausea, anxiety, irritability, restlessness and insomnia) which were being effectively addressed with methadone and supportive measures. The patient had associated clinical features that included lack of sober supports and limited insight, impaired judgment and poor control of impulses. Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did necessitate the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management as the patient was at high risk for treatment failure if detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, American Society of Addiction Medicine (ASAM) Criteria, scientific literature, and the of NYS LOCADTR 3.0 Criteria.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic lower back pain.
Treatment: Psychological testing.
The insurer denied the psychological testing.
The denial is overturned. 

Yes, the Psychological Testing was medically necessary.

The patient is a male with chronic low back pain for whom a spinal cord stimulator was recommended. As part of the pre-surgical screening, a psychological evaluation was ordered prior to the SCS (spinal cord stimulator) placement. 

The usage of pre-psychological screening prior to SCS trial and implant is a Medicare requirement, and is typically required by most insurers. While it may not be "standard of care," it is utilized by the vast majority of pain management physicians prior to SCS trial, primarily in part that is a requirement by most carriers. It is rare to find an insurance plan that does not require this or at least cover this.  

The usage or pre-SCS psychological screening has been shown to be effective in the literature at preventing unnecessary procedures.  In fact, it has been shown that the success rate of implantation of SCS is improved by pre-surgical psychological evaluation, as those with poor prognosis due to pre-existing psychological issues are either excluded, are receive appropriate treatment for those issues prior to consideration of the procedure. Pre-surgical psychological testing is commonly attached to the work up for SCS, in most cases it is considered as part of the work up to determine if the patient is an appropriate candidate for SCS.  Given the above, the requested psychological testing was medically necessary and should be covered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with a past medical history significant for CAD (Coronary Artery Disease), BPH (Benign prostatic hyperplasia), and substance abuse, who presented to the ER for evaluation of chest pain, which was present for three days duration. The patient was hemodynamically stable. ECG revealed no acute ischemic changes. Cardiac troponin was negative. The chest X-ray was unremarkable. D-Dimer was elevated, and patient underwent a CT angiogram, which revealed no evidence of pulmonary embolism. The patient was admitted to telemetry to rule out ACS (Acute Coronary Syndrome). The patient was seen in consultation by cardiology. A nuclear stress test was obtained and was negative for ischemia. The patient was discharged from the hospital with a plan for outpatient follow-up.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (acute myocardial infarction) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test. Ischemia was ruled out by stress testing. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (Congestive Heart Failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness and a fall, history of history of tobacco abuse, seizure disorder, hypertension, polysubstance abuse, and schizophrenia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a history of tobacco abuse, seizure disorder, hypertension, polysubstance abuse, and schizophrenia.  He presented to the hospital with dizziness and a fall.  
On presentation, the patient's blood pressure was 97/58.  Laboratory indices were notable for a white blood cell count of 3.6 and creatinine 0.8.  Urine drug screen was positive for cannabis and cocaine.  Computed tomography of the brain demonstrated no acute process.  The patient was monitored on telemetry, and intravenous fluids were provided.  The blood pressure normalized.  Psychotropic medications were held.  Psychiatry and neurology were consulted.

The patient's dizziness was not accompanied by evidence of syncope.  There was no evidence of arrhythmia or acute coronary syndrome.  Computed tomography of the brain demonstrated no acute process.  There were no focal neurologic deficits and there was no seizure activity.  The patient did not suffer a fracture or other significant injury during the fall.  The blood pressure promptly normalized.  Symptoms improved with adjustment of psychotropic medications.  The patient remained hemodynamically stable and afebrile.  
In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness, shortness of breath, neck pain
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male who presented with the complaint of generalized weakness, shortness of breath and neck pain for four to five months.  At presentation his neurological examination was normal.  Computed tomography (CT) of the brain was negative for acute event. 

The patient presented with a five month history of multiple symptoms and he had a normal neurological examination at presentation. The chronicity of his symptoms, his clinical presentation, examination findings and results of diagnostic studies completed at presentation did not warrant further evaluation at an inpatient level of service. He could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain 
Treatment: Inpatient Hospital Stay 

The insurer denied the inpatient hospital stay. The determination is upheld. 

The patient was admitted with complaints of (c/o) a one-week history of intractable vomiting associated with abdominal pain. The patient was discharged from the emergency department (ED) the day prior to presentation, after receiving anti-emetics to which he did not respond. Vital signs were remarkable for a temperature of 100.3 degrees Fahrenheit, with no tachycardia. The physical exam was notable for a well-nourished patient in no apparent distress (NAD), periumbilical tenderness to palpation. Lab work showed mild hypokalemia, with a blood urea nitrogen (BUN) of 5. A computed tomography (CT) scan of the abdomen showed non-specific findings suggestive of gastroenteritis. The patient was diagnosed with gastroenteritis and treated with intravenous (IV) fluids, anti-emetics, imaging and biochemical monitoring, and electrolyte repletion. The patient was discharged. At issue is the medical necessity of an inpatient stay. 

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o abdominal pain associated with several episodes of vomiting and fever. The patient did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. In addition, while the patient had mild electrolyte abnormalities, the patient responded to electrolyte repletion. He did not have a bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, blood urea nitrogen (BUN) and creatinine were not elevated, he did not have acute kidney injury, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with acute gastroenteritis with mild dehydration, was treated and responded to intravenous fluids (IVF), anti-emetics, and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.