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

Diagnosis: Left shoulder and breast pain, UTI, hyperglycemia
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a female with diabetes and schizophrenia. She presented to the ED with left shoulder and breast pain, cough and diagnosed with urinary tract infection. She had generalized weakness and was unable to walk. 

The patient's glucose was 400 milligrams per deciliter (mg/dL). Creatinine was elevated at 1.73 mg/dL. Chest x-ray showed questionable left upper lobe mass. She was treated with intravenous (IV) morphine and ceftriaxone. She left against medical advice. Urine culture demonstrated Escherichia (E) coli. Computed tomography (CT) of the abdomen and pelvis showed bladder thickening suspicious for cystitis; asymmetric right perinephritic stranding could be due to underlying infection.  

This patient was diagnosed with a urinary tract infection with concern for possible pyelonephritis. The patient was afebrile and hemodynamically stable at presentation. The documentation does not support that she was unable to take oral antibiotics or that she had persistently high fever or another indication for ongoing intravenous antibiotics. She was hyperglycemic, but there was no indication of acidosis to support diabetic ketoacidosis or change in mental status to support a diagnosis of hyperosmolar hyperglycemic state or another indication for intravenous insulin. She did present with weakness and an elevated creatinine, but the documentation does not support that she had any medical requirements beyond the emergency department. Therefore, no, the proposed inpatient stay was not 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 woman with a past medical history notable for hypertension and diabetes mellitus.  She presented to the Emergency Room with complaints of chest pain, which radiated to her left arm and jaw.  The electrocardiogram (EKG) was unremarkable, showing normal sinus rhythm with no ischemic changes.  The physical examination was unremarkable.  The chest radiography revealed no acute cardiopulmonary findings.  The cardiac troponins were negative.  She was discharged to home.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. The patient presented with chest pain.  The initial evaluation in the ER was unremarkable, including non-diagnostic EKG and cardiac biomarkers.  The inpatient admission was not medically necessary for this patient.  The patient's care could have been provided in the Observation setting, allowing for additional diagnostic testing.  Further evaluation was warranted, however inpatient admission criteria was not met.  There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

The insurer's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic hidradenitis
Treatment: Inpatient admission

The inpatient admission was medically necessary.

The patient is a male with hidradenitis, admitted to hospital due to enlarging mass near rectum with concern for abscess and cellulitis.  

It would be within standard of care to admit a patient with concern for abscess and cellulitis with cultures and appropriate antibiotics.  The patient was appropriately discharged after stabilization.  Given the intensity of services and concerns of the attending providers, a lower level of care would not have been appropriate in this patient's clinical course.
Appeal type: Medical necessity
Decision: Upheld

Alcohol Abuse/Addiction
Inpatient hospital
The patient with a past medical history significant for alcoholism, heroin abuse, depression, and hepatitis C who presented to the hospital with alcohol withdrawal symptoms. Apparently, the patient was recently admitted for similar complaints and signed out against medical advice (AMA). When seen by the admitting physician at the bedside, the patient was not in acute distress and was able to answer all questions appropriately. A review of systems was obtained and was positive for shakiness but negative for everything else. Specifically, it was negative for depression, anxiety, mood swings, difficulty sleeping.

The health plan's determination is upheld. No. The admission at the acute inpatient level of care was not indicated in this clinical case as the patient had very mild symptoms of alcohol withdrawal to start with. Subsequently, the patient's symptoms improved within a short period of time. Even though she was tremulous when seen by an emergency room provider, she had no tremors seen on the exam performed by the admitting physician The results of the laboratory studies were clinically unremarkable. The patient had mild thrombocytopenia, which was most likely related to chronic alcohol use. She also had mild hypokalemia, which was clinically insignificant. The abnormal transaminases were typical for cases of chronic alcoholism..In this particular case, the patient did not develop symptoms of severe alcohol withdrawal that would require admission at the inpatient level of care. In fact, the patient's recovery was fast, and she was discharged home in a stable clinical condition the very next day after the day of admission.
In conclusion, admission for a lower level of care was reasonable. At the same time, the severity of the patient's condition did not justify the medical necessity of the acute inpatient level of care. The patient's laboratory results were clinically unremarkable, even though she had very mild hypokalemia and elevated transaminases, which were most likely related to chronic alcohol use. The patient's recovery was fast, to the point that she was able to go home the next day after the day of admission. The acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD); obstructive sleep apnea (OSA)

Treatment: Home ventilator (CPT code E0466RRx3)

The insurer denied coverage for home ventilator (CPT code E0466RRx3). The denial was reversed.

This patient is a female with history of chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), morbid obesity, acute on chronic respiratory acidosis, obesity hypoventilation syndrome and restrictive lung disease secondary to obesity.  The patient was hospitalized with acute on chronic respiratory failure with hypercapnia and hypoxia secondary to COPD exacerbation.  The patient was maintained at home with supplemental oxygen and bilevel positive airway pressure (BIPAP).  However, the patient was non-compliant with the BIPAP.  After admission, the patient was treated with intravenous (IV) steroids, bronchodilators via nebulizers and Azithromycin.

By a specified date the patient started showing improvement with treatment. On a later date the patient was cleared for discharge home. Arterial blood gases (ABGs) at discharge included a pH of 7.42, a partial pressure of carbon dioxide (PCO2) of 69, a partial pressure of oxygen (PO2) of 70 and oxygen saturation of 93%. This patient has chronic hypercapnia and hypoxic respiratory failure.  This patient would benefit from home ventilation with noninvasive ventilation (NIV) to decrease readmissions and improve quality of life.  Previously this was denied due to lack of appropriate grounded outlets and amperage at the patient's home. However, this patient has an Oxygen Concentrator and also had BIPAP, which required the same outlets and amperage and is already functional since early 2019.  Due to daytime hypercapnia and the patient's multiple conditions, she is a good candidate for Home Ventilation with NIV.  The prior denial is reversed.

The carrier's denial of coverage for home ventilator (CPT code E0466RRx3) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Chest Pain
Inpatient hospital

The patient is a  female who presented to the ED with chest pain. The patient was brought by ambulance. The patient reported two days of persistent chest pain, rated 3/10, intermittent substernal and associated with palpitations, diaphoresis, shortness of breath and paresthesia of both arms. (By another description, her pain was on the right side and radiated to the left side).

In the ED, the patient was evaluated by a physician. Her blood pressure (BP) was 168/80. The rest of her vitals were normal. Her arterial blood gas (ABG) revealed PH of 7.49. Her total creatine kinase (CK) was 296, blood urea nitrogen (BUN) was 45, creatinine was 1.91, hemoglobin (Hb) was 8.4. Her troponin was normal. Her electrocardiogram (ECG) was normal. Her chest x-ray (CXR) was normal. Her physical examination revealed lower extremity (LE) edema. 

The patient was admitted to the telemetry unit. At issue is the medical necessity of the inpatient stay.

The health plan's determination is upheld. The patient presented with atypical chest pain. The patient had multiple coronary risk factors. Her chest pain was associated with multiple symptoms. But her chest pain was atypical, it was positional and reproducible on palpation. However, there was no support of ongoing acute coronary syndrome, based on ECG, troponin and CXR. The patient's serial troponin was normal. Her ECG was normal. Her stress nuclear perfusion test was negative for ischemia. The patient remained stable and was treated with oral medications. The patient had low Hb, but it remained stable during hospital stay. There was no workup or specific treatment for her anemia, which would require inpatient admission.

Based on above, inpatient level of care was not met. The patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right upper quadrant pain

Treatment: Inpatient admission

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

This patient is a female with psoriasis, diabetes, hypertension, asthma, thyroid disorder, and cirrhosis. The patient had a liver biopsy two days earlier and presented with right upper quadrant pain.  She also had been vomiting and on one occasion vomited frank blood emesis. She was afebrile and the vital signs were stable. On physical exam there was a mild ecchymosis at the biopsy site. There was no rebound or guarding. A stool guaiac was negative. A Computer Axial Tomogram (CAT) scan was consistent with a minimal amount of bleeding from the biopsy site. The patient received intravenous (IV) fluids, proton pump inhibitor (PPI) therapy and pain medications. Her symptoms then improved.

Clinical indications for admission for abdominal pain (M-05) include the need for surgery that cannot be performed on an ambulatory basis and peritoneal signs. The patient did not have these conditions. She also did not have hemodynamic instability intestinal obstruction, bacteremia, or a severe electrolyte abnormality.  

Clinical indications for admission for upper gastrointestinal bleeding (M-180) include ongoing bleeding, high risk endoscopic features, severe liver disease, hemodynamic instability and a severe anemia associated with cardiac ischemia. The patient did not have these conditions.

This patient had minor bleeding after a liver biopsy. She remained hemodynamically stable and did not require any acute interventions. Her treatment included; intravenous hydration, proton pump inhibitor therapy and pain medications could have been given at the Observation level of care. She did not meet MCG criteria for admission for either undiagnosed abdominal pain or upper gastrointestinal bleeding. The healthcare plan acted reasonably and with sound medical judgment. An inpatient hospital admission was not medically necessary. The health plan acted reasonably and with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mass in the right (R) lung
 
Treatment: Inpatient admission

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

This patient is a female with history of hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM), coronary artery disease (CAD), status post percutaneous coronary intervention (PC), asthma and chronic obstructive pulmonary disease (COPD).  The patient presented to the Emergency Department (ED) as he was referred by his primary care physician for inpatient bronchoscopy and biopsy for an abnormality found on PET CT.  The patient was found to have a 1.7 X 1.8 cm spiculated mass in the right (R) lung.  The patient denies fever, chills, cough, shortness of breath (SOB) or weight loss. Vital signs in the ED were: Temperature 98.2 F, blood pressure (BP) 154/61, respiratory rate 18, heart rate 55 and oxygen saturations were 100% on room air.  The patient was in no acute distress. Lungs were clear with good air entry bilaterally; possibly some expiratory rhonchi.  cardiovascular system was normal.  The patient was awake and alert X 3. White blood cell (WBC) count was 5.8K, hemoglobin (HB) 10.9, electrolytes were within normal limits (WNL).  BUN/Creatinine was within normal limits.  Also EKG was within normal limits.  Brain natriuretic peptide (BNP) was normal. As per History & Physical (H&P) the patient was afebrile and hemodynamically stable.  Lungs were clear.

The patient was scheduled for elective faecal occult blood (FOB) and biopsy the next day for her Solitary Pulmonary Nodule. The patient underwent FOB with biopsy.  The procedure was uneventful.  The patient remained stable.  The patient was discharged with outpatient follow up appointment. It appears that this patient did not need acute hospitalization to perform his bronchoscopy.  The patient was afebrile, hemodynamically stable.   There was no evidence of chronic obstructive pulmonary disease (COPD) exacerbation.  This patient had suspicion of malignancy but there was no oncologic emergency noted.  The patient underwent FOB and biopsy which was unremarkable.

Diagnostic testing for suspected malignancy of the lung could have been easily and safely done in the outpatient/ambulatory surgery setting.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for the inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient hospital admission

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

This patient is a man with a past medical history notable for hypertension, diabetes mellitus, coronary artery disease, stroke, prior coronary stenting, and myocardial infarction.  He presented to the Emergency Room (ER) with complaints of chest pain, which radiated to his left shoulder, an episode of syncope, headache, and vomiting.  EKG showed no acute ST-T changes.  Drug screen was positive for cocaine.  Troponin was negative initially and on repeat evaluation.  He remained chest pain free during his brief hospitalization. He was discharged home after a period of medical stability.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The acute inpatient admission was not medically necessary. The patient presented with chest pain.  The initial evaluation in the ER was unremarkable, including nondiagnostic EKG and negative cardiac biomarkers. Inpatient admission was not medically necessary for this patient.  The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing.  Further evaluation was warranted, however inpatient admission criteria was not met.  There was no evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.  

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

Diagnosis:  Dyspnea
Treatment:  Inpatient admission
The proposed treatment was medically necessary.

The patient is a male with a past medical history significant for hypertension (HTN), dyslipidemia, coronary artery disease (CAD) (status post [s/p] percutaneous coronary intervention [PCI]), systolic congestive heart failure (CHF) (reduce ejection fraction [HFrEF]) with severely depressed left ventricular (LV) function, ejection fraction (EF) of 27%, atrial fibrillation, chronic obstructive pulmonary disease (COPD), and psychiatric disorder.  He was non-compliant with medical therapy in the psych ward and was admitted due to worsening dyspnea, consistent with CHF exacerbation. 

The patient was hemodynamically stable, but had episodes of oxygen desaturations. Troponin was negative; brain natriuretic peptide (BNP) was severely elevated.  The patient was treated with intravenous (IV) diuretics, and his losartan was held due to low blood pressure (BP).  The patient had episodes of rapid atrial fibrillation, and his medications were adjusted for better control.  Arterial blood gas (ABG) was abnormal. 

The patient was treated for COPD and CHF exacerbation and gradually improved. There was ongoing problem with medication non-compliance. The patient was not cleared for discharge by psychiatry and was transferred to a psychiatric unit upon discharge from telemetry/medicine.

This patient with multiple risk factors, known CAD, and severe systolic CHF, presented with CHF and COPD exacerbation, oxygen desaturation and required IV diuresis.  His management was more complex due to episodes of rapid atrial fibrillation, hypotension, requiring adjustment of medical therapy, as well as medication non-compliance and psychiatric instability.  A patient such as this one could not be safely managed in a lower level of care setting, and it would be consistent with the current standard of care that this patient be managed in an inpatient setting; therefore, the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Overturned

Mental Health
Inpatient Hospital

The patient has an extensive past history, including physical and sexual assaults, blackouts, and a recent one month psychiatric hospitalization for psychosis from which the patient was discharged on Zoloft and risperdone with outpatient follow up. The patient was living in a homeless shelter with a parent. The patient became physically aggressive with staff at school and was brought by Emergency Medical Services (EMS) to the emergency department (ED). On arrival, the patient was afebrile with normal vital signs and appeared fatigued and agitated. To the ED physician, the patient denied intention to hurt the patient or others. To the consulting psychiatrist in the ED, the patient reported that the patient is a friend of Spidergirl, hears voices, feels that the TV is speaking directly to the patient, and believes being monitored by cameras, and that people are out to get the patient. The patient could not remember the aggressive behavior at school that prompted the EMS call. The patient and parent both said that the patient has problems with adherence to the risperdone because of the side effects. The patient admitted to use of marijuana, and the urine tox screen was positive for cannabinoids, but nothing else. The patient's general blood chemistry values were normal. The psychiatrist recommended admission for psychosis and stabilization. 

The health plan's determination is overturned. The inpatient admission was medically necessary for this patient. This patient with a past history of psychosis and poor compliance with the antipsychotic medications and had acute psychosis with aggressive behavior. According to the consulting psychiatrist, the patient was not appropriate to be discharged from the ED (the patient resided in a homeless shelter), and that the patient needed to have the psychosis stabilized and be transferred back to the acute psychiatric facility where the patient had spent a month not long before this presentation. There was no less intense alternative to hospitalization at the time the patient was admitted from the ED, and the two nights the patient spent in the hospital being stabilized and monitored prior to transfer to the acute psychiatric hospital is a fairly short duration. It is not clear from the information provided why the plan changed from transfer to the acute psychiatric hospital to discharge "home" with intense outpatient follow up. Nonetheless, the two days were medically necessary in order to stabilize the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type II diabetes, osteoarthritis, prostate cancer
Treatment: Increase in Consumer Directed Personal Assistance Services to 8 hours/day, 7 days/week 

The Increase in Consumer Directed Personal Assistance Services to 8 hours/day, 7 days/week is not medically necessary.

The health plan did act reasonably with sound medical judgment and in the best interest of the patient by providing the 3 hours per day 7 days per week of consumer directed personal care assistance.

The patient is a male with medical history Type II diabetes, osteoarthritis, chronic low back pain, prostate cancer, hypertension and chronic dizziness resides in an assisted living apartment.  He currently receives consumer directed personal assistance services for shopping, cleaning, meal preparation, transportation, bathing, dressing, toileting and locomotion.  Current level of customer directed personal assistance services is three hours per day seven days per week.  Based upon recent community survey the level of medical services required is met by this level of assistance.  There was no medical necessity for additional services documented in the records that were reviewed.

Therefore, the Increase in Consumer Directed Personal Assistance Services to 8 hours/day, 7 days/week is not medically necessary.