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

Diagnosis:  Schizophrenia
 
Treatment:  Continued Inpatient Mental Health Stay

The insurer denied the Continued Inpatient Mental Health Stay.  The denial was upheld. 

This is a young female patient who presented to the emergency room for a psychiatric evaluation.  The patient reported that her symptoms included auditory and visual hallucinations, paranoid delusional thinking, homicidal ideation, and threatening behavior- as she admitted to using a knife and threaten her family.  She had a history of schizophrenia and Cannabis Use Disorder.  She has had past psychiatric hospitalizations.  While in the hospital, it was noted that the patient was cooperative with medication compliance, and she participated in therapies that included: milieu, individual, group, supportive psychotherapy, and psychoeducation.  As of the first date in question, the patient was calm with an appropriate affect.  She was no longer having suicidal ideations or auditory or visual hallucinations.  She was discharged after a period of stability.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia indicates that; patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior are candidates for inpatient treatment. 
As of 4 days before discharge, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital treatment setting or that could not be achieved in a less restrictive level of care.

Based on the above, the medical necessity for the continued inpatient mental health stay is substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Sepsis secondary to pneumonia and COPD/asthma exacerbation
 
Treatment:  Inpatient admission, medication, monitoring

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

This is a female with a history of chronic obstructive pulmonary disease (COPD) and substance abuse, and she is immunocompromised.  She presented to the Emergency Department (ED) with complaints of shortness of breath, cough, night sweats, and chills for about eight days.  Initial vital signs were: temperature 101.7 F., blood pressure 130/72, heart rate 110 and respiratory rate 20.  Oxygen saturation was 95% on room air.  The patient was in mild distress; her lung fields were clear.  A white blood cell (WBC) count was 9.3 K.  Electrolytes were within normal limits.  Lactate was 1.8. Influenza test was negative; urine toxicology was positive for opiates, cocaine and cannabinoids.  The chest x-ray revealed pneumonia.  The patient was admitted for sepsis secondary to pneumonia and COPD /asthma exacerbation.  She was treated with intravenous (IV) steroids, bronchodilators and Levofloxacin.  A computer axial tomogram (CT) chest showed moderate bilateral lower lobe patchy air space disease compatible with pneumonitis +/- superimposed on chronic changes.  There was no hypoxia, and oxygen saturation was 98% on room air.  The peak expiratory flow (PEF) was 170. 

It appears that this patient did not need acute hospitalization.  She could have been placed in observation while diagnostic testing and treatment were initiated.  The patient had a CURB 65 score of zero.  The patient did not have hypoxia.  The white blood cell count (WBC) was normal.  The patient was tolerating oral intake.  She was stable for discharge on oral antibiotics and other Asthma/COPD medications with close follow-up in an outpatient setting. 

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

Diagnosis: Viral gastroenteritis
 
Treatment: Inpatient admission, intravenous fluids, monitoring

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

This was a female child with a history of recent upper respiratory tract infection. She presented to the Emergency Department (ED) with vomiting x 5 episodes in the past 2 hours. Vitals on arrival were: heart rate 135, temperature 97 F, and respiratory rate 20. She was awake and in no distress. Skin was dry with normal skin turgor. Her mucus membranes appeared dry. There was nasal congestion but the lungs were clear. Her abdomen was soft with mild, intermittent diffuse tenderness to palpation. Bloodwork revealed blood urea nitrogen 21, creatinine 0.48, chloride 103, bicarbonate 23, white blood cell count 28.1 with a left shift (neutrophils 86%, no bands). Urinalysis showed specific gravity 1.010, pH 8.5, and dip + for trace leukocyte esterase. Abdominal films showed abundant stool in non-dilated, non-obstructed bowel. She was given a normal saline bolus followed by fluids at 50ml/hour. The patient had additional vomiting episodes (bilious) in the ED and she was admitted to the hospital.

This patient appears to have viral gastroenteritis with persistent vomiting resulting in mild dehydration and abdominal cramps. The approach to nausea and vomiting in children from Up-To-Date state reasons to admit would include: signs of significant dehydration poorly responsive to intravenous hydration in the Emergency Department, hemodynamic instability, significant electrolyte imbalance, demonstrated oral hydration intolerance to oral challenge, poorly controlled pain with an oral pain medication regimen, concerning physical exam findings for a surgical process or findings consistent with significant blood loss or bowel obstruction. Given that her vomiting continued in the ED, and that bilious vomiting suggested a potential bowel obstruction, she met criteria for inpatient admission.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis

Treatment: Inpatient admission

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

This patient is a female, with unremarkable past medical history other than recent Caesarean section who presented to the emergency department with complaints of erythema and swelling of the right calf.

The vital signs on presentation included: Temperature 97.9 F., Blood Pressure 123/80, Pulse 92, Respiratory Rate 17, Oxygen (O2) sat 99% on room air (RA). The laboratory values were notable for the following: white blood cell count (WBC) 7.7, Hemoglobin (Hgb) 15.3, Hematocrit (Hct) 46.1, creatinine 0.6, glucose 95.

This patient was admitted for possible right lower leg cellulitis with bullous formation. She was empirically started on intravenous antibiotics (Ceftriaxone and Doxycycline) and topical ointments. All cultures were negative. The patient remained afebrile, hemodynamically and clinically stable. The patient requested discharge; she was sent home on oral Doxycycline and Cefdinir and instructed to follow-up as an outpatient.

According to documentation, the patient was admitted for possible right lower extremity cellulitis. She was otherwise afebrile, hemodynamically stable with unremarkable laboratory findings including a normal white blood cell count (WBC). The patient had a localized infection with no failure of outpatient intervention. The patient did not require surgical intervention and she was tolerating oral intake. Based on above findings, this patient did not meet criteria for acute inpatient admission.

The prior determination of denial of inpatient admission was appropriate. The health plan acted reasonably and with sound medical judgment in the best interest of the patient.

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

Diagnosis: Substance Abuse 

Treatment: Continued Inpatient Detoxification Services

The insurer denied the Continued Inpatient Detoxification Services. The denial was reversed.     


This patient presented for detoxification treatment for substance abuse. He was experiencing withdrawal symptoms such as tremor, abdominal pain, irritability, nausea, vomiting, and anxiety. He had a COW score of 16. He had a history of four prior inpatient substance detoxification treatments. He had a positive toxicology for heroin, cocaine, opiates and benzodiazepines. The patient was treated with Methadone and discharged. It was recommended that he continued inpatient substance rehabilitation treatment.  

The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be co-operative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This patient was using large amounts of IV heroin daily and had past reported overdose a couple of years prior to admission so he was a high risk patient.  He also was using cocaine and cannabis daily. The patient reportedly could not stop using these substances despite 4 past inpatient substance detoxification treatments as he lacked coping skills and ability to identify relapse triggers. He had a positive toxicology screen for opiates, cocaine and benzodiazepines so he was a high risk for overdose. He also was at risk for severe withdrawal symptoms due to the large amounts of daily multiple substances of use. The patient required the entire detoxification Methadone protocol as he was at risk for severe withdrawal symptoms if he stopped the detoxification treatment prematurely and possibly complicated withdrawal.

Based on the above, the medical necessity for the continued inpatient detoxification services is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of human leukocyte antigen (HLA) B27 positive spondyloarthropathy. He was diagnosed as a child and tried and failed Enbrel as he developed a severe reaction (pigmented purpuric vasculitis and hematuria). He then tried methotrexate (MTX) but did not respond to MTX monotherapy. Because of this, his pediatric rheumatologist added Xeljanz, which he has an excellent response to for a number of years. The health plan's determination is overturned. The patient has been on this for a number of years for his HLA B27 positive spondyloarthropathy and he is doing well. It would not be medically appropriate to try another tumor necrosis factor (TNF) agent given his severe reaction to Enbrel. Moreover, there is data showing that Xeljanz is effective in ankylosing spondylitis (AS). In a study published in Ann Rheum Dis. 2017, 'tofacitinib 5 and 10 mg twice daily demonstrated greater clinical efficacy versus placebo in reducing signs, symptoms and objective endpoints of active AS in adult patients with a similar 12-week safety profile as reported in other indications.'
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse
 
Treatment:  Inpatient substance detoxification treatment, medication, monitoring

The insurer denied the continued inpatient substance detoxification treatment.  The denial was reversed.

This female was admitted to inpatient substance detoxification treatment due to substance detoxification.  She had withdrawal symptoms including nausea, vomiting, sweats, a blood pressure of 136/94, a heart rate of 88, as well as anxiety.  She was using intravenous (IV) heroin daily with a 1 year history, benzodiazepines 1-3 times in the past month, and had a 14 year history of smoking crack daily.  She had a positive toxicology for opiates, cocaine, and benzodiazepines.  She had prior suicidal ideation and a bipolar disorder diagnosis.  She was started on a Methadone protocol and was discharged after completion. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  This patient had use of multiple substances and was at risk for overdose, in addition to severe withdrawal symptoms.  According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), she required 24-hour treatment, as she could not safely and effectively be treated for detoxification in a less restrictive setting.  She could not maintain abstinence.  She required and received detoxification medication to modify withdrawal from heroin.  It was not likely that she could safely or effectively be treated in an outpatient substance detoxification treatment, as she could not stop substances of use without being in a sober therapeutic treatment setting.  She was considered at risk for worsened withdrawal symptoms if not in this 24-hour setting.  If she were prematurely discharged from this detoxification treatment before the completion of treatment, she likely would have relapsed.  

Based on the above, the medical necessity for the continued inpatient substance abuse services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
 
Treatment: Inpatient substance detoxification treatment, medication, monitoring

The insurer denied continued inpatient substance detoxification treatment. The denial was reversed.

This male was admitted to inpatient substance detoxification for detoxification treatment. He had multiple withdrawal symptoms and a Clinical Opioid Withdrawal Scale (COWS) score of 15. His toxicology was positive for opiates, barbiturates, amphetamines, and cannabis. He was using intravenous heroin multiple bags daily with an 8 year history, smoking methamphetamine daily with an 8 year history, and 8 joints per day of cannabis with a 19 year history. He was given a 5 day Methadone protocol for detoxification. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. This patient had use of multiple substances and was at risk for overdose and severe withdrawal symptoms. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), he required 24-hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting. He continued to use multiple substances despite these substances interfering with his interpersonal functioning, and he lacked coping skills to maintain abstinence. He required and received detoxification medication to modify withdrawal from heroin. He had long term use of multiple substances and needed 24-hour treatment as he was at risk for worsened withdrawal symptoms if not in this setting.  He likely would have relapsed again as he had relapsed after a prior abstinence and had poor coping skills. He would also be at risk for worsened severe withdrawal symptoms as he was using large amounts of heroin.

Based on the above, the medical necessity for the continued inpatient substance abuse services is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

The patient's medical condition at that time includes dorsalis, gastroesophageal reflux disease, depression, schizoaffective disorder, pain in left shoulder, and otitis externa. The patient is requesting personal-care assistant services. 

The health plan's determination is upheld. The Personal Care Assistance (PCA) are not medically necessary for this patient. Based upon information provided, the patient is ambulatory and is able to care for herself in regards to ADLs. She does need some help in regards to remembering to take medicine, however, this is an area where a family member may assist her. There is also notation that she needs help with meal preparation. Alternate methods such as Meals on Wheels may be appropriate. The requested personal-care assistance services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This case involves a male who presented to the emergency department with abdominal pain, concerning for appendicitis. He underwent a workup including ultrasound of the abdomen confirming acute appendicitis. His blood work demonstrated minimally elevated white count. He was admitted to the pediatric medical/surgical unit with a diagnosis of acute appendicitis. He was given intravenous (IV) antibiotics and underwent an uneventful laparoscopic appendectomy on the following day. He had an uncomplicated recovery and was discharged home on the same day of surgery.

The health plan's determination is upheld.

An inpatient stay could be justified if there was some diagnostic dilemma (e.g., complicated appendicitis when computed tomography [CT] had been read as uncomplicated), an untoward perioperative event, intraoperative injury or complication, inadequate physiologic recovery, hemodynamic instability, acute organ injury, persistent altered mental status, fever or other signs of septic complications, surgical site complication, management of complex comorbid medical condition or a finding of an occult or new medical condition.

Surgical treatment of otherwise healthy pediatric patients with acute non-perforated appendicitis does not usually require an inpatient level of care. No evidence was presented in the documentation or in the primary medical records that would indicate that an acute inpatient level of care was necessary.

An inpatient level of care was not necessary for this patient. The patient could have been safely and appropriately managed at a lower level of care status. Patients with acute non-perforated appendicitis like this patient had can often be discharged home the same day from the hospital, without an overnight stay.

Indeed, in one study authored by Aguayo et.al., in over 500 cases, approximately 28% (number [n]=128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n=59) stayed overnight for medical reasons, 0.4% (n=2) stayed for social reasons, 3.9% (n=18) stayed because the operation ended late in the evening, and 82.8% (n=381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, probability [P]=0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P=1.0), and complication rate (0.7% versus 2.6%, P=0.3). Patients whose operation ended later in the day had a longer hospital stay. Thus, same day discharge is safe for patients undergoing laparoscopic appendectomy for non-perforated appendicitis. Indeed, these data strongly suggest that for most patients with acute, non-perforated appendicitis who undergo an uncomplicated appendectomy, observation in the hospital thereafter is entirely appropriate since their needs are low acuity and the recovery is generally smooth and uneventful.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented to the emergency room (ER) with a history of progressively worsening fever. Her maximum temperature at home was 104.6 degrees () Fahrenheit. This was also associated with a cough, clear runny nose, congestion and one day of by mouth (PO) intolerance. She also had three episodes of vomiting. One day prior to admission, she was seen in the emergency room and diagnosed with herpangina. At that time blood tests were benign. She was given 2 normal saline boluses and discharged home on Motrin and Tylenol. Her mother states that upon returning home she started having a reduced appetite and vomiting which is that why they returned to the emergency room.

In the ER, she was febrile with pharyngeal erythema and vesicles. The basic metabolic panel (BMP) was suggestive of dehydration. Upon admission, she was started on maintenance IV fluid for dehydration. Her PO intolerance improved and she was gradually weaned off of fluids. Her vital signs and intake and output were closely monitored during her stay to evaluate her hydration status. By the day of discharge, she was having no further episodes of vomiting and she was tolerating a regular diet with no IV fluids. Rocephin was started at the time of admission to cover for acute otitis media and clinical pneumonia. A chest x-ray (CXR) was reported as normal, however, given the patient's cough and crackles on auscultation, clinical pneumonia was still suspected. By the day of discharge, her otitis media had resolved and cough and crackles improved. Motrin and Tylenol were provided for the fever as needed. By the day of discharge, she was afebrile for greater than 24 hours. Blood cultures #1 and #2 came back negative. Urine cultures were also negative. 

The health plan's determination is overturned. The patient presented with a history of progressively worsening URI symptoms and high fever up to 104.6 at home. She presented to the ER the day prior and was discharged but returned with new symptoms of emesis, decreased activity and decreased PO intake. She was noted to have vesicles to her pharynx confirming a diagnosis of herpangina but also was found to have crackles to her lungs bilaterally (B/L) on exam. A CXR that was done was negative but often times CXRs lag behind the clinical presentation of the patient. She was reported to have signs of dehydration and PO intolerance. After admission she continued with high fevers, poor PO intake and she then developed diarrhea. Based on current criteria, this patient was a candidate for admission due to her inability to maintain oral hydration (eg, needs IV fluid support) and concern for other possible illnesses complicating the clinical course.
Appeal type: Medical necessity
Decision: Upheld

Other
Inpatient Hospital

The patient is a male with a history of metastatic colorectal cancer. He presented with flank pain, dysuria, and upper lip swelling. He was afebrile and his vital signs were normal. The oxygen saturation was 99%. He was in no acute distress. Physical exam revealed poor dentition and swelling under the upper lid. The urine analysis revealed a large number of red blood cells (RBCs) and white blood cells (WBCs) per high powered field. Otherwise, the labs were non-contributory. A computed tomography (CT) scan revealed a premaxillary periapical abscess. The electrocardiogram (EKG) was negative for ischemia. The patient was admitted for further treatment and evaluation.

Upon admission, the patient was treated with intravenous antibiotics, oral medications and a diet. A several-day hospitalization ensued. The urine culture was essentially negative. The ear, nose, and throat (ENT) consultant recommended an oral surgery consultation. The left flank pain improved with tamsulosin and oxybutynin, and the patient was discharged.

The health plan's determination is upheld.

Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints. There is no evidence that the patient required intravenous antibiotics or intravenous fluids, and there was no evidence that he failed an appropriately aggressive course of outpatient treatment. There were no objective findings to substantiate the need for acute inpatient care. The patient could have been treated at a lower level of care status.