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

Diagnosis: Chest Pain
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.  

This is a male patient with a medical history of coronary artery disease, myocardial infarction and coronary stent placement in the setting of a heroin overdose. He presented to the hospital via Emergency Medical Service (EMS) with complaints of chest pain that he reported began 6 hours prior to presentation. He described the pain to be 10/10 in intensity. An electrocardiogram (EKG) was done which revealed no evidence of ST or T wave changes. Serum creatine kinase (CK) and troponin were not elevated. Neurology consulted on the patient. He underwent a cardiac catheterization that showed patent stents in the right coronary artery (RCA) and first diagonal (D1) artery and pre-existing small vessel coronary artery disease. He was medically treated and discharged.

In this case, physical examination was unremarkable and the ECG failed to reveal specific findings consistent with an acute coronary syndrome.  Serum blood testing did not reveal elevated troponin levels. 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG as well as negative cardiac enzymes was performed by Poldervaart et al. (1)  Using the HEART score risk stratification schema, this patient would have a low risk of future myocardial infarction or death within one year.  Other 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.(2, 3)  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 that were managed in an observation unit had similar 30 day myocardial infarction rates as those admitted to the hospital.(3)  

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient.  

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

Diagnosis: Pregnancy/childbirth/other 
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay 
The denial is upheld in whole 

This patient is under consideration for medical necessity of acute inpatient level of care for the indication of renal pyelonephritis. This patient  gravida (G)3 para(P)2 A0 who is currently weeks pregnant who presented to the emergency department with a chief complaint of right lower quadrant abdominal pain that began on the day prior.
No, the inpatient stay is not medically necessary.
The patient was noted to have a urinary tract infection or pyelonephritis upon presentation to the hospital and assessment of the urine studies. There was no nausea or vomiting that would have prevented a lower level of care management at the time of admission. There was no pelvic abscess suspected or confirmed by ultrasound imaging (which was normal in this case). The renal ultrasound was normal (right hydronephrosis is normal physiology for pregnancy). There was no consideration of a surgical abdomen and the exam remained normal. There was also no endometritis as the patient was not delivered. There was no uterine tenderness or suspicion of amnionitis. There was no abdominal guarding or rebound to suggest peritonitis. There was no pelvic abscess on ultrasound imaging. There was no physical exam or suspicion of peritonitis given the normal abdominal exams. Thus, no criteria were met for inpatient admission in this case. (1)
Thus, there is Level I data to support the ability to provide this care at the lower level of care in pregnancy.  Based upon this data, admission to acute inpatient level of care is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pressure ulcers
Treatment: Subacute rehabilitation
The insurer denied the Subacute rehabilitation
The determination is upheld.

The patient was admitted for rehabilitation and wound care. The patient has a history of morbidly obesity and has stage 3 pressure injuries on her right elbow and upper coccyx. At issue is the medical necessity of subacute rehabilitation.

No, the requested service of subacute rehabilitation  is not medically necessary for this patient. The patient has a history of morbidly obesity and has stage 3 pressure injuries on her right elbow and upper coccyx but the wound care team noted that both had improved and dressing changes were downgraded. Therefore, skilled nursing was not supported. Therapy had also noted none to minimal functional improvement and, therefore, skilled therapy was no longer supported. The patient required moderate assistance (MODA) for rolling and maximal assistance (MAXA)/MODA of 2 for supine to sit. The patient was unable to ambulate. She required MAXA of 2 for sit to stand transfers in the parallel bars and wheelchair to bed transfers required a mechanical lift. Supine to sit had improved to MODA of 2 but sit to stand still required MAXA of 2 and wheelchair to bed transfers required a Hoyer lift. The patient was not ambulating. Despite continued therapy, documentation noted minimal improvement. Rolling still required MODA and supine to sit was now MAXA of 2. The patient remained totally dependent with bed to wheelchair transfers and sit to stand had only improved to MAXA. Therefore, at this point skilled therapy was not supported as the patient was not making functional gains. Even looking forward, the patient still required MODA for rolling and supine to sit had only improved to MODA of 2 people. Sit to stand was also MAXA of 2 and while the patient was now completing wheelchair to bed transfers with therapy it was still requiring MODA of 2 which is not functional. Also, while the patient did require skilled nursing, a review of the wound care notes documented that  the patient had right elbow, stage 3, with small amount of drainage and no odor. Progress improved. The treatment plan was to discontinue (d/c) collagen + clear film and change to xeroform and cover with retention tape every Monday, Wednesday and Friday. Upper coccyx, stage 3, was also noted as improved and treatment plan was stop hydrogel and change to calmoseptine twice daily (BID). Therefore, treatment was no longer skilled as wound care was minimal.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis Abdominal Pain
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is overturned.

The patient was admitted with complaints of (c/o) abdominal pain associated with nausea and vomiting. Vital signs were unremarkable. The physical exam was notable for: abdomen soft, nontender (NT),  no rebound, no guarding. Lab work was notable for aspartate aminotransferase (AST) / alanine aminotransferase (ALT) 518/402, alkaline phosphatase (AP) 292. A right upper quadrant (RUQ) ultrasound (US) showed cholelithiasis and a dilated common bile duct (CBD), magnetic resonance cholangiopancreatography (MRCP) showed findings concerning for early acute cholecystitis and likely mild acute pancreatitis. The patient was diagnosed with early acute cholecystitis and choledocholithiasis and treated with intravenous fluids (IVF), nothing by mouth (NPO), anti-emetics, deep vein thrombosis (DVT) prophylaxis, endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy, with a laparoscopic cholecystectomy. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient stay was medically necessary for this patient. This patient presented to the ED with c/o abdominal pain associated with nausea and vomiting. The patient was found to have imaging and laboratory findings suggest of an acute intra-abdominal process. A follow-up MRCP demonstrated suspicions for early acute cholecystitis and acute pancreatitis. The patient underwent an ERCP, with a performed sphincterotomy. The patient was then taken to the operating room (OR) for a cholecystectomy and discharged the same day. This patient presented with a surgical abdomen due to acute cholecystitis, which was complicated by acute pancreatitis and required extensive imaging work-up, an ERCP with (w/) sphincterotomy and cholecystectomy. All cases of acute cholecystitis should be admitted for parenteral antibiotics, analgesia, fluid replacement, and cholecystectomy. The patient received intravenous fluids (IVF), nothing by mouth (NPO), anti-emetics, deep vein thrombosis (DVT) prophylaxis, ERCP with sphincterotomy, with a laparoscopic cholecystectomy. Given the complexity of the patient's medical needs and multiple procedures, these services could not have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroenteritis.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a male child with history of some feeding difficulties. He presented to the ED with one-week history of vomiting initially once daily and up to three times on the day of presentation, one-day history of diarrhea having fifteen stools with mucus but no blood, tactile fever, and irritability. His mother was also having loose stools. 

The patient was treated with Zofran and two IV fluid boluses followed by 1.5 maintenance IV fluids. Repeat labs revealed improved but still abnormal CO2 (11). He was able to tolerate some milk and ginger ale in the ED, but also passed several diarrhea stools. He was admitted for ongoing management of significant dehydration, ongoing diarrhea, and inability to keep up with fluid losses. While admitted, he had several episodes of emesis (mainly post-tussive), ongoing viral upper respiratory infection symptoms including skin rash, and slowly improving diarrhea. He was deemed stable for discharge to follow-up with his pediatrician in two to three days.

Yes, the Inpatient admission was medically necessary.

This young child presented to the ED with a prolonged course of vomiting and worsening diarrhea. He was moderately to severely dehydrated upon arrival, with dry lips, tachycardia, no tears with crying. Laboratory evidence supported the diagnosis, with CO2 9 and elevated lactate. He received two fluid boluses in the ED and was able to tolerate some ginger ale, Pedialyte, and milk. However, he continued to have profuse diarrhea and was not able to keep up with his fluid losses. He required hospitalization for ongoing parenteral fluid resuscitation until his stool losses slowed sufficiently. The entirety of his hospital stay was medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Developmental delay, Autism, Severe intellectual disabilities.

Treatment: Home Care/Personal Care HHC - Level 2 Personal Care Services (CDPAS), per 15 minutes, 84 hours per week.

The insurer denied coverage for Home Care/Personal Care HHC - Level 2 Personal Care Services (CDPAS), per 15 minutes, 84 hours per week.

The denial is overturned.

This is female patient with profound developmental delay, autism, and severe intellectual disabilities. The patient also has memory impairment and severely impaired decision making. The patient lives with her aunt. The aunt and 2 cousins provided care to the patient. The patient was approved for Consumer Directed Personal Assistance Services (CDPAS) 63 hours per week. The patient's aunt requested an increase of services to 84 hours per week which was denied. 

The Uniform Assessment System (UAS) functional assessment indicates that the patient is totally dependent for most instrumental activities of daily living (IADLs) except medications (maximal assistance), transportation (extensive assistance), and stairs (supervision). Regarding activities of daily living (ADLs), the patient needs extensive assistance for bathing, and limited assistance or supervision for most other ADLs except walking, locomotion and transfers (independent). With greater severity of intellectual disability, the ability to perform daily activities (IADLs and ADLs) is more impaired. For this patient, there is almost complete dependence on caregivers for IADLs. The patient also needs assistance or supervision with most ADLs. The patient's need for assistance with daily activities appears to be primarily due to autism and intellectual disability. 

As a result of the patient's functional impairment due to autism and severe intellectual disability, caregiver assistance is medically necessary for IADLs and ADLs during daytime hours, with assistance needed for some ADLs into the evening/night hours for both scheduled and unscheduled tasks. Most of the patient's care is needed from morning through evening hours, which should be covered by CDPAS 12 hours per day, 7 days per week (84 hours per week). Informal caregiver assistance is necessary for ADL care, when needed, the other 12 hours of the day. 

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 HHC - Level 2 Personal Care Services (CDPAS), per 15 minutes, 84 hours per week is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis (left foot ulcer)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a diabetic female who presented with three days of worsening diabetic foot ulcer. She was admitted to the hospital and was placed on intravenous (IV) antibiotics. She was found to have an elevated white count. She also had redness and swelling to the knee. Podiatry was consulted and the patient underwent a heel debridement. In addition to IV antibiotics, the patient received fluid resuscitation as well as consultation for elevated glycated hemoglobin (A1C) up to 12.1. After the patient was stabilized, and no need for further surgical intervention was determined, she was discharged.

Yes, the proposed inpatient admission was medically necessary.

The inpatient admission was medically necessary. It is within standard of care to admit patients such as this with diabetic foot infection resulting in need for IV antibiotics, monitoring, surgical treatment, and advanced diagnostic testing. Failure to do so could lead to worsening symptoms including sepsis and death. Therefore, this medical admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes Mellitus

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.

This male patient has a history of pre-diabetes, hypertension, atrial fibrillation/flutter status post ablation, gout, polymyalgia rheumatica, diverticulitis and nephrolithiasis, status post mitral valve prolapse (MVP) repair who was admitted the hospital with polyuria, polydipsia, and polyphagia. After three weeks treatment with prednisone was found to be dehydrated. BUN/creatinine: 31/1.37, blood sugar 525, A1c 13, -OH Butyric Acid 3.1 (elevated) PH 7.4, AG 17, urinalysis (+) glucose, nitrates, large leukocytes. The patient was hydrated, and seen by an endocrinologist who started the patient on insulin. The patient also got intravenous antibiotic for treatment of urinary tract infection.  

Based on literature, the hospitalization for this patient is justified. 

1) The patient has new onset diabetes and was symptomatic, and the elevated -OH-BA of 3.1 suggests that the patient is going into diabetic ketoacidosis (DKA). 2) Based on the Hospital Admission Guidelines for Diabetes by the American Diabetes Association hyperglycemia associated with volume depletion (that the patient had) justify admission to the hospital. 3) In studies the average length of stay in the hospital for patients with DKA has been 3.4 to 5.7 days. This patient was in the hospital 4 days.

In the above data and the information provided to this reviewer the hospital admission and length of stay is justified. 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 the inpatient hospital admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis 
Treatment: Inpatient admission 

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

This is a male patient with no significant medical history.  The patient presented to the emergency department with complaints of nausea, vomiting, diarrhea, and abdominal pain.  His abdomen had right lower quadrant tenderness (possible McBurney point).  The patient underwent a computed tomography (CT) of the abdomen which revealed early appendicitis.  Laboratory work up was done that revealed white blood cell count was 3.20.  The patient was treated with intravenous fluids and antibiotics.  The patient underwent a laparoscopic appendectomy without complication.  The patient was medically stable and discharged.  

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  

Acute, uncomplicated appendicitis being treated with laparoscopic appendectomy does not mandate an inpatient admission.  Discharge may be safely undertaken once the operation is completed and the patient's pain is well controlled with a safe discharge plan.  The patient went home the following day; the patient should have been admitted to observation.  In fact, data has emerged that discharge on the same day of surgery or within 12-24 hours after surgery is safe based on large national database study (Grigorian et al., 2019).  Another study found that implementing a protocol to discharge patients within 24 hours of laparoscopic appendectomy resulted in a successful discharge in 95% of patients with an extremely low return to hospital rate (Bradley et al., 2019).  Therefore, this patient should not have been admitted to inpatient and could have been successfully managed as an outpatient. 

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: Upheld

Diagnosis: Intractable Nausea

Treatment: Inpatient hospital admission
 
The insurer denied the inpatient hospital admission.

The denial was upheld.

This is a female patient who presented to the Emergency Department with complaints of epigastric pain associated with nausea and multiple episodes of emesis similar to prior episodes. She reported having an endoscopy that was previously negative and admitted to smoking marijuana daily.  Physical examination revealed a blood pressure of 140/90 with a pulse of 70 beats per minute with an oxygen saturation of 100% on room air. She had abdominal pain with tenderness in the epigastric area. Laboratory studies were unremarkable, except for lactic acidosis likely secondary to retching and vomiting versus dehydration. The patient was medicated with Reglan and Zofran which stopped her vomiting. She reported abdominal pain relief after receiving Haldol. She was admitted to medical services for intractable nausea, emesis and the inability to tolerate oral intake.  The documentation did detail that she continued with ongoing treatment which included intravenous (IV) fluids and medications.  She underwent a CT scan of the abdomen which revealed mild apparent wall thickening of the colon which may be secondary to under distention versus mild colitis.  The patient requested to be discharged the following day.  Despite instruction to continue treatment, the patient signed out against medical advice.  She was recommended to return to the Emergency Department for any further issues.

The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.

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: Substance Abuse

Treatment: Inpatient detoxification admission 
 
The insurer denied the inpatient detoxification admission. The denial was overturned.

This is a male patient who was admitted to inpatient detoxification treatment. He had withdrawal symptoms that included nausea, diarrhea, sweats, anxiety, tremors, sleeping problems, diffuse discomfort, nasal stuffiness, dilated pupils, irritable mood, and he had a CIWA of 12. He reportedly had many past inpatient detoxification treatments including a recent one 1/2020. He reportedly had a positive toxicology for opiates and methadone. He was using 4-5 bags of IV heroin per day, 70 mg of Methadone, and drinking twelve 24 ounce beers per day, using cannabis, and had reports of intranasal cocaine use. He reportedly was put on an Ativan and Methadone taper and discharged.

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. In this case this patient had use of multiple substances including large amounts of alcohol, heroin, Methadone, and cannabis and was at risk for severe, complicated and life threatening withdrawal as well as death from overdose. 

According to the LOCADTR he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use substances and alcohol despite multiple past inpatient detoxification treatments including a recent one 2020, and he needed 2 detoxification medications including Ativan and Methadone to modify withdrawal, had long term multiple substances of use including using alcohol, heroin, methadone, and cannabis. He needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then, and he likely would have relapsed again as evidenced by relapsing after multiple past treatments. He reportedly lacked coping skills and ability to identify relapse triggers and was struggling to remain abstinent and continued to relapse despite so many past inpatient detoxification treatments. Also, his environment was not conducive to recovery as evidenced by his continued use.  As a result, the recommendation is to reverse the previous decision and approve coverage for continued inpatient substance detoxification. It did not appear that the health care plan acted reasonably, with sound clinical judgment, or in the best interests of the patient then.

Based on the above, the medical necessity for the inpatient detoxification admission is substantiated. The insurer's denial is overturned.