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

Diagnosis: Bronchiolitis

Treatment: Inpatient hospital admission 

The insurer is denied coverage for inpatient hospital admission. 
The denial is overturned. 

This was a male child who was sick for several days with coughing. The patient developed nausea, vomiting and post-tussive emesis. The patient had a family history of asthma and a sick contact at home. The patient was initially seen in the Urgent Care center the day prior to this admission and was feeding poorly with intolerance to oral liquids. When this patient's symptoms worsened over the day with signs of difficulty breathing, fussiness and poor feeding, the patient was taken to a clinic where he did not improve with albuterol; the patient was directly transferred to the hospital for further care.

In the Emergency Room (ER) the patient was noted to have moderate respiratory distress with a significant increase in his work of breathing. There were subcostal and supraclavicular retractions. The patient's pulse oximeter reading was 92% but intermittently dropped to the high 80s. On physical exam, the patient was noted to have decrease air entry with decrease breath sounds in the left lower lobe of the lung. The patient's test for respiratory syncytial virus (RSV) was negative. The patient was begun on intravenous (IV) ceftriaxone, IV fluids and albuterol and hypertonic saline via a nebulizer. The patient's chest x-ray showed evidence of an infiltrate. With failure to respond to appropriate treatment in the ER, the decision was made to admit the patient to the hospital for ongoing care with albuterol administration every 2 hours and hypertonic saline every 3 hours for a diagnosis of bronchiolitis.

Based on the review of the literature, this pediatric patient was treated appropriately in the ER. Since this patient was not drinking well due to the increased work of breathing rate, the patient was treated with intravenous (IV) fluids. The patient continued to have low oxygen levels and failed to show much clinical improvement with the treatment provided in the ER. Thus, the patient was appropriately admitted to the hospital for ongoing care. The patient had persistent tachypnea, respiratory distress with increased work of breathing, and inability to take adequate fluids by mouth despite ER treatment. The patient required ongoing treatment with intravenous (IV) fluids to prevent dehydration, as well as antibiotics and inhaler therapy. The patient required albuterol every 2 hours and hypertonic saline every 3 hours. This treatment therapy was appropriate and consistent with standard of care, and required inpatient admission.

The health plan did not act reasonably with sound medical judgment, and 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 reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD exacerbation 
Treatment: Inpatient admission 

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

This patient is a female with history of chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD) status post coronary artery bypass graft (CABG), and hypertension (HTN) who presented to the Emergency Department (ED) with complaints of progressive shortness of breath (SOB) and cough productive of yellow sputum for several days. The patient lived in a homeless shelter. The patient denied fever or chills. On arrival to the ED, the patient's temperature was 97, heart rate was 91, respiratory rate was 23, blood pressure was 126/79 mm Hg and oxygen (O2) saturation was 93 % on room air. On exam, the patient was in no acute distress; lungs had bilateral wheezes; normal cardiac and abdominal exam. The patient was awake and alert. The patient's white blood cell (WBC) count was normal, and her electrolytes were within normal limits. The patient's chest x-ray showed some sub-segmental atelectasis. The patient was admitted for COPD exacerbation. The patient was treated with intravenous (IV) steroids, bronchodilators and antibiotics. 

As per the admitting note, the patient was in no acute distress. The patient was afebrile with stable vitals. The patient's vitals were: respiratory rate of 18, blood pressure of 138/66, heart rate of 98 and O2 saturation of 99%. The patient was in no acute distress. Despite mild wheezing noted on exam, the patient was speaking in full sentences. The patient's troponin level was negative, and the patient's electrocardiogram (EKG) showed normal sinus rhythm. The patient was treated with Symbicort, bronchodilators and oral prednisone. Because the patient did not have fever, hypoxia or infiltrate on chest x-ray, antibiotics were discontinued. By a specified date the patient was doing well. The patient was afebrile and hemodynamically stable. The patient's lung exam was clear to auscultation. The patient was on oral medications. The patient was cleared for discharge awaiting shelter placement. 

Based on the review of the medical record, this patient's condition did not meet the clinical criteria for acute inpatient hospitalization. The patient could have been placed in observation status while diagnostic testing and treatment were initiated. The patient was hemodynamically stable and remained stable after admission. The patient was afebrile and was tolerating oral medications. The patient was not hypoxic and did not need supplemental oxygenation. The patient had normal white blood cell count, and chest x-ray was negative for pneumonia. The patient could have been discharged after a period in observation on oral medications with close follow-up in an outpatient setting. Thus, inpatient admission was not medically necessary to treat this patient's medical condition. 

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 should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-ST segment elevation myocardial infarction (NSTEMI) 
Treatment: Inpatient hospital stay 

The insurer denied coverage for inpatient hospital stay. The denial is upheld. 

This patient was a male with a history of coronary artery disease status post multiple percutaneous coronary intervention (PCI) and stent placement, hypertension, insulin-dependent diabetes mellitus, hyperlipidemia, angina, peripheral vascular disease and chronic kidney disease stage 3. He presented to the ER following a syncopal episode, progressive chest pain x 1 week, and nausea. An initial EKG showed mild ST elevation, and the clinical impression was non-ST segment elevation myocardial infarction (NSTEMI). 

The patient was admitted for further management. He was started on a heparin drip, loaded with Brilinta, and cardiac enzymes were trended. The patient underwent a diagnostic left heart catheterization which showed non-obstructive coronary artery disease. There were no procedural complications. He ruled out for myocardial infarction with negative cardiac troponins. Later EKGs normalized and the patient noted minimal ongoing chest tightness. The patient ambulated with physical therapy prior to leaving and was deemed safe for discharge. 

The patient presented with a single syncopal event associated with chest pain, however there were no signs or symptoms of hemodynamic instability, myocardial ischemia, arrhythmia, heart failure, cerebrovascular insufficiency or other organ dysfunction requiring inpatient admission status. The care could have been rendered under observational level of care with up to 23 hours of monitoring, or could have been administered solely the emergency department with administration of IV fluids. The observational level of care would have been appropriate. 

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

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

Diagnosis: Wheezing and shortness of breath, history of asthma.
Treatment: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld.

The patient is a female with asthma who presented to the emergency room with wheezing and shortness of breath (SOB). The patient was found to be in mild asthma exacerbation. The patient was seen in the ER one day prior and did not pick up medications from the pharmacy. In the emergency room the patient was hemodynamically stable and was not in any respiratory distress. With oral steroids and nebulization treatments, the patient's wheezing and SOB improved.

The patient's mild asthma exacerbation improved with emergency room care. The patient was tolerating oral medications. The patient was discharged home after one day hospitalization. The patient could have been safely and effectively treated as an outpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Exacerbation of asthma or gastroesophageal reflux disease

Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission. 

The denial is upheld. 

This patient is a female with a history of diabetes, hypertension, bipolar disorder and obsessive compulsive disorder.  The patient also had a recent history of hospitalization for angioedema related to a cashew allergy.  The patient was brought to the Emergency Department (ED) by ambulance from her physician's office due to complaints of orthopnea, chest tightness and dyspnea.  

The patient's initial vital signs included blood pressure of 156/96, heart rate of 114, respiratory rate of 20, and temperature of 97.9 and oxygen saturation of 97% on room air. The patient's  laboratory test results from included white blood cell (WBC) count of 9.1, hemoglobin of 15.3, creatinine of 0.94, BNP of 10.0, and troponin <0.03, with subsequent troponin also <0.03. The patient's electrocardiogram (EKG) revealed sinus tachycardia and was normal. The patient's chest x-ray and computed tomography angiography (CTA) of the chest were negative. The patient was treated with intravenous (IV) Lasix, Solumedrol, Pepcid and duo-nebulizer. 

The patient underwent coronary angiography which was normal and she was diagnosed with an exacerbation of asthma or gastroesophageal reflux disease (GERD) as the cause of her symptoms.  The patient was discharged home on aspirin, atorvastatin, metformin, glipizide, amlodipine, and omeprazole.

Based on literature review, there is no clinical evidence that this patient required an acute inpatient level of care to determine that her chest discomfort was not related to an acute coronary syndrome. Further clinical workup and treatment could have been provided to the patient at the Observation level of care. The patient was not critically ill to require inpatient level of care. 

The health care plan acted reasonably with sound clinical judgment, and 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: Anemia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. The patient was noted to have a history of squamous cell carcinoma of the foot, treated with amputation. He was known to have chronic osteomyelitis. He was sent to the emergency department for evaluation of anemia.  He had been noted to have a hemoglobin of five in the outpatient setting and it was noted that he had bled from his foot a couple of times before this evaluation.  He had no shortness of breath, chest pain or palpitations and no active bleeding at the time of initial evaluation.  The most recent episode of bleeding from his foot occurred three weeks before hospitalization.  Physical examination was unremarkable.  His foot was bandaged and he refused exam with removal of the bandages. Hemoglobin in the emergency department was 6.5g/dl. White cell count was markedly elevated at 58.8 with left shift.  He had a heart rate of 107 and no fever.  Computed tomography (CT) was done and revealed bony changes concerning for osteomyelitis.  Blood cultures were obtained and he was given a dose of vancomycin.  He was admitted for transfusion and discharged on the following day as he refused to stay for further evaluation.

This patient had anemia and was known to have chronic osteomyelitis and also suspected to have iron deficiency based on prior labs done during a prior admission.  He had significant anemia but no findings indicative of hypoxemia or hemodynamic compromise.  He required transfusion which could have been done on an outpatient basis.  He was also known to have chronic osteomyelitis and there were no findings at the time of admission indicating that he had any acute worsening of this known chronic infection.  While the patient required treatment for his chronic infection, that treatment did not require acute care hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post-traumatic stress disorder (PTSD), major depressive disorder, suicide attempts, alcohol abuse.
Treatment: Inpatient psychiatric admission
The insurer denied the inpatient psychiatric admission. 
The denial is overturned. 

The patient is a female with a history of mental illness who received inpatient psychiatric hospitalization.

The patient has a history of mental illness including diagnosis with post-traumatic stress disorder (PTSD) and major depressive disorder.  She has a history of prior suicide attempt and alcohol abuse.  She has a medical history of malnourishment and hypertension.

She was initially evaluated in the emergency room after ingesting alcohol and pills as a suicide attempt.  She was admitted to the medical service and was treated.  She was medically cleared for psychiatric admission.  She was treated by a multidisciplinary team including psychiatry, nursing, and therapy staff.  She received group and individual therapy.  She received a psychopharmacology evaluation and was started on Wellbutrin, Abilify, Minipress, and other as needed (PRN) medications for her symptoms.  

The patient was noted to have poor judgment, limited insight, guarded, suspicious, and selectively compliant with medications.  The patient was also noted to be agitated, irritable, guarded, and her judgment remained poor, as well as isolated and not interacting with peers. 
The patient was discharged to follow up psychiatric care.

The patient represented an acutely elevated risk of dangerous behaviors and there was no less-restrictive treatment environment appropriate.  The acute risk factors of recent suicide attempt with the chronic risk factors of potentially dangerous behaviors suggest that the patient would have been at an acute risk of self-injurious behaviors (including but not limited to suicide) were she to have been discharged from the inpatient hospital setting.  The patient was discharged from the inpatient psychiatric hospital setting as soon as a less-restrictive treatment setting was appropriate. Therefore, the treatment was medically necessary.  While the patient was not endorsing active suicidality or homicidality, the patient remained acutely symptomatic.  The patient had multiple static risk factors for potentially dangerous behaviors including recent suicide attempt, prior suicide attempt, and substance abuse and diagnosis with a severe mental illness.  Therefore the patient represented a chronic risk of potentially dangerous behaviors.  The fact that patient remained with depressive symptoms and limited treatment compliance were acute risk factors for dangerous behaviors.  Furthermore, the fact that there was no less-restrictive environment of care appropriate suggests that ongoing inpatient psychiatric hospitalization was medically necessary and should be covered by the patient's health plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure

Treatment: Inpatient admission

The insurer is denied coverage for inpatient admission. 

The denial is reversed. 

This case involves then a female who presented to the Emergency Department (ED) with complaints of seizures.  The patient's home attendant stated that the patient had two episodes of seizures.  Upon arrival to the ED, the patient was awake, alert and oriented. The patient denied dizziness.  The patient had a past medical history of hydrocephalus as well as prior seizure and substance abuse. On physical exam, the patient was in no apparent distress, and the patent's neurological exam showed no motor or sensory deficits. The patient's lab results were unremarkable. The patient was recommended to receive intravenous (IV) morphine as well as phenytoin. The patient's electrocardiogram (EKG) revealed normal sinus rhythm. The patient's chest x-ray revealed mild left basilar discoid atelectasis. The patient's computed tomography (CT) scan of the head revealed mild to moderate cerebral atrophy and mild periventricular matter disease with low attenuation subdural fluid collection which may be secondary to over-shunting. The patient's urine toxicology was positive for cannabinoids.  It was recommended that the patient be admitted for further evaluation.  The patient underwent a neurology consultation who recommended that the patient continue with treatment.  The patient was then transferred to another facility the following day. 

The insurer's decision to call the admission not medically necessary is incorrect.  They base their decision on MCG headache guidelines.  The patient does in fact meet MCG criteria for admission for headache because she has evidence of both bleeding and high pressure in the brain. More importantly, the patient was not actually admitted for headache.  She was admitted for seizures and unstable hydrocephalus with indication on neuroimaging of overshunting.  She required neurosurgical investigation of her shunt1 and following admission she was transferred to a hospital able to do this.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

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

Diagnosis: Skin Disorders - Abscess
Treatment: Inpatient Hospital
The insurer denied the inpatient hospital stay.
The denial was upheld.

The patient is a previously healthy man who presented to the ED with a perirectal abscess. The patient had previously undergone an incision and drainage procedure 3 days prior to the ED presentation. At the time of initial evaluation there was an indurated and tender 3-cm area of the right perirectal area. His vital signs were normal. The white blood cell (WBC) count was 17 K. A computed tomography (CT) scan showed inflammatory changes in the bilateral buttocks with an associated abscess. He was treated with IV antibiotics and IV fluid. On the day he presented to the ED a surgical incision and drainage of the perirectal abscess was performed. The operative dictation describes opening of the perirectal abscess with placement of a Seton and Penrose drain in the course of an uncomplicated procedure. The diagnosis was that of an ischiorectal horseshoe abscess. This procedure was performed with general anesthesia in the operating room. Vital signs were normal following this procedure. He was discharged from the inpatient setting the following day with continued oral antibiotics and short term follow up.

The health plan has denied the acute inpatient admission. The health plan's determination is upheld. The care and treatment provided including IV fluid, IV antibiotics, surgical incision and drainage and overnight monitoring could have appropriately been provided at a lower level of care and did not require or mandate an inpatient designation.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Substance Abuse: Inpatient

Diagnosis: Substance Abuse
Treatment: Inpatient Rehab
The insurer denied the inpatient rehab. The health plan's determination is upheld. 

The patient is a female who presented for inpatient rehabilitation substance use disorder treatment to address substance use disorders with stimulant (cocaine); alcohol; cannabis; and opioids (heroin) class substances. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. She had a history of substance use disorder beginning in adolescence with multiple prior treatments with relapses.

The Inpatient Rehabilitation is not medically necessary for this patient.
The patient presented with substance use disorders with use of heroin, alcohol and cocaine and cannabis. She received inpatient detoxification treatment transitioning to inpatient level rehabilitation treatment. She readily engaged in treatment with continued use of medications to address the anxiety and mood disorder including as needed (prn) medication for anxiety and insomnia. During the time interval under review, the patient was noted to be in no apparent distress with improved functioning and active participation in treatment including positive interactions with staff and peers. There were no treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care. The application of NY State OASAS LOCADTR Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting. Thus, medical necessity for the Inpatient Rehabilitation is not met in this case scenario consistent with American Society of Addiction Medicine (ASAM) Criteria, the scientific literature and published guidelines, referenced below.