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

Diagnosis: Dyspnea

Treatment: Inpatient Admission

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

This patient is a young male child who presented to the Emergency Room (ER) with increased work of breathing. The child was noted to be in respiratory distress with retractions, belly breathing, and mild wheezing. He had tachycardia and a pulse oximeter reading of 94%; his respiratory rate was elevated at 34. He was treated with three back to back treatments with Duoneb, dexamethasone, and an intravenous (IV) bolus of normal saline. A chest x-ray was significant for bilateral peribronchial thickening. Testing for Respiratory Syncytial Virus (RSV) and influenza viruses was normal. The patient had gone to the Pediatrician's office earlier that day, where he was treated with two doses of albuterol as well as prescribed albuterol for use at home. Instruction was given for the child to go to the ER if his work of breathing increased. It was reported that the child became less active and had a decrease in drinking and an episode of vomiting. A directed, the mother brought the patient to the Emergency Room (ER) for additional treatment.

INDICATIONS FOR HOSPITALIZATION - Children can be managed as outpatients if they are adequately hydrated, and have no signs of moderate to severe respiratory distress (e.g., nasal flaring; retractions; grunting; respiratory rate >70 breaths per minute; dyspnea; or cyanosis) and do not require supplemental oxygen. Infants with bronchiolitis who are not hospitalized should be monitored in the outpatient setting by their clinician for progression of disease.
Although clinical practice varies widely, hospitalization for supportive care and monitoring usually is indicated for infants and young children with:

1)  Toxic appearance, poor feeding, lethargy, and dehydration	
2) Moderate to severe respiratory distress, manifested by one or more of the following    signs: nasal flaring; intercostal, subcostal, or suprasternal retractions; respiratory rate >70 breaths per minute; dyspnea; or cyanosis.
3) Apnea.
4) Hypoxemia with or without hypercapnia (arterial or capillary carbon dioxide tension  >45 mmHg). Studies evaluating SpO2 (oxygen saturation) <95 percent as a predictor of disease severity or progression among outpatient children with bronchiolitis have inconsistent results; nonetheless we use SpO2 <95 percent on room air at sea level as a threshold for admission."

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of hypertension and sciatica. Patient presented to the emergency department (ED) with complaints of right sided hip and buttocks pain with radiation down the right leg. The patient also complained of an inability to walk due to the pain.  The patient reported that gabapentin usually helped with pain but did not relieve pain upon presentation.

The health plan's determination is upheld.  The Inpatient Hospital Admission was not medically necessary for this patient.  This patient did not have an inpatient need such as surgery or continuous intravenous medications to control her pain.  Physical examination showed only lumbar tenderness without focal neurological findings.  This patient could have had testing and monitoring at a lower level of care.  This patient did not meet criteria for inpatient admission.  None of the severity of illness criteria are present to support inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

The patient was admitted for acute inpatient psychiatric treatment. The patient had become increasingly anxious and depressed with suicidal ideation, plan and intent in the context of psychosocial stressors that included primary support and occupational and economic domains. The patient made a suicide attempt with an overdose of Klonopin and alcohol which resulted in the referral and admission for inpatient level psychiatric treatment. At the time of the referral, the patient remained severely depressed with persistent suicidal ideation. The functioning had deteriorated with social isolation culminating in her suicide attempt. 

The health plan's determination is overturned. The Continued Psychiatric Acute Inpatient Mental Health Level of Care is medically necessary for this patient.The patient had severe symptoms of depression, was a safety risk, and, outpatient treatment had failed to prevent the worsening symptoms of depression with onset of severe symptoms in the context of a potential lethal suicide attempt with mixed benzodiazepine and alcohol and deterioration in functioning. The patient remained a safety risk and functionally impaired with high risk for relapse if discharged from acute inpatient level care and the patient needed to reach a stable baseline of functioning with assurance of medication tolerability with a solid disposition and safety plan prior to discharge from inpatient level care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension, diabetes, coronary artery disease, left bundle branch block and congestive heart failure with a left ventricular ejection fraction of 30%. She presented to the emergency department for scheduled implantation of a biventricular implantable cardioverter defibrillator. Upon presentation, there were no signs of decompensated heart failure.  The health plan's determination is upheld.
Upon presentation, the patient was hemodynamically stable, without decompensated heart failure. There were no intra-procedural complications. The morning following the procedure, a chest x-ray showed that the atrial lead had been dislodged. The records provided do not indicate that there was a medical reason why lead revision could not have been performed that day, with subsequent discharge. The patient's clinical status was stable, she did not require intensive observation, and no particular treatment other than lead repositioning was required for management of the lead dislodgment. Atrial lead revision is considerably less complicated than initial biventricular ICD implantation and would not have required an upgrade to inpatient status in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis

Treatment: Inpatient admission

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

This is a female patient with past medical history of hypertension, diabetes, and kidney stones who presented to the Emergency Department (ED) for severe right flank pain and vomiting, after a stent removal.  White blood cell (WBC) count was 16,450.  The patient was given Zofran, morphine, hydromorphone in the ED and admitted with diagnosis of pyelonephritis. A CT scan revealed mild right hydronephrosis and mild right perinephric stranding.  The patient was given intravenous (IV) Dilaudid as needed and IV Zofran.  The patient was taken to the Operating Room (OR) for cystoscopy, right retrograde, right ureteroscopy with stone extraction, and stent placement under general anesthesia.  The patient tolerated the procedure well, continued to have postoperative right flank and groin pain.  She improved on IV fluids and IV antibiotics, and she was ultimately discharged home after a period of medical stability.  

The insurer denied coverage for the inpatient admission as not medically necessary.  

Per MCG Health (22nd Edition) Renal Colic & Kidney Stones, the patient fails to meet clinical indications for admission to inpatient care.  These include hemodynamic instability, acute renal failure, bilateral obstruction, urinary tract infection, and transplanted kidney with obstruction, etc.  Also per MCG Health (22nd Edition) Urologic Surgery or Procedure GRG, the patient is noted to have met the General Recovery Course discharge parameter within 24 hours postoperatively.  The patient had mild right flank/groin pain, which is expected after a right ureteroscopy and stent placement, but urine was clear.  The patient was voiding without difficulty and was afebrile.   A progress note states "on exam there is no [right upper quadrant] RUQ tenderness," and ultrasound is negative for signs of cholecystitis.  Cystoscopy/ureteroscopy/stent placement is considered ambulatory surgical procedures.  The patient had no acute medical issues of instability after the procedure.

The healthcare plan acted reasonably and with sound medical judgment and in the best interests of the patient.  

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

Diagnosis: Dizziness and Facial Numbness
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The available medical records indicate the presence of a sensory deficit with concern for stroke in the context of chest heaviness complaints.  The available medical records indicate that the patient was recommended for neuro checks every four hours.  The available medical records reflect that the patient underwent imaging and further testing to review risk factor for stroke given the patient was noted to have neurologic symptoms consistent with possible stroke.  Stroke evaluation was medically indicated with neurologic evaluation being neuro checks every four hours to ensure no neurologic progression.  This clinical scenario would support a request for inpatient hospitalization.  The patient was noted to have been evaluated completely and discharged as of the next day.

The question of inpatient versus outpatient evaluation of stroke patient is important to distinguish.   In this case, the patient was recommended for frequent neuro checks to ensure no progression of symptoms, and this supported inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy
Treatment: Medical day care, three days per week
The medical day care, three days per week is not medically necessary.
The patient is a female with recent inter-uterine pregnancy. She receives medical attention at Brightpoint Health with psychiatric treatment at Keran Hill Mental Health.  Medical diagnosis includes elevated cholesterol, depression, anxiety, bipolar, and asthma.  The patient's medical conditions based upon medical records and recent uniform assessment survey; comprehensive care plan and existing care plan all demonstrate patient's current diagnosis are adequately managed and the patient's medical and mental needs are being met.
The comprehensive care plan and existing care plan all demonstrate that the patient's current diagnosis are adequately managed, and the patient's medical and mental needs are being met. Medical records reviewed do not demonstrate one or more care services that require provision by a credentialed staff member of an Adult Day Care Center.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fracture
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The medical record demonstrates that the patient underwent non-complicated ORIF to her medial malleolus. This procedure was limited and not extensive. The fracture itself was minimally displaced. The physician placed a single incision on her medial ankle. He placed four screws and a plate without problem. There were no other procedures completed. There was little blood loss. The duration of the procedure was 90 minutes. This type of operation can be completed in ASU (ambulatory surgical unit) or Outpatient surgical center. 

The patient did not receive treatment of other associated injuries or underlying medical problems. She could have received oral pain medications. Physical therapy services were provided on the afternoon of surgery. Physical therapy services were limited, as the patient was advised not to weight bear. She was provided with a wheelchair. 

There was no need for monitoring as reported in record. The physician reported need for discharge planning on post-operative day one. There were no extenuating circumstances to substantiate necessity of this admission and length of stay. 

This was non-complicated limited surgery with post-operative instructions of non-weight bearing. Wheelchair was provided. These DMEs (durable medical equipment) could have been in place prior.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) with abdominal pain of 2-days duration. She was known to have gallstones from a prior admission. At the time of presentation, the patient was without a fever and vital signs were normal. She was tender in the right upper abdomen. An ultrasound showed gallstones and no gallbladder wall thickening. She was initially treated with intravenous (IV) fluid and IV antibiotics. She underwent a laparoscopic cholecystectomy.  The health plan's determination is upheld.

The submitted records document that this patient was clinically and hemodynamically stable at the time of presentation. Surgery was performed and the perioperative period was uncomplicated. Inpatient stay may be needed for failure to achieve discharge status criteria, conversion to open surgery, systemic infection, care for active comorbidities, complications of procedure. In this case none of these conditions existed to warrant an inpatient level of care.
Inpatient care is indicated when there is right upper quadrant pain, and systemic signs of inflammation (fever, C-reactive protein greater than [>] 10, white blood cell count (WBC) count > 10 thousand [K]). Inpatient admission is also indicated for acute cholangitis, common bile duct obstruction, vomiting that is severe or persistent, dehydration that is severe or persistent, hemodynamic instability, severe pain requiring acute inpatient management, signs of intestinal obstruction, bacteremia, need for percutaneous or open procedures, or other condition that requires inpatient admission. In this case, none of these indications existed to justify an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

This is the case of an ex-22 week preemie with mitochondrial disease, global developmental delays, seizure disorder, bronchopulmonary dysplasia (BPD), microcephaly, and G-tube dependence due to silent aspiration who presented to the emergency department (ED) with increasing behavioral outbursts, irritability, insomnia, and G-tube dislodgement.  There was no fever, vomiting, diarrhea, cough, or other signs of illness.  Mother reported a 2.5 lb weight loss over the week prior to presentation.  The inpatient stay is under review. 

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  This patient did not have removal of her surgical feeding tube or inability to tolerate feeds.  There was no indication of infection or illness.  The triage note in the ED stated the patient was "well appearing, playful and interactive with staff."  The patient was able to tolerate J-tube feedings while in the ED.  Laboratory evaluation was normal; there was no indication of dehydration or malnutrition.  An inpatient admission was not medically necessary, and the patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left-sided weakness
 
Treatment: Inpatient admission and monitoring

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

This case involves a patient with a past medical history of hyperlipidemia.  The patient presented to the emergency department for sudden onset of weakness and numbness of left lower extremity. The patient also reported vomiting.  The patient had a temperature of 98.6 with a blood pressure 110/75, heart rate 70, respirations 18 and oxygen saturation 95% on room air.  The patient was alert and in no acute distress and oriented to person, place and time.  The patient had a National Institute of Health Stroke (NIHSS) total score of 0.  Strength to the left lower extremity was 4/5.  The patient stated he had been drinking during the evening and also admitted to cocaine use.  He was attempting to walk across the street when his left leg stopped working.  Family/friends stated that the patient was slurring speech.  Computerized Tomography (CT) of the head and neck revealed no acute intracranial abnormality.  Electrocardiogram revealed normal sinus rhythm.  Magnetic Resonance Imaging (MRI) of the spine revealed degenerative changes.  The patient had normal laboratory results including a troponin less than 0.01.  He was given Alteplase and Zofran and was admitted.  The patient was discharged 2 days later.

The medical literature indicates that inpatient admission may be indicated for patients with acute ischemic stroke, encephalitis, severe Central Nervous System (CNS) infection, vasculitis, cerebral aneurysm, new onset neurological finding requiring inpatient care, multiple sclerosis, myasthenia gravis, Parkinson's disease, amyotrophic lateral sclerosis,, severe myopathy, complications of congenital or degenerative disease, suspected or confirmed nerve or muscle toxic injury or neurological trauma.  There were no findings of ischemic stroke on imaging.  There was no indication that the patient had severe CNS infection, vasculitis, cerebral aneurysm, new onset severe neurological findings, myasthenia gravis, multiple sclerosis, Parkinson's disease, severe myopathy, suspected to confirm nerve or muscle toxic injury or neurological trauma.  The patient's condition was appropriate for level of observational care rather than inpatient level of care. 

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: RSV Bronchiolitis

Treatment: Inpatient Admission

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

This patient is a young female child who presented to the Emergency Room for a fever and shortness of breath for one week.  She was noted to have labored breathing with an increased rate. She was also noted to have some desaturations of her pulse oximeter when drinking. A chest x-ray was done which showed a diffuse interstitial pattern with no evidence of pneumonia. She has a history of Down's syndrome and ventricular septal defect. She was transferred from another facility with respiratory syncytial virus. She was noted to have Oxygen (O2) desaturation while sleeping and was admitted for oxygen support for a diagnosis of RSV bronchiolitis.

Sixty percent of 208 children with DS in a 2004 survey were reported by their parents to have respiratory conditions, including sleep apnea and asthma, although this may be an underestimate based upon results from other studies. Other pulmonary complications that are more common in children with DS include disorders of the pulmonary vasculature, parenchymal lung disease, upper and lower airway abnormalities, and chronic aspiration. Respiratory tract infections are also more frequent and often more severe than in children without DS.

Sleep apnea - Obstructive sleep apnea (OSA) occurs in at least 30 to 75 percent of children with DS, including those who are not obese. In a population of 65 unselected 3.5 year olds with DS, polysomnograms were classified as abnormal with evidence of OSA in 57 percent. Among the 45 children whose parents reported no sleep problems, 54 percent had abnormal results. The mechanism includes soft tissue and skeletal alterations that lead to upper airway obstruction. In infants with DS, OSA was associated with dysphagia, gastrointestinal conditions such as gastroesophageal reflux disease, and congenital heart disease. Intermittent hypoxemia may lead to pulmonary hypertension and contribute to mental impairment

"SEVERITY ASSESSMENT - Severe bronchiolitis is indicated by persistently increased respiratory effort (tachypnea; nasal flaring; intercostal, subcostal, or suprasternal retractions; accessory muscle use; grunting), hypoxemia, apnea, or acute respiratory failure. 

Risk factors for severe disease and/or complications of bronchiolitis include:

Prematurity (gestational age <37 weeks)
Age <12 weeks
Chronic pulmonary disease, particularly bronchopulmonary dysplasia (also known as chronic lung disease)
Congenital and anatomic defects of the airways
Congenital heart disease
Immunodeficiency
Neurologic disease

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient admission 
The Inpatient admission was medically necessary for this patient.

The requested benefit of Inpatient admission could not have been effectively provided at a lower level of care in this case scenario. The patient in this case was using heroin with up to 12 bags of heroin with IV administration that did warrant the admission and the continued inpatient level detoxification with withdrawal management and inpatient level monitoring. Detoxification with a methadone taper, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had psychosocial stressors including parole status that supported the necessity for structure and a supervised and medically monitored detoxification treatment. 

The patient presented with a lack of sober supports and limited insight, impaired judgment and poor control of impulses that also supported the admission and the continued inpatient level detoxification in order to prevent relapse and complete his detoxification which allowed for his preparation for a recovery effort and referral to rehabilitation services. Thus, the continued detoxification treatment of this patient's substance use disorders did warrant and require the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patient's history of substance use (frequency and quantity) together with the severe psychosocial stressors, and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if detoxification and withdrawal management were to have been attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria/Guidelines referenced below.

The requested benefit of the Inpatient admission is clinically appropriate, medically necessary and warranted, and is therefore should be covered in this case scenario. The admission and the continued inpatient level treatment through discharge could not have been effectively provided with lower level services, as noted above. Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of ASAM Criteria and application of NY State OASAS LOCADTR 3.0 Criteria, referenced below.