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

Diagnosis: Chest pain 
Treatment: Inpatient hospital 

The patient is a man with a history of hypertension, coronary artery disease, mitral valve repair, chronic obstructive pulmonary disease (COPD) and polysubstance use. He presented to the emergency department complaining of four days of intermittent, sharp, stabbing, left-sided chest pain, diaphoresis and palpitations. 

The health plan's determination is upheld. The inpatient admission was not medically necessary. This man, with known coronary artery, presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers. There were no electrocardiographic findings diagnostic of ischemia. He did not require intensive monitoring or infusion of intravenous cardioactive medications. There is no indication in the records provided that other potentially serious diagnoses were considered likely. The care this patient received did not require an inpatient admission and could have been provided at a lower level. This approach has been shown to be both safe and effective and is in accordance with the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible right arm cellulitis  
Treatment: Hospital inpatient admission  

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

This patient is a male with a past medical history significant for intravenous drug abuse, opioid dependency, and bipolar disorder who presented to the Emergency Department (ED) with complaints of right arm swelling and pain. Vital signs on presentation included a temperature of 99.9F, a blood pressure of 112/71, a pulse of 90, a respiratory rate of 18, and an oxygen saturation of 98% on room air.  Laboratory results included a white blood cell (WBC) count of 14, a hemoglobin of 12.3, a hematocrit of 37.6, a D-dimer of 1739, and a creatinine of 1.19.  

The patient was started empirically on intravenous antibiotics (vancomycin and ceftriaxone) for right arm cellulitis.  An ultrasound done in the ED was negative for deep vein thrombosis (DVT) of the arm.  A chest x-ray was negative.  A CT scan of the right arm showed no acute abnormalities.  Surgery consulted and no surgical intervention was deemed necessary.  Infectious Diseases also consulted and recommended a course of antibiotic therapy.  The patient remained afebrile and hemodynamically and clinically stable.  He was discharged to continue follow-up as an outpatient on oral antibiotics.  The patient chose to sign out against medical advice (AMA).  

According to the documentation, the patient was admitted for a possible right arm cellulitis.  He was otherwise afebrile and hemodynamically stable.  Laboratory results were only notable for a mildly elevated WBC count.  The patient had a localized infection with no evidence of systemic toxicity, no failure of outpatient intervention, and no surgical intervention was required.  Based on the above findings, the patient was clinically stable for outpatient management.  The patient did not meet criteria for acute inpatient admission.  

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

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

Cardiac/Circulatory Problems - Chest Pain
Inpatient Hospital

The patient is an obese male with a history of hypertension, hyperlipidemia, coronary artery disease, paroxysmal atrial fibrillation and chronic obstructive pulmonary disease (COPD). He presented to the emergency department complaining of constant left-sided chest pain that was worsened with coughing, dyspnea and a productive cough. His blood pressure was 101/69 millimeters of mercury (mmHg) with a heart rate of 99 beats/minute. His respiratory rate was 16/minute with a room air oxygen saturation of 98%. He was afebrile. His cardiac and respiratory exams were unremarkable. His electrocardiogram showed sinus tachycardia at 105 beats/minute with right bundle branch block and QT prolongation. This was unchanged from prior tracings. His serum troponin level was normal. Chest X-ray showed mild emphysema and no acute pathology. Urine toxicology was positive for cocaine. The patient was admitted to the hospital to rule out acute coronary syndrome. Repeat troponin level was normal. The patient was in no distress. He was treated with antibiotics for presumed bronchitis. He was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld.

An inpatient admission was not medically necessary for this patient. This patient, with known coronary artery disease, presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both safe and is in accordance with the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left arm abscess
 
Treatment: inpatient hospital admission 

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

This patient is a male with past medical history significant for intravenous drug abuse and alcohol abuse who presented to the Emergency Department (ED) with complaints of left forearm erythema, swelling, and pain. The patient's vitals on presentation included: temperature 98.8 F, blood pressure-140/77, pulse-117, respiratory rate-18, and oxygen (O2) saturation-97% on room air.  The patient's laboratory results included the following; white blood cell (WBC) count-12.2, hemoglobin (Hgb)-13.3, hematocrit (Hct)-39.2, lactate-1.3, and creatinine-0.93; the patient was admitted. During hospital admission, the patient was evaluated by Infectious Disease, and was started empirically on intravenous antibiotics (vancomycin and aztreonam) for left arm abscess. As per the Surgery consult, the patient was taken to the operating room for an incision and drainage procedure of the left forearm abscess. The patient's wound cultures were positive for viridans streptococci and Haemophilus parainfluenzae.  The patient remained afebrile, hemodynamically and clinically stable.  The patient was discharged to continue follow-up as an outpatient on oral antibiotics. 

According to the review of the medical record, the patient was admitted for a left forearm cellulitis.  Though the patient was afebrile on initial presentation, the patient developed a high fever with a maximum temperature of 101 and tachycardia (hear rate of 117) in the presence of an infection.  The patient's laboratory results were notable for an elevated white blood cell count, and the patient required a surgical intervention in the Operating Room for incision and drainage (I&D) of his left forearm abscess.  Based on these clinical findings in this high-risk patient with an active history of polysubstance abuse, literature review supports this patient's inpatient admission for the administration of intravenous antibiotics and surgical intervention.

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

The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Ectopic pregnancy
 
Treatment:  Inpatient hospital admission

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

This patient is a female who complained of vaginal bleeding.  She had a HCG level of 1594, hemoglobin 13.6, and hematocrit 39.9.  An ultrasound showed no definite intrauterine pregnancy; heterogeneous echotexture lesion and complex fluid was noted in the right adnexa; ectopic pregnancy could not be excluded.  The patient was given intravenous fluids in the ER and was admitted to the Gynecology service with a diagnosis of ectopic pregnancy.  Repeat beta-HCG results were 1481 and 1354.  The patient remained stable with no abdominal pain and was discharged.

This patient was stable; there was no evidence of hemodynamic instability, no elevated temperature, good hematocrit and no peritoneal signs.  The patient was tolerating oral intake.  If an ectopic was high on the list, then a laparoscopy could have been performed to rule it out.  It is not clear why the patient was admitted.  There was no indication for admission, as nothing was done in the hospital that could not have been done as an outpatient.  The patient could have easily been observed in the Emergency Room.  Once the provider ascertained that the patient was stable, she could have been sent home with follow up as needed with serial HCG levels.

Since the patient was stable with no evidence of any acute condition, she could have been sent home.  The health care plan acted reasonably, with sound medical judgment and in the best interest of the patient.  The inpatient hospital admission is not considered medically necessary for this patient.

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: Pneumonia
Treatment: Inpatient admission
The proposed treatment of Inpatient admission is deemed medically necessary. 

The patient is a female with a history of hypothyroidism. She presented to the ER for further evaluation/management of shortness of breath and left lower extremity swelling/pain. 

The patient's intake vitals were noted to be afebrile, hemodynamically stable and not significantly hypoxemic on room air. Examination was notable for chest CT with evidence of right lower lobe pulmonary embolus with associated pleural effusion. The patient was admitted to the inpatient medical service where she received treatment including therapeutic anticoagulation and supportive care measures. During the course of her hospitalization, she spiked a febrile temperature and was found to have pneumonia requiring treatment with IV antibiotics. She responded well to the prescribed therapies and was subsequently discharged in stable condition. An appeal review was requested for potential approval of Inpatient admission.

This is a female with a history of hypothyroidism who presented to the ER for further evaluation/management of shortness of breath and left lower extremity swelling/pain. Intake vitals were noted to be afebrile, hemodynamically stable and not significantly hypoxemic on room air. Examination was notable for chest CT with evidence of right lower lobe pulmonary embolus with associated pleural effusion. Patient was admitted to the inpatient medical service where she received treatment including therapeutic anticoagulation and supportive care measures. During the course of her hospitalization, she spiked a febrile temperature of 101.3 F and was found to have a right basilar pneumonia requiring treatment with IV antibiotics for potential hospital acquired pneumonia. She responded well to the prescribed therapies and was subsequently discharged in stable condition. 

The febrile illness and development of hospital acquired PNA (pneumonia) represents evidence of intensification of services during the course of this patient's hospital stay. Hence, the patient's care could not have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome. For these reasons, the proposed treatment of Inpatient admission is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Pneumonia 

Treatment:  Inpatient hospital services 

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

This patient is a female with a family history of asthma.  The patient had been sick for a few days with cough, congestion and one day of fever and vomiting.  Because of the vomiting and the ongoing illness, the patient was brought to the Emergency Room (ER) for an evaluation.  In ER, the triage nurse noted that the patient's lungs were clear and the patient was not in any respiratory distress.  The ER physician noted some mild wheezing upon auscultation of the lungs and prescribed albuterol.  Following the administration of albuterol the wheezing was more apparent and the pulse oximeter reading dropped to 94%.  The ER physician then ordered two additional albuterol treatments, and the albuterol treatments were administered at one hour intervals.  The patient's chest x-ray showed a right upper lobe infiltrate, but the patient's blood testing did not reveal an elevated white blood cell count (leukocytosis).  The decision was made to admit the patient with a diagnosis of pneumonia for ongoing treatment with antibiotics and albuterol every 4 hours.   

Based on the review of the medical record and the literature, the patient was treated appropriately in the ER for a cough, wheezing and vomiting with evidence of pneumonia on chest x-ray.  However, there was no evidence that the patient was experiencing respiratory distress or increased work of breathing upon physical examination.  The patient's lab was remarkable for a low HCO3 level of 17 but did not present with other evidence of dehydration despite the patient's history of vomiting at home that would require hydration as an inpatient.  Since it is not uncommon for wheezing to become more apparent following administration of a bronchodilator, the worsening of wheezing with initial treatment in the absence of increased work of breathing and respiratory distress does not warrant inpatient level of care.  The acuity of this patient's clinical presentation and the care that this patient received as inpatient could have been safely provided in the ER or at the observation level of care.  Thus, this patient's inpatient hospital admission is not considered medically necessary for this patient.

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

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

Diagnosis: Cerebrovascular Accident 
 Treatment: Inpatient Admission 

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

This is a female patient with a history of diabetes, hypertension, hyperlipidemia, depression, a prior stroke, chronic tobacco and marijuana use. She presented to the Emergency Department with complaints of slurred speech, difficulty eating and swallowing. On physical examination she was alert and oriented with no motor/sensory deficits. Her stroke scale score was 1. She was consulted by Neurology. A computed tomography (CT) of the head was performed with negative results for acute stroke; with evidence of old right cerebral and left cerebellar infarcts. A magnetic resonance imaging (MRI) of the head was performed that showed multiple chronic infarcts. An electrocardiogram (EKG) was done that revealed a normal sinus rhythm. An echocardiogram was performed that revealed a left ventricular hypertrophy and an ejection fraction of 65%. She was admitted to the hospital and monitored on telemetry. She received aspirin, Plavix, and Lipitor. Neuro checks were performed hourly. Laboratory work up revealed the patient had magnesium of 1.5; she received intravenous (IV) magnesium. Neurology recommended the patient start Remeron. The patient was medically stabilized and was discharged home. 

According to the literature review, patients may be admitted to inpatient services when there is evidence of severe central nervous system (CNS) infection, vasculitis, or a new onset severe neurologic finding requiring inpatient care, or altered mental status that is severe or persistent. Additionally, if the patient has a severe neurologic condition with evidence of a flare needing inpatient services, literature support that inpatient admission may be appropriate. However, according to the medical record, this patient's CT scan along with this patient's follow-up MRI scan both confirmed that this patient did not have acute stroke. The patient received neurological consultation, along with diagnostic testing, such as echocardiogram, CT and MRI of the brain that could have been performed in the emergency department or on an observation setting. Thus, inpatient admission was not considered medically necessary for this patient's case. 

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

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

Diagnosis: Respiratory, respiratory infection 
Treatment: Inpatient hospital stay 

The pediatric patient has no significant past medical history (PMH) who presented with nonspecific complaints such as an upper respiratory infection (URI)< congestion, fever, and decreased by mouth (PO) intake. While in the pediatric emergency department (ED) the patient was not in distress, was "mildly tachypneic" and had a peripheral capillary oxygen saturation (SpO2) of 93%. There were mild intercostal retractions noted. The complete blood count (CBC) was normal, and the patient's basic metabolic panel (BMP) and urinalysis (UA) were reassuring. A chest x-ray (CXR) was completed which showed an interstitial pattern which the radiologist read as bronchopneumonia. The patient was administered Ceftriaxone, intravenous (IV) fluids and admitted for monitoring. The hospital course was uneventful. The patient was not persistently hypoxic nor in need of oxygen. The health plans determination of medical necessity is upheld in whole. The patient could have been treated at a lower level of care. As per the American Academy of Pediatrics (AAP) guidelines, a bronchiolitis admission is needed if the patient's SpO2 is less than 90, the patient has preexisting conditions such as cyanotic congenital heart disease or chronic lung disease, the patient's age is less than 12 weeks, or dehydration. In this case the patient's SpO2 was 93% in ED and the patient was "mildly tachypneic" only. The patient did not require any positive pressure ventilation (noninvasive) or any other resuscitative effort. After the patient was admitted to the pediatric floor there was no documentation of clinical worsening nor any perturbation in either hemodynamic status or labs. If one were to assign a Clinical Respiratory score for this patient at the time of arrival to ED, it would have been 3 or less. At this severity, the patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Central Nervous System/Neuromuscular Disorder - Epilepsy
Treatment:  Inpatient Hospital

This is the case of a male with a past medical history of epilepsy, schizophrenia, polysubstance use, and medication non-compliance, who presented to the emergency department in the setting of having two witnessed seizures while talking to his friend.  On presentation to the emergency department, he was afebrile with blood pressure of 119/71 millimeters of mercury (mmHg), a heart rate of 90 beats per minute (bpm), a respiratory rate of 18/minute, and an oxygen saturation of 97% on room air.  His exam otherwise noted a mild contusion on the right eyebrows and initial post-ictal state without clear neurologic deficits.  He was noted to have another seizure in the emergency department that stopped after administration of intravenous (IV) Ativan.  Labs showed a white blood cell count (WBC) of 9.6, a hemoglobin (HGB) of 13.1, platelets of 140, a sodium (NA) of 141, a potassium (K) of 3.7, a blood urea nitrogen (BUN) of 13, a creatinine of 1.23, he was hypoglycemic with glucose of 67, and had a subtherapeutic Dilantin level of 3.3, a subtherapeutic valproic acid level, and a mildly elevated creatinine kinase.  A urine drug screen was positive for cocaine.  An electrocardiogram (EKG) did not show evidence of acute ischemia or arrhythmia.  A computed tomography (CT) of the head, CT of the facial bones, and chest x-ray noted no acute findings.  In the emergency department, he was given Keppra intravenous (IV), phenytoin by mouth (PO), and valproic acid PO.  He was subsequently brought into the hospital with a concern for seizures in the setting of medication non-compliance and cocaine use.
After presentation, the patient remained hemodynamically stable.  He had no further seizures after being initiated on his home medications.  A magnetic resonance imaging (MRI) of the brain was performed which was unremarkable.  The patient was subsequently discharged on 10/18/2019.

The issue is whether the inpatient level of care was medically necessary.

The health plan's determination is upheld.

An acute inpatient stay was not medically necessary.  This is a patient who presented with 2 seizures witnessed by a friend and one in the emergency department in the setting of medication non-compliance and cocaine use.  He was otherwise hemodynamically stable with very mild rhabdomyolysis and renal insufficiency with creatinine of 1.23 and negative neuroimaging.  After care in the emergency department and being re-started on his home medications he had no further seizures.  A lower level of care would have been appropriate for this patient, who presented with seizures in the setting of medication non-compliance and cocaine use with mild rhabdomyolysis and renal insufficiency with negative neuro-imaging and who would have been expected to recover quickly once his seizure medications were re-started and he received gentle hydration.  Inpatient care was not medically necessary, and a lower level of care would have been appropriate.