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 female patient with a history of hyperlipidemia, gastroesophageal reflux disease, hypothyroidism, hernia surgery, and uterine fibroids. She presented to the Emergency Department (ED) with complaints of chest pain; she rated it 10/10 in severity. Cardiology service was consulted. An electrocardiogram (EKG) was done that revealed a normal sinus rhythm. A chest x-ray was done that revealed mild pulmonary edema. Troponin levels were drawn with negative results. An echocardiogram was done that revealed an ejection fraction of 60 to 65% with no regional wall motion abnormalities.

Computed tomography angiography of the chest was done revealed no acute pathology.
The patient had a period of medical stability and was discharged home with outpatient follow up instructions.

Utilizing the HEART score she was considered low risk. Utilizing the TIMI risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati, et al. Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG)) in the six weeks following presentation.  Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation.  In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been treated at a lower level of care.

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 inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right hemiparesis secondary to cerebral vascular accident
Treatment: Continued subacute rehabilitation 
The insurer denied the continued subacute rehabilitation.
The denial is upheld.
The continued subacute rehabilitation was not medically necessary.

The patient is a male with history of right hemiparesis secondary to left cerebro-vascular accident (CVA) s/p (status post) thrombectomy. He was admitted to SNF (skilled nursing facility). He had associated complications of incontinence, depression and aphasia. His relevant past medical history includes depression, atrial fibrillation, hyperlipidemia, hypertension, psychotic symptoms due to chronic schizophrenia, vascular dementia, etc.

Prior to admission, the patient was living with family members (brother) and was independent with ADLs (activities of daily living).

As of the day prior to the days under review, the patient was ambulating 150 feet under supervision without assistive device, grooming, requires modified independence with bed mobility, requires set-up for feeding, upper body dressing,  requires supervision for transfers, toileting, requires contact guide for bathing, lower body dressing, functional mobility during other ADLs, requires minimum assistance for bed mobility, etc.

The patient was admitted to SNF. By the day prior to the days under review, he was ambulating 150 feet under supervision without assistive device, grooming, requires modified independence with bed mobility, requires set-up for feeding, upper body dressing,  requires supervision for transfers, toileting, requires contact guide for bathing, lower body dressing, functional mobility during other ADLs, requires minimum assistance for bed mobility, etc.  The plan is to discharge to a long-term care in the same facility in which he has the option to continue at a lower level of care.

As stated above, the proposed continued stay in SNF was not medically necessary, and withholding the continued stay in SNF in whole or in part is not reasonably expected to affect the patient's health adversely. The patient will be better in a lower level of care to meet his continued rehabilitation needs.

The continued subacute rehabilitation was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Infection (left foot cellulitis)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned.
The Inpatient admission was medically necessary.

The patient is a female whose inpatient admission is under review. The patient had developed a left foot cellulitis and abscess five days prior to her ER visit. At the time in the PMD's (primary doctor's) office, the patient underwent I/D (incision and drainage), placed on clindamycin. After initial improvement, she worsened and then came to the ER with left foot pain.

In the ER, the patient's vitals were as follows:  T (temperature) - 97.3, P (pulse) - 83, RR (respiration rate) - 18, BP (blood pressure) - 119/61, O2 sat (oxygen saturation) - 99%. On general exam, the patient was NAD (no acute distress). Examination of her chest, CVS (cardiovascular system) and abdomen were normal. Examination of her skin revealed left posterior heel with blister, scant pus, mild surrounding erythema, + echymosis and swelling.

The patient's labs were as follows:
WBC (white blood count) - 8.2, Hg (hemoglobin) - 14.6, Hct (hematocrit) - 43.0 Plt (platelets) - 189.

The patient's skin culture was significant for MSSA (methicillin-sensitive Staphylococcus aureus).

In the ER, the patient was thought to have failure of antibiotics. She was treated with IV vancomycin and admitted. She improved, and she was placed on PO (oral) Bactrim and discharged.

The patient failed outpatient treatment, which is an indication for admission according to the Infectious Diseases Society of America guidelines (1). Thus, this admission was warranted, supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, septic shock, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertensive Emergency
 
Treatment: Inpatient Admission

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

This is a female patient with a medical history of end-stage renal disease, diabetes mellitus and hypertension. She presented to the Emergency Room (ER) with hypertensive crisis with associated vomiting and diarrhea. While in the ER she had a witnessed tonic-clonic seizure. A computed tomography (CT) of the head was performed with negative results. She was admitted to the intensive care unit (ICU) where she was treated with a Nicardipine infusion and received oral clonidine and hydralazine. She was discharged home.

The acute inpatient admission was not medically necessary.  The patient presented with an elevated blood pressure and gastrointestinal symptoms, which promptly resolved.  She had no evidence of acute neurological injury, myocardial ischemia, heart failure, arrhythmias, hemodynamic instability, or other general medical conditions necessitating inpatient admission status.  The patient's care could have been provided under observational level of care. The inpatient admission status was not met or justified based on her clinical presentation and clinical course of evaluation. The health care plan acted reasonably and 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: Sickle Cell Crisis
 
Treatment: Inpatient Admission 

The insurer denied the Inpatient Admission. The denial was upheld.   
This is a female patient with medical history of sickle cell disease. She presented to the emergency department with complaints of shoulder and back pain for one day. A chest ray was performed that revealed right lung pneumonia. Her treatment included morphine for pain with methadone, antibiotics and antiemetic. When her pain was well controlled and she was discharged home. 
Per Borhade, M.B., Kondamudi, N.P., (2019), "Rapid pain assessment and initiation of analgesia should be undertaken promptly. Depending on the degree and severity of pain, an analgesic administration can be given intravenously (IV) or intranasally. For patients who are not in severe pain and can tolerate oral medications, oral analgesics can be used. Generally, the type, route, and dose of the analgesic should be individualized to the patient. Most guidelines recommend early initiation of parenteral opioid analgesics, usually with morphine at 0.1 mg/kg IV or subcutaneously (SC) every 20 minutes and maintaining this analgesia with morphine at doses of 0.05 to 0.1 mg/ kg every 2 to 4 hrs (SC/IV or PO). Those with persistent pain benefit from a PCA pump. Close monitoring of vital signs including oxygen saturation should be maintained with frequent reassessments of pain severity or resolution.[8] If the pain is controlled, the patient may be ready for discharge with a home care plan and oral analgesia.[9] 
	
If the pain is uncontrolled despite the above treatment plan, consider hospitalization and the use of stronger forms of analgesia or higher doses titrated to the patient's needs. Simple or exchange transfusion may be warranted.[10] LMWH tinzaparin has been found to shorten the course of pain. A randomized, controlled, double-blind study has suggested that the clinical effects of tinzaparin are due to its effect on cellular factors. No special monitoring is needed for once-daily dosing.[10] Adjuvant therapy includes hydroxyurea, antihistamines, anxiolytics, and antiemetics.[10] It is prudent to maintain adequate hydration and be vigilant in identifying other causes of pain that may need additional treatment."

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

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

Diagnosis: Pregestational diabetes
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female.  She was admitted to the hospital at 36 3/7 weeks' gestation for a variety of presenting complaints, of which the most urgent and potentially risky was that her pregestational diabetes was out of control.  In addition to this problem, she also complained of back pain, vomiting, palpitations, and decreased fetal movements.  

Based on her history, she was felt to be noncompliant with her treatment regimen as outpatient.  It is documented that she refused insulin treatment for her diabetes, and that she stated that her blood sugars ran in the 200s at home.  Random blood sugar obtained was 154-148.  At the time of presentation, she had a tachycardia to 118, blood pressure 111/61, temperature 37.2, and benign chest and abdominal physical exam.  Her pulse came down to 91 without treatment.  She received sliding scale insulin and fetal monitoring.  The heart rate tracing, back pain, palpitations, and vomiting resolved within one day of admission, and it was felt that she was safe for discharge.  

The facility contends that the admission level of care was medically necessary due to the fear of fetal compromise and that there was no feasible way to discharge the patient and cites MCG Obstetric and Gynecologic criteria.  The health plan contends that the admission was not medically necessary, that the care was approved at observation level, and cites MCG 23rd edition.  

None of the abnormalities noted at admission was life threatening to either mother or baby and all resolved within one day of admission without specific treatment.  The diabetes was not sufficiently severe to merit admission unless the patient had failed outpatient treatment with intermittent insulin administration due to brittle diabetes and/or hypoglycemic episodes, and per the records the patient had refused this treatment and had no documentation of brittle diabetes or hypoglycemia.  Therefore, the admission was not medically necessary, and the care could have been given at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
 
Treatment: Inpatient Rehabilitation

The insurer denied the Substance and Alcohol Rehabilitation. The denial was reversed. 
This is a male patient with a medical history of crack/cocaine abuse and alcohol abuse for over 3 decades. He was referred to the facility by his parole officer as it was reported that he had a history of arrests and incarcerations. He had been in inpatient rehabilitation years earlier and expressed his lack of sober support. He expressed that his substance use was out of control. He had a past reported inpatient rehabilitation treatment for 24 days several years ago. He had strained family relations. He was discharged back to his assigned shelter with outpatient substance treatment referral.  
This reviewer disagrees with the decision to deny coverage for inpatient rehabilitation treatment. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. 

In this case this patient was considered in need of 24 hour substance rehabilitation treatment. This patient was using multiple serious substances daily including large amounts of crack / cocaine and also using alcohol which put him at risk for overdose and serious medical consequences to use. According to the LOCADTR he met criteria for inpatient substance rehabilitation treatment as he continued to use crack/cocaine daily and alcohol despite past inpatient substance rehabilitation treatments and despite negative consequences to use including multiple arrest and prison time as well as being currently on parole. Also, he had negative consequences related to his relationship with his brother who was his only support due to substance use. His parole officer recommended this as his substance use was out of control and he required a locked intensive and restrictive 24 hour inpatient substance rehabilitation treatment setting to allow him to work on improving coping skills, identification of relapse triggers, relapse prevention skills, motivation, insight, impulse control, and to try to develop a sober support network. Without this structured and supervised therapeutic inpatient substance rehabilitation treatment, he likely would have relapsed quickly.

Based on the above, the medical necessity for the inpatient rehabilitation at Cornerstone of Rhinebeck is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Distension, Dyspnea
 
Treatment: Inpatient Admission

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

This is a patient with a medical history of liver disease, thrombocytopenia, alcohol abuse, and hemorrhoids. He was admitted to the hospital with abdominal distension and dyspnea. A paracentesis was performed and new medication was administered to aid his diseased liver. The admission was medically necessary at the acute inpatient level of care based on the past medical history, co-morbidity, and high-risk clinical criteria.  The patient could not have been safely and effectively managed at an observational level of care or been directly discharged from the Emergency Department (ED) or ambulatory surgery unit.

There are several generally accepted indications for abdominal paracentesis, such as the evaluation of new-onset ascites, testing of ascitic fluid in a patient with preexisting ascites who is admitted to the hospital, regardless of the reason for admission, and for the evaluation of a patient with ascites who has signs of clinical deterioration, such as fever, abdominal pain/tenderness, hepatic encephalopathy, peripheral leukocytosis, deterioration in renal function, or metabolic acidosis.

Performing a paracentesis at the time of admission to the hospital in patients with cirrhosis and ascites may decrease mortality rates.  This was examined in a database study that included 17,711 patients with cirrhosis and ascites who were admitted to the hospital with a principal diagnosis of ascites or encephalopathy.  Paracentesis was performed in 61 percent of the patients, and the patients who underwent paracentesis had lower in-hospital mortality rates than those who did not (6.5 versus 8.5 percent, adjusted odds ratio 0.55, 95% CI 0.41-0.74). Paracentesis can also identify unexpected diagnoses, such as chylous, hemorrhagic, or eosinophilic ascites.

Diagnostic paracentesis should be performed promptly, especially if there is a concern for spontaneous bacterial peritonitis (SBP; e.g., the patient is febrile or has abdominal pain). Paracentesis should be carried out promptly in patients with suspected SBP.  Delays in performing paracentesis or failure to perform paracentesis have been associated with increased mortality in patients with SBP (in one study, every hour delay in performing a paracentesis was associated with a 3.3 percent increase in mortality).

The inpatient admission was medically necessary for this patient's clinical condition. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

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

Diagnosis: Cholecystitis
 
Treatment: Inpatient Admission

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

This is a female patient who presented to the emergency department with complaints of abdominal pain and vomiting. She had an ultrasound of her abdomen that revealed a 1cm gallstone at the gallbladder neck. The patient's vital signs revealed a temperature of 97.4 degrees with a heart of 66 bpm. Blood pressure was 140/77 and oxygen saturation was 100%. The physical exam revealed tenderness to the left upper quadrant and right upper quadrant. It was recommended the patient undergo laboratory and diagnostic studies. The patient's laboratory studies did not reveal any significant abnormalities. The patient did undergo an ultrasound of the right upper quadrant revealing a 1 cm gallstone at the gallbladder neck. There was no sonographic evidence of cholecystitis.  A CT scan of the abdomen and pelvis revealed moderate constipation.  The patient was treated with intravenous (IV) fluids, IV Morphine for pain and anti-emetic for nausea. Her symptoms resolved and she was discharged with follow up instructions for treatment. 

According to current literature inpatient care is appropriate for a patient when there is evidence of acute cholecystitis as indicated by right upper quadrant pain, systemic signs of inflammation such as a white blood cell count greater than 10,000, C-reactive protein level greater than 10 mg/liter or fever. Additionally, if the patient has common bile duct obstruction diagnosed by imaging, severe persistent vomiting, severe persistent dehydration, hemodynamic instability or severe pain requiring acute inpatient management patient may be admitted. The submitted documentation revealed the patient had a 1 cm gallstone at the gallbladder neck however there was no sonographic evidence of cholecystitis.  While the documentation detailed the patient did have additional episodes of nausea and vomiting while in the Emergency Department the guidelines indicate there must be numerous episodes of vomiting occurring in 24 hours such as every 1-2 hours that is not controlled with appropriate anti-medic treatment to include repeated oral or parenteral dosing.

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: Oligohydramnios
 
Treatment: Inpatient Admission 

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

This is a female patient who was admitted to the hospital because of oligohydramnios. Her biophysical profile was 6/8 and Amniotic Fluid Index was 3.5 centimeters. She denied fever, loss of flood, vaginal bleeding, or decreased fetal movement. She had continued fetal heart and vital sign monitoring. The tocodynamometer transducer revealed irregular contractions; betamethasone intramuscular (IM) was administered. The patient was discharged home ambulating and tolerating a diet.

Patients with oligohydramnios newly diagnosed in the third trimester need to undergo evaluation of possible causes, daily non-stress tests, and maternal hydration in an attempt to increase amniotic fluid volume. In ambulatory patients, a non-stress test (NST) and AFI (or biophysical profile) are performed once or twice weekly until delivery, depending upon the maternal and fetal condition. Combined use of the NST and AFI is associated with a low rate of unexpected fetal death. Serial sonographic examinations are obtained to monitor fetal growth.

In cases of isolated oligohydramnios in which delivery is not indicated, oral hydration with one to two liters of water can transiently increase amniotic fluid volume and may have some benefit, particularly in patients with dehydration. This approach is easier and safer than intravenous fluid administration or amnioinfusion. Hydration with water appears to reduce maternal plasma osmolality and sodium concentration, resulting in osmotically driven maternal to fetal water flux; it also improves uteroplacental perfusion.

This patient had oligohydramnios. Ultrasound did not show fetal anomalies. The fetal heart was reactive. There was no evidence of labor. The mother could have been asked to drink lots of fluid and could have been followed as an outpatient with non-stress tests and biophysical profile.

It is unclear why this patient was admitted. There was no elevation in her blood pressure. Her membranes were not ruptured. The fetal heart rate was reactive and there was no contraction.

MCG guidelines list the following clinical indication for antepartum admission:
1) Condition requiring premature delivery 
2) Delivery
3) Fetal distress or demise
4) Preterm labor and positive fFN
5) Significant maternal disease, infection or comorbidity as cause
6) Significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accrete 
7) Continued fetal monitoring 
8) Tocolytic therapy that requires inpatient care 
9) Complications of tocolytic treatment

This patient did not have any of the above. 

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated. The insurer's denial is upheld.