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

Diagnosis: Fever
Treatment: Inpatient admission

The inpatient admission was not medically necessary.

The patient is a male infant born prematurely at 35 weeks' gestation with medical history of hyperbilirubinemia requiring phototherapy that presented to the emergency department (ED) with fever. The infants rectal temperature at home was 100.9. He was otherwise well, with no upper respiratory infection (URI) symptoms or gastrointestinal (GI) symptoms. An older sibling had URI symptoms. 

The patient's vital signs included temperature 99.9 to 100.4, heart rate 189, and respiratory rate with 100% saturation in room air. Examination was significant for non-toxic appearance, no acute distress, clear lungs, anterior fontanelle open and flat, benign abdomen, and non-focal neurologic exam. A partial septic work-up was performed, including blood and urine studies. Significant laboratory findings included normal white blood cell (WBC) count (11.0K) with 68% lymphocytes, mild anemia with hemoglobin 12.4, thrombocytosis with platelets 555K, elevated potassium (6.1), metabolic acidosis (carbon dioxide [CO2] 19), normal C-reactive protein (CRP) (0.45), negative urinalysis, and viral panel positive for coronavirus 229E. The patient was treated with Tylenol and admitted for observation and intravenous (IV) hydration without antibiotics pending culture results. Admission orders included IV fluids at maintenance, ad lib feeding, follow-up of cultures, nasal saline with bulb syringe suctioning prior to feeding, and possible repeat metabolic panel. The patient remained afebrile overnight, feeding well. Blood culture returned positive for likely contaminant so was repeated and was negative. The patient continued to do well, with no fevers and good intake. He was deemed stable for discharge to follow-up with his pediatrician the next day.

In this case, the infant had been born prematurely and the infant later developed fever. Temporal probe initially read 102, but rectal thermometer read 100.9. Evaluation in the ED was significant for lymphocytosis, thrombocytosis, and respiratory panel positive for coronavirus. With suspected viral URI (older brother with URI symptoms), he was monitored in the hospital without antibiotics pending culture results. This was a very reasonable approach, consistent with the current standards of care. However, because he was overall stable with no signs of sepsis, no ongoing losses or dehydration, and no underlying chronic medical condition, he did not require acute inpatient admission. He could have been safely and appropriately managed at a lower level of care such as observation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Quadriplegia
 
Treatment: SonderCare Sequoia Specialty Hospital Bed

The insurer denied the SonderCare Sequoia Specialty Hospital Bed. The denial was reversed. 

This is a female patient with a history of quadriplegia and is ventilator dependent.  It is reported that the patient is a high risk for pressure ulcers. The patient has had a hospital bed since 2008; however it was changed out in 2015 and was not replaced with the same bed. 

Patients who are unable to feel pain or move themselves to relieve pressure while bed-ridden are at high risk for the development of pressure ulcers.  Pressure ulcers can lead to other health problems.  The standard of care for bedridden patients is to turn them every two hours.  Yet, even if adhered to and properly performed, a fixed schedule is not sufficient to prevent all ulcers.  Bed design can significantly impact and decrease the risk of pressure ulcers in patients at risk of pressure ulcers due to traumatic brain injury or inadequate consciousness.  According to the manufacturer website, this specific bed is available with a pressure relieving mattress.  The bed has the ability to be adjusted to multiple positions.  The documentation detailed that the patient has a very long-standing history of quadriplegia, as well as stage IV pressure sores.  The documentation indicated that she has an inability to change positions and is in need of a hospital bed such as the one requested as a replacement for the bed she has that is no longer safe and functional.  

The carrier's denial of coverage for the requested E1399 Sondercare Sequoia Specialty Hospital Bed is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Substance Abuse: Inpatient

The patient is a male with multiple substance use disorders who was admitted to inpatient detoxification level of care related to problematic use of alcohol, heroin, cocaine, and cannabis. He reported using two bags of heroin on the day prior to presentation for treatment, along with $60-$100 worth of cocaine, and some beer. Vital signs on admission were remarkable only for a slightly low blood pressure of 96/67. His main treatment concerns were for detoxification from alcohol and heroin. He complained on admission of nonspecific pain on the right side of his back, attributed to muscle soreness. Otherwise, he denied shortness of breath, chest pains, palpitations, syncope, dizziness, cough, wheezing, hemoptysis, dysuria, hematuria, incontinence, auditory or visual hallucinations. He denied any suicidal or homicidal ideation or any recent or past suicide attempts. He described last being sober approximately 10 to 20 years prior. The inpatient detoxification level of care is under review.

The health plan's determination is upheld. The Continued Inpatient Detoxification Stay is not medically necessary for this patient.
The concurrent review module of Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) was used for evaluation for continuing need of inpatient detoxification level of care.
There had been no changes in the patient status that required a higher level of care. The patient did not continue to require 24 hour medical oversight in a hospital setting due to serious or life-threatening complications. The patient did not continue to require 24 hour medical supervision, stabilization, and regular vital sign monitoring. The patient does not meet criteria for continuing in this level of care.
The patient did not have significant withdrawal symptoms or medical complications during the dates of service in question. He could have been safely and effectively treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unspecified asthma with acute exacerbation

Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission. The denial was upheld.

This patient is a male child with asthma presenting with cough and fever. The temperature in the emergency department (ED) was 37.3 C., Respiratory Rate 36, partial Oxygen (SpO2) 92% on room air. The patient had bilateral wheezing and had substernal retractions. He was treated with DuoNebs and Steroids. The patient was still slightly tachypneic and the ED physician decided to use magnesium sulfate and racemic epinephrine. The lab studies showed essentially a normal complete blood count (CBC), Basic Metabolic Panel (BMP) showed mild hypokalemia for which patient was treated with potassium supplementation. The patient was admitted for every 2 hours nebulization treatments, and monitoring. The Albuterol treatments were weaned to every 4 hour nebulizers. The patient was discharged the next day.

The patient could have been managed in an Observational status. There was no need for noninvasive ventilation or high flow nasal cannula. This patient did not require subcutaneous epinephrine, or terbutaline or a second dose of magnesium sulfate. Apart from the duo nebs, other bronchodilators the patient received only magnesium sulfate. 

As per current literature the patient could be discharged from the ED after magnesium sulfate (ref 1). 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 level of severity, the patient could be discharged or could be observed overnight (ref 2, 3) lastly, the nurses, documented that patient had a PEWS (Pediatric Early Warning Score) of 0 in the ED note; a PEWS of 0 means patient is stable enough to be discharged home (ref 4).

Due to above reasons, this patient could have been observed overnight for the prescribed bronchodilator therapy. The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. 

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

Diagnosis: Chest Pain 
Treatment: Inpatient stay 

Summary:
The patient is a female. She has a past medical history significant for HTN (hypertension), PACs (premature atrial complexes) AVNRT (atrioventricular nodal reentrant tachycardia) s/p (status post) ablation in 2016. 

This patient presented for evaluation of chest pain of two weeks duration. There was an initial concern for STEMI, however upon review of the ECG in the ER, it was found to be unchanged from prior tracing and this diagnosis was not confirmed, so the patient was admitted to rule out ACS (acute coronary syndrome). The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. Cardiac catheterization revealed no coronary obstruction, and patient was discharged for outpatient follow-up. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented for detoxification and substance-related services. He has a history of severe substance use disorders with alcohol, opioids (heroin and non-prescription methadone), and cannabis (marijuana) class substances of abuse. He had recent substance use disorder treatment but relapsed and was using large quantities of alcohol on a continuous daily basis with up to one pint of liquor plus beer together with seven to eight bags of heroin with intravenous (IV) administration and 20 milligrams (mg) of methadone, as well as intermittent and frequent use of cannabis with one blunt daily. He had multiple prior substance use disorder treatments with a chronic relapsing course, and early onset of the substance use at age eleven years with escalating use and progression of the disease.
At the time of presentation, the patient was also requesting referral for rehabilitation substance use disorder treatment. He denied current legal issues but was unemployed and reported severe psychosocial stressors within the primary support, social environment, occupational and housing domains. The patient reported functional decline as the substance abuse/disease had progressed which prompted his self-referral for detoxication treatment.
The patient provided no past history of withdrawal seizures, delirium tremens or severe alcohol withdrawal symptoms. He was medically screened and admitted for inpatient level detoxification with plans for a five day detoxification treatment with Librium and methadone and supportive measures. His Clinical Institute Withdrawal Assessment (CIWA) scale score showed mild withdrawal symptoms with a score of 8, and his Clinical Opiate Withdrawal Scale (COWS) scale score was moderate at 13. Withdrawal symptoms and signs included sweats, yawning, nausea and abdominal cramps, joint pain, and anxiety, as well as insomnia. A drug screen was consistent with his history.
The health plan's determination is overturned.
The requested services could not have been safely or effectively provided at a lower level of care in this case scenario. The patient was using large quantities of alcohol and opioids on a daily continuous basis that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease

Treatment: inpatient hospital admission

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

This patient is a male who was scheduled for a coronary angiogram in three days and now presents with discomfort in his left arm.  The symptoms have been going on and off for the past 2-3 days.  He denies trauma to the arm and still has full range of motion of the arm. According to his family he has also been complaining of worsening fatigue and light headedness over the last few days.  He denies chest pain or shortness of breath.  He has an appointment scheduled with his cardiologist tomorrow for pre-catheterization follow-up.  He has a past medical history of hypertension, borderline diabetes mellitus, hyperlipidemia and coronary artery disease (CAD) with previous percutaneous coronary intervention (PCI).  The patient had serial EKGs without pain and with pain and did not demonstrate any diagnostic ischemic changes.  Troponins x 2 were within normal limits.  His home medications include Plavix, Norvasc, aspirin, simvastatin, Pepcid, Ventolin and metformin.  The patient had a coronary angiogram performed through access via the right radial artery.  There were no ischemic EKGs noted and troponins were also negative following a coronary angiogram no interventions were needed.  The patient was discharged home with arrangements made for outpatient follow-up.

High-sensitivity cardiac troponin T (hs-cTnT) has been introduced as a highly sensitive and early biomarker of myocardial damage. (1) In two prospective cohorts of patients admitted to the hospital for chest pain, undetectable hs-cTnT was found to have a very high negative predictive value for MI. (2,3) A 2014 study from Sweden evaluated the significance of undetectable troponin levels and EKGs which did not show signs of ischemia in patients presenting to the emergency department with chest pain. (4) All patients who sought medical attention for chest pain and had at least 1 hs-cTnT analyzed during 2 years at the Karolinska University Hospital, Stockholm, Sweden, were included. They conclude that all patients with chest pain who have an initial hs-cTnT level of <5 ng/l and no signs of ischemia on an ECG have a minimal risk of MI or death within 30 days, and can be safely discharged directly from the ED. 

Observation units have been developed to improve care of patients who do not have an obvious clinical condition after their Emergency Department (ED) evaluation.  Selected people with chest pain are one of the most prominent groups of such patients.  They benefit from observation unit care with standardizing timely and accurate risk assessment, implementation of clinical decision rules, and use of accelerated diagnostic protocols.  They are a modern structure for cost-effective, high-quality outpatient/in-hospital patient care. (5)

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 hospital admission at the acute level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath during pregnancy
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

The patient is a G2 P1 female; at ten weeks' gestation she presented to the emergency room with worsening shortness of breath for a month.

At this patient's gestational age, treatment for asthma exacerbation would be no different than that for a non-pregnant patient.  The patient rapidly improved both symptomatically and objectively with resolution of her respiratory distress and well as improvement in her pulmonary function back to what she considered her typical range.  Her disease severity did not meet criteria for hospital admission per the National Asthma Education and Prevention Program EPR-3 or the guidelines for treatment of asthma in pregnancy promulgated by the American College of Obstetricians and Gynecologists.  Therefore the admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: growth hormone deficiency (GHD)

Treatment: Genotropin

The insurer denied coverage Genotropin. The denial was reversed.

This patient is a male child diagnosed with growth hormone deficiency (GHD). This request is for Genotropin. His GH stimulation test in mid-2019 with arginine and clonidine peaked at 7 and 7.8 respectively. His bone age in early 2019 was 15 years 6 months. His height in mid-2019 was 157.5 cm (-1.94 SDS). His mid- parental height is 174.5 cm (-0.33 SDS).

The health plan did not act in the best interest of the patient.

Classic GH deficiency

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society, (1)  the Lawson Wilkins Pediatric Endocrinology Society, (2,3)  and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists. (4)  The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on auxological, biochemical and sometimes radiological findings. The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 standard deviations (SD) below the mean; 2) height more than 1.5 SD below the mid-parental height; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml.

This patient met biochemical criteria. GH stimulation testing peaked at less than 10ng/ml. The patient had a low IGF1. The patient met auxological criterion 2 as his height is more than 1.5 SD below the target height. The patient met both auxological and biochemical criteria for the diagnosis of GH deficiency. 

Based on the above, the medical necessity for Genotropin is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production. Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention. Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1) Unfortunately, asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough. "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients... our review findings support the importance of controlling persistent asthma... early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)
 
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression. This is achieved with supplemental oxygen, bronchodilators, and steroids. Fluid hydration may also be necessary. For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.

This young male child with no personal or family history of asthma presented to the ED in significant respiratory distress that persisted after three DuoNebs, two one-hour rounds of continuous albuterol, steroids, and magnesium. He was diagnosed with status asthmaticus after having no atopic history and no prior wheezing episodes. He was not safe for discharge home, and not appropriate for outpatient management. He required the frequent evaluations, family asthma education, and medication manipulations only available in a hospital setting, specifically an ICU setting. Once he no longer required treatments every hour and was tolerating every two hour treatments, he was stepped down to the pediatric floor, where his treatments and education continued until he was deemed stable for discharge. Acute inpatient admission and management was medically necessary and appropriate. He could not have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered Mental Status
 
Treatment: Increase in personal care assistant (PCA) services from 7 days x 8 hours per week to 7 days x 12 hours per week

The insurer denied the Increase in personal care assistant (PCA) services from 7 days x 8 hours per week to 7 days x 12 hours per week. The denial was reversed. 

This is an elderly female who lives alone and has a personal care assist (PCA) 7 days a week for 8 hours a day. She is requesting an increase of hours due to her medical issues and her inability to safely perform her activities of daily living (ADL). It is reported that the patient's family does not live nearby and is unable to care for her. It was documented that during the MD's last 2 visits, he found the patient on the floor. She was unable to get up or call for help. At the times of the falls the doctor noted her mentation to be poor as she was only oriented x1 or 2 at the last visit. The patient has multiple risk factors falls which include pain, arthritis, dizziness, poor balance, and unsteady gait. She is cognitively impaired and remains at risk of attempting activities without using good judgment. The patient is bed bound most of the day and is diapered due to incontinence. When the aid completes her shift, the patient is essentially left alone and remains in the same soiled diaper until the aid returns the next day. 

The UAS and the physician indicate that there is very limited assistance from informal caregivers. The patient depends on PCA services for her daily needs. Due to her need for assistance with ADLs that occur throughout the day at unscheduled times, 8 hours per day of PCA services is not adequate. It is medically necessary for assistance to be available to the patient for transfers, walking, toileting and incontinence care at any time of the day these activities/tasks occur. 

Based on the above, the medical necessity for the requested increase in personal care assistant (PCA) services from 7 days x 8 hours per week to 7 days x 12 hours per week is substantiated. The insurer's denial is reversed.