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

Diagnosis: Hydronephrosis and obstructing stone

Treatment: Inpatient admission, diagnostic testing and intravenous evaluation.

The insurer denied inpatient admission. That denial was upheld.

This patient presented to the Emergency Room and was admitted with complaints of left flank and groin pain.  A CT scan revealed left hydronephrosis and an obstructing stone at the left uretero vesicular junction (UVJ).  The white blood cell (WBC) count was 11,000.  The patient was admitted to Urology and treated with intravenous (IV) fluids/IV antibiotics.  The patient improved. A renal ultrasound was performed on 8/20/18 showing resolution of the left hydronephrosis and no evidence of stone.  She was discharged home with outpatient Urology follow-up.

The insurer has denied coverage for the full hospital admission as not medically necessary.  In their final adverse determination letter, they note that the patient was found to have a kidney stone.  They stated that the hospital care provided could have been given without a full admission. This may include monitoring up to 23 hours.  Urology wanted to discharge the patient home earlier, but the patient declined to be discharged until the following morning.  

Per MCG Health (22nd Edition) Renal Colic and Kidney Stones RRG, the patient fails to meet clinical indications for admission to inpatient care. The patient had no urinary tract infection, acute renal failure, bilateral obstruction, or hemodynamic instability. Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history for poorly controlled diabetes mellitus and gastritis who presented to the emergency department with complaints of productive cough with yellow sputum that he had experienced for at least one week. The patient also complained of a subjective fever, chills, malaise, and right-sided back pain aggravated by taking a deep breath. The patient apparently tried to take Tylenol at home without any improvement in his symptoms. In addition, he complained of abdominal pain and increased frequency of urination for several days. The health plan's determination of medical necessity is upheld.

This patient was admitted to the hospital with the diagnosis of community-acquired pneumonia. The CURB-65 score for pneumonia severity is a risk stratification tool estimating the mortality of community-acquired pneumonia to help determine inpatient versus outpatient treatment. Based on the calculations, this patient received one point for BUN being greater than 19 milligrams per deciliter (mg/dl). According to these calculations, the patient belonged to a low-risk group of the 30-day mortality. Therefore, a lower level of care should have been considered.

This patient presented to the hospital with severe hypoglycemia that was treated effectively with a significant reduction in the serum glucose levels right after admission. Even though the patient's anion gap was elevated, the potential hydrogen (pH) was 7.39, which was a normal level, therefore the patient did not have diabetic ketoacidosis.
Finally, despite complaints of dysuria, there were no strong indications that the patient had a urinary tract infection severe enough to necessitate admission at an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain; hematuria 
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

Pneumatosis intestinalis (PI) refers to the presence of gas within the wall of the small or large intestine. Intramural gas can also affect the stomach, but this condition is referred to as gastric pneumatosis. 

The pathogenesis of PI is poorly understood, and is probably multifactorial. In some cases, PI is an incidental finding associated with a benign etiology, whereas in others, it portends a life-threatening intra-abdominal condition. As a result of the wide array of clinical settings in which PI is encountered, its implications are often misinterpreted. 

Pneumatosis intestinalis (PI) is usually detected on imaging or endoscopy performed for evaluation of abdominal symptoms. Assessment of patients with suspected PI should include a history, physical examination, laboratory studies, and abdominal imaging. A contrast-enhanced abdominal computed tomography (CT) scan to establish the diagnosis, determine the underlying etiology, and diagnose associated complications. 

Patients with pneumatosis intestinalis (PI) and any one of the following should undergo emergent exploratory laparotomy:

1) Signs of peritonitis on abdominal exam (e.g., abdominal rigidity, rebound tenderness, and/or pain that worsens when the examiner lightly bumps the stretcher)

2) Metabolic acidosis (arterial pH <7.3, HCO3 <20 mmol/L)

3) Lactate > 2.0 mmol/L

4) Portal venous gas

Pneumoperitoneum caused by PI may be managed medically if there are no clinical features suggesting an underlying acute abdominal emergency.

In patients who do not require emergent exploratory laparotomy, management is based upon the severity of symptoms. Mild symptoms include abdominal pain that does not interfere with functioning and the ability to perform activities of daily living. Moderate to severe symptoms include abdominal pain or bleeding that interfere with functioning and the ability to perform activities of daily living.

Asymptomatic patients and those with mild symptoms can be managed as outpatients. Patients with moderate to severe symptoms require hospitalization for monitoring to assess any change in symptoms. In this case, inpatient hospitalization was not required, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient  with a Class I, crowded occlusion with a deep bite. The orthodontist states he has anterior crossbites on teeth 22 and 27. He is treatment planned for orthodontics to correct his malocclusion. The health plan's determination of medical necessity is upheld.
There is no medical reason to correct his mild crowding with braces. The patient does have slightly retroclined maxillary incisors. However, that alone is not a medical necessity to treat.The patient has some crowding but a solid Class I occlusal relationship. His bite is deep but there is no indication of damage to the incisors or the palate in the photographs, and his cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate. Teeth 22 and 27 are not in anterior crossbite, as shown by the photographs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain

Treatment: Physical Therapy

The insurer denied physical therapy services. That denial was upheld.

This is a patient with low back pain.  Treatment included physical therapy.  Under review is the medical necessity of physical therapy services using CPT code 97110 (therapeutic exercise) x 4 (visits 8-12).

The physical therapy notes fail to document specific functional measures of improvement to support the medical necessity of the requested CPT code for visits 8-12.  

Denying CPT 97110 (x 4) for visits 8-12 as not a skilled service was appropriate. This was due to the repetitive nature of the treatment and lack of documented improvement which no longer supported its legitimacy as a skilled therapy service requiring the clinical assessment of a licensed physical therapist or its medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
This patient presented for alcohol detox and evaluation of chronic chest pain. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. His cardiac enzymes were cycled and ECGs trended, he was ruled out for ACS and was medically cleared for detox on 02/15/2019. No inpatient ischemic work-up (stress test, coronary CTA or catheterization) was performed. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care with subsequent transfer to detox.
Appeal type: Medical necessity
Decision: Upheld

The patient with a history of diabetes, hypertension, heart failure with reduced ejection fraction and cocaine use presented to the emergency department complaining of worsening dyspnea, orthopnea and paroxysmal nocturnal dyspnea.  The patient admitted to being noncompliant with the medical regimen and to recent cocaine use.  Blood pressure was 125/85 millimeters of mercury (mmHg) with a heart rate of 73 beats/minute.  Respiratory rate was 18/minute.  Room air oxygen saturation was 97%. Lungs were clear.  There was no jugular venous distension and no S3 gallop.  There were no acute electrocardiographic changes.  Chest x-ray showed mild pulmonary vascular prominence.  Serum troponin level was normal.  Urine toxicology screen was positive for cocaine.  The patient was treated with intravenous furosemide and admitted to the hospital for management of congestive heart failure exacerbation.  The home medications were restarted except for the beta-blocker, which was held due to recent cocaine use.  The patient reported improvement in symptoms.  Lungs were clear. Intravenous furosemide was continued.  The patient was discharged.  The health plan's determination is upheld. 

This patient presented with dyspnea, orthopnea and paroxysmal nocturnal dyspnea.  The patient was in mildly decompensated heart failure secondary to noncompliance with his medical regimen.  The patient was hemodynamically stable, in sinus rhythm and was not tachypneic or hypoxic.  There was no evidence of ischemia or acute kidney injury.  The chest x-ray showed mild vascular prominence without pulmonary edema or pleural effusions.  The patient improved after a dose of intravenous furosemide in the emergency department.  In heart failure patients, such as this patient, without high risk features, studies have shown that observation level care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients.  Thus, in this instance, the patient could have been safely treated at a lower level of care status, an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness and dizziness

Treatment:  Inpatient hospital stay

Summary:
The inpatient admission is not deemed medically necessary.  The medical records indicate that this patient was admitted to the inpatient medical service in stable condition where she received supportive care with IV fluids and continued cardiac monitoring.  She responded well to the prescribed therapies and was subsequently discharged in stable condition.  There is no evidence of intensification of services throughout the course of this patient's hospital stay.  Hence, patient's care could have been safely furnished in a less intensive setting without adversely affecting patient's safety or outcome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath. Past Medical History: Chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), Immune compromise, Depression, and polysubstance abuse.

Treatment: Inpatient admission, diagnostic evaluation, and medication management.

The insurer denied inpatient admission. That denial was upheld.

The patient presented to the Emergency Department (ED) with complaints of shortness of breath off and on for one week.  The patient also complained of shortness of breath and wheezing. The patient was admitted with diagnoses of chronic obstructive pulmonary disease (COPD)/Asthma secondary to upper respiratory infection (URI), rule out Infection.  The patient improved with therapy.  She remained afebrile and hemodynamically stable.  Vital signs were:  Afebrile, blood pressure 100/65, respiratory rate 19, and oxygen saturations were 97%.  Peak expiratory flow (PEF) was 350.  Lungs were clear.

This patient did not need acute hospitalization.  She could have been placed in observation status while diagnostic testing and treatment were initiated.  The patient was afebrile and hemodynamically stable.  She was not hypoxic.  Peak expiratory flow (PEF) improved to baseline of 350 by the next day.  The patient's condition improved with treatment.  Lungs were clear the next day. The patient was stable for discharge on oral steroids, Bronchodilators and antibiotics as clinically indicated.  The patient was stable for discharge after a period of observation.  She could have been followed up in an outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breathing and productive cough

Treatment: Inpatient stay 

Summary:
The patient presented with persistent cough and increased work of breathing, and was diagnosed with influenza A and possible bacterial secondary infection. She was tolerating an age-appropriate diet and had no oxygen requirement. While she did merit close monitoring and evaluation, she did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Inpatient detox
The proposed treatment, inpatient detox, was medically necessary for this patient.
The requested benefit of inpatient substance use disorder detoxification services and withdrawal management could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol on a daily continuous basis together with the risk for severe medical consequences that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as indicated, 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. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient struggled with withdrawal symptoms in the context of co-occurring symptoms of depression and anxiety, and with associated clinical features that included lack of sober supports and limited insight, impaired judgment, and poor control of impulses.
Thus, the adult inpatient stay and detoxification treatment of this patient's substance use disorders did necessitate the structure of an inpatient level setting with structure, supports, and 24-hour monitoring. The patient's history of substance abuse of alcohol (frequency and quantity) together with the symptoms of depression and anxiety and functional impairments and medical co-morbidity 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 or general medical complications such as seizures if detoxification and withdrawal management were to be 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, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below, and, is consistent with New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria-referenced below. The requested benefit of inpatient substance use disorder detoxification services and withdrawal management: is clinically appropriate, medically necessary and warranted in this case scenario, and is therefore a covered benefit. The admission and the continued inpatient level treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: Inpatient Detoxification Services

The insurer denied Inpatient Detoxification Services. The denial was reversed.

This is a middle aged male patient who was admitted to inpatient substance detoxification in early 2019 for alcohol and opioid detoxification treatment. He reportedly had a Clinical Institute Withdrawal Assessment for Alcohol (CIWA) score of 11. He had withdrawal symptoms including tremors, nausea, headache, joint pain, anxiety, and irritable mood.  He reportedly had a significant history of drinking alcohol, intravenous (IV) heroin, and smoking marijuana/hashish daily, and benzodiazepine use. He reportedly had multiple past substance inpatient detoxification; at least 5, and 2 to 3 rehabilitation treatment, the most recent in late 2018. He was currently in a Methadone maintenance program prior to admission, and admits to still using heroin, alcohol, and cannabis. He was unemployed and lived with family. He had a positive toxicology for opiates, cocaine, cannabis, and Methadone. He reportedly took Librium for alcohol detoxification in early 2019. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence for patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case, this patient had been using large amounts of alcohol, heroin, and was smoking large amounts of cannabis/hashish. He was at risk for severe, complicated, and life threatening withdrawal due to the large amount of use and he also was at high risk for overdose due to the large amount of alcohol and heroin use.  According to the LOCADTR, he did require 24 hour treatment as he could not safely and effectively be treated in outpatient detoxification setting, as he continued to use very large amounts of alcohol and large amounts of heroin, and he required and needed 2 detoxification medications including Librium and Methadone to modify withdrawal and prevent severe, complicated, and life threatening withdrawal symptoms. He also was unemployed and had limited supports to safely and effectively be treated for detoxification in an outpatient setting.  It was unlikely that he would remain abstinent so he required the time in this treatment setting to decrease the chance that he would relapse again when not in this 24 hour setting and also to prevent severe  and life threatening withdrawal symptoms.

Based on the above, the medical necessity for the continuation of inpatient detoxification services is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Use Disorder
 
Treatment: Admission to Inpatient Detoxification 

The insurer denied the coverage. The denial was reversed.

This is an adult patient who was admitted to inpatient substance detoxification treatment due to alcohol withdrawal symptoms including tremors, vomiting, lightheadedness, anxiety, and sleeping problems. The patient's Clinical Institute Withdrawal Assessment (CIWA) was 10.  The patient had an elevated blood pressure as high as 179/84.  The patient had a reported history of hypertension, diabetes, and back pain.  The patient was drinking six 24 oz. beers and 1/2 pint of vodka.  The patient also had a history of cannabis and cocaine use, and multiple past inpatient substance detoxification and rehabilitation treatments, with the most recent in early 2019.  The patient was placed on a five day Librium taper.  The plan was to step the patient down to inpatient substance residential treatment for rehabilitation.

The insurer denied coverage for continued inpatient substance detoxification treatment in the hospital for the early 2019 admission.  They stated that there were no acute medical or psychiatric issues requiring 24-hour hospital treatment, and they recommended a less restrictive level of care.

This reviewer disagrees with the decision to deny coverage for continued inpatient substance detoxification treatment in the hospital as the chart notes provided did support that the patient still required 24-hour inpatient substance detoxification treatment in this hospital. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  It also states that patients with past complicated or life-threatening withdrawal symptoms, including withdrawal seizures or delirium tremens, are in need of inpatient hospital treatment for the management of withdrawal. They also report that patients with co-morbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), the patient did require 24-hour treatment as the patient could not safely and effectively be treated in outpatient detoxification settings as the patient continued to use alcohol daily despite previous multiple failed inpatient substance detoxification and rehabilitation treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fatigue, weakness, loss of appetite and easy bruising
Issue under review: Inpatient admission

Determination: 
The inpatient admission was not medically necessary.

Myelodysplastic syndrome (MDS) in childhood encompasses a diverse group of bone marrow disorders that share a common clonal defect of stem cells and that result in ineffective hematopoiesis with dysplastic changes in the marrow. These disorders are characterized by one or more cytopenias despite a relatively hypercellular bone marrow. MDS disorders have been referred to as "preleukemias," because of their tendency to transform into acute myeloid leukemia (AML).

On the dates under review the patient was admitted  and had a low white blood cell count and no evidence of tumor lysis. The patient was monitored and then had a bone marrow aspiration and biopsy. There was no indication of fever, infection or sepsis. The patient did not begin chemotherapy until later, which was tolerated well.

The patient could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history significant for pre-diabetes, hypertension (HTN), obesity, dyslipidemia, past smoker, and past polysubstance abuse. The patient presented to the emergency department (ED) with substernal chest pain. Patient was seen in consultation by Cardiology and a cardiac catheterization was recommended. The health plan's determination of medical necessity was overturned in whole. This patient's thrombolysis in myocardial infarction (TIMI) risk score is 2, due to  cardiac risk factors and for the use of aspirin in the past 7 days (home medication). This equals an 8% risk at 14 days of all-cause mortality, new myocardial infarction (MI), or severe recurrent ischemia requiring urgent revascularization. The concern was significant enough to warrant a heparin drip and cardiac catheterization with the plan for revascularization.